🔙 Quay lại trang tải sách pdf ebook Phẫu thuật tiết niệu trẻ em Ebooks Nhóm Zalo TS. NGUYEN THANH LIEM PHfiU THU6T TIET NIECI TRE EM n h a x u a t b a n y h o c PHfkl THU6T TIET NIEU TRE EM TS. N G U Y tN THANH U €M PHfitl THUflT TIET NIEU ■ TRE EM n h A xu tfr b An v h o c HA N § l - 2002 LCfl N O I D A U Benh hoc tiet nieu ma chu yeu la cac di tat ducmg tiet nieu la mot nhom benh If quan trong trong benh hoc ngoai khoa tre em. Cac di tat duong tiet nieu co bieu hien lam sang rat da dang va co tien lircmg tot neu duoc chan doan va dieu tri sdm. Tren the giai trong nhQng nam gan day da co rat nhidu tien bo trong chan doan va dieu tri cac di tat nay. Cac phucrng phap chan doan hinh anh hien dai dac biet la sieu am truoc sinh da giup chan doan duoc cac dj tat tiet nieu o giai doan rat som va vi vay co the chu dong hoach dinh ke hoach dieu tri. Nhieu phuong phap phau thuat moi lien tuc duoc nghien cuu va ap dung da gop phan ciru song va cai thien dang ke chat luong song cua nhieu benh nhan. O niroc ta hien nay do nhieu If do khac nhau, cac benh duong tiet nieu van con duoc chan doan muon, nhieu benh nhan den vien trong giai doan suy than. Da so benh nhan duoc phau thuat trong giai doan muon, vi vay ket qua han che ve ca phuong dien chuc nang va tam sinh If. Cuon “Phiu thuat tiet nieu tre e m ” duoc bien soan voi mong muon giup cac ban dong nghiep, nhat la cac dong nghiep d cac tuyen trudc co the phat hien duoc cac benh ducmg tiet nieu ngay mot sdm hon. Chung toi xin cam on gia dinh va cac dong nghiep da tao cho toi moi dieu kien thuan loi de hoan thanh cuon sach nay. Toi cung xin chan thanh cam on cac benh nhan ma chung toi co dip phau thuat da cho phep chung toi tich luy nhieu kinh nghiem bo ich v6 chuyen mon. Chac chan cuon sach nay con co nhung thieu sot nhat dinh, vi vay rat mong nhan duoc cac y kien dong gop cua ban be dong nghiep xa gan d6 cuon sach ngay cang duoc hoan thien hon. TAC GIA 3 MUC LUC • • Trang 1. Than u nude do ike ph&n noi be than - nieu quan 7 2. Than - nieu quan doi 24 3. Nieu quan lac ch6 42 4. Phinh to nieu quan tien phat do ike 51 5. Luong trao nguoc bang quang - nieu quan tien phat 66 6. Tui sa nieu quan hay gian nieu quan 94 trong long bang quang thanh nang 7. Hoi chung bung qua man (Prune belly syndrome) 110 8. Di dang do ton tai ong nieu - ron 119 9. Cac benh do ton tai ong phuc tinh mac 124 10. Bang quang than kinh va 138 tao hinh tang dung tfch bang quang 11. Van nieu dao sau 158 12. Di tat 16 tieu lech thap 172 13. H epbaoquydau 196 14. Gian tinh mach tinh 203 15. Tinh hoan khong xuong biu 213 16. Tinh trang gidi tinh khong xac dinh 235 17. Xo^n tinh hoan 264 18. Dai dam 270 19. Ung thu nguyen bao than (khoi u wilms) 280 1 THAN 0 N l/O C DO TAC PHAN NOI BE THAN - NIEU QUAN ■ ■ Than u nude do ike phan noi be than - nieu quan (TPNBTNQ) gap voi tan suat khoang 1/5000 tre so sinh. Benh hay gap d con trai nhi6u hon con gai (65% a con trai), ben trai bi nhi6u hon ben phai vdfi ty le 1, 5/1. Khoang 5% cac trudng hop co ton thuong ca 2 ben (1). H inh 1.1. Tdc phan noi be: than - nieu quan 7 Tai Vien Nhi quoc gia, m6i nam co khoang 15 benh nhan duoc dieu tri (2). Truoc the ky XIX, phuong phap dieu tri chu yeu la cat than. Trendelenburg duoc coi la ngudi dau tien da thuc hien ky thuat tao hinh de dieu tri tac phan noi be than - nieu quan 6 nhirng nam cuoi cua the ky XIX. Tru6c nam 1891, phau thuat tao hinh duoc tien hanh theo kieu Heineken - Mikulicz. Nam 1891, Kuster lan dau tien da dieu tri thanh cong TPNBTNQ bang that phan cuoi be than va noi be than voi nieu quan ben - ben. Ky thuat tao hinh phan noi be than - nieu quan theo kieu chu Y duoc Foley giai thieu nam 1936. Ky thuat cat pMn cuoi be than va phan tren nieu quan, sau do noi be than vdi nieu quan tan - tan duoc Anderson va Hynes gioi thieu nam 1946 de di£u tri hep nieu quan do nieu quan chay sau tinh mach chu nhimg sau do da duoc su dung rong rai de di6u tri TPNBTNQ (3). Cac phuong phap dieu tri bang ky thuat dieu tri noi soi duoc phat trien tir dau thap ky 80 vdi nhieu con dudng tiep can khac nhau (4). I. THlfONG TON GIAI PHAU NHU MO THAN Chi6u day cua nhu mo than phu thuoc vao miic do tac va muc do gian cua dai than. Nhirng truong hop tac nang nhu mo than hau nhu khong con ton tai. DAl THAN VA BE THAN Dai than va be than co the gian nhe hoac gian r£t rong phu thuoc vao mire do va thdi gian TPNBTNQ. Be than co th6 gian tu vai den hang chuc centimet. 8 Phan noi be than - nieu quan: nho hep, co the co nga'n lorn o phfa ngoai. Nieu quan co the noi vdi be than o vi tri blnh thuong hoac cao. Trong hau het cac truong hop co the cho duoc mot que tham do di qua doan noi be than - nieu quan. NIEU QUAN Long nieu quan thucmg nho hon blnh thuong. Mach mau bat thuong 6 cuc dudi than. Khoang 1/3 so trucmg hop TPNBTNQ duoc bao cao la co cac mach mau bat thucmg o cuc duoi than (3), tuy nhien Stephens cho rang mach mau bat thucmg o cuc duoi co lien quan den qua trinh quay cua than. Neu mach mau cua cuc duoi duoc hinh thanh sdm hon va di vao ron than truoc khi than quay het se gay chen vao be than va gay tac (5) CAC DI TAT PHOI HOP Luong trao nguoc bang quang - nieu quan phoi hop gap tir 10 - 15% cac truong hop TPNBTNQ (6). Cac di tat khac nhu tac phan noi nieu quan - bang quang, than mong ngua, than nieu quan doi gap voi ti le thap hon. II. CO CHfe B$NH SINH Tac phan noi be than - nieu quan co the do cac nguyen nhan tu ben ngoai hoac ben trong. Bat thuong ve cau true to chuc hoc cua doan noi be than - nieu quan da duoc mot so tac gia bao cao: cac soi co vong bi thay the boi cac soi co doc, co qua nhieu soi keo giua cac bo co, cac te bao co bi mat lien tuc. Cac bat thucmg nay lam cho doan noi be than - nieu quan khong co nhu dong va khong co kha nang day nude tieu xuong nieu quan, vi vay doan noi be than - 9 nieu quan duoc goi la doan mat churc nang hoac doan khong co dong hoc (7, 8, 9). Trong than u nude do tac ph15 phut (19). 4. CHUP BANG QUANG - NIEU DAO TRONG KHI DAl Chup bang quang nieu dao co gia tri xac dinh cac trudng hop tac phan noi be than - nieu quan co kem theo trao nguoc bang quang - nieu quan. 5. CHUP NIEU QUAN NGUOC DONG Cho phep loai tru tac phan cuoi nieu quan phoi hop, mac du vay chi duoc mot so tac gia thuc hien tren ban mo trudc khi tien hanh phau thuat. VI. THAN IT Nl/CfC VA LUONG TRAO NGUOC BANG QUANG - NIEU QUAN PHOI HOP Luong trao nguoc bang quang - nieu quan phoi hop dat ra nhung kho khan ca trong chan doan va didu tri bdi vi can phai xac dinh xem luong trao nguoc bang quang - nieu quan la thuong ton phoi hop hoac la nguyen nhan gay gian be than va phai mo d phan nao cua nieu quan trudc. Trao nguoc bang quang - nieu quan cung vdi than U nude co the xay ra dudi 3 hinh thai: - Hinh thai thur nhat la cac benh nhan co than u nude nang do tac nhung cung co trao nguoc bang quang - nieu quan nhe phoi hop. Trong tinh huong nay, tac phan noi be than - nieu quan tien phat ton tai va bieu hien ro, trong khi do trao nguoc bang quang - nieu quan lai co bieu hien khong dang ke. 16 Ph^u thuat duoc tien hanh d phan noi be than - nieu quan, luong trao nguoc bang quang - nieu quan duoc tiep tuc theo doi va xu ly sau. - Hinh thai thur hai bao gom nhung benh nhan co luong trao nguoc bang quang - nieu quan nang, nieu quan gian to dong thdi co than ur nude va hep tuong doi d phan noi be than - nieu quan. Cac phim chup bang quang cham se khong thay nude tieu u dong d be than va toan bo he thdng tiet nieu hau nhu khong con dong chat can quang, dieu nay chung to trao nguoc la van de tien phat. Nhung trudng hop nay can dieu tri luong trao nguoc bang quang - nieu quan trudc. - Hinh thai thu ba bao gom nhung benh nhan co trao nguoc trung binh ket hop vdi than u nude dang ke va co bieu hien tac phan noi be: than - nieu quan. Be than van con day sau khi nieu quan da rdng. Trong cac trudng hop nay the tich nude tiSu tir ngoai trao nguoc vao be than da lam mat can bang giua nude tie:u den va nude tieu thoat khoi be than lam cho be than bi gian cang qua muc. De chan doan can phai xac dinh lieu phan noi be than - nieu quan co thich ung vdi dong nude tieu thoat qua khi khong co trao nguoc khong. Dieu nay co the duoc thuc hien bang chup than do vdi dong vi phong xa trong khi dat sonde bang quang de dan luu nude tidu lien tuc, bang cach nay co the’ loai trir duoc trao nguoc va xac dinh duoc co tac phan noi b6 than - nieu quan khong, neu khong co tac phai chu y den phan noi nieu quan - bang quang thay vi can thiep vao phan noi be than - nieu quan. 17 VII. DI^U TRI Cac ky thuat di6u tri than ut nude do tac phan noi b t than - nieu quan bao gom: - Ky thuat tao hinh be than theo Anderson - Hynes - Ky thuat tao hinh ki£u chu Y cua Foley - Ky thuat tao hinh vat thang va vat xodn - Cac ky thuat noi soi Dudng mo: nhieu dudng mo duoc su dung de tao hinh be than nhu dudng trang giua, trang ben, dudng ngang phia bung that lung va dudng phia sau lung tuy nhien hien nay 2 con dudng duoc su dung nhidu nhat la dudng ngang phia bung va dudng lung. 1. KY THUAT ANDERSON - HYNES BANG DUCJNG NGANG PHIA BUNG Benh nhan nam ngira co don d vung than. Rach da va co phia dudi xuong sudn XII tu bo ngoai co thang to va keo dai ra phia ben. Khi den phuc mac thi day phuc mac vao trong. Boc tach vao b6 than. Cat rdi nieu quan khoi be than. Cat bo doan noi be than - nieu quan. Dung mot ong thong nho cho vao nieu quan day sau ve phia bang quang va bom nude de kiem tra su luu thong. Md doc nieu quan dai khoang 1 cm. Cat bo bdt mot phan be than theo chieu tren dudi de lam hep bdt be than (trir trudng hop be than gian nhe). Khau lai be than theo chieu tu tren xuong dudi va tru lai khoang 1 cm phan thap nhat. Dat mot ong thong nho qua nhu mo than vao be than va sau do xuong nieu quan. Khi nhu mo than con day, nen dat dan luu true tiep qua be than. Noi dau tren nieu quan vdi phan tha'p cua be than bang chi vicryl hoac PDS 6/0 (hinh 1. 