Is vesicoamniotic shunt for complete urinary tract obstruction is partially effective?

目的：儿童梗阻性尿路病变产前干预后的长期结果令人失望。我们报告了在胎羊模型中，梗阻3周后肾脏发育不良的改变。我们使用这个模型来研究胎儿干预后的肾脏发育和膀胱功能。方法：我们通过结扎尿路和脐尿管建立了妊娠60天胎羊的梗阻性泌尿系疾病模型。21天后行膀胱造瘘术(女性)或尿路造口术(男性)。在足月(145天)时处死胎儿并测量其膀胱容量。对尿路进行组织学检查。结果：40例胎儿发生梗阻性尿路病变。其中11人流产或死产。29例存活，24例成功分流小膀胱(8±5毫升)，对照组(71±19毫升)，P&lt；0.05。分流膀胱的依从性很差。组织学上可见黏膜下结缔组织增厚，肌肉肥大。肾组织的组织学显示相对保存良好的肾脏结构，9只羔羊的肾单位质量减少(少肾)，3只小羊的多囊性发育不良改变(MCDK)。13例(54%)肾功能正常或肾盂轻度扩张为肾积水。结论：在我们的模型中，梗阻性尿路疾病后的分流手术不能保留膀胱功能。分流术改善了囊性语言障碍的发展，但有一半的羔羊出现了少肾或MCDK。这些患者在以后的生活中可能会发展为肾功能衰竭，但54%的患者在分流术后有正常的肾脏生成。

Purpose : The long-term outcome for children after antenatal intervention for obstructive uropathy is disappointing. We reported that renal dysplastic changes are well-established 3 weeks after obstruction in a fetal lamb model. We used this model to explore renal development and bladder function after fetal intervention.Methods : We created an obstructive uropathy in fetal lambs at 60 days gestation by legating the urethra and urachus. A vesicostomy (female) or urethrostomy (male) were performed 21 days later. The fetuses were sacrificed at term (145 days) and bladder volume and were measured. The urinary tract was processed for histological examination.Results : Forty fetuses created an obstructive uropathy. Eleven miscarried or were stillborn. Twenty-nine survived and twenty-four had a successful shunt with a small bladder (8±5ml) compared to controls (71±19ml), p<0.05. Shunted bladders had poor compliance. Histologically, they had thickened sub mucosal connective tissue with hypertrophied muscle. Histology of the renal tissue demonstrated relatively well-preserved renal architecture with reduced nephrons mass (oligonephronia) in nine lambs and multicystic dysplastic change (MCDK) in three. Thirteen (54%) had normal nephrogenesis or slightly dilated pelvis as a Hydronephrosis.Conclusions : In our model, shunt operations after obstructive uropathy fail to preserve bladder function. Shunting ameliorated the development of cystic dysphasia but half of the lambs had oligonephronia or MCDK. These might develop renal failure later in life but 54% had normal nephrogenesis after shunting.