标题 | 盆腔脂肪增多症两例报告 |
范文 | 张勇?刘君昌?高小林?姜泰茂 【摘要】盆腔脂肪增多癥(PL)指盆腔脂肪组织过度增生,盆腔脂肪组织包绕并压迫周围器官,使之形状和位置发生改变,导致泌尿系统及下消化道发生梗阻,从而产生一系列临床症状。该文回顾性分析2例PL患者的临床资料,2例患者均因尿频、尿急为主诉就诊,经影像学检查确诊为PL。例1年轻患者临床症状较重,早期行膀胱镜检查取病理组织提示腺性膀胱炎,给予膀胱灌注治疗,后期患者临床症状加重,行经尿道腺性膀胱炎电切+盆腔脂肪清除术+双侧输尿管膀胱再植术,术后随访肾盂输尿管积水较术前明显减轻,远期效果满意。例2老年患者临床症状较轻且身体状况欠佳,给予保守治疗,随访1年,双肾输尿管积水未见明显减轻,症状略缓解。该2例的诊治过程提示,PL的影像学检查有其特征性的表现,对于病情进展缓慢且肾功能良好的患者可定期随访观察,对于年龄较大或身体条件不允许的患者可考虑行尿流改造术改善症状。对于病情重的年轻患者应以解除梗阻症状、改善患者生活质量为目的,解除盆腔脂肪对膀胱、输尿管及结直肠的压迫,改善尿路梗阻造成的严重肾积水甚至肾衰竭及消化道症状。 【关键词】盆腔脂肪增多症;肾积水;尿路梗阻 Pelvic lipomatosis: report of two cases Zhang Yong, Liu Junchang, Gao Xiaolin, Jiang Taimao. Department of Urology, Air Force Hospital of the Northern Theater of the Chinese Peoples Liberation Army, Shenyang 110042, China Corresponding author, Jiang Taimao, E-mail: shenyang463@ vip. sina. com 【Abstract】Pelvic lipomatosis (PL) is an overgrowth of pelvic adipose tissue, which surrounds and compresses the surrounding organs and changes its shape and position, resulting in obstruction of urinary system and lower digestive tract, thus a series of clinical symptoms. In this article, clinical data of 2 cases of PL was retrospectively analyzed. Two patients were admitted to our hospital due to the chief complaint of urine frequency and urgency, and diagnosed with PL by imaging examination. Case 1 was a young patient with severe clinical symptoms. Preliminary cystoscopy combined with pathological examination prompted the signs of glandular cystitis, and bladder perfusion treatment was delivered. In the late stage, relevant clinical symptoms of this patient were aggravated, and the patient underwent transurethral cystitis glandular resection + pelvic fat removal + bilateral ureterovesical replantation. Postoperative follow-up revealed that hydronephrosis was significantly relieved after surgery. The long-term results were satisfactory. Case 2 was an elderly patient presented with mild clinical symptoms and poor physical condition. Conservative treatment was given. The patient was followed up for 1 year, and the hydroureter of bilateral kidneys was not significantly alleviated, whereas relevant symptoms were slightly mitigated. These two cases