2) 18 H inh 1.2. Ky thuat Anderson - Hynes. A.cdt bdt mot phan be than va cat nieu quan theo dudng cheo B. Khau lai phan tren be? than. C. Noi phan dudi bi than \'di nieu quan 2. DI/CJNG SAU LUNG Khong chi dinh cho than lac ch6, quay be than hoac than mong ngua, m6 lai. nieu quan doi, doan hep dai. Sir dung cho tre nho, than u nude d muc do trung binh. Benh nhan nam sap. don d bung. Sd nan bd ben cua co cung gai song de1 lam moc, rach da theo dudng ngang dudi xuong sudn 12 tu bd ngoai cua co dai khoang 4 - 5 cm, mo can co cung gai song theo chieu doc. Keo co cung gai song va co vuong that lung vao trong de boc lo be than. Cac thi con lai tiep tuc tien hanh nhu ky thuat mo bang dudng bung. 19 3. cAc k y t h u A t N0I SOI Tao hinh b6 than bang noi soi ducmg tiet nieu hoac bang ky thuat m6 noi soi o bung duoc ap dung nhieu d ngudi Ion, tuy nhien chua duoc ap dung nhieu d tre em. Ky thuat Anderson - Hynes co ket qua rat cao. Ti le thanh cong dat tren 95%. Cac bien chung nhu ro mieng noi, hep mieng noi gap vdi ti le tir 2 - 3% (16). VIII. THAN ITNUCIC TRONG THCU KY THAI NHI Thai nhi bat dau san xuat nude tieu vao khoang tir tuan thur 5 den tuan thur 9 cua thdi ky bao thai. Nude tieu thai nhi noi chung la nhuoe truong (14), khoi luong nude tieu tang dan va dat den dinh cao d cuoi thdi ky thai nghen, nhung lai dot ngot giam xuong sau khi de tir vai ngay den vai tuan va sau do tang dan len. on dinh d toe do 1 - 2 ml/kg/h. DiSu nay giai thfch tai sao trong mot so trudng hop cac xet nghiem tham do tien hanh sdm sau de co the khong thay be than gian nhung lai co cac bidu hien rd rang ve sau (1). Hien nay nhung tien bo trong ky thuat sieu am da cho phep nghien cuu duoc hinh thai cua dudng tiet nieu trudc de. O thai nhi binh thudng, bang quang co the quan sat thay luc 14 tuan. than cung bat dau nhin thay luc 14 tuan nhung the hien ro luc 18 tuan (14). Theo doi lien tuc bang sieu am da cho phep hieiu ro hon di6n bien cac trudng hop than u nude duoc phat hien trong thdi ky thai nhi. Than ur nude trong thdi ky thai nhi co the tiep tuc phat trien nang hon sau khi de nhung cung co th6 on dinh hoac tu het. Grignon theo doi 92 trudng hop than u nude duoc phat hien trong thdi ky thai nhi da thay 50% cac trudng hop co bieu hien binh thudng sau khi de (20). Dejter da quan sat tha'y cac than ur nude trong thdi ky thai nhi mac du co bieu hien binh 20 thuong tren sieu am sau de nhung 50% trong so nay lai co b6 than gian va cac benh ly tiet nieu ro rang khi sieu am lai sau 2 thang (21). Ransley bao cao 142 trudng hop than ur nude duoc chain doan trudc de khi benh nhan duoc kidm tra sau de 1 thang da thay 9 trudng hop chuc nang than giam, trong do 6 trudng hop khong con chuc nang (22). Nhung nghien curu ve di£n bien tu nhien cua than u nude duoc chain doan trudc sinh da cho ohep rut ra chi dinh theo doi va dieu tri nhu sau: Tat ca benh nhan chain doan trudc luc sinh can phai sieu am lai sdm sau de, neu sieu am binh thudng phai tiep tuc theo doi va lam lai vai lan trong nam dau trudc khi loai trir duoc tac phan noi be! than - nieu quan, neu sieu am thay be: than gian can lam UIV, than do. chup bang quang. Neu tac duoc xac dinh can mo sdm khi chuc nang than giam hoac than ur nude nang. Nhung trudng hop co tac nhung chuc nang than binh thudng nen mo tir 2 - 4 thang sau de TAI LIEU THAM KHAO 1. FLASHNER SC, KING LR. Ureteropelvic junction. In: Kelalis PP, King LR. Belma AB, eds. Clinical Pediatric Urology. Philadelphia: WB Saunder company; 1992: 693 - 725. 2. NGUYEN DANH TINH, NGUYEN THANH LIEM: Chain doan va ket qua dieu tri than ur nude do tac phan noi be than - nieu quan. Nhi khoa so 2, 1998: 11 - 114 3. STEINHARDDT GF. Ureteropelvis junction obstruction. In: Gonzales ET, Bauer SB. Pediatric Urology Pratice. Philadelphia: Lippincott Williams&Wilkins: 181 - 204. 4. WICKHAM JEA, KELLET MJ. Percutanous pyeloplasty. Eur Urol 9: 122 - 124, 1983. 21 5. STEPHENS FD. Ureterovascular hydronephrosis and the aberrant renal vessels. J Urol 1982, 128: 984 - 987. 6. HOLLOWELL J, ALTMAN H, SNYDER H, ET AL. Co - existing UPJ obstruction and vesicouretral reflux: diagnosis and therapeutic complications . J urol 1989. 142: 490 - 493. 7. HANNA MK, JEFFS RP, STURGESS JM, ET AL. Ureteral structure and ultrastructure. Part II: Congenital ureteropelvic junction obstruction and primary obstructive megaureter. J Urol 1976, 116: 725-727. 8. NOTLEY RG. Electron microscopy of the upper ureter and the pelvi - ureteric junction. Br J Urol 1968, 40: 37 - 39. 9. KOFF SA. Anomalies of the renal collecting system. In: O ’Donelle B, Koff SA, eds. Pediatric Urology. Oxford: Butterworth;1997: 371 - 379. 10. RUANO - GIL D, COCA - PAYERAS A, TEJEDO - MATEN A. Obstruction and normal recanalization of the ureter in the human embryo: its relation to congenital ureteric obstruction. Eur Urol 1975, 1: 287 - 289. 11. MACKSOOD MJ, ROTH DR, CHANGCH, ET AL. Benign fibroepithelial polyps as a cause of intermittent ureteropelvic junction obstruction in a child: a case report and review of the litarature. J Urol 1985, 134: 951 - 952. 12. JOHNSTON JH, EVAN JP, GLASSBERG Kl, ET AL. Pelvic hydronephrosis in children. Br J Urol 1969, 41: 724 - 726. 13. GRIFFITHS DJ, NOTCHAELE C. The mechanics of the urine transport in the upper urinary tract. Neurourol urodynamic 1983, 2: 155 - 157. 22 14. ELDER JS, KOFF SA. The pathophysiology and biological potential of hydronephrosis in the fetus and neonate. In: O’Donelle B, Koff Sa, eds. Pediatric Urology. Oxford: Butterworth;1997: 381 - 395. 15. GILLENWATER J. HYDRONEPHROSIS. In: Gillcnwater J, Grajhack J, Howard S, et al. Adult and pediatric urology. 3rd ed. St Louis: Mosby, 1996: 973 - 998. 16. ROWE MI, O "NEILL JR, GROSFELD Jl.t ET AL, eds. Essential pediatric Surgery. St Louis: Mosby; 1995: 693 - 702. 17. ANDERSON N, CLAUTICE - ENGLE T, ALLAN R, ET AL. Detection of obstructive uropathy in the fetus: predictive value of sonographic measurements of renal pelvic diameter at various gestational ages. A J Ar 1995, 164: 719 - 7120. 18. FERN BACK SK, MAIZELS M, CONWAY JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for fetal urology. Pediatr Radiol 1993,23:478 - 479. 19. KASS EJ, FINK - BENETT D. Comtemporary techniques for the radioisotop evaluation of a dilated urinary tract. Urol Clin North Am 1990,17: 2 - 5. 20. GRIGNON A, F1LON R, FILIATRAULT D, ET AL. Urinay tract dilatation in utero: classification and clinical applications. Radiology 1986, 160: 645 - 647. 21. DEJIER SU'. GIBBONS MD. The fate of infant kidney with fetal hysronephrosis but initially normal ultrasound. J urol 1989, 192: 661 -663. 22. RANSLEY PG, DLULLON HK, GORDON I, ET AL. The postnatal management of hydronephrosis diagnosed by prenatal ultrasound. J Urol 1990, 144: 584 - 587. 23 2 THAN - NIEU QUAN OO I ■ ■ Than - nieu quan doi la di tat hay gap nhat cua duong tiet nieu tren vdi ti le 0,7% tren md tu thi va tu 2-4% tren tong so phim chup dudng tiet nieu (1,2). Ty le di tat tim thay trong cong dong la 0,5% (1). O nhieu benh nhan, di tat duoc phat hien tinh cd, khong co trieu chung lam sang va khong can dieu tri. Di tat gap d con gai nhieu hon con trai gap 3,4 lan, ti le gap d ben phai va ben trai khong khac nhau, than - nieu quan doi ca hai ben chiem ti le 15% (3). Tien sir gia dinh kha ro net, tan suat benh nhan co anh em ruot hoac bd me cung bi di tat la 1/8 (1). 1. CAC HINH THAI CUA THAN - NIEU QUAN DOI Than - nieu quan doi co the hoan toan hoac khong hoan toan (1, 2, 4, 5). Cac hinh thai than - nieu quan doi co the gap la (hinh 2.1): - Nieu quan doi hoan toan: hai nieu quan chay tir hai b i than khac nhau, hai Id nieu quan do vao cac vi tri khac nhau. - Nieu quan doi khong hoan toan: hai nieu quan dan luu tir hai be than khac nhung chi chay rieng nhau mot doan roi sau do dd chung vao mot phan tan ciing, doan chung co the dai tao thanh hinh chu Y hoac ngan sat bang quang tao thanh hinh chu V. Nieu quan che doi khong hoan toan nguoc chi6u: meu quan d tren tach thanh 2 nieu quan rieng nhau d phia dudi. - Nieu quan doi hoan toan hoac khong hoan toan vdi mot nhanh tan cung thanh tui ciing tit trudc khi den be than. - Cac trudng hop 3 hoac 4 nieu quan do co nhieu mam nieu quan rat hiem gap (2,5). 24 H inh 2.1. Cac hinh thai cua than - nieu quan doi. A. Nieu quan doi khong hoan toan. B. Nieu quan doi hoan toan 25 II. SINH BENH HOC Nieu quan doi la hau qua cua nhung bat thudng trong qua trinh phat trien bao thai. Nieu quan duoc hinh thanh tu ong Wolf. Cac ong Wolf co nguon goc tu trung mo duoc hinh thanh trong moi lien quan vdi cac ong ti6n than va trung than nam d thanh lung cua xoang co the. Cac ong trung than phat tridn ve phia duoi cua bao thai va sau do quay ngoat ve phia trudc de gap o nhdp va do vao do khoang vao tuan 16 thu 5 (thai 4mm). Nieu quan duoc hinh thanh tir mot mam nieu quan, phat sinh tir ong Wolf (ong trung than), noi ong nay uon cong trudc khi den o nhdp (thai 5-6mm). Mam nieu quan dai ra tien ve va xuyen vao mam hau than trong khi hau than dang di chuyen tir viing xuong cung len vung that lung. Tir mam nieu quan se hinh thanh nen he thdng ong trong than va dai than, trong khi do cac nephron lai duoc hinh thanh tir to chuc hau than. Trong giai doan phat trien tiep theo. ong Wolf gian ra va hoa vao trong xoang tiet nieu sinh due. Cac nieu quan tach rdi khoi ong trung than, cac 16 nieu quan do vao phan thap cua xoang tiet nieu sinh due de tao thanh trigon. 