鄒毓華 謝昆林△ 張國璽 袁源湖 肖日海 薛義軍 劉佛林 劉全亮 廖云峰 江波 徐瑞權(quán) 徐剛 鄒曉峰
1贛南醫(yī)學(xué)院第一附屬醫(yī)院泌尿外科 江西省尿路結(jié)石現(xiàn)代治療中心 341000 江西贛州
論 著
去頂輸尿管導(dǎo)管在經(jīng)皮腎鏡取石術(shù)中的應(yīng)用
鄒毓華1謝昆林1△張國璽1袁源湖1肖日海1薛義軍1劉佛林1劉全亮1廖云峰1江波1徐瑞權(quán)1徐剛1鄒曉峰1
1贛南醫(yī)學(xué)院第一附屬醫(yī)院泌尿外科 江西省尿路結(jié)石現(xiàn)代治療中心 341000 江西贛州
△共同第一作者
目的:探討去頂輸尿管導(dǎo)管在經(jīng)皮腎鏡取石術(shù)(PCNL)中的應(yīng)用價值。 方法:患者126例,男73例,女53例,年齡 25~72歲,平均43.2歲。左側(cè)65例,右側(cè)53例,雙側(cè)8例。均先在輸尿管鏡下于患側(cè)輸尿管置入導(dǎo)絲,循其留置去頂F5輸尿管導(dǎo)管,后行PCNL。 結(jié)果:126例手術(shù)均順利完成,無輸尿管導(dǎo)管損傷腎實質(zhì)致出血等并發(fā)癥發(fā)生。手術(shù)時間20~100 min,平均60 min。術(shù)中經(jīng)皮腎通道順行留置雙J管74例;循輸尿管導(dǎo)管逆行置入斑馬導(dǎo)絲,在其引導(dǎo)下尋及腎盂開口并順行留置雙J管20例,將斑馬導(dǎo)絲自皮腎通道牽至體外、順行留置雙J管21例,循導(dǎo)絲逆行留置雙J管11例。 結(jié)論:PCNL預(yù)留去頂輸尿管導(dǎo)管安全、便利,有助于提高手術(shù)成功率和縮短手術(shù)時間,值得臨床應(yīng)用。
經(jīng)皮腎鏡取石術(shù);輸尿管導(dǎo)管;雙J管
隨著腔內(nèi)泌尿外科技術(shù)進(jìn)步和相關(guān)器械的研發(fā)應(yīng)用,經(jīng)皮腎鏡取石術(shù)(percutaneous nephrolithotomy,PCNL)已成為微創(chuàng)治療腎臟和輸尿管上段結(jié)石的首選方法[1,2]。該技術(shù)通常需預(yù)先在患側(cè)輸尿管留置輸尿管導(dǎo)管,以便術(shù)中建立人工腎積水及防止結(jié)石碎屑落入輸尿管造成“石街”。我們于2012年7月~2014年7月,對126例上尿路結(jié)石施行PCNL治療時術(shù)中預(yù)留去頂F5輸尿管導(dǎo)管,效果良好?,F(xiàn)報告如下。
1.1 臨床資料
本組126例,男73例,女53例,年齡 25~72歲,平均43.2歲。左側(cè)65例,右側(cè)53例,雙側(cè)8例。腎結(jié)石90例,輸尿管上段結(jié)石27例,腎結(jié)石合并輸尿管上段結(jié)石9例。術(shù)前常規(guī)行B超、腹部平片(KUB)、靜脈尿路造影(IVU)和CT檢查明確診斷。既往有開放性輸尿管上段切開取石術(shù)史9例,腎盂切開取石術(shù)史3例。
1.2 手術(shù)方法
