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О патогенетическом лечении пузырно-мочеточникового рефлюкса у детей – Мазин – Казанский медицинский журнал

On the pathogenetic treatment of vesicoureteral reflux in children

О патогенетическом лечении пузырно-мочеточникового рефлюкса у детей

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В возникновении пузырно-мочеточникового рефлюкса у детей основная роль принадлежит инфекции и аномалии устьев мочеточника. Разнообразные клинические проявления этой патологии заставляют подвергать рентгеноурологическому исследованию всех детей с дизурией, энурезом, болями в животе, эпизодической лихорадкой. Пузырно-мочеточниковый рефлюкс 1—2-й, а иногда и 3-й степени хорошо поддается консервативному лечению антибактериальными препаратами с использованием местных внутрипузырных процедур. Противорефлюксное оперативное Пособие требуется в основном при 3, 4 и 5-й степени пузырно-мочеточникового рефлюкса.

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Патогенез и лечение пузырно-мочеточникового рефлюкса (ПМР) представляют, пожалуй, самую малоизученную проблему детской урологии. Некоторые исследователи [4, 8] считают начальные стадии ПМР у детей раннего возраста физиологическим состоянием, другие (и мы солидарны с ними) находят, что это явление патологическое и обусловлено аномальным развитием интрамурального отдела и устья мочеточника [2, 5, 10], обструктивными изменениями в шейке мочевого пузыря и задней уретре и другими факторами 11, 6]. Недостаточно четко очерчена клиническая картина ПМР, особенно в грудном и раннем детском возрасте. Нет единогласия в отношении показаний к консервативному и оперативному лечению ПМР и выбору метода оперативного вмешательства.

Мы посчитали целесообразным поделиться своим клиническим опытом, основанным на наблюдениях за 335 детьми (девочек — 250, мальчиков—85). Возраст детей и степень ПМР по Хейкелю и Паркулайнену (1966) представлены в табл. one.

Рефлюкс в левый мочеточник выявлен у 103 детей, в правый — у 101, двусторонний у 131 ребенка. Пассивное затекание контрастного вещества в мочеточник при цистографии отмечено у 226 пациентов, активное — у 109.

Мы, как и большинство клиницистов, пришли к выводу о полиэтиологической природе ПМР. Безусловно, возникновение ПМР облегчается физиологическими особенностями детского мочеточника, формой и позицией его устья, затруднением оттока мочи при обструктивных изменениях в шейке мочевого пузыря и задней уретре, сужением уретры и крайней плоти. Но наряду с дефектами в анатомическом строении мочевых -органов встречаются и функциональные расстройства, обусловливающие ПМР. Так, у преобладающего большинства больных ПМР мы наблюдали подковообразные, лункообразные или зияющие устья мочеточников. Изменения в шейке мочевого пузыря и. уретре выявлены лишь у 38 больных. Однако ПМР бывает ji при обычной форма устья и отсутствии аномалий развития мочевыводящих путей. Причем у девочек он наблюдался в 2 раза чаще, чем у мальчиков.It is known that inflammatory processes * of the urinary tract, which ranks second after acute respiratory diseases, are much more common in girls than in boys.

Data on the age composition of patients and the degree of VUR

Number of patients (by age group)

At in children, as in adults, sluggish current cystitis, especially cervical and urethrocystitis, is not always accompanied by pyuria. Dysuria can be minor and is not always noted by the child and parents. However, the inflammatory process in the bladder is easily detected by cystoscopy. In 132 children with initial stages of VUR, endoscopic examination revealed inflammation of the bladder of varying degrees and prevalence. Most often, the inflammation was localized in the region of Lieto's triangle, the bottom of the bladder and the posterior semicircle of its neck and spread to the region of the mouths of the ureters, necessarily capturing their intramural part. Attention was drawn to the gaping of the mouths of the ureters, their rigidity during contractions. The mucosa of the bubble around the mouths was edematous, hyperemic, the vessels were injected. As a result of inflammatory infiltration of the bladder wall, the position of the orifice changed, the intramural part of the ureter shortened, rigidity of the orifices occurred, which caused reflux. In the early stages of the inflammatory process, when there is still no significant fibrosis, these phenomena are reversible. So, in 97 of our patients with symptoms of cystitis and VUR of the 1st and 2nd degree, after the treatment of cystitis, it disappeared into reflux. In cases where the inflammatory process of the bladder wall has already led to irreversible changes in the intramural ureter, VUR progresses. In such patients, we, like A. L. Cheskis and V. I. Vinogradova (1973), found an identical chronic inflammatory process of the bladder wall and ureter during biopsy during surgery and histological examination. In connection with the above, we tend to assign a large role in the etiology of VUR infection of the lower urinary tract.