0 con trai, ong Wolf di chuyein vao giua va xuong dudi de hinh thanh ong dan tinh, tui tinh, ong phong tinh va do vao nieu dao tien liet tuyen, d con gai ong Wolf teo di hoac ton tai nhu mot di tich nam d mat trudc ben thanh am dao, tir cung va day chang rong (1, 2, 4, 5, 6). Than - nieu quan doi hoan toan la do co hai mam nieu quan phat sinh tir ong Wolf rieng re nhau. Mot mam d phia tren va mot mam d phia dudi. Moi mam nieu quan tien rieng ve phia hau than. Nieu quan tren hinh thanh dai than tren va dan luu be! than tren. Nieu quan dudi hinh thanh dai than giua va dudi, dan luu 26 phan giua va duoi cua than. Ve phia xoang tiet nieu sinh due, sau mot qua trinh tien trien phuc tap ong Wolf do vao phia dudi va phia trong so vdi vi tri ban dau va khong eon nam trong bang quang ma d phan day cua xoang tiet nieu sinh due noi ma cu Muller se hinh thanh u nui d nam gidi hoac tien dinh d nu gidi. Trong qua trinh di chuyen nay, ong Wolf loi keo mam nieu quan tren lam cho no di vao phia trong va sau do di ra phia sau nieu quan dudi roi do vao bang quang d vi tri tha'p hon (quy luat Weigert-Meyer). Nieu quan doi khong hoan toan la do mam nieu quan phan doi sdm trudc khi tien den mam than (1,2, 5). III. THUONG TON GIAI PHAU 1. THAN - NIEU QUAN DOI HOAN TOAN 1.1. Than Thudng chi co mot khoi nhu mo than duoc bao quanh bdi mot vo than. Than co hinh dang cua than binh thudng, tuy nhien kfch thudc nho hon va dai hon. Be than tren nho, be than tren thuc ra chi co mot dai than tuong irng vdi khoang 1/3 nhu mo, be than dudi to hon. Giua hai be than doi khi co mot ngan nho phan cach. Khi co viem than-be than (phan tu than tren) hoac u nude (phan tu than dudi), gidi han giua hai viing than va nieu quan trd nen ro hon. Doi khi giua hai be than co the co mot khoi mo cau than tuong ung vdi mam hinh thanh 2 cue than va du phat trien de co the hinh thanh mot khoi tan sinh trong than (6). Thuc ra thudng khong co binh dien boc tach ro rang giua hai be than, nen khi can phai md bi than cua don vi benh ly de: lay bo no ma khong lam rach be than con lai hoac lam ton thuong mach mau. Co the; co hai cuong than nhung thudng chi co 1 cuong than chung, tuy nhien co mot hoac hai mach mau di vao circ tren tir ngoai ron than, vi vay cat phan tir than tren thudng di. 27 1.2. Nieu quan Nieu quan tren chay sau cac mach mau cua than roi chay vao phia trong so voi be than duoi, sau do hai nieu quan co the chay song song va khong bat cheo nhau nhung da so trudng hop hai nieu quan bat cheo nhau hai lan. Nieu quan tren luc dau chay tu trong ra ngoai roi sau do chay tu ngoai vao trong, thudng d phia trudc nieu quan dudi. Co the tach hai nieu quan xa nhau ma khong so lam thuong ton mach mau cua m6i nieu quan trir doan sat bang quang. Khi den sat bang quang, hai nieu quan co the dinh chat vao nhau va nam trong mot bao chung cung vdi he thdng mach mau chung. Khi tach rdi hai nieu quan, co the lam mat nuoi dudng mach mau con lai. Hai nieu quan chui vao bang quang cung mot khe chung neu khong co nieu quan nao do lac ch6 ra ngoai bang quang. Sir sap xep cua chung tuan theo quy luat Weigert-Mayer (nieu quan tren do xuong dudi thap, trong khi do nieu quan dudi lai do cao d phia tren) (1, 2, 7) L6 nieu quan dudi thudng d vi tri binh thudng trong tarn giac Trigone nhung co the lac ch6 sang ben va len cao, do do dudng ham dudi niem mac ngan de gay trao nguoc bang quang-nieu quan. Nieu quan tren chay qua 16 nieu quan d phia trong nieu quan dudi, roi chay ra phia sau no do vao trong va xuong thap hon vi vay co dudng ham dudi niem mac dai hon va co lien quan bat thudng vdi co d vung Trigone nen d i bi u dong nude ti6u va tac. Tuong quan giua cac nieu quan khong theo quy luat Weigert-Mayer hiem gap. L6 nieu quan tren nam canh va phia trong 16 nieu quan dudi, tham chi co the do len phia tren 16 nieu quan dudi (8). 28 2. THAN NIEU QUAN DOI KHONG HOAN TOAN 2.1. Than Hinh dang cua than giong nhu trong nieu quan doi hoan toan. 2.2. Nieu quan Nieu quan tren n^m d phia trudc so vdi nieu quan dudi, nieu quan hoa vao vdi nhau d cac vi tri rat khac nhau co thi tir rat cao den rat thap d trong thanh bang quang (2). IV. CAC HINH THAI BENH L t GAP TRONG NI$U q u An DOI Ben canh 16 nieu quan do lac ch6 ra ngoai bang quang va gian doan cuoi nieu quan trong long bang quang se duoc trinh bay d cac phan sau, di tat nieu quan doi con co the dan den cac bien chung sau: 1. TRAO NGUOC BANG QUANG - NIEU QUAN Luong trao nguoc tu bang quang vao nieu quan dudi rat thudng gap, Fehrenhaker gap 75% cac trudng hop nieu quan doi co bieu hien nhiim trung tiet nieu (9). Lu6ng trao nguoc thudng d muc do nang. Mollard thay 58% cac trudng hop be than dudi bj bien dang vdi cac dai than bi co keo (2). Luong trao nguoc thudng ket hop vdi viem than-be than nguoc dong. Luong trao nguoc vao nieu quan tren hoac vao ca hai nieu quan co thi xav ra nhung hiem gap, nguyen nhan la do 16 nieu quan cua nieu quan tren md rong hoac cung do ngang muc vdi nieu quan dudi (6). 29 2. PHINH TO NIEU QUAN La bien chung dac trung thur hai cua nieu quan doi hoan toan. Nieu quan tren bi phinh to do doan chay trong dudng ham duoi niem mac bang quang qua dai va co tuong quan bat thudng vdi co d Trigone hoac co bang quang. 10% cac trudng hop nieu quan doi co nieu quan tren phinh to (2). Thuong ton do phinh to nieu quan thudng nang ne, 90% cac trudng hop be than tren bi pha huy, gian cuc dai kern theo viem than-be than nang. Phan tu than tren thudng khong ngam thudc tren phim chup UIV, nhung day dai be than dudi xuong dudi va ra ngoai. Phinh to nieu quan tren ket h(^) vdi luong trao nguoc vao nieu quan tren va dudi rat hiem gap. Mollard gap 5 trudng hop phinh to nieu quan tren va trao nguoc vao nieu quan dudi (2). 3. TRAO NGUOC NIEU QUAN-NIEU QUAN VA IT DONG 6 VUNG HOP LUU Trao nguoc nieu quan-nieu quan la hien tuong trao nguoc nude tieu tir nhanh nieu quan nay vao nhanh nieu quan kia trong cac trudng hop nieu quan doi khong hoan toan. Luong trao nguoc la do cac co bop d hai nhanh cua nieu quan khong dong bo va do ap luc trong nhanh nieu quan luc nghi thap horn so vdi vung hop luu va vung nieu quan chung. Luong trao nguoc khong gap khi hop luu nam thap trong thanh bang quang vi luc do cac song nhu dong se lam cho doan nieu quan tan cung chi co cac dai co doc d i dang mo ra va nude tieu duoc tong xuong bang quang (10, 11). 4. TAC PHAN NOI BE THAN-NIEU QUAN Tac phan noi be than-nieu quan thudng xay ra d be than va nieu quan dudi. Khi be than dudi khong ngam thudc, hinh anh 30 tren phim chup UIV d i nham vai u Wilms vi mat hinh cac dai than giua va dudi. V. TRIEU CHUNG VA CHAN DOAN Nhiim khuan tiet nieu, dai kho, dau vung tren xuong mu hoac that lung cung vdi cham tang trudng la cac bieu hien thudng gap. Cac benh nhan co nieu quan tren lac ch6 ngoai bang quang thudng co bieu hien son nude tieu lien tuc dong thdi van co cac lan tieu tien binh thudng. 0 con trai neu nieu quan tren lac ch6 vao ong dan tinh, tui tinh, thudng co bieu hien viem tinh hoan hoac mao tinh hoan cung ben. Cac benh nhan den muon co gian nieu quan va u mu be than, co the co bieu hien noi bat la mot khoi u bung cong vdi da'u hieu nhiim khuan (13). Nghien curu 40 trudng hop bi than nieu quan doi, chung toi thay cac dau hieu lam sang chu yeu nhu sau (3): B A N G 2.1. C A C DAU HIEU LAM SANG CUA THAN NIEU q u A n d o i Dau hieu lam sang So benh nhan % Dai due 31 77,5 Dai buot 21 52,5 Dai dat 14 35 Dai ri 12 30 Dai mau 1 2,5 Bi dai 1 2,5 Dau bung 9 22,5 Khoi u mang siron 7 17,5 Tui sa nieu quan ra ngoai 2 5 T3PTTNTE 31 Chup UIV: la phuong phap chan doan co gia tri nhat. Chup UIV co the: thay hinh anh true tiep cua nieu quan doi (hai nhom dai be than, hai nieu quan) khi ca hai dcm vi than con chuc nang va ngam thuoc tot (hinh 2.2). Khi don vi than khong con chuc nang, chan doan than nieu quan doi co the? dua vao cac dau hieu gian tiep sau: Bong than dai hon binh thudng. Be than va dai than dudi bi day xa cot song, xuong dudi, nam ngang hon so vdi binh thudng (hinh anh bong hoa ru) (hinh 2.3). - Nieu quan dudi dai va uon khuc, co khi bi day lech sang phia doi dien. Sieu am: thay duoc hai khoi nhu mo than va co th6 thay duoc be than cung vdi nieu quan tuong irng bi gian. Chup bang quang: phat hien trao nguoc bang quang - nieu quan hoac tui sa nieu quan ket hop. VI. DIEU TRI Than nieu quan doi chi co chi dinh dieu tri khi co nieu quan do lac ch6 ra ngoai bang quang hoac khi co cac bien chung. D iiu tri cac trudng hop nieu quan doi co nieu quan tren lac cho co th6 la cat nieu quan cung vdi don vi than tren hoac d iiu tri bao ton nhu noi nieu quan-nieu quan hoac trong lai ca hai nieu quan tuy thuoc vao churc nang than. 1. CAT BO PHAN TUTHAN TREN CUNG VCti NIEU QUAN TUONG UNG KHI THAN TREN KHONG CON CHUC NANG. Ky thuat tien hanh nhu sau: Benh nhan nam ngua co don sau lung. Rach da theo dudng ngang sau ben, ngay dudi xuong sudn XII. Sau khi cat co, day 32 phuc mac vao trong, tim nieu quan. Nieu quan tren thucmg gian to hon nieu quan dudi neu khong co trao nguoc tu bang quang vao nieu quan duoi. Phau tfch nieu quan tren khoi nieu quan duoi. Cat doi nieu quan tren. Tiep tuc boc tach nieu quan tren khoi nieu quan dudi len den sat be than. Luon nieu quan phia dudi cuong mach cua than keo nguoc len phia tren. Cap cat va buoc cac mach mau di vao phan than tren. Sau khi cap cat mach mau co the nhin thay r5 ranh gidi giua vung than tren va than dudi dua vao mau sac cua nhu mo. Cat phan than tren bang cach di sat theo bd ngoai be than tren. KMu cam mau mom cat. Tiep tuc tach nieu quan tren khoi nieu quan dudi cho den sat thanh bang quang. Chu y khong lam ton thuong mach mau nuoi nieu quan dudi. Cat bo nieu quan tren sat thanh bang quang. Md rong mom cung, co the dot niem mac cua phan tan cung va de ho mom cat (hinh 2.4). Co the cat than-nieu quan tren bang cat than trudc. Sau khi boc lo than, tim, cap cat va buoc cac mach mau cua cuc tren than. Cat than tren khoi than dudi. Tach be than tren khoi be than dudi va tach nieu quan tren khoi nieu quan dudi theo chieu tir tren xuong dudi de cat bo nieu quan dudi d phan thap nhat. Tu nam 2000, chung toi da bat dau cat than - nieu quan tren bang ky thuat noi soi. Benh nhan nam ngua hoi nghieng sang ben doi dien. Vao o bung bang 3 cua so: cua so qua ron cho ong soi, mot cua so dudi ron va mot cua so tren ron cho dung cu. Cac chi tiet ky thuat con lai tien hanh nhu trong phau thuat quy udc. 33 Hinh 2.2. Phoi thai hoc cua nieu quan doi. A. Hai mam nieu quan phat sinh tir ong Wolffian. B. Mam nieu quan duoi do vao phia tren xoang tiet nieu sinh due khi ong Wolffian bi cuon vao thanh bang quang. C. Mam nieu quan tren do vao phan thap cua xoang tiet nieu sinh due. D. Hinh anh cuoi cung cua nieu quan doi sau khi ong Wolffian do vao nieu dao nhu ong xuat tinh H inh 2.3. A. Hinh anh true tiep cua than nieu quan doi. B. Hinh anh gian tiep cua than nieu quan doi phai kern tui sa hieu qua 35 H inh 2.4. Cat nieu quan va don vi than tren. A. Cat doi nieu quan. B. Luon lieu quan phia sau cuong mach len tren. C. Cap cat cac mach mau vao don vi than tren va cat dai dan vi than tren