泌尿外科學的介紹

高考結束了，現在即將進入填報志願的階段，這時候除了考慮學校，還要考慮專業。有人想了解泌尿外科學是什麼。接下來小編爲大家整理了泌尿外科學的介紹，希望對你有幫助哦!

泌尿外科

泌尿外科，是主要診斷和治療泌尿系統“外科”部分疾病的醫院科室，主要治療各種泌尿性疾病。

治療範圍

各種尿結石和複雜性腎結石;腎臟和膀胱腫瘤;前列腺增生和前列腺炎;睾丸附睾的炎症和腫瘤;睾丸精索鞘膜積液;各種泌尿系損傷;泌尿系先天性畸形如尿道下裂、隱睾、腎盂輸尿管連接部狹窄所導致的腎積水等等。

泌尿外科是個比較古老的專科，有較久的歷史;但同時卻又是個比較新的專科，甚至到2013年，在有的分科醫院裏，還是有別的專科而唯獨沒有泌尿外科。這說明，這個專科是重要的，但發展也是不平衡的。

區別

泌尿外科不應該叫“泌尿科”，因爲它不包括與尿有關的“內科”部分，如腎炎、糖尿病、尿崩症等，這應當加以區別而避免混淆。然而情況在變化，科學在前進，不斷地有新的項目由內科範圍轉入到泌尿外科中來，例如腎血管性高血壓、腎上腺的一些疾病等，所以也必須辯證唯物地看待問題。

泌尿外科學

泌尿外科學主要內容爲腎臟移植，腹腔鏡手術，腎上腺腺瘤、嗜鉻細胞瘤、原發性醛固酮增多症等腎上腺手術治療，腎、膀胱、前列腺腫瘤手術，前列腺癌手術，腎盂輸尿管交接部狹窄手術，腎、輸尿管、膀胱結石手術治療，經膀胱、恥骨後前列腺增生摘除手術，經尿道膀胱腫瘤電切手術，經膀胱鏡應用鈥激光進行膀胱腫瘤切除，尿道下裂、陰莖下屈整形等手術，體外碎石治療腎、輸尿管、膀胱結石。近年來開展了慢性前列腺炎的病因檢查和治療，以及男性性功能障礙和男性不育的診治。

案例：梗阻性尿路疾病

Obstruction is one of the most important abnormalities of the urinary tract， since it eventually leads to decompensation of the muscular conduits and reservoirs， back pressure， and atrophy of renal parenchyma. It also invites infection and stone formation， which cause additional damage and can ultimately end in complete uniLateral or bilateral destruction of the kidneys.

梗阻是泌尿道最重要的異常之一，因其最終使肌性管道及其容器失去代償能力，發生反壓及腎實質萎縮。它亦可導致感染及結石形成，加重腎臟損害，最終使一側或雙側腎臟完全破壞。

Both the level and degree of obstruction are important to an understanding of the pathologic consequences. Any obstruction at or distal to the bladder neck may lead to back pressure affecting both kidneys. Obstruction at or proximal to the ureteral orifice leads to unilateral damage unless the lesion involves both ureters simultaneously. Complete obstruction leads to rapid decompensation of the system proximal to the site of obstruction ，with immediate muscular failure. For example， acute retention occurs if the obstruction is distal to the bladder， and anuria occurs if obstruction involves both ureters. Partial obstruction leads to gradual progressive muscular hypertrophy followed by gradual dilation. decompensation ，and hydronephrotic changs. Vesicoureteral reflux may develop in some cases.

梗阻的平面及程度對了解其病後果是重要的。膀胱頸或膀膛頸以下部位梗阻，其反壓可影響雙側腎臟，而輸尿管口或其近端梗阻則引起單側損害，除非雙側輸尿管同時有病變。完全梗阻可能可使梗阻以上泌尿系統迅速增值失代償能力，伴有立刻肌力喪失。例如梗阻在膀胱以下部位可以引起急性尿瀦留，而雙側輸尿管發生梗阻則可出現無尿。部分梗阻則逐漸引起進行性肌肉肥厚，隨後出現逐漸擴張，代償功能喪失及腎積水變化。膀胱輸尿管反流可在某些病例出現。

Etiology

病因

Acquired urinary tract obstruction may be due to inflammatory or traumatic urethral strictures， bladder outlet obstruction (benign prostatic hypertrophy or cancer of the prostate)， vesical tumors， neuropathic bladder， extrinsic ureteral compression (tumor， retroperitoneal fibrosis， or enlarged lymph nodes)， ureteral or pelvic stones， ureteral strictures， or ureteral or pelivic tumors.