prompted that PL is characterized with unique imaging features. Patients with slow progression and normal kidney function can be followed up on a regular basis. For elderly patients with poor physical conditions, urological modification surgery is recommended to improve relevant symptoms. For young patients with severe disease, it is of significance to relieve the obstruction symptoms, improve the quality of life, reduce the compression of pelvic fat on bladder, ureter and colorectal, and mitigate the symptoms of severe hydroureter and even renal failure or digestive tract symptoms caused by urinary tract obstruction. 【Key words】Pelvic lipomatosis;Hydronephrosis;Urinary tract obstruction 盆腔脂肪增多症(PL)指盆腔脂肪组织过度增生,盆腔脂肪组织包绕并压迫周围器官,使之形状和位置发生改变,导致泌尿系统及下消化道发生梗阻,从而产生一系列临床症状。PL在临床较为少见,病因尚不明确。目前全球已报道的PL病例少于150例,且大多为个案报告[1]。临床医师若对PL认识不足,容易漏诊误诊。目前有关PL的诊治尚未有共识。近年我科收治2例PL患者,现结合文献对其临床特征及治疗方式讨论如下。 病例资料 一、病例1 1. 病史与体格检查 患者男,30岁。因尿频、尿急2月余,发现双肾积水8 d于2017年5月16日入院。患者2个月来每日尿12 ~ 16次,夜尿6 ~ 8次。2017年5月8日在外院行彩色多普勒超声(彩超)检查,结果示双肾积液、膀胱壁增厚、双侧肾盂输尿管扩张、输尿管末段变窄;尿液分析提示尿比重低,渗透压低。患者既往有高血压史多年,血压最高达180/110 mm Hg(1 mm Hg = 0.133 kPa),规律服用替米沙坦控制血压。 入院体格检查:体温36.2℃,脉搏86次/分,呼吸18次/分,血压186/123 mm Hg。一般情况可,发育正常,BMI 29.3 kg/m2。皮肤、黏膜无黄染,浅表淋巴结未触及。头颈部发育正常,心肺听诊无异常,腹软无压痛,肝脾肋下未扪及。四肢关节无畸形,生理反射存在,病理反射未引出。专科检查:双肾区对称,双侧输尿管区未触及肿物,无触痛,膀胱区无充盈,无触痛,外生殖器未见明显异常。 2. 实验室及辅助检查 血常规示血红蛋白121 g/L,红细胞4.5×109/L,白细胞5.9×109/L,中性粒细胞0.66,淋巴细胞0.34,血小板232×109/L。生化检查示白蛋白44.7 g/L,ALT 21 U/L,AST 15 U/L,血尿素氮3.23 mmol/L,血清肌酐110 μmol/L,血钾4.42 mmol/L,血钠145mmol/L,血氯104 mmol/L。 CT+ CT尿路造影(2017年5月16日)示双侧肾盂、输尿管扩张积水;右侧输尿管上段迂曲,迂曲处略窄,膀胱受压变形、移位及上抬,呈“泪滴状”或“倒梨形”,膀胱周围脂肪间隙密度增高、模糊,见图1。 3. 诊治过程 予患者膀胱镜检查+留置双J管,进镜时可见后尿道明显拉伸延长,镜体勉强能够进入,见膀胱内口周围大范围滤泡样改变,膀胱壁凹凸不規则,表面无坏死及钙化,可见明显膀胱小梁。钳取部分组织,病理提示腺性膀胱炎。术后第4、11 d,给予羟喜树碱膀胱灌注。治疗后彩超检查示患者双肾及输尿管积液减轻,予出院,嘱继续膀胱灌注每周1次(连续10次)。2017年10月患者尿频、尿急症状加重,伴排尿困难并腰部酸胀,彩超检查示:左肾可见8.3 cm×4.5 cm的液性暗区,右肾可见7.9 cm×3.6 cm的液性暗区,左侧输尿管上段宽1.6 cm,右侧输尿管上段宽1.0 cm。 MRI(2017年10月12日)示膀胱形态欠规则,膀胱壁增厚显著,厚约2.5 cm,累及双侧输尿管膀胱壁内段,双侧输尿管盆段及部分腹段扩张、积液,尿道前列腺部增宽。膀胱周围脂肪间隙见多发条索状、斑片状长T1长T2信号,压脂像呈高信号,见图2。血清肌酐133 μmol/L(参考值范围40 ~ 120 μmol/L)。考虑患者尿频加重伴排尿困难,输尿管扭曲梗阻并出现肾功能受损,给予患者行经尿道腺性膀胱炎电切术+输尿管膀胱再植术,经尿道电切将膀胱滤泡样组织完整切除至肌层。后腹部切开口(输尿管再植),逐层分离,可见盆腔内布满脂肪组织,与盆腔周围脏器粘连严重,界限不清晰。