KHO ST CHN ON V THI X TR

CC D TT BM SINH NG TIT NIU TRN

Nguyn Khoa Hng, Trng Quang Bnh, L nh Khnh, Nguyn Vn Thun, Phm
Ngc Hng, Trng Vn Cn, Cao Xun Thnh, L nh m, Hong Vn Tng

TM TT
Mc tiu: Kho st c im lm sng, cn lm sng v thi x tr cc d tt bm
sinh ng tit niu trn. i tng v phng php nghin cu: 123 bnh nhn b d tt
bm sinh ng niu trn (142 n v thn) c chn on v iu tr ti Bnh vin Trung
ng Hu v Bnh vin Trng i hc Y Dc Hu t thng 2/2012 n thng 5/2014. Kt
qu: 123 bnh nhn, t l nam/n = 1,6/1; tui trung bnh l 18,63 20,43. 14 (11,4%)
trng hp chn on trc sinh bng siu m trong thai k. Bnh l khc ni b thn-niu
qun chim a s vi 83 n v thn (58,4%) n thun hay kt hp vi cc d tt khc. 115
d tt (81,0%) c phu thut, cc trng hp cn li c theo di nh k. Kt lun: Cc
xt nghim chn on hnh nh, c bit l siu m trc sinh gip chn on sm d tt bm
sinh ng tit niu trn. Ch nh iu tr ph thuc vo bin chng ca d tt.
ABSTRACT
INVESTIGATION OF STATE AND MANAGEMENT OF
CONGENITAL UPPER URINARY TRACT ABNORMALITIES
Purpose: To investigate the clinical, subclinical characteristis and management of
congenital upper urinary tract abnormalities. Materials and methods: 123 patients (142
kidneys) with congenital upper urinary tract abnormalities at Hue Central Hospital and Hue
University Hospital from 2/2012 to 5/2014. Results: 123 patients, sex ratio was 1,6 male(s)/1
female; mean age of 18,63 20,43. 14 (11,4%) cases diagnosed by prenatal ultrasound.
Pelvi-ureteric junction obstruction was more predominantly affected with 83 kidneys
(58,4%), simple or combined with another congenital abnormalities. Surgical treatment in
115 abnormalities (81,0%), medical treatment in another cases. Conclusion: Diagnostic
imaging, especially prenatal ultrasound helps to detect early the congenital upper urinary tract
abnormalities. Indication of treatments depends on the complications of abnormalities.

T VN
D tt bm sinh ng tit niu trn l mt nhm bnh l quan trng trong bnh
hc ngoi khoa tr em. Cc d tt ng tit niu trn c biu hin lm sng rt a
dng v tin lng tt nu c chn on v iu tr sm. Trn th gii trong nhng
nm gn y c rt nhiu tin b trong chn on v iu tr cc d tt bm sinh
ng tit niu trn. Cc phng tin chn on hnh nh hin i, c bit l siu m
trc sinh gip chn on c cc d tt giai on rt sm, v vy c th ch
ng hoch nh k hoch iu tr. Nhiu phng php phu thut mi lin tc c
nghin cu v p dng gp phn cu sng v ci thin ng k cht lng sng ca
nhiu bnh nhn. nc ta hin nay do nhiu l do khc nhau, cc d tt bm sinh
ng tit niu ni chung v ng tit niu trn ni ring vn cn c chn on
mun, nhiu bnh nhn vo vin trong giai on c bin chng. a s bnh nhn
c phu thut trong giai on mun, v vy kt qu hn ch v c phng din chc
nng v tm sinh l [5]. Ti BVTW Hu v BV Trng HYD Hu c mt s
I.