cung vai nieu quan. D. Khau cam mau mom cat than. 36 H inh 2.5. Noi nieu quan tren vao bS than duoi Hinh 2.6. Noi nieu quan tren vao nieu quan duoi sat thanh bang quang 37 2. CAC KY THUAT BAO TON Khi benh duoc phat hien sdm, dan vi than tren co churc nang tot co the tien hanh noi nieu quan tren vao be than duoi (hinh 2.5) hoac noi nieu quan tren vao nieu quan dudi sat thanh bang quang (hinh 2.6) hoac trong lai ca hai nieu quan vao bang quang (hinh 2.7). Ky thuat duoc chung toi hay dung hien nay la noi nieu quan vao nieu quan sat thanh bang quang. Ky thuat duoc tien hanh nhu sau: Rach da theo dudng Pfanenstiel. Boc lo bang quang. Boc tach thanh ben ngoai bang quang. Tim day chang tron, cat day chang tron. Dung day chang tron lam moc tim nieu quan. Tach rdi hai nieu quan d vi tri sat bang quang. Nieu quan tren thudng to hon nieu quan dudi neu khong co trao nguoc vao nieu quan dudi. Cat rdi nieu quan tren sat thanh bang quang. Noi nieu quan tren vdi nieu quan dudi tan ben bang chi tieu 6/0. Cac nguyen tac dieu tri luong trao nguoc bang quang-nieu quan trong nieu quan doi giong nhu ludng trao nguoc bang quang-nieu quan don. Tuy nhien kha nang trao nguoc tu het bang khang sinh du phong d cac trudng hop than-nieu quan doi it hon trong cac trudng hop nieu quan don (6, 12, 14). Trong cac trudng hop co chi dinh trong lai nieu quan thi nen trong lai ca hai nieu quan tren va dudi cung vdi nhau. K y thuat nhirsau: Rach da theo dudng Pfannenstiel. Boc lo va md bang quang theo chieu doc. Tim cac lo nieu quan. Dat sonde vao cac nieu quan de lam moc. Khau hai soi chi d hai lo nieu quan can trong lai. Rach vong quanh ca hai 16 nieu quan. Boc tach ca hai nieu 38 quan khoi thanh bang quang. Tao mot ducmg ham dudi niem mac tu vi tri 16 nieu quan cu sang phia doi dien phia tren 16 nieu quan ben kia. Kco ca hai 16 nieu quan qua dudng ham nay sang phia doi dien. Khau niem mac bang quang vdi 16 nieu quan. Khi thuong ton nhu mo cua phan tu than dudi nang do viem than-be than, churc nang than kern hoac khong co thi can phai cat bo phan tu than dudi cung vdi nieu quan va giir lai phan tu than tren vi kha nang phat triin bii tru tot (2). Vao o than bang dudng ngang. Phau tfch va that cac mach mau den cuc dudi d ngoai ron than. Lan theo bd tren cua be than, cat bo phan nhu mo da bi co rut cua than dudi doc theo bd tren cua be than va cua dai than giua. Md dai than giua, co the de lai phan day va dot bo phan niem mac. Tach nieu quan dudi khoi nieu quan tren den sat thanh bang quang. Cat nieu quan dudi sat thanh bang quang. Md doc phan tan cung, dot dien phan niem mac cua mom cung. Khi phai cat bo than-nieu quan dudi vi mat chuc nang do trao nguoc bang quang-nieu quan thi can phai ket hop vdi md bang quang de cat bo toan bo nieu quan dudi va trong lai nieu quan tren d6 tranh nguy co trao nguoc nude tieu vao mom cat. Luong trao nguoc nieu quan-nieu quan trong than-nieu quan doi khong hoan toan chi co chi dinh dieu tri khi nieu quan gian nang hoac dau vung that lung nhieu. Muc dfch cua phau thuat la nham bien mot nieu quan che doi thanh mot be than che doi bang cach noi be than tren vao be than dudi va cat bo phan nieu quan tren con lai. Tac phan noi be than-nieu quan trong nieu quan doi thudng xay ra d be than dudi. Neu nhu mo cua phan tu than dudi con tot thi co the noi be than dudi vdi nieu quan tren, neu nhu mo khong con chuc nang thi cat don vi than dudi cung vdi nieu quan. Cat than toan bo khi ca hai don vi than khong con chuc nang. Dieu tri cac trudng hop than-nieu quan doi co tui sa nieu quan se dupe trinh bay trong phan tui sa nieu quan. 39 TAl LI$U THAM KHAO 1. SCHULMAN CC. The uretet in: O’Donnel B, Koff DA. Pediatric Urology. Oxford: Butterworrth, 1997: 397^418. 2. MOI J ARP P. Precis d’urologie de l’enfant. Paris: Masson, 1984: 99-118. 3. NGUYEN MAI HONG, TRAN DINH LONG, NGUYEN THANH UEM. Nghien cuu cac dac diem lam sang, X quang va sieu am trong chan doan than nieu quan doi. Tap chi Nhi khoa so 1-2001 (dang in) 4. WILIAMS DI. Ureteric duplication and ectopia. In: W illiams DI, Johnston JH, eds. Paediatric Urology. London: Butterworths, 1982: 167-187. 5. STEPHENS FD. Bifid and double ureters, ureteroceles, and fused kidneys. In: Weleh KJ, Randolph JG, Ravitch MM, O’Neil JA, Row M, eds. Pediatric Surgery. Chicago: year book medical publisher, 1986: 1157-1165. 6. GONZALES ET. Anomalies of the renal pevis and ureter. In: Kclalis PP, King LR. Clinical pediatric urology. Philadelphia: WB saunder company, 1976: 505. 7. BELMAN AB, FILMER RB, KING LR. Surgical management of duplication of the collecting system. J urol 1974, 112: 316-319. 8. STEPHENS FD. Congenital malformations of the rectum, anus and genito-urinary tract. Edinburg: Livingtone. 1969. 9. FENRENBAKER LG, KELAUS PP, STICKLER GB. Vesico ureteral reflux and ureteral duplication in children. J urol 1972, 107: 862-865. 40 10. TRES1DIDER GC, BLANDY JP, MURRAY RS. Pyelo-pelvic and uretero-ureteric reflux. Br J urol 1970,42: 728-730. 11. LENAGHAN D. Bifid ureters in children: an anatomical, physiological and clinical study. J urol 1962,87: 808-811. 12. RAP LAN WE, NASRALLAH P, KING LR. Reflux in complete duplication in children. J urol 1978,120: 220-222. 13. NGUYEN THANH UEM, PHUNG TAN ClfdNG, HOANG BOI CUNG. Than nieu quan doi bieu hien nhu mot khoi u bung. Ngoai khoa so 2,1985: 55-59. 14. CALDAMONE AA. Duplication anomalies of the upper tract in infants and children. Urol Clin North 1985,12: 75-91. 41 3 NIEU QUAN LAC C H 6 ■ ■ Nieu quan lac ch6 la cac truong hop 16 nieu quan do ra ngoai bang quang. Benh gap vdi ty le 1/2000 ngudi, gap 6 con gai nhieu gap 6 lan so voi con trai. Khoang 80% cac trudng hop nieu quan lac ch6 la co nieu quan doi (1, 2, 3, 4). Benh dupe Schrader mo ta lan dau tien nam 1674 tren mo tir thi cho thay co 16 nieu quan do ra ngoai bang quang. Nam 1843. Civiale mo ta mot trudng hop nieu quan do lac cho vao nieu dao sau d mot benh nhan co nieu quan doi. Nam 1926, Young bao cao cac trudng hop nieu quan lac ch6 vao ong dan tinh, tui tinh. ong phong tinh, nieu dao a con trai va vao ti£n dinh, ong Gartner, tu cung va voi trung d con gai (2). I. SINH BENH HOC Nieu quan lac cho la do su phat trien bat thudng cua nieu quan trong thdi kv bao thai. Vi tri bat thudng cua mam nieu quan tren ong Wolf (ong trung than) hoac mam nieu quan tach khoi ong W'olf muon deu co the; dan den nieu quan lac ch6 (1). Khi mam nieu quan tach khoi ong Wolf sdm, 16 nieu quan lac cho se do vao trong duong tiet nieu (co bang quang) hoac nieu dao sau 6 con trai hay vao nieu dao d con gai. Khi mam nieu quan xuat phat tu ong Wolf cao hon vi tri binh thudng thi nieu quan se khong bao gid tiep xuc vdi xoang tiet nieu sinh due. 42 trong khi phan cuoi cua ong Wolf bi hoa vao xoang nay vi vay nieu quan se do ra ngoai duong tiet nieu va do vao duong sinh due duoc hinh thanh tu ong Wolf. C) con trai nieu quan co the do vao ong d§n tinh, tui tinh va ong xuat tinh (1). O con gai, ong Wolf teo di nhung cung co the ton tai duoi hinh thuc cua mot ong goi la ong Gartner. Ong nay nam 6 vj tri trudc ben doc theo am dao, tu cung va trong day chang rong ap len voi trung (5). Nieu quan co the: do vao bat cur noi nao cua ong Gartner va sau do md vao am dao, co tu cung hoac tu cung sau khi bi vd. Nieu quan don thudng lac ch6 vao dudng sinh due con nieu quan doi hay lac cho vao dudng tiet nieu. Do mam nieu quan lac ch6 phat sinh cao d ong Wolf va tien vao mam than d vi tri cao hon binh thudng trong mot vung ft co tiem nang biet hoa va con ton tai to chufc trung than nen nieu quan lac ch6 thudng kern theo loan san than (1). Nieu quan lac ch6 vao true trang thudng chi duoc phat hien khi md tu thi. Di tat nay la do ong Wolf di chuyen lac ch6 vao thanh sau cua o nhdp hoac do co sai sot trong qua trinh phan chia o nhdp. (5) II. TRIEU CHUNG VA CHAN DOAN 1. NIEU QUAN LAC CHO 6 CON GAI 1.1. Lam sang Nieu quan lac ch6 d con gai thudng co kern nieu quan doi. L6 nieu quan co the; do vao co bang quang hoac nieu dao (35%), vao xung quanh mieng sao (30%) va am dao (35%). Nieu quan co the do vao ong Gartner va sau do qua ong nay md vao am dao hoac tu cung (5%). Doi khi nieu quan do vao ong Gartner tao thanh mot nang canh nieu dao nhu la mot tui thua cua nieu dao (1) (hinh 3.1) 43 H inh 3.1. Vi tri nieu quan lac ch6 d con gai O con gai, nieu quan lac cho bieu hien rat da dang. Trieu chung dac hieu nhat la son nude tieiu lien tuc nhung van kern theo cac lan di tieu binh thudng. Tuy nhien dau hieu nay chi trd nen ro ret va duoc chu y a cac tre ldn da biet di tieu theo gid. 0 so sinh va tre nho, dau hieu nay ft dupe chu y va kho phat hien. Dau hieu nay cung co the vang mat d tre ldn neu 16 nieu quan do vao co bang quang hoac than tuong ung co chiic nang qua xau khong con kha nang bai tiet nude tieu. NhiSu tre gai co nieu quan lac ch6 den kham vi cac bieu hien cua nhidm khuan dudng tiet nieu. Nguyen nhan nhidm khuan la do luong trao nguoc nude tieu vao nieu quan khi 16 nieu 44 quan do lac ch6 vao co bang quang hoac do 16 nieu quan bi tac gay u dong nude tieu. Khi nuoc tieu bi nhidm khuan, benh nhan co the bieu hien bang chay mu tu am dao nhu ra khi hu, vung am ho thucmg xuyen bi kich thich tay do. Cac trudng hop 16 nieu quan bi tac co the bieu hien bang gian nieu quan hoac u mu be than. Mot so truong hop benh chi duoc phat hien 6 ngudi ldn, sau khi sinh thay co ro nude tieu vao am dao do nang Gartner bi vd (1). Quan sat ky vung am ho va quanh mieng sao doi khi co the phat hien thay 16 nieu quan lac ch6. Dung tay a'n vao bung benh nhan co the thay nude tieu hoac mil thoat qua 16 nieu quan lac ch6 d vung am ho. Phat hien 16 nieu quan lac ch6 giua cac nep gap vung am ho thudng kho khan, vi vay co the ket hop vdi nghiem phap bom cac chat mau. Co the dat mot cu au nho vao trong am dao roi tiem xanhmethylen cho benh nhan. Dan benh nhan khong di tieu. Rut cu au khoi am dao sau mot thdi gian cho dpi, neu chat mau ngam vao phia tren cu au co the nghl den nieu quan lac ch6. Nghiem phap nay phu thuoc vao churc nang cua than tuong ling vdi nieu quan lac ch6. Neu chuc nang cua than qua xau, nghiem phap co the am tinh gia. 1.2. Can lam sang Chup he tiet nieu co chuan bi doi khi thay dupe hinh anh true tiep cua nieu quan lac ch6 do thap dudi co bang quang. Da so cac trudng hop chan doan dupe xac lap dua tren cac hinh anh gian tiep cua than - nieu quan doi. Than khong nga'm thudc d ben nghi ngd, trong khi do than nieu quan ben doi dien co hinh anh binh thudng la mot dau hieu gian tiep co gia tri chain doan. 45 Sieu am co the xac dinh duoc hinh anh than nieu quan doi. Cac truong hop than-nieu quan doi lac ch6 thudng thay kich thuoc than nho hon binh thudng. Trong cac trucmg hop nieu quan lac ch6 ket hop vdi than lac ch6 thi sieu am khong thay than d vj tri binh thudng va co the xac dinh dupe vi tri lac ch6 cung vdi nieu quan gian. Tuy nhien khi than bi teo nho va lac ch6, sieu am rat kho phat hien va thudng dupe chuain doan la khong co than. Soi bang quang-nieu dao doi khi thay dupe 16 nieu quan lac ch6 vao nieu dao hoac co bang quang vi 16 nieu quan thuong ma rong (1,3). Chup bang quang-nieu dao trong khi dai co the: thay luong trao nguoc qua 16 nieu quan d ch6 do vao co bang quang hoac nieu dao va co the cung thay co trao nguoc vao nieu quan cuc dudi.. Chup xa do than la xet nghiem cho phep danh gia chmh xac chuc nang cua than va co gia tri hudng dan lira chon phuong phap phau thuat. 