The clinical manifestations of VUR in ‘children were quite varied. Dysuria* was noted in 159 patients, nocturnal enuresis in 37; 98 children complained of pain in the abdomen and lumbar region, sometimes in connection with urination. In infancy and early childhood, VUR was usually detected already in the presence of pyelonephritis, which proceeded with high fever, intoxication, dyspeptic disorders (chills, vomiting, stool instability) and often was initially regarded by pediatricians as an acute respiratory disease, intestinal infection, sepsis. The study of the anamnesis in children over 3 years old made it possible to establish that most of them: before hospitalization in the children's urological department, suffered one or more attacks of pyelonephritis. Leukocyturia, bacteriuria are also mainly characteristic of the associated secondary pyelonephritis.In the early stages of the PMR, when the pyelonephritis is not yet expressed, but there is only urethrocyst, the results of urine analysis can be normal. The so-called "aseptic" PMR in 42 children was a random clinical find.

X-rayurological examination of children with suspicion of PMR We have always started with an excretory urography. On excretory urograms, 101 children revealed some expansion of ureterals, in 174 children were noted, hypotension of lochanks and ureters. The most effective method of research 36 was cystography, which made it possible to establish or clarify the diagnosis of 335 children.

In order to choose a conservative or operational treatment and the operation method, it was necessary to use telescopy. To eliminate the obstructive processes in the bladder neck and the rear urethra, the narrowings of the urethra were used large-frame cystourethrofluorography, urooflorometrium and tsstotonometry with a calibration of urethra.

The choice of the method of treating the PMR is extremely complex and often requires repeated observations. In patients with obstructive processes in the bladder neck and urethra, we eliminate the operational way of an obstacle to urine outflow, and then carry out massive antibacterial treatment for 3-4 months. Sometimes in such cases, even the 3rd degree PMR. In case of unsuccessful, such treatment has to resort to surgical intervention.

As already mentioned, the PMR 1, 2nd, and sometimes the 3rd degree, due to chronic cystitis, is well amenable to conservative therapy. In addition to antibacterial drugs, it is advisable to use local intrapaulic procedures in such patients (instillation of silver sulfate 1: 5000, 1: 10,000 solution, 1- 2% collargol solution for 10 days; electrophoresis on the bladder area with calcium chloride solution). However, some authors offer unreasonably tighten conservative therapy. In our opinion, the operation may be appropriate, depending on the circumstances, at any age. We had to operate 26 children under 4 years old with good nearest and remote results.

We consider the contradulted operational manual shown in the following cases: 1) If the reflux does not disappear and is not exposed to reverse development for 6 months of conservative therapy; 2) if the attacks of pyelonephritis are often repeated, despite the antibacterial therapy; 3) if, with reflux 2 and 3rd degrees, cystoscopy reveals large, gaping, rigid mouths of ureters, and telescopy detects a decrease in the tone and the expansion of the ureter; 4) with bubble-ureteral reflux 4 and 5th degrees.

We are operated on 49 children, a total of 64 operations produced. With operational allowances for the PMR, we do not adhere to a unified technique, but select one or another operation depending on the degree of reflux, the state of the ureter's mouth and its diameter, age and the overall condition of the child.In small children, it is technically difficult to produce intrinsic interventions (by politano-ice-ledged), while in children of older age, with the 3-4th degree, intrapaulic operations are easily carried out, effective and less trauma. All operations made by us depending on the degree of PMR are presented in Table. 2