ti nghin cu v d tt bm sinh h tit niu ring bit nh bnh l khc ni b thn

niu qun [3], tinh hon lc ch, d tt l i thp, nhng cha c nghin cu no nh
gi mt cch tng th cc d tt bm sinh ca ng tit niu trn. V vy, chng ti
tin hnh ti ny nhm mc tiu kho st c im hnh thi lm sng, cn lm
sng v thi x tr cc d tt bm sinh ng tit niu trn c chn on v iu
tr ti c s ca chng ti.
II. I TNG V PHNG PHP NGHIN CU
i tng nghin cu l 123 bnh nhn b d tt bm sinh ng tit niu trn
c chn on v iu tr ti BVTW Hu v BV Trng HYD Hu t thng
2/2012 n thng 5/2014.
Cc d liu nghin cu bao gm: Nghin cu c im chung (tui, gii),
cc c im lm sng ca d tt bm sinh ng tit niu trn (L do vo vin: au
tht lng, st, nhim khun niu, i mu, pht hin tnh c d tt bm sinh qua cc
xt nghim chn on hnh nh), cc c im v chn on hnh nh d tt bm
sinh (siu m, KUB, UIV, CT Scan): mc nc thn, cc bin chng do d tt
gy nn (nhim khun, si, gim chc nng thn); chn on loi d tt v thi
x tr cc d tt bm sinh.
III. KT QU NGHIN CU
1.1. Mt s c im chung: T thng 2/2012 n thng 5/2014 c 123 bnh nhn
b d tt bm sinh ng niu trn (vi 142 n v thn) c chn on v iu tr ti
Bnh vin Trung ng Hu v Bnh vin Trng i hc Y Dc Hu. Trong ,
nam c 75 chim 61,0%; t l nam/n = 1,6/1; tui trung bnh ca cc bnh nhn l
18,6 20,4 tui (nh nht 1 ngy tui, ln nht 75 tui). 72,4% s bnh nhn sng
nng thn.
V hon cnh pht hin bnh, trong 123 bnh nhn c 14 trng hp c chn
on mc d tt bm sinh ng niu trn trc sinh bng siu m nh k trong thai
k i vi ngi m mang thai, chim 11,4%; cn li l cc trng hp vo vin v
nhiu l do khc nhau (Bng 1)
Bng 1: L do vo vin
L do vo vin
Siu m thai trc sinh
Tnh c khm, siu m
St n thun
au hng lng
Nhim khun niu
Khi g vng bng
Tiu kh, b tiu
Tiu khng t ch
Tiu mu
Tng

S bnh nhn
8
24
4
64
11
6
2
3
1
123

T l (%)
6,5
19,5
3,3
52,0
8,9
4,9
1,6
2,4
0,8
100

V c im lm sng, a s cc bnh nhn c au vng hng cng bn vi d

tt bm sinh (68 trng hp, chim 55,7%). C 30 trng hp pht hin thy thn ln
(32/142 n v thn, chim 22,5%) (Bng 2)
Bng 2: c im lm sng
c im lm sng
St

S bnh nhn
23

T l (%)
18,7

Bun nn, nn
au hng, bng
Tiu but, tiu rt
Tiu c
Tiu mu
Tiu KKS
Tiu kh, b tiu
Thn ln

9
68
21
15
4
8
3
32/142

7,3
55,7
17,1
12,2
3,3
6,5
2,4
22,5

V cc c im chn on hnh nh, 123 bnh nhn c lm cc xt

nghim nh siu m bng, chp KUB, UIV v CT Scan niu. Cc xt nghim ny
gip chn on v tr bn b d tt, mc nc, bin chng si niu(Bng 3, 4, 5)
Bng 3: V tr bn d tt
V tr d tt
Tri
Phi
Hai bn
Tng

S bnh nhn
68
36
19
123

T l (%)
55,3
29,3
15,4
100

Bng 4: Bin chng nc thn ti thn v gin niu qun trn SA, UIV
Phn nc
Khng nc
1
2
3
Tng

S n v thn
24
35
46
37
142

T l (%)
16,9
24,6
32,4
26,1
100

V chc nng thn nh gi qua UIV (n=104 n v thn), 99 trng hp chc

nng thn cn bo tn (chim 95,2%); c 5 trng hp thn khng ngm thuc cn
quang (chim 4,8%). V bin chng c si niu, c 18/142 n v thn c si niu (si
thn, si niu qun), chim 12,7 %.
Cc xt nghim chn on hnh nh cho php chn on cc d tt c trnh
by cc bng 5, 6, 7.
Bng 5: Cc d tt bm sinh chn on bng siu m bng
D tt bm sinh
BLKNBTNQ
NQHT
NQKHT
NQHT + NQCLC
PTNQTP do tc
TNBQNQ
TSNQ
Khng chn on
Tng