2. NIEU QUAN LAC CHO 6 CON TRAI 2.1. Lam sang O con trai, nieu quan lac ch6 thudng la nieu quan dan nhu la mot quy luat, khi 16 nieu quan lac ch6 cang xa vi tri binh thudng thi cang ft co kha nang ket hop vdi nieu quan doi (3). L6 nieu quan co the do vao nieu dao sau, thudng la tren co that (50-60%) hoac vao dudng sinh due (ong dan tinh, tui tinh, ong phong tinh: (40-50%) (1,3) (Hinh 3.2). Tui tinh co the gian rong thanh nang (2). Nieu quan va ong dan tinh co the do vao mot ong chung (6). 46 H inh 3.2. Vi tri nieu quan lac ch6 0 con trai d con trai, nieu quan lac ch6 thuofng dupe phat hien trong benh canh nhi6m khuan tiet nieu. Benh nhan co cac bieu hien cua nhi£m khuan dudng tiet nieu co the kern theo dai mau va co cac giot mu chay qua mieng sao sau khi dai (7). Khi nieu quan do vao dudng sinh due, viem tinh hoan-mao tinh la cac bieu hien chu yeu khien benh nhan di kham benh. Khi nieu quan do vao ong din tinh, co the sd thay mot u nang khi tham true trang (1,8). T4-PTTNTE 47 2.2. Can lam sang Luon luon phai nghi ngd co nieu quan lac ch6 d bat cu mot tre nam nao co nhidm khuan dudng sinh due (viem tinh hoan-mao tinh) va phai lam cac xet nghiem X-quang, sieu am toan dien de phat hien nieu quan lac ch6 (1,9). Nieu quan don lac ch6 d con trai thudng co than bi loan san nang nen khong ngam thudc tren phim chup UIV. Chan doan bat san than khi than khong ngam thudc chi dat ra khi da loai tru cac benh ly khac nhat la nieu quan don lac ch6 (8). Sieu am la xet nghiem co fch cho thay than co kich thudc be thudng lac ch6 kem theo nieu quan gian. Soi bang quang nieu dao thay chi co mot 16 nieu quan o bang quang va co the thay duoc 16 nieu quan lac ch6 d co bang quang hoac nieu dao. Chup bang quang - nieu dao co the thay trao nguoc vao nieu quan hoac vao he thong ong d in tinh. Chup xa do cho phep danh gia chfnh xac chuc nang than. III. NIEU QUAN DON HAI BEN LAC C H 6 Nieu quan don ca hai ben d£u do ra ngoai bang quang la di tat hiem gap va thudng gap d con gai hon d con trai. Do ca 2 nieu quan khong nam trong bang quang nen bang quang, c6 bang quang va vung Trigone kem phat trien. Trong phim chup bang quang thay co bang quang hep va khong dong km. Bang quang co dung tfch be va thanh mong. Loan san than 2 ben nang ddn den suy than (1). 48 IV. DI^U TRI Phuong phap dieu tri tuy thuoc vao chuc nang than tuong ung. Cat bo nieu quan lac ch6 cung vdi than tuong ung trong nieu quan doi neu than tuong urng khong con churc nang. Trong mot so ft truong hop khi nhu mo than con chutc nang tot, co the noi nieu quan cuc tren voi nieu quan cuc dudi sat thanh bang quang. Nieu quan don lac ch6 thudng kem theo than khong co chuc nang do loan san kem theo viem than be than, vi vay nen cat bo than va nieu quan lac ch6 bang phau thuat md hoac phau thuat noi soi. Tuy nhien trong lai nieu quan vao bang quang phai dat ra khi chi co mot than duy nhat vdi nieu quan don lac ch6 hoac chuc nang cua than tuong irng con tot. Dieu tri nieu quan don hai ben lac ch6 phuc tap hon cac trudng hop nieu quan lac ch6 mot ben rat nhieu vi trong lai nieu quan hai ben vao bang quang don thuan thudng khong co ket qua tot. Can tien hanh tao hinh lam tang dung tich bang quang kem theo vi the tich bang quang be. 0 con trai nieu quan thudng do vao nieu dao tren co that nen dung tfch bang quang co the binh thudng (1.3). TAI LIEU THAM KHAO I. SC HULM AN CC. The ureter. In: O ’Donnell B, Koff SA. Pediatric Urology. Oxford: Butterworth, 1997: 397-409. 2 BLOOM DA, BELMAN AB. Ectopic ureter and ureterocele. In Retix AB, Cukier J. Pediatric Urology. Baltimore: William & Wilkins, 1987: 166-183. 3 SCHUMAN C. Ectopic ureter. In:Cendron J, Schulman C, eds, Urologie Pediatrique. Paris: Flammarion, 1989:i47-152.. 49 4 STEPHENS FD. Bifid and double ureters, ureteroceles, and fused kidneys. In: Welcch KJ, Randolph JG, Ravitch MM, O ’Neil JA, Rove M, eds. Pediatric Surgery. Chicago: Year book medical publisher, 1986:1157-1165. 5. USON AC, SCHULMAN CC. Ectopic ureter emptying into the rectum: report of a case. J urol 1972, 108: 156-157. 6. SEITZMAN DM, Patton JF-Ureteral ectopia: combined ureteral and vas deferens anomaly. J urol 1960, 84: 604- 608. 7. MOLLARD P. Precis d ’urologie de l’enfant. Paris: Masson, 1984: 118-132. 8. CENDRON J, BON HOMME C. Uretere a terminaison ectopique extra-vesicale chez des sujets de sexe masculin (a propos de 10 cas) J urol nephrol 1968, 74: 31-50. 9. ROGNON L, BRUEZIERE J, SORET JY, MPUTU JB. Abouchement ectopique de 1’uretere dans le tractus seminal. A propos de 10 cas. Chirurgie 1973, 99: 741-748. 50 4 PHINH TO NIEU QUAN TIEN PHAT DO TAC ■ Phinh to nieu quan la mot dj tat tiet nieu tuong doi hiem gap. Co che benh sinh con co nhung van de chua duoc sang to. Mac du benh da duoc Carlk mo ta ldn dau tien tir nam 1923 (1) nhung 6 nuoc ta van con la mot van de tuong doi moi (hinh 4.1) Khi nao co the coi mot nieu quan la phinh to ? Nhung cong trinh nghien cuu gan day ve kich thudc binh thuong cua nieu quan d tre em da cho phep dua ra tieu chuan cu the. Cussen khi nghien cuu tir thi cua tre duoi 12 tuoi da thay kich thuoc nieu quan it khi Ion hon 5mm (2). Hellstrom va cong su khi do kich thuoc cua 100 tre trai va 94 tre gai tren phim chup dudng tiet nieu co can quang ( khong ke cac benh nhan co cac benh duong tiet nieu bam sinh hoac mac phai) cung tha'y kich thuoc cua nieu quan ft khi ldn hon 5 mm. H inh 4.1. Phinh to nieu quan 51 Dua tren cac nghien cuu nay ngudi ta coi mot nieu quan bi phinh to khi kich thudc cua nieu quan Ion hon 7 mm (1). I. PHAN LOAI Co nhieu each phan loai phinh to nieu quan dua vao hinh thai cua nieu quan va chuc nang cua than(4,5,6). 1.1. Beurton chia phinh to nieu quan thanh 4 muc do: 1A,IB,II va III (4) (hinh 4.2) IA IB II III H inh 4.2 Phan loai phinh to nieu quan theo Beurton Do IA: nieu quan chi gian d vung tieu khung Do IB: nieu quan gian d vung ti£u khung va chau hong nieu quan ngay dudi be than khong gian Do II: toan bo nieu quan gian, cac dai than gian nhung nieu quan khong bi keo dai. Do III: toan bo nieu quan gian, nieu quan dai va bi xo£n van (hinh 1) Phinh to nieu quan la hau qua cua nhieu nguyen nhan. 52 1.2. Smith va cong sir (1977) chia phinh to nieu quan lam 3 loai: - Phinh to nieu quan do trao nguoc - Phinh to nieu quan do tic - Phinh to nieu quan khong do trao nguoc va cung khong do tic. Trong m6i loai tren lai chia thanh tien phat va thir phat (bang 4.1) (5) BANG 4.1. PHAN LOAI QUOC TE VE PHINH TO NIEU QUAN Nguyen nhan Tien ph&t Thirphdt Do tac Tac trong long nieu quan Tac nieu dao hoac nguyen nhan ben ngoai Ket hop vdi tac dudng thoat Do trao nguoc Trao ngudc la di tat duy nhat bang quang hoac bang quang than kinh Khong do trao nguoc, khong do tac gian nieu quan Khong ro nguyen nhan Do qua nhieu nude tieu ( dai dudng) hoac nhiim trung Phan loai quoc te nam 1977 la phan loai chi tiet va d&y du nhung mot so tac gia cho la qua phuc tap de sir dung. 1.3. King chia phinh to nieu quan tien phat lam 4 loai (7) - Phinh to nieu quan khong do trao nguoc, khong do ike - Phinh to nieu quan do tic phan noi nieu quan-bang quang - Phinh to nieu quan do trao nguoc 53 - Phinh to nieu quan do tac doan noi nieu quan-bang quang nhung bi che khuat bdi trao ngupc Trong pham vi bai nay chung toi chi de cap den loai phinh to nieu quan tien phat do tic ca nang phan noi nieu quan bang quang dua theo cac tieu chuan cua Beurton va Kass . Phinh to nieu quan tien phat la gian nieu quan tien thien tren co so bi tac co nang d doan cuoi nieu quan, doan bj tac co dudng kinh hep tao thanh mot vuot nho(radicele). Doan nay cam vao bang quang d vi tri binh thudng tuy dudng kinh nho nhung trong long nieu quan khong co bit tac thuc su nen van cho ong thong qua de dang (hinh 1)(2,4). II. SINH BENH HOC CUA PHiNH TO NI$U QUAN TIEN PHAT DO TAC Nam 1952, Swenson va cong su da cho rang co sir giong nhau giua phinh to nieu quan tien phat va phinh dai trang bam sinh do khong co hach than kinh. Theo ho gian nieu quan co the la do tac churc nang cua doan nieu quan tan cung do so luong hach pho giao cam bi giam xuong d bang quang va doan nieu quan tan cung (8). Tuy nhien Leibowitz da phu nhan gia thuyet nay va cho rang nguyen nhan cua gian nieu quan la do cac khuyet tat tien thien cua ldp co cua thanh nieu quan (9). Binh thudng doan nieu quan ngay sat bang quang co hai ldp co: ldp co doc d trong va ldp co hinh xoan d ngoai. Doan nieu quan chay trong bang quang bao gom cac soi co doc va co rat it hoac khong co cac soi co vdng . Khoang mo lien ket giua cac te bao co hep va chi chua mot so it chat keo (10) Mackinnon khi nghien cuu doan nieu quan tan cung bi cat bo khi mo da thay co thieu hut co cua nieu quan bi hep cung nhu co phi dai bo co doc cua doan nieu quan phia tren vung hep. Cac tac gia nay cho rang vung thieu hut co bam sinh nay la vung 54 khong co nhu dong va "la co che co ban trong benh ly