獲得性尿路梗阻可能由於炎性或損傷性尿道狹窄，膀胱出口梗阻(良性前列腺肥大或前列腺癌)、膀胱腫瘤、神經性膀胱疾病、外源性輸尿管壓迫(腫瘤、腹膜後纖維化或巨大的淋巴結)、輸尿管結石或腎盂結石、輸尿管狹窄、及輸尿管或腎盂腫瘤引起。

Pathogenesis

病原學

Regardless of its cause， acquired obstruction leads to similar changes in the urinary tract， which vary depending on the severity and duration of obstruction.

不論何種原因，獲得性梗阻引起尿路內相類似的改變，而改變的具體情況則因梗阻的嚴重程度和時間長短有所不同。

a. Urethral Changes： Proximal to the obstruction， the urethra dilates and balloons. Aurethral diverticulum may develop， and dilatation and gaping of the prostatic and ejaculatory ducts may occur.

a.尿道改變：梗阻近端尿道擴張及膨脹可發展爲尿道憩室、前列腺管及射精管擴張及裂口。

b. Vesical Changes： Early， the detrusor and trigonal thickening and hypertrophy compensate for the outlet obstruction， allowing complete bladder emptying . This change leads to progressive development of bladder trabeculation， cellules， saccules， and then， diverticula. Subsequently， bladder decompensation occurs and is characterized by the above changes plus incomplete bladder emptying， resulting in residual urine. Trigonal hypertrophy leads to secondary urteral obstruction owing to increased resistance to flow through the intravesical ureter. With detrusor decompensation and residual urine accumulation， there is strectching of the hypertrophied trigone， which appreciable increases ureteral obstruction. This is the mechanism of back pressure on the kidney in the presence of vesical outlet obstruction (while the urterovesical junction maintains its competence)。 Catheter drainage of the bladder relieves trigonal stretch and improves drainage from the upper tract.

b.膀胱改變：早期爲使膀胱完全排空，逼尿肌及膀胱三角增厚及肥厚，以代償膀胱出口梗阻。這種改變逐漸發展成膀胱小樑、小腺泡、囊泡，終成爲膀胱憩室，最後膀胱失去代償功能，表現長期持徵爲上述改變加重，和膀胱排空不完全，最終出現殘餘尿。膀胱三角區肥厚可引起繼發性輸尿管口梗阻，這是由於尿液通過膀胱壁部分輸尿管時阻力增加而造成的。由於逼尿肌失代償及殘餘尿增加，肥厚的三角區過度伸展，加重輸尿管梗阻，這就是由於膀胱出口梗阻對腎臟發生反壓的機制(此時膀胱輸尿管連接處功能健全)。膀胱置管引流減少三角區牽張，並改善上尿路引流。

A very late change with persistent obstruction (more frequently encountered with neuropathic dysfunction) is decompensation of the ureterovesical junction， leading to reflux. Reflux aggravates the back pressure effect on the upper tract by exposing it to abnormally high intravesical pressures——in addition to favoring the onset or persistence of urinary tract infection.

持續性梗阻(常由於神經原疾病膀胱功能失常)非常晚期限改變爲輸尿管膀胱連接處失償導致尿液反應。面對膀胱非常高的壓力，尿液反流除促使尿路發生感染或使感染持續性，還加重上尿路的反壓。

c. Ureteral Changes： The first noted change is a gradually progressive increase in uretereal distention. This increases ureteral wall stretch， which in turn increase contractile power and produces ureteral hyperactivity and hypertrophy. Because the ureteral musculature runs in an irregular helical pattern， stretching of its muscular elements leads to lengthening as well as widening. This is the start of ureteral decompensation， where tortuosity and dilatation become apparent. These changes progress until the ureter becomes atonic， with infrequent and ineffective or completely absent peristalsis.

c.輸尿管改變：最先可見的改變爲輸尿擴張逐漸增加，這就增加輸尿管壁的牽張，從而增加收縮力，產生輸尿管過度活動及肥厚。因爲輸尿管是不規則螺旋形走向，肌內成份的牽張使輸尿管延長及增寬。輸尿管的彎曲及擴張標誌着它功能失償的開始，這種改變繼續進行直至輸尿管失去張力，蠕動減少或完消失。

d. Pelvicaliceal Changes： The renal pelvis and calices， being subjected to progressively increasing volumes of retained urine， progressively distend. The pelvis first shows evidence of hyperactivity and hypertrophy and then progressive dilatation and atony. The calices show the same changes to a variable degree， depending on whether the renal pelvis is intrarenal or extrarenal. In the latter， caliceal dilatation may be minimal in spite of marked pelvic dilatation. In the intrarenal pelvis， caliceal dilatation and renal parenchymal damage are maximal. The Successive phases seen with obstruction are rounding of the fornices， followed by flattening of the papillae and finally clubbing of the minor calices.