S n v thn
42
8
3
1
9
5
9
65
142

T l (%)
29,6
5,6
2,1
0,7
6,3
3,5
6,3
45,8
100

(Ghi ch: BLKNBTNQ: Bnh l khc ni b thn-niu qun, NQHT: Niu qun i hon ton, NQKHT:
Niu qun i khng hon ton, NQCLC: Niu qun cm lc ch, PTNQTP: Phnh to niu qun tin pht,
TNBQNQ: Tro ngc bng quang - niu qun, TSNQ: Ti sa niu qun, NQSTMC: Niu qun sau tnh mch
ch di)

Bng 6: Cc d tt bm sinh chn on bng UIV

D tt bm sinh
BLKNBTNQ
NQHT
NQKHT
NQHT + TSNQ
PTNQTP do tc
TNBQNQ
TSNQ
NQSTMC
Khng chn on
Tng

S n v thn
56
5
7
2
8
3
6
2
15
104

T l (%)
53,8
4,8
6,7
1,9
7,7
2,9
5,8
1,9
14,4
100

(Ghi ch: BLKNBTNQ: Bnh l khc ni b thn-niu qun, NQHT: Niu qun i hon ton, NQKHT:
Niu qun i khng hon ton, NQCLC: Niu qun cm lc ch, PTNQTP: Phnh to niu qun tin pht,
TNBQNQ: Tro ngc bng quang - niu qun, TSNQ: Ti sa niu qun, NQSTMC: Niu qun sau tnh mch
ch di)

Bng 7: Cc d tt bm sinh chn on bng CT Scan

D tt bm sinh
BLKNBTNQ
BLKNBTNQ + PTNQTP do tc
NQHT
NQKHT
NQHT + NQCLC
NQHT + TSNQ
PTNQTP do tc
TSNQ
TSNQ + PTNQTP do tc
NQSTMC
Tng

S n v thn
28
1
7
4
5
2
3
1
1
1
53

T l (%)
52,8
1,9
13,2
7,5
9,4
3,8
5,7
1,9
1,9
1,9
100

(Ghi ch: BLKNBTNQ: Bnh l khc ni b thn-niu qun, NQHT: Niu qun i hon ton, NQKHT:
Niu qun i khng hon ton, NQCLC: Niu qun cm lc ch, PTNQTP: Phnh to niu qun tin pht,
TNBQNQ: Tro ngc bng quang - niu qun, TSNQ: Ti sa niu qun, NQSTMC: Niu qun sau tnh mch
ch di)

Chn on d tt cui cng kt hp chn on hnh nh v nh gi trong m

c trnh by bng 8; trong bnh l khc ni b thn-niu qun chim a s vi
83 n v thn, chim 58,4%, n thun hay kt hp vi cc d tt khc.
Bng 8:Cc hnh thi d tt bm sinh ng niu
D tt bm sinh
BLKNBTNQ
BLKNBTNQ + PTNQTP do tc
NQHT
NQKHT
NQHT + NQCLC
NQHT + TSNQ
NQHT + NQCLC + TSNQ
NQKHT + PTNQTP do tc

S n v thn
80
1
4
13
9
3
1
1

T l (%)
56,3
0,7
2,8
9,2
6,3
2,1
0,7
0,7

NQKHT + BLKNBTNQ n v di

1,4

NQCLC
PTNQTP do tc
TNBQNQ
TSNQ
TSNQ + PTNQTP do tc
NQSTMC
Tng

2
9
6
8
1
2
142

1,4
6,3
4,2
5,6
0,7
1,4
100

(Ghi ch: BLKNBTNQ: Bnh l khc ni b thn-niu qun, NQHT: Niu qun i hon ton, NQKHT:
Niu qun i khng hon ton, NQCLC: Niu qun cm lc ch, PTNQTP: Phnh to niu qun tin pht,
TNBQNQ: Tro ngc bng quang - niu qun, TSNQ: Ti sa niu qun, NQSTMC: Niu qun sau tnh mch
ch di)

V thi x tr, c 115/142 d dng c phu thut, chim 81,0%. Cc

trng hp cn li c theo di nh k. Cc phng php phu thut c trnh by
trong bng 9.
Bng 9: Cc phng php phu thut iu tr d tt bm sinh ng niu
Phng php
To hnh b thn
To hnh b thn + ly si
Gii phng niu qun + ly si
X on hp ni soi
Cm li niu qun
To hnh niu qun
Ct thn mt chc nng
Ct cc thn mt chc nng
Ct chm ti sa
Ct chm ti sa + cm li niu qun
Tng