khong gian no nieu quan" (11). Tanago khi nghien curu hang loat cac tieu ban cat ngang cua doan nieu quan tan cung da thay co thanh nieu quan chu yeu bao gom cac spi vong vdi rat it hoac khong co cac soi xoan theo chieu doc trong khi do doan nieu quan phia tren lai co ca hai loai co (12). Gregoir (13) da mo ta ba nhom to chuc hoc cua phinh to nieu quan tien phat do tac dua tren nghien curu 30 trudng hop phinh to nieu quan: - Tham nhidm chat keo day dac d nieu quan tan cung ( da so cac trudng hop). - Phi dai co vong. - Loan san co nieu quan d cac mire do khac nhau. Hanna (14) khi nghien ciru to churc hoc cua doan nieu quan tan ciing va doan gian cua 13 nieu quan bi phinh to, dudi kinh hien vi thudng cac tac gia thay hinh anh to churc hoc cua cac doan nieu quan rat khac nhau tir cau true binh thudng cho den cau true bat thudng ro ret. Mac du vay, dudi kfnh hien vi dien tu, cau true to chuc hoc cua doan nieu quan tan ciing luon luon bat thudng bao gom: - Co qua nhieu sgi keo trong va quanh cac te bao co. - Mot nhom cac te bao co bi hu bien d phia tren doan keo. Nieu quan cang xa doan cuoi thi thi hinh anh to chuc hoc cang lanh manh. Tac gia nay cho rang cac bat thudng ve to churc hoc nay la nguyen nhan gay gian doan chuc nang cua nieu quan va dan den phinh to nieu quan. Pagano khi do thanh phan d spi chun cua nieu quan binh thudng va nieu quan bi gian da thay thanh phan spi chun dudi 55 1% toan bp khoi to chiic d cac nieu quan binh thudng, trong khi do chiem tir 3-5% d cac nieu quan bi gian(15). Tokunaka va cong sir (16) da thay trong da so cac truong hop phinh to nieu quan khong do trao ngupc deu co su xao tron cua co va tang mo lien ket ke d doan nieu quan tan cung va co cau true co blnh thudng cua doan nieu quan phia tren. Cac tac gia nay cung bao cao mot nhom nho phinh to nieu quan khong do trao ngupc vdi cac te bao co bat thudng va tang mo dem kMp doan nieu quan bi gian va hien tuong nay dupe goi la loan san co nieu quan. Cac nieu quan co loan san co khong co hoac co nhu dong kem va thudng kem theo loan san than vdi ty le cao. Ho da tim thay ty le loan san co la 24% trong tong so cac trudng hop phinh to nieu quan khong do trao ngupc va cho thay trong cac trudng hop loan san lan rong, phau thuat tao hinh co the khong co ket qua. Dang chu y la nhieu nghien curu da cho thay cau true to chuc hoc binh thudng hoac gan nhu binh thudng dudi kfnh hien vi thudng nhung dudi kinh hien vi dien tu lai thay co qua nhieu chat keo giua cac te bao co. Chinh nhung rdi loan ve to churc hoc da lam cho doan nieu quan tan cung khong co kha nang co bop binh thudng de day nude tieu xuong bang quang gay ur dong nude tieu va gian nieu quan d phia tren. Benh co the bieu hien muon neu bat thudng to chuc hoc cua doan nieu quan tan cung nhe va co cua doan nieu quan phia tren tuong doi binh thudng nhung khi thanh nieu quan co bat thudng to chuc hoc nghiem trong benh co the biSu hien rat sdm (1). III. BIEU HIEN LAM SANG VA CAN LAM SANG 1. CAC BIEU HIEN LAM SANG Benh gap d con trai nhieu hon con gai , ben trai nhieu hon ben phai, ty le ben trai so vdi ben phai tu 2/1-3/1 (4). 56 Trudc khi co sieu am, nhi6m trung la bieu hien dau tien trong da so trudng hop. Benh nhan co the sot don doc hoac co the kem theo dai due, dai mau,dau lung, dau bung... Cac trieu chung khac nhu u bung, vo nieu cap, suy than ( khi co 1 than) huyet ap cao ft gap (4). Bieu hien lam sang theo mot so nghien cuu dupe trinh bay qua bang (2). BANG 4.2. CAC BIEU HIEN LAM SANG CUA PHINH TO NIEU QUAN Tac gia N h iim trung (%) Dai mau(%) Dau bung (%) ure cao (%) Williams (1970) 73 13 29 11 Pfister (1971) 32 52 42 0 Panago (1977) 90 0 10 0 Pfister (1978) 70 7 5 7 Rabinowitz (1979) 78 17 10 10 Nghien curu 39 benh nhan bi phinh to nieu quan dupe dieu tri tai Vien Nhi tu nam 1992 den nam 2000 chung toi thay cac bieu hien lam sang dupe the hien bang 2 nhom trieu chung chmh (17): - Cac trieu chung cua nhilm trung dudng tiet nieu (sot, dai due) chiem 56,4%. - Cac bieu hien cua tac dudng tiet nieu( nieu quan gian to tham chi co khi bieu hien nhu la motk khoi u bung, than ur nude) chiem 63,8%. 2. CAC PHUONG PHAP CHAN DOAN CAN LAM SANG 2.1. Sieu am Sieu am cho phep xac dinh dupe nieu quan phinh to va phan biet no vdi hoi chung phan noi be than nieu quan. Sieu am cung 57 cho phep danh gia dupe muc do gian dai, be than, tinh trang nhu mo than cung nhu cac di tat cua bang quang. Ngay nay voi viec phat trien nhanh chong cua sieu am trong san khoa, nhieu truong hop phinh to nieu quan tien phat da duoc chan doan nho sieu am trudc de chinh vi vay mot so ldn benh nhan la cac tre so sinh co nieu quan phinh to nhung khong co trieu chung lam sang . 2.2. Chup dudng tiet nieu can quang dudng tinh mach (UIV) UIV van la mot xet nghiem can thiet cung cap cac thong tin ve hinh thai cua nieu quan, chieu dai doan hep va cung cho cac thong tin ve chuc nang cua than. Hinh anh dac hieu la nieu quan phia tren gian to trong khi do doan nieu quan sat bang quang nho gian va tan cung nhu mot r6 cay (hinh 2). Trong cac trudng hop chuc nang than bi suy giam chup UIV co do tin cay kem hon so vdi chup dong vi phong xa. 2.3. Chup bang quang trong khi dai Chup bang quang la mot xet nghiem bat buoc de loai trvr luong trao nguoc bang quang nieu quan, van nieu dao sau, bang quang than kinh va cac trudng hop phinh to nieu quan thu phat do cac nguyen nhan khac. Tuy nhien nen nhd rang su hien dien cua trao nguoc khong hoan toan loai trir kha nang co tac doan cuoi nieu quan phoi hop. Blikman da gap 9 trudng hop co kem theo trao nguoc trong so 75 trudng hop phinh to nieu quan tien phat (18). Dau hieu X quang dac trung cua cac trudng hop nay la nieu quan phia tren gian rat rong ket hop vdi doan nieu quan ngay canh bang quang co dudng kfnh binh thudng, doan nay can tro su thao thoat chat can quang da trao ngupc len doan nieu quan gian(l). Vi vay, tat ca tre co luong trao ngupc bang quang nieu quan va co gian nang cua dudng tiet nieu tren can dupe ki6m tra can than dd phat hien tac doan noi nieu quan - bang quang do 58 phinh to nieu quan tien phat phdi hop. Thuoc can quang til dudng tiet nieu tren dupe thao thoat cham sau khi dai co the la dau hieu chu yeu cua tac phan noi nieu quan-bang quang phoi hop (1). 2.4. Chup hinh than bang dong vi phong xa Chup hinh than bang dong vi phong xa trong khi bai nieu da dupe sir dung d cac tre em bi ur nude be than tfir hon 20 nam nay. Ngay nay ky thuat da dupe phat trien va hoan chinh d mu’c do cao vdi sir h6 trp cua he thdng may trnh. Ket qua dupe cat nghla dua vao do thi dudng cong bieu di6n kha nang thao thoat nude tieu hoac vao thdi gian ban thai. Khong co tac khi thdi gian ban thai <15 phut, co tac khi thdi gian ban thai >20 phut, nghi ngd khi thdi gian ban thai tir 15-20 phut (1). 2.5. Thur nghiem Whitaker Ap lire trong be than co the binh thudng d nhieu benh nhan u nude be than tuy nhien se tang len khi dupe truyen them dich va neu co tac nieu quan . Dua tren nguyen ly nay nam 1973 Whitaker da nghien cuu va pho bien thur nghiem truyen ap luc de chan doan tac doan noi nieu quan-bang quang(19). Tac gia da xac dinh dong nude tieu trong khi bai nieu toi da la khoang 10 ml/phut va vi vay mot nieu quan binh thudng co the chiu dupe toe do truyen lOml/phut ma khong gay nen tang ap luc dang ke trong be than, ngupc lai d benh nhan co dudng tiet nieu bi tac , vdi mot toe do truyen nhu vay se lam tang ap luc trong be than. Tac gia cung thay binh thudng chenh lech ap luc giua be than va bang quang khong qua 15cm nude ngay ca khi dupe truyen vdi toe do lOml/phut, nhung chenh lech ap luc nay se tang len tren 22 cm nude neu co tac. 59 Uu diem cua thur nghiem nay la dich dirpc truyen vao bi than tir he thong ben ngoai vi vay khong bi anh hucmg bdi churc nang than nhirng nhuoc diem la phai luon mot ong thong qua da vao be than vi vay benh nhan c£n phai duoc an than va tham chi phai gay me. III. D l£ u TRI 1. CHI DINH Cac chi dinh phau thuat chung bao gom : - Chuc nang than cung ben bi anh hucmg - Dieu tri bao ton khong co ket qua :chuc nang than tiep tuc giam, nhilm trung ducmg tiet nieu, dau bung. Muc dich cua phau thuat la nham loai bo doan nieu quan tan cung gay tac va trong lai nieu quan phia tren vao bang quang theo co che chong trao ngucfc co hoac khong kem theo tao hinh lam nho bdt dudng kfnh nieu quan. 2. KY THUAT MO Mac du co nhieu ky thuat mo nhung co le ky thuat Hendren duoc cha'p nhan rong rai hon ca (20,21,22).Ky thuat duoc tien hanh nhu sau: Rach da theo dudng Pfannestiel. Boc tach da va to chuc dudi da len sat ron. Md can theo dudng giua vao mat trudc bang quang. Md bang quang theo chieu doc. Tim 16 nieu quan hai ben. Dat mot ong thong so 8 vao nieu quan ben benh. Co dinh ong thong vao mep 16 nieu quan bang mot mui kMu. Rach niem mac vong quanh lo nieu quan. Boc tach nieu quan khoi to chuc xung quanh, giai phong nieu quan len cao ra phia ngoai bang 60 quang cho den doan nieu quan gian.Cat bo doan nieu quan tan cung co dudng kinh nho. Dat mot sondesol2vao long nieu quan. Cat bat nieu quan gian theo chi6u doc tren chieu dai khoang 4 cm. Khau lai nieu quan bang chi tieu 6/0. Tao duong ham dudi niem mac tu 16 nieu quan cu sang phia doi dien. Luon nieu quan ben dudi dudng ham. Co dinh 16 nieu quan mdi vao niem mac xung quanh (hinh 4.3). Mac du mot so tac gia chu truong trong lai nieu quan ben doi dien trong cac trudng hop co luong trao nguoc bang quang-nieu quan mot ben vi nguy co trao nguoc d ben doi dien sau mo cao nhung nghien cull cua Caione cho thay ti le trao nguoc ben doi dien sau mo trong lai nieu quan do tac nieu quan tien phat rat thap vi vay khong can thiet phai trong lai nieu quan ben doi dien (22). Thai do dieu tri doi vdi cac trudng hop phinh to nieu quan tien phat duoc phat hien bang sieu am trudc de van con la mot van de can duoc tiep tuc nghien curu. Oliveira theo doi 8 benh nhan vdi 11 nieu quan bi phinh to duoc phat hien bang sieu am trudc de vdi thdi gian theo doi trung binh la 75 thang da thay dudng kinh nieu quan trung binh la 13,6mm luc mdi sinh giam xuong chi con la 8,4mm d cuoi giai doan theo doi. Tac gia da ket luan di6u tri bao ton an toan cho cac trudng hop phinh to nieu quan tien phat duoc phat hien trudc de nhirng khong co bieu hien lam sang sau khi sinh (24). 