d.腎盂腎盞改變：腎盂腎盞由於承受的殘餘尿容量逐漸增加而擴張。腎盂早期表現是蠕動增強及肥厚，以後逐漸擴大及無張力。腎盂根據其是腎內腎盂抑或外腎盂，而呈不同程度的同樣改變。如爲後者，雖然腎盂已明顯擴大，腎盞擴張可能不明顯;而若爲腎內腎盂，腎盞擴張和腎實質損害均嚴重。其梗阻連續相(Successive phase)所見爲穹窿呈圓形，接着腎乳頭呈扁平，最後腎小盞呈杵狀。

e. Renal Parenchymal Changes： With progressive pelvicaliceal distention， there is parenchymal compression against the renal capsule. This， plus the more important factor of compression of the arcuate vessels as a result of the expanding distended calices， results in a marked drop in renal blood flow. This leads to progressive parenchymal compression and ischemic atrophy. Lateral groups of nephrons are affected more than central ones， leading to patchy atrophy with variable degrees of severity. The glomeruli and proximal convoluted tubules suffer most from this ischemia. Associated with the increased intrapelvic pressure， there is progressive dilation of the collecting and distal tubules， with compression and atrophy of tubular cells.

e.腎實質改變：隨着腎盂腎盞進行性擴大，腎實質向包膜側受壓，加上由於腎盞擴大，向弓形動脈壓迫這一重要因素終於使血流明顯下降，而導致進行性腎實質受壓和缺血性萎縮。側組腎單位受累較中央組爲重，而導致嚴重程度不等的斑狀萎縮。腎小球及近曲小管受缺血損害最重。伴隨腎盂內壓增加，集合管及遠曲小管呈進行性擴大，腎小管細胞受壓和萎縮。

Clinical Findings

臨牀表現

a. Symptoms and Signs： The findings vary according to the site of obstruction：

症狀與體徵：其表現因梗阻位置而異。

Infravesical obstruction——Infravesical obstruction leads to difficulty in initiation of voiding， a weak stream， and a diminished flow rate with terminal dribbling. Burning and frequency are common associated symptoms. A distended or thickened bladder wall may be palpable. Urethral induration of a stricture， benign prostatic hypertrophy， or cancer of the prostate may be noted on rectal examination. Meatal stenosis and impacted urethral stones are readily diagnosed by physical examination.

膀胱下梗阻：膀胱下梗阻導致起始排尿困難，排尿無力及尿流率減少，伴隨尿後滴瀝。燒灼感及尿頻爲常見伴隨症狀。可觸及膨脹或增厚的膀胱壁，肛門檢查可發現狹窄部尿道變硬，良性前列腺增加或前列腺癌。尿道口狹窄和尿道嵌塞結石常可由物理學檢查而獲診斷。

Supravesical obstruction——Renal pain or renal colic and gastrointestinal symptoms are commonly associated. Supravesical obstruction may be completely asymptomatic when it develops gradually over a period of several weeks or months. An enlarged kidney may be palpable. Costovertebral angle tenderness may be present.

膀胱上梗阻：腎區疼痛或腎絞痛常與胃腸道症狀同時出現。當膀胱上梗阻發展緩慢時。經數週或數月可完全無症狀。可觸及增大的腎臟。肋脊角可有壓痛。

b. Laboratory Findings： Evidence of urinary infection， hematuria， or crystalluria may be seen. Impaired kidney function is noted by elevated blood urea nitrogen and serum creatinine， with the ratio well above the normal 10：1 because of urea reabsorption.

b.化驗結果：可觀察到感染尿，血尿或晶體尿，血尿素氮及血清酐升高，由於尿素氮再吸收以致其比值高於10：1.這表明腎功能受損害。

c. X-Ray Findings： Radiologic examination is usually diagnostic in cases of stasis， tumors， and strictures. Dilatation and anatomic changes occur above the level of obstruction， whereas distal to the obstruction， the configuration is usually normal. This helps in localizing the site of obstruction ined antegrade imaging by intravenous urograms and retrograde imaging by ureterograms or urethrograms， depending on the site of obstruction， is sometimes needed to demonstrate the extent of the obstructed segment. In supravesical obstruction， demonstration of stasis and delayed drainage is essential to establish and measure the severity of obstruction.

c.X線表示：尿液胡滯，腫瘤或狹窄的病例，放射學檢查可獲診斷。梗阻平面以上有擴張和解剖學改變，而在梗阻遠端形態爲正常，這有助於診斷梗阻位置。根據梗阻位置有時需同時作順利性靜脈尿路造影及逆行性輸尿管造影或尿道造影，以確定梗阻段的伸延。在膀胱以上梗阻，顯示鬱滯及延遲，引流，對於確定及估計梗阻的嚴重性是重要的。

d. Special Examinations：

d.特殊檢查：

Antegrade urography via percutaneous needle or tube nephrostomy is of particular value when the obstructed kidney fails to excrete the radiopaque material on excretory urography. This procedure allows application of the Whitaker test， during which fluid is introduced into the renal pelvis at varying rates. The fluid transport can be measured and the degree of obstruction estimated by the use of a pressure monitor.