S n v thn
57
8
1
1
21
2
3
11
9
2
115

T l (%)
49,6
7,0
0,9
0,9
18,3
1,7
2,6
9,6
7,8
1,7
100

IV. BN LUN
Cc d dng bm sinh ng tit niu trn c gio khoa kinh in ca Niu
nhi lm sng gp chung vo mt bnh cnh chung, l bnh l ng niu do tc
nghn (obstructive uropathy), do cc tn thng sm mun cng s dn n tc
nghn, gy nn tnh trng gin pha bn trn (gin i thn, b thn, niu qun) [9].
Trn lm sng, chn on tnh trng gin ng niu trn do cc d tt bm sinh ngay
ti ng niu trn hay do tro ngc bng quang niu qun (tin pht hay mc phi
do tc nghn ti bng quang) lun c t ra, t c thi x tr chnh xc nhm
bo v cho chc nng ca thn bn b bnh.
1. V hon cnh pht hin bnh: Trc y, vic pht hin cc d tt ng
tit niu thng mun do biu hin lm sng m h, khng r rng. Ngy nay, nh s
ph bin ca siu m, mt s trng hp c pht hin khi cha c triu chng,
thm ch trc sinh [1], [3], [4], [7]. Trong nghin cu ny, 19,5% cc trng hp tnh
c pht hin c nh siu m bng. C 11,4% pht hin khi siu m thai k. Nh
vy, c ti 30,9% pht hin bnh nh siu m. iu chng t bnh c th c
chn on rt sm khi cha c triu chng lm sng hay ngay c khi cn trong bo
thai, to iu kin thun li tip cn theo di v iu tr sm. Tuy nhin, c bnh
nhn 75 tui mi pht hin ra d tt, gy nh hng nhiu n thn bnh.
2. Cc xt nghim chn on hnh nh gip chn on d tt: Nhiu
phng tin chn on hnh nh c gi tr trong chn on d tt bm sinh ng tit
niu trn. Trong , siu m tin tin c ch nh rng ri, c xem l phng tin