61 Hinh 4.3. Ky thuat Hendren A. Cat bo nieu quan hep va edt bdt nieu quan gian theo chieu doc B. Khau lai nieu quan hai lop C. Tao dudng ham dudi niem mac bang quang va dua ni&u quan sang phia doi dien 62 t Ai l ie u t h a m k h Ao 1. KASS EJ. MEGAURETER. IN: KELALIS PP, KING LR, BELMAN AB,EDS. Clinical pediatric urology. Philadelphia:Saunders company, 1992:781-821. 2. CUSSEN U . Dimension of normal ureter in infancy and childhood. Invest urol 11967,5:164-68. 3. HELLSTROM M, HJALMAS K, JACOBSON B, ET AL. Normal ureteral diameter in infancy and childhood. Acta Radiol 11985,26:433-437. 4. BEURTON D. Chirurgie du megaureter obstructif primitif de l’enfant et de l’adult.EMC .Paris 1985,4.11.09:41135-41146. 5. SMITH ED, CUSSEN U , GLENN J,ET AL. Report of working party to establish an international nomenclature for the large ureter. Birth defect 1977,13;3-5 6. GLASSBERG KI. Dilated ureter: classifiction and approach. Urology 1977,9:1-5. 7. KING LR. Megalouretendefinition, diagnosis and management.J Urol 1980,123:22-224. 8. SWENSON O , MAC MAHON E, JACQUES WE.ET AL. A new concept of the etiology of megaloureters. N Engl J Med 1952,2246:41-43 9. LEIBOWITZ S, BODIAN M. A study of the vesical ganglia in children and the relationship to the megaureter megacystis syndrome and Hirschsprung disease. J Clin Pathol 1963,16:342-345. 10. TAN AGO E, PUGH RCB. The natomy and function of the ureterovesical junction. Br J Urol 1963,335:151-1154. T 5 -P T T N T E63 11. MACKINNON KJ, FOOTE JW, WIGLESWORTH FW,ET AL. The pathology of the adynamic distal ureteral segment. J Urol 1970,103:134-136. 12. TAN AGO EJ, SMITH DR,GUTHRIE TH. Pathophysiology of functional ureteral obsstruction. J Urol 1970,104:73-75. 13. GREGOIRE W, DEBLED G. L ’etiologie du reflux congenital et du megaureter primaire. Urol Int 11969,24:119-201. 14. HANNA MJ, JEFFS RD.STURGESS JM,ET AL. Ureteral structure and ultrastructure: Part II. Congenital uretopelvic junstion obstruction and primary obstructive megaureter. 15. PAN AGO F, PASS ERIN I G, CORTIVO R, ET AL. The elastic component of normal and dilated ureters in children :chemical and histochemical characterisation. Br J Uro; 1976,48:13-15. 16. TOKUNAKA S, GOTOH T, KOYANAGIT, ET AL. Muscle dysplasia in megaureters. J Urol 1984, 131:383-385. 17. NGUYEN VU PHUONG, NGUYEN THANH LI EM Dac diem lam sang, can lam sang va ket qua phau thuat phinh to nieu quan tien phat.Tap chi thong tin y duoc so 1/2001:28-32. 18. BLICKMAN JG, LEBOWITZ RL. The coexistence of primary megaureter and reflux. Am J Roentgen 1984,143:1053-1055. 19. WHITAKER RH. Methods of assessing obstruction in dilated ureters. Br J urol 1973,45:15-18. 64 20. KALICINSKI ZH, KANSY J, KOTARBINSKA B, ET AL. Surgery of megaureters-modification of Hendren’s operation. J Pediatr SSurg 1977,12:183-185. 21. STARR A. ureteral plication : a new concept in ureteral tapering for megaureter. Invest urol 1979,17:153-1157. 22. HENDREN WH. operative repair of megaureter in children.J urol 1969,101:491-495. 23. CAIONE P, CAPOZZA N, AS1LLI L, ET AL. is primary obstructive megaureter repair at risk for contrateral reflux? J urol 2000,164:1061 -1063 24. OLIVEIRA EA, D1NIZ JS, RABELO EA,ET AL. Primary megaureter detected by prenatal ultrasonography: conservative management and prolonged follow-up. J urol Nephrol 2000,32:13-18. 65 5 LUONG TRAO NG UO C BANG QUANG-NIEU QUAN TIEN PHAT Luong trao nguoc bang quang - nieu quan (LTNBQNQ) la hien tuong trao nguoc nuoc tiSu tu bang quang vao nieu quan, co th6 len den dai, be than va ca trong than. Benh chiem ty le gan 0,5% 6 tre khoe manh nhung len den tu 13% - 51% 6 cac tre co nhiam khuan duong tiet nieu (1,2). Nho sieu am trudc de ma nhung nghien cuu gan day cho thay ti le LTNBQNQ chiem den 38% tre so sinh (3). 6 nuoc ta cho den nay so benh nhan bi LTNBQNQ duoc phat hien con ft va thuong da d vao giai doan muon (4) Benh duoc Pozzi phat hien lan dau tien d ngudi nam 1893 tren mot benh nhan co trao nguoc nuoc tieu tu bang quang len phan tan cung cua nieu quan sau khi cat than. Co che chong trao nguoc nuoc tieu duoc Young de xuat lan dau nam 1898 (1). Phau thuat di£u tri trao nguoc bang quang - nieu quan duoc Hutch thuc hien thanh cong lan dau tien nam 1952 (3). Cac ky thuat trong lai nieu quan nhu ky thuat Leadbetter-Politano, Pakin. Lich-Gregoire va ky thuat Cohen duoc gidi thieu vao cac nam 1958, 1959, 1961, 1964 va 1975 (5,6,7,8,9,10). Phuong phap di6u tri luong trao nguoc bang tiem Teflon qua noi soi duoc Matouschek gidi thieu lan dau nam 1981 (11). Luong trao nguoc bang quang - nieu quan co the! do cac nguyen nhan tien phat hoac thur phat. Cac nguyen nhan thudng gap la: 66 - Do bat thudng ve phat trien bao thai lam cho doan nieu quan chay dudi niem mac bang quang ngan hon binh thudng (luong trao nguoc tien phat). - Nhi6m khuan man tinh gay phu ne va xoan goc bang quang - nieu quan. - Tdc dudng thoat nude tieu nhu van nieu dao sau, hep nieu dao, xo chit co bang quang. - Bang quang than kinh co doan noi bang quang - nieu quan kem chuc nang va do tang ap luc trong long bang quang. - Do chan thuong phan noi nieu quan - bang quang hoac vung Trigone ngay dudi 16 nieu quan sau phau thuat hoac sau lay soi nieu quan bang noi soi. C) tre em, da so cac trudng hop LTNBQNQ la do nguyen nhan tien phat. I. GlAl PHAU VA SINH LI CUA DOAN NOI NIEU q u An - b An g QUANG Nieu quan chay vao bang quang theo chieu nghieng. Chieu dai doan nieu quan trong bang quang d so sinh dai 0,5 cm va khoang 1,3 cm d ngudi ldn. Ti le giua chieu dai cua doan nieu quan dudi niem macbang quang vdi dudng kfnh nieu quan la 4/1 (12,13,14). Doan nieu quan d ngoai thanh bang quang co ba ldp co: ldp doc d trong, ldp vong d giua va ldp doc d ngoai. Trong thanh bang quang, ldp ao cua nieu quan va ldp co vong tiep tuc phat trien d phfa tren khe nieu quan de hinh thanh tam Waldeyer, gan nieu quan vao khe nieu quan. Tuy nhien su gan bo nay long leo nen khi bang quang dang lap day, khe nieu quan co the truot doc theo nieu quan ra ngoai. Trong long bang quang, ldp co vong bien mat, cac soi co doc tiep tuc chay xuong phfa dudi vuot 67 qua 16 nieu quan vao trong Trigone hinh thanh co cua Trigone va nieu dao sau (15). Phurc hop nay hoat dong nhu la mot don vj chuc nang duy nhat co dinh 16 nieu quan, ngan chan khong cho no di chuyen qua muc. Neu don vi nay bi gian doan thi goc bang quang - nieu quan se bi bat luc va trao nguoc d6 xuat hien (13). Binh thuong nuoc tieu khong the trao nguoc tu bang quang len nieu quan nho mot he thong van chong trao nguoc phuc tap. Nuoc tidu khi den nieu quan duoc tong xuong bang quang nho ap luc trong long nieu quan tao ra boi cac song nhu dong. Trong giai doan lap day bang quang, khi khoi nuoc tieu den khe nieu quan, co bang quang co that keo 16 nieu quan len cao va lam cho doan nieu quan trong bao Waldeyer trong co Detrusor ngdn lai lam cho sue can 6 doan nay giam xuong. Cung luc do chieu dai cua nieu quan duoi niem mac bang quang cung ngan lai nhung dudng kinh lai rong hon nen da cho phep nude tieu tu nieu quan chay xuong bang quang. Khi cac co bop cua nieu quan het di, doan nieu quan trong co Detruso va dudi niem mac tro lai vi tri binh thudng, khi do co che chong trao nguoc thu dong phat huy tac dung ngan chan nude tieu tu bang quang trao nguoc len nieu quan. Trong khi tieu tien co cua vung Trigone va co doc cua doan noi nieu quan - bang quang co bop lam cho 16 nieu quan bi dong kin dong thdi doan nieu quan dudi niem mac cung bi dong kin do ap luc trong long bang quang tang len ep doan cuoi nieu quan vao ldp co cua thanh bang quang. Khi tieu tien xong, ap luc trong long bang quang giam xuong, doan tan cung cua nieu quan md ra cho don cac dot nude ti6u tiep tuc tong xuong (14). Trong LTNBQNQ, bang quang co cau true binh thudng. L6 nieu quan gian rong, nhieu trudng hop do lech sang phia ben. dudng ham dudi niem mac bang quang ngan. Lyon va cong su thay 16 nieu quan co the co 4 hinh thai sau (hinh 5.1) (16): 68 Hinh 5.1. Cac hinh thuc cua 16 nieu quan A. L6 nieu quan binh thucmg B. L6 nieu quan hinh san van dong C. L6 nieu quan hinh mong ngua D. L6 nieu quan hinh 16 gon - L6 nieu quan blnh thucmg hoac hinh non - L6 nieu quan hinh san van dong (stadium) - L6 nieu quan hinh mong ngira - L6 nieu quan hinh 16 gon Nieu quan gian d cac muc do khac nhau. O do 4 va 5, nieu quan tang kich thudc ca ve chidu dai va chieu rong, nieu quan gian to, xo^n van ngo^n ngoeo. O do 1,2 bd than va dai than khong bi anh hudng nhung d do 4 va 5 be than va dai than gian nang. Nhu mo than bi co rut seo hoa d giai doan cuoi do viem than-be than man tinh. II. SINH BENH HOC CUA LUONG TRAO NGUOC BANG QUANG - NIEU QUAN TIEN PHAT Luong trao nguoc bang quang - nieu quan xuat hien khi cac yeu to tham gia vao co che chong trao nguoc co nhung thay doi bat thudng nhu: 1. CHIEU DAl CUA DOAN NIEU QUAN D U 6l NIEM MAC BANG QUANG BI NGAN Nieu quan phat sinh tu doan cuoi cua ong Wolf d ngay phfa tren phan noi vdi o nhdp. Nieu quan cung vdi 16 nieu quan bi cuon vao thanh bang quang khi ong Wolf bi cuon vao xoang tiet nieu sinh due. Khi nieu quan bi cuon vao thanh bang quang sdm, 16 nieu quan n^m d phfa thanh ben bang quang xa dudng giua nhieu hon, do do dudng ham niem mac dudi bang quang ngSn hon lam cho nude tieu de trao nguoc tu bang quang len nieu quan (2). 