順行時尿路造影：當阻塞的腎臟在排泄性尿路中造影劑不能排泄時，使用經皮針或者說導管行腎造瘻特別有價值，這種操作可施行Whitaker試驗， 在試驗期間液體可以不同程度注入腎盂。可測量液體轉移，以壓力監測器來估計梗阻程度。

Ultrasonography——This will reveal the degree of dilatation of the renal pelvis and calices and allows for diagnosis of hydronephrosis in the prenatal period.

超聲顯像：它可展示腎盂及腎盞的擴大程度，及可在胎兒期診斷腎積水。

Isotope studies——A technetium Tc 99m DMSA scan portrays the degree of hydronephrosis， as well as renal function. Use of diruretics during the scan can provide information similar to that obtained with the Whitaker test.

同位素檢查：用鍀99M DMSA掃描可瞭解腎盞積水程度及腎功能。在掃描時使用利尿劑可得到與Whitaker試驗相似的效果。

CT scan——This may be of value in revealing the degree and site of obstruction as well as the as the cause in many cases. The use of contrast agents will allow estimation of residual renal function.

CT掃描：在某些病例，對顯示梗阻部位，程度以及原因有一定價值，使用對比劑可估計殘留有腎功能。

Complications

併發症

The most important complication of urinary tract obstruction is renal parenchymal atrophy as a result of back pressure. Obstruction also predisposes to infection and stone formation， and infection occurring with obstruction leads to rapid kidney destruction.

尿路梗阻最重要的併發症爲反壓所致的腎實質萎縮。梗阻也可以使腎臟易於感染和形成結石，而發生於梗阻的感染則可加速對腎臟的破壞。

Treatment

治療

The aim of therapy is relief of the obstruction(eg， catheterization for relief of acute urinary retention)。 Surgery is often necessary. Simple urethral stricture may be managed conservatively by dilation or urethrotomy. However， urethroplasty may be required. Benign prostatic hypertrophy and obstructing bladder tumors require surgical removal.

治療的目的在於解除梗阻(例如：上導尿管以解除急性尿瀦留)。常常需要外科治療。單純尿道狹窄可用尿道擴張及尿道切開等保守法治療，但有時需行尿道成形術。良性前列腺增生及阻塞性膀胱腫瘤需外科切除。

Impacted stones must either be removed or bypassed by a catheter if it is thought that they may pass spontaneously. If they do not pass spontaneously， the stones must be removed surgically later.

嵌頓性結石必須取石;如認爲結石可能自行排出，亦可經旁道置管。如不能自行排出，以後必須手術取石。

Ureteral or ureteropelvic junction obstruction requires surgical revision and plastic repair， either by ureterovesicoplasty， ureteroureteral anastomosis， bladder flaps to bridge a gap in the lower ureter， transureteroureteral anastomosis or ureteropyeloplasty. Penal stones may be removed instrumentally via percutaneous nephrostomy or by irrigation through a tube placed directly into the kidney.

輸尿道或腎盂輸尿管交界梗阻需行手術矯正或行整形修補;輸尿管膀胱成形術，輸尿管輸尿管吻合術，或輸尿管腎盂成形術。在下段輸尿管則可用膀胱瓣作搭橋填補缺損。腎結石可通過皮穿器械摘除，或者經皮穿刺腎造瘻或經腎直接置管進行沖洗。

Preliminary drainage above the obstruction is sometimes needed to improve kidney function. Occasionally， permanent drainage and diversion by cutaneous ureterostomy， ileal or colonic loop diversion， or permanent nephrostomy is required. If damage is advanced， nephrectomy may be indieated.

有時爲改善腎功能可先在梗阻上方置管引流，有時需作永久性引流，輸尿管皮膚造口尿流改道術，迴腸或結腸改道或永久性腎造口等。如損害加重，可通適用腎切除。

Prognosis

預後

The prognosis depends on the cause， site， duration， and degree of kidney damage and renal decompensation. In general， relief of obstruction leads to improvement in kidney function except in seriously damaged kidneys， especially those destroyed by inflammatory scarring.

預後取決於原因，位置，病程及腎臟損害和腎臟失償程度。一般來說，解除梗阻可使腎功能改善，除非腎臟嚴重受損，尤其是炎性疤痕所破壞的。