rt c gi tr khng ch gip chn on sm m cn s dng theo di v nh gi

sau phu thut. Siu m c u im l mt k thut n gin, khng xm nhp, v hi,
v c th lp li nhiu ln ph hp vi bnh nhi. c bit, siu m c th pht hin cc
di tt ngay t thi k bo thai. Trong nghin cu ny, chng ti dng siu m nh
gi mc nc thn v chn on d tt theo siu m. Kt qu chn on c d
tt l 54,2%.
UIV l mt xt nghim hnh nh kinh in v c bn nh gi cc tc nghn
ng tit niu v cc d tt ng tit niu. Khi nh gi vai tr ca UIV v siu m
trong chn on, theo di iu tr, nhiu tc gi cho rng UIV vn l phng tin c
tin cy cao hn, mc d k thut siu m tin b rt nhiu v c xem l
phng tin an ton, hiu qu, c chp nhn ca a s bnh nhn tr em. Trong khi
, UIV cng c nhng hn ch nht nh, kh nh gi chnh xc trong cc trng
hp suy thn nng v c th xy ra mt s tai bin khi tim thuc cn quang. Trong
nghin cu ny, chn on d tt theo UIV cho kt qu 85,6% (89/104).
3. Cc hnh thi d tt c chn on: Rt a dng, trong nghin cu ny,
loi d dng thng gp nht l bnh l khc ni b thn niu qun (BLKNBTNQ), c
th n thun hoc kt hp vi cc d tt khc, chim tng s 58,4% cc trng hp.
iu cng ph hp vi a s cc nghin cu trn th gii. Vic s dng rng ri
siu m trong thai k gip chn on sm bnh l ny ngay khi cn trong bo thai,
vi t l 1/800-1500 ph n c thai [10]. Nu khng chn on trc sinh, bnh l
ny s biu hin trn lm sng vi nhim khun niu tr em (vi cc biu hin au
bng, st), khi u bng. Theo Bryan (1975) [10], 50% cc khi u bng tr em
l c ngun gc t thn v 40% trong s l do thn nc v BLKNBTNQ. Chn
on c da trn siu m (vi hnh nh b thn gin, niu qun khng kho st
c) hoc UIV (b thn gin rng niu qun mnh mai)Trong nghin cu ny,
niu qun tch i hon ton hay khng hon ton ng hng th hai, 21,8%, v 50%
trong s (11,2% tng s cc d dng trong nghin cu ny) c kt hp thm cc bt
thng khc nh niu qun cm lc ch, ti sa niu qun...iu ny l ph hp vi y
vn. Cc loi d dng khc (tro ngc bng quang-niu qun tin pht, phnh niu
qun do tc) chim cc t l thp hn, t di 1 n 2-3%.
4. V thi x tr: Ty thuc loi d dng cng nh bin chng ca n gy
ra m c thi x tr khc nhau. i vi BLKNBTNQ, phu thut to hnh b thn
theo Anderson Hynes (m m hay m ni soi bng ng sau phc mc) c p
dng cho tt c cc trng hp. Cc trng hp bt thng ca niu qun c x tr
bng cch cm li niu qun vo bng quang c hay khng to hnh li niu qun ty
thuc trng hp. Cc trng hp bin chng c si th vic ly si l tin quyt, sau
to hnh li ng niu. C 12,2% cc trng hp phi ct ton b thn hoc ct
phn thn c d dng do mt chc nng, iu ny chng t bnh nhn c chn on
mun. i vi cc trng hp ti sa niu qun, phng php iu thng c p
dng l ct m ti sa bng laser qua soi bang quang, an ton v hiu qu.
V. KT LUN
Bnh l d tt bm sinh ng niu trn rt a dng, n thun hoc phi hp.
Chn on hnh nh (siu m, chp niu tnh mch, chp ct lp vi tnh) l nhng
phng php cho php chn on cc d dng ny ng thi nh gi cc bin chng
gy nn. iu tr bo tn c cho l an ton nu bnh nhn c theo di cht ch.
iu tr bo tn c ch nh cho cc trng hp: khng c triu chng lm sng,

thn cha nc hoc nc nh, chc nng thn khng gim, kim sot nhim
trng niu hiu qu. Phu thut em li kt qu tt trong hu ht cc trng hp.
TI LIU THAM KHO
1. Hi tit niu-thn hc Vit Nam (2007), D tt bm sinh h tit niu-sinh dc, Bnh
hc tit niu, tr. 485-532.
2.

Nguyn Thanh Lim (2002), Phu thut tit niu tr em, Nh xut bn Y hc, H Ni.

3. Carr MC, Casale P (2012), Anomalies and surgery of the ureter in children,
Campbell-Walsh urology, pp. 3212-3235.
4. Kubo T, Kawamura S (1992), Anatomy and function of the upper urinary tract,
Nihon Hinyokika Gakkai Zasshi, 83(11), pp. 1759-66.
5. Mure PY, Mouriquand P (2008), Upper urinary tract dilatation: prenatal diagnosis,
management and outcome, Semin Fetal Neonatal Med, 13(3), pp. 152-63.
6. Peters CA et al. (2012), Congenital urinary obstruction: pathophysiology and clinical
evaluation, Campbell-Walsh Urology, pp. 3028-3047.
7. Peters CA et al. (2012), Ectopic ureter, ureterocele, and ureteral anomalies, CampbellWalsh Urology, pp. 3236-3266.
8. Traubici J, Lim R (2008), Imaging the Pediatric Urinary Tract, Comprehensive
Pediatric Nephrology, pp. 1-38.
9. Weiss MR (1992), Obstructive Uropathy: pathophysiology and diagnosis, Clinical
Pediatric Urology, edited by Kelalis PP, King LR, Belmann AB, 3th edition, WB Saunders
Company; Philadelphia, London, Toronto, Montreal, Sydney, Tokyo, Volume 2, pp.664-682.
10. Flashner SC, King LR (1992), Obstructive Uropathy: ureteropelvic junction, Clinical
Pediatric Urology, edited by Kelalis PP, King LR, Belmann AB, 3th edition, WB Saunders
Company; Philadelphia, London, Toronto, Montreal, Sydney, Tokyo, Volume 2, pp.693-725.