70 2. VUNG TRIGONE BI LONG LEO Trigone long leo lam cho phan tan cung cua nieu quan khong duoc dong kin nhat la khi bang quang day nude tieu. 3. THIEU HUT CO TRONG NIEU QUAN VA TRONG LC)P CAN WALDEYER Thieu hut co cua nieu quan va ldp c&n Waldeyer gop phan lam cho vung Trigone bj long leo them va lam thay doi hinh dang cua 16 nieu quan. 4. THIEU HUT NANG DO CO CUA DOAN NIEU QUAN TAN CUNG Trong mot so truong hop ngudi ta da thay vung niem mac bang quang quanh 16 nieu quan bi bat thudng, doi khi co nhung tui thua nho (Tui thira Hutch). Do la mot thoat vi niem mac canh 16 nieu quan tao nen phan ngoai bang quang cua nieu quan tan cung. Khi co cac tui thua nay kem theo, thi ti le khoi benh bang dieu tri bao ton rat thap. III. PHAN LOAI Hien nay phan loai quoc te chia luong trao nguoc bang quang-nieu quan lam 5 muc do duoc chap nhan va sir dung rong rai (1,2,12) (hinh 5.2): 71 Hinh 5.2. Phan loai muc do trao nguoc Do I: Chi trao nguoc len nieu quan Do II: Trao nguoc len nieu quan, be than va dai than nhung bei than va nieu quan khong gian, cac nhu dai than binh thuong. Do III: Gian nhe hoac vua d nieu quan va be than nhung cac nhu cua dai than chi tu nhe hoac khong (nieu quan co the bi xotin van kem theo) - Do IV: Gian vira cua ni£u quan, be than, dai than, mat hoan toan goc nhon cua nhu dai than nhung van con an tuong cua nhu than d da so dai than (va hoac kem theo xoan van nieu quan) - Do V: Gian nang nieu quan, be than va dai than, khong con hinh anh cua dai than d hau het cac dai than (nieu quan bi xoan van) IV. HAU QUA CUA LUONG TRAO NGUOC BANG QUANG - NI$U QUAN Luong trao nguoc bang quang - nieu quan co nhung anh hudng co hoc len dudng tiet nieu tren, dong thdi cung la mot yeu to thuan loi gay nhi6m khuan dudng tiet nieu. Neu benh didn bien lau dai se gay cac thuong ton nghiem trong den nhu mo than va anh hudng den su tang trudng cua than. 1. CAC HAU QUA CO HOC Luong trao nguoc gay tang ap lire trong long nieu quan lam cho nieu quan gian rong va dai ra, d cac giai doan cuoi nieu quan bi dai, gian rong va xoan van. Anh hudng cua luong trao nguoc len dudng tiet nieu tren dac biet nghiem trong d thdi ky bao thai va so sinh. Luong trao nguoc cho phep ap luc trong long bang quang duoc truyen tu do len be va dai than. Do ap lire be than khi co trao nguoc cho thay ap lire cao hon binh thudng va tang len cao den 40 mm thuy ngan trong khi dai (17). Ngoai anh hudng don thuan len nieu dong hoc thi tang ap luc do luong trao nguoc co the lam thay doi cung luong va ap luc cua mau den than. 73 2. TRAO NGUOC TRONG THAN VA BENH THAN DO TRAO NGUOC Thuat ngu “Benh than do trao nguoc” (Reflux nephropathy) duoc Baily gidi thieu nam 1973 thay the cho thuat ngu “Viem teo than - be than man tinh” da duoc suf dung tir trudc (18). Tac gia cho rang thuat ngu “Benh than” do trao nguoc la mot thuat ngu thich hap de chi mot tinh trang than bi co rut, seo, teo nho do viem teo than - be than man tinh, khong do tac ma la thu phat do trao nguoc. Thuat ngu benh than do trao nguoc duoc phan ban tiet nieu cua Vien han lam Nhi khoa Hoa Ky su dung co khai niem rong rai hon. Benh than do trao nguoc duoc dung d6 chi than co hinh thai bat thudng do bam sinh hoac mac phai ket hop vdi luong trao nguoc bang quang - nieu quan va thudng co cac hau qua ve lam sang (19). Luong trao nguoc bang quang - nieu quan la nguyen nhan hang dau gay viem than - be than man tinh d tre em. Do la mot su hu bien d khoang cira do viem phat trien thanh timg dam ben canh cac vung lanh, tien trien dan den xo hoa. Nam giua chung la cac cau than nho be, xo hoa hoac bi bo chat trong mot vo Bowman day va cac ong than bi teo. Khi cac thuong ton nay tien tridn hinh thanh cac seo d nhu mo than lam cho vo than bi co rut va teo nho (12). Seo than co the phat hien duoc tren X quang, sieu am, chup dong vi phong xa va chup vi tinh cat ldp. Dau hieu sdm nhat tren chup UIV la giam be day cua vo than. Be day cua nhu mo than la khoang cach giua dudng noi cac dinh cua nhu than, cua dai than va dudng vien cua bong than. Khi seo than hinh thanh ro hon thi dudng vien cua bong than bi loi lorn, cac dai than tuong ung bi det va cuoi cung bi bet han. Seo thudng xuat hien d hai cuc cua than va nhat la d cuc tren (20). 74 Bon hinh thai cua seo than da duoc hoi luong trao nguoc quoc te gidi thieu la (2): - Khong co qua 2 seo than. - Co hon 2 seo than cung voi cac vung nhu mo than day len dang ke. - Toan bo nhu mo than bi mong kem theo gian toan bo dai than. - Than nho vdi chieu day cua nhu mo khong con dang ke. Mac du con co nhung y kien chua thdng nhat v£ co che gay seo than nhung da so y kien deu cho rang luong trao nguoc trong than la co che chinh. Trao nguoc trong than la hien tuong trao nguoc cua nude tieu qua dai than vao he thdng ong gop d benh nhan co luong trao nguoc bang quang - nieu quan (2). Binh thudng cac ong gop do vao non nhu dai than theo mot dudng chech, vi vay khi ap luc be than tang, cac ong nay bi dong lai va ngan chan trao nguoc. Khi hinh thai nhu dai than thay doi se lam cho cac ong gop do vao nhu dai than theo mot dudng thang, co che chong trao nguoc bi mat va xuat hien trao nguoc trong than (2). Rolleston va cong su phat hien thay 20 trudng hop co trao nguoc trong than, tren tong so 386 trudng hop chup bang quang trong khi dai va 13 trong so 20 trudng hop nay da co seo than. Cac seo than da xuat hien dung d noi tren X quang thay co bieu hien cua luong trao nguoc trong than (21). Cac thi nghiem tren Ion da cho thay trao nguoc nude tieu vo khuan lap di lap lai nhieu lan gay nen cac thuong ton cua nhu mo than, nhung chi can mot lan trao nguoc co vi khuan cung du gay hu bien nhu mo than. Robert thay yeu to quyet dinh gay seo than la trao nguoc trong than vdi su co mat cua vi khuan, da gay ra phan ung xuat 75 tiet, giai phong cac goc oxy tir do va cac men tieu protein. Chinh cac yeu to nay da gay xo hoa va seo than (22). Tran nude tieu vao khoang ke co the gay thuong ton than do true tiep gay xo hoac gay phan ung mifen dich chong lai mot loai protein, mot thanh phan binh thudng co trong nuoc tieu do cac te bao bieu mo cua ong than 6 quai Henle va cuoi nephron san xuat ra, protein Tamn - Hofsfall. Cac ky thuat mi6n dich huynh quang da phat hien duoc loai protein nay d ngoai ong than, trong khoang ke cua than d cac benh nhan co luong trao ngupc bang quang - nieu quan va luong trao ngupc trong than (22) 3. LUONG TRAO NGUOC, SUY THAN VA TANG HUYET Ap Luong trao ngupc co the dan den suy than, tuy nhien ty le khong cao. Theo Mathieu, benh ly nay chiem 11% cac truefng hop suy than man tinh noi chung va 16% cac trudng hop can phai chay than nhan tao hoac ghep than d tre em (23). Tang huyet ap dong mach co the xuat hien trong qua trinh tien trien cua luong trao ngupc bang quang nieu quan co ton thuong than hoac xuat hien nhieu nam sau khi luong trao ngupc da dupe dieu tri khoi. Benh than do trao ngupc la nguyen nhan gay tang huyet ap pho bien nhat d tre em va tuoi thanh thieu nien (24). Wallace thay 18,5% tre em bi seo than hai ben va 11,3% bi seo than mot ben xuat hien cao huyet ap sau phau thuat tren 10 nam (25). Co che cua tang huyet ap la do Renin dupe san xuat qua muc. Renin dupe giai phong tir cac nephron ngay canh cac seo than d phan thuy di vao mau tinh mach (26). 76 V. LAM SANG VA CAC TINH HUONG PHAT HIEN Khoang 5% - 10% cac benh nhan bi LTNBQNQ dupe phat hien tinh cd do cac benh khong phai nhidm khuan dudng tiet nieu (27). Luong trao ngupc co the dupe phat hien trong qua trinh lam xet nghiem tham do tong quat do benh nhan co protein nieu, dai mau, roi loan tieu tien, cao huyet ap, suy than, di tat hau mon true trang, IP dai lech thap. Tuy nhien, da so cac trudng hop luong trao ngupc bang quang - nieu quan deu dupe phat hien trong benh canh nhiSm khuan dudng tiet nieu. NhiSm khuan dudng tiet nieu va luong trao ngupc bang quang - nieu quan co lien he chat che vdi nhau. Ti le luong trao ngupc bang quang - nieu quan trong so cac benh nhan bj nhifim khuan tiet nieu la rat cao: 50% d tre nho va 30% d tre ldn. Bi6u hien lam sang thudng phu thuoc vao muc dp trao ngupc va vao tuPi cua benh nhan. Trieu chung khong dac hieu d tre nho. O tre so sinh, bieu hien toan than thudng nang: met thiu, non, ia chay, mat nude, dai ft, rdi loan chuyen hoa, ha nhiet do. Cac rdi loan tieu hoa cung vdi cham tang trudng the chat thudng lai la bieu hien hang dau d tre con bu, nhieu khi benh nhan chi co sot don doc. Cac trieu chirng cua nhidm khuan dudng tiet nieu the hien ro d tre ldn vdi rdi loan tieu tien (dai dat, dai buot, dai kho), dai due hoac dai ra mu, sot cao cung vdi dau vung ha vi, vung mang sudn hoac ho than. Di tieu tien hai lan ke tiep nhau va dau di chuyen ngupc tu ha vi len vung that lung trong hoac ngay sau khi tieu tien dupe coi la trieu chung dac hieu cua luong trao ngupc bang quang - nieu quan (27). Tuy nhien day la trieu chung ft gap d tre nho, thudng chi phat hien dupe d tre ldn va ngudi ldn. De phat hien sdm luong trao ngupc, can phai chup bang quang cho tat ca tre trai co nhilm khuan dudng tiet nieu ngay tu lan dau va cho cac tre gai bi nhidm khuan dudng tiet nieu tai phat. 77 Hien nay vdi nhirng tien bo cua sieu am trudc de, nhieu trudng hop co luong trao nguoc bang quang - nieu quan da dupe phat hien bang sieu am trudc de. Hinh anh sieu am trudc de chu yeu la gian be than va nieu quan, chan doan duoc khang dinh bang chup bang quang sau khi de (28). VI. CAC XET NGHlfiM CAN LAM SANG 1. CHUP BANG QUANG Chup bang quang nieu dao trong khi tieu tien van la xet nghiem chuan de chan doan va phan loai luong trao ngupc. Xet nghiem phai tien hanh sau khi nhilm khuan dudng tiet nieu da dupe kiem soat bdi vi viem bang quang cap tinh lam phu nd doan noi bang quang - nieu quan, lam tang ap luc bang quang tarn thoi, lam giam truong luc va nhu dong cua nieu quan vi vay co the tao nen luong trao ngupc tarn thdi hoac lam thay doi muc do cua luong trao ngupc thuc te da co. Chup bang quang co the tien hanh khi benh nhan tinh neu benh nhan phoi hop hoac co the cho thuoc an than hoac tham chi gay me neu benh nhan khong phoi hop. Chat can quang phai am va dupe bom tir tir vao bang quang qua mot ong nho. Do cao cua binh dich khong qua 100 cm so vdi ban X quang (1). Chup 3 phim d cac thdi diem khac nhau: truoc khi dai, trong khi dai va sau khi dai. Can quan sat chat che trong qua trinh bom thudc vi luong trao ngupc co khi chi xuat hien trong khoanh khac hoac chi xuat hien trong khi dai. Can ghi nhan luong trao ngupc la “bi dong”, xuat hien trong qua trinh lap day bang quang hoac la “chu dong”, xuat hien trong khi dai (12) (hinh 5.3) Can quang d ong than do trao ngupc xuat hien dudi dang nhung vet can quang rat km dao trong mot vung than la bi£u hien cua trao ngupc trong than. Ngay sau khi bang quang xep va nieu quan lai dupe lap day bdi nude tieu trao ngupc d phfa tren, doan noi bang quang - nieu 78