仔细分离并清除盆腔部分脂肪组织,找到双侧输尿管,可见周围脂肪浸润压迫双侧输尿管,末端管壁扩张,左、右侧直径约1.5、1.0 cm,蠕动弱,远端粘连严重,予以切断结扎,取膀胱左右侧前壁,切开长约2 cm,更换输尿管双J管,并与膀胱吻合。于膀胱前壁留置膀胱造瘘管备用。术后病理提示成熟脂肪组织,腺性膀胱炎。术后1周患者恢复良好,予出院。随访至撰稿日,患者双肾输尿管积水扩张、尿路刺激症状好转,肾功能指标均正常,效果满意。 二、病例2 1. 病史与体格检查 患者男,64岁。因尿频、尿急、排尿困难、大便不畅2个月于2018年8月14日收入院。患者诉近日来日尿及夜尿明显增多,且伴排尿困难及便秘两个月。既往BPH史2年,规律口服药物非那雄胺和坦索罗辛。 体格检查:体温36.5℃,脉搏76次/分,呼吸18次/分,血压136/83 mm Hg(1 mm Hg = 0.133 kPa)。一般情况可,发育正常,BMI 28.9 kg/m2。皮肤黏膜无黄染,浅表淋巴结未触及。专科检查:双肾区对称,双侧输尿管区未触及肿物,无触痛,膀胱区无充盈,无触痛,外生殖器未见明显异常。直肠指诊:可触摸到盆腔内肿物,前列腺位置后延,不容易触及。 2. 实验室及辅助检查 血常规示血红蛋白134 g/L,红细胞4.4×109/L, 白细胞8.0×109/L,中性粒细胞0.68,淋巴细胞0.32,血小板262×109/L。生化检查示白蛋白43.7 g/L,ALT 14 U/L,AST 12 U/L,血尿素氮5.03 mmol/L,血清肌酐112 μmol/L,血钾4.04 mmol/L,血钠144 mmol/L,血氯103 mmol/L。 泌尿系统彩超示BPH,膀胱位置及形状发生改变、周围均匀强回声,双侧肾盂输尿管扩张积水。CT示盆腔内大量低密度脂肪影,肾盂及输尿管上段扩张积水,膀胱有不同程度受压、变形,呈“倒梨形”或“泪滴状”,见图3A、B。盆腔MRI平扫:膀胱充盈可,膀胱壁显著增厚,膀胱及直肠周围充满大量脂肪组织,T1加权像为高信号,T2加权像为中等稍高信号。矢状位见膀胱受压扁平,直肠-乙状结肠受压变窄,见图3C、D。 [3] 王晓庆, 王慕文. 盆腔脂肪增多症. 泌尿外科杂志? (电子版), 2015, 7(3): 55-57. [4] 刘喆,欧阳骏. 盆腔脂肪增多症的诊断和治疗. 临床泌尿外科杂志,2013, 28(1):13-15. [5] Sun Y, Wang J, Chiang M, Li H, Liu JB, Wang S. Value of multimode sonography for assessment of pelvic lipomatosis compared with computed tomography. J Ultrasound Med, 2016, 35(6):1143-1148. [6] Chen Y, Yang Y, Yu W, Xiao Y, Fan Y, Duan J, Tang Y, Jin J, Wang H, Wang H, Zhu S, Xi Z, Wu S. Urodynamic characteristics of pelvic lipomatosis with glandular cystitis patients correlate with morphologic alterations of the urinary system and disease severity. Neurourol Urodyn, 2018, 37(2):758-767. [7] 方露, 于德新, 王毅, 謝栋栋, 毕良宽, 陈磊, 邹慈, 张涛, 闵捷. 腹腔镜手术治疗盆腔脂肪增多症1例报告并文献复习. 临床泌尿外科杂志, 2016, 31(7):660-662. [8] Kotidis E, Stamatiou I, Ioannidis O, Pramateftakis MG, Kanellos I, Tsalis K. Laparoscopic resection of large pelvic lipoma causing obstructive uropathy in a 66 year old female - A case report from Greece. J Pak Med Assoc, 2018, 68(9):1400-1402. [9] 谷亚明. 经皮肾穿刺双侧输尿管支架植入术治疗盆腔脂肪增多症伴急性肾衰(附1例报告并文献复习). 临床和实验医学杂志, 2013, 12(10):763-765. [10] Baas W, OConnor B, El-Zawahry A. Bilateral hydronephrosis and acute kidney injury secondary to pelvis lipomatosis. Can J Urol, 2018, 25(1):9217-9219. (收稿日期:2020-08-23) (本文编辑:林燕薇) |
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