患者于全麻下取截石位。經(jīng)尿道置入Wolf F8/9.8硬性輸尿管鏡,尋及患側(cè)輸尿管開口,逆行插入斑馬導(dǎo)絲。將F5輸尿管導(dǎo)管頭端(盲端)剪去,循導(dǎo)絲逆行留置,留置導(dǎo)尿。改俯臥位。在C臂X線或B超引導(dǎo)下于腋前線和肩胛線間11肋間或12肋下穿刺,建立皮腎通道,留置F18Peel-away鞘或F24金屬鞘,在Wolf F8/9.8輸尿管鏡或Wolf F20.8腎鏡下,采用美國科醫(yī)人60 W鈥激光或瑞士EMS第四代混合動力碎石清石系統(tǒng)碎石[3,4]。術(shù)中腎盂出口尋找困難時,自輸尿管導(dǎo)管逆行插入斑馬導(dǎo)絲至腎盂,幫助指引。術(shù)畢,經(jīng)皮腎通道順行留置雙J管。順行留置困難者,自輸尿管導(dǎo)管逆行插入斑馬導(dǎo)絲并自皮腎通道引出體外,循其順行留置雙J管。腎盂出口難以尋及者,先自輸尿管導(dǎo)管逆行留置斑馬導(dǎo)絲,不改變體位,直接循導(dǎo)絲逆行留置雙J管。留置腎造瘺管。術(shù)后12~24 h行KUB復(fù)查,若無結(jié)石殘留,施行即刻二期不置腎造瘺管的PCNL[5],或于術(shù)后5~7 d拔除腎造瘺管,術(shù)后1個月拔除雙J管。
126例手術(shù)均順利完成,無輸尿管導(dǎo)管插入腎實質(zhì)致出血等并發(fā)癥發(fā)生。手術(shù)時間20~100 min,平均60 min,其中留置輸尿管導(dǎo)管時間3~10 min,平均5.5 min。術(shù)中經(jīng)皮腎通道順行留置雙J管74例;循輸尿管導(dǎo)管逆行置入斑馬導(dǎo)絲,在其引導(dǎo)下尋及腎盂開口并順行留置雙J管20例,將斑馬導(dǎo)絲自皮腎通道牽至體外、順行留置雙J管21例,循導(dǎo)絲逆行留置雙J管11例。1例輸尿管導(dǎo)管術(shù)中無法逆行注入生理鹽水,經(jīng)斑馬導(dǎo)絲疏通后通暢。
目前,PCNL已取代開放性手術(shù)成為復(fù)雜性腎結(jié)石微創(chuàng)治療的首選方法[1,2]。手術(shù)時通常預(yù)先在膀胱鏡或輸尿管鏡下于患側(cè)輸尿管內(nèi)逆行留置輸尿管導(dǎo)管。但是,在實際操作中,可因輸尿管導(dǎo)管插入腎實質(zhì),致人工腎積水失敗及腎實質(zhì)損傷出血。我們在斑馬導(dǎo)絲引導(dǎo)下留置去頂輸尿管導(dǎo)管,上述情況得以避免,保證了手術(shù)后續(xù)過程的順利進(jìn)行。
對腎積水嚴(yán)重或既往有上尿路開放手術(shù)史者,腎盂出口在PCNL術(shù)中常不易尋及;此時可采用經(jīng)輸尿管導(dǎo)管逆行注射亞甲藍(lán)或稀碘伏以幫助尋找,但有時效果不理想。我們于去頂輸尿管導(dǎo)管內(nèi)逆行插入斑馬導(dǎo)絲,鏡下循集合系統(tǒng)內(nèi)導(dǎo)絲尋找腎盂出口。本組即有20例經(jīng)此方法順利尋及腎盂出口。手術(shù)結(jié)束時,患者無須改變體位,直接循導(dǎo)絲留置雙J管,方便快捷。但如此留置的雙J管末端常位于尿道內(nèi),甚至尿道口外。應(yīng)在嚴(yán)格消毒后,男性改平臥位在輸尿管鏡下將雙J管末端推入膀胱,女性則直接用彎血管鉗將雙J管送入。
因部分患者PCNL術(shù)中結(jié)石碎屑可被沖入輸尿管,或因輸尿管上段迂曲、固定,難以順行留置雙J管。須將患者改截石位,行輸尿管鏡檢并取石、留置雙J管。操作過程中可能有結(jié)石碎屑被沖入腎臟內(nèi),需再次改俯臥位,重新消毒、鋪巾,沿原皮腎通道再次取石,導(dǎo)致出現(xiàn)“翻燒餅式”繁瑣操作。本組21例經(jīng)去頂輸尿管導(dǎo)管逆行留置斑馬導(dǎo)絲并將其自皮腎通道引出體外,拔除輸尿管導(dǎo)管后再循導(dǎo)絲順行留置雙J管,術(shù)程簡潔,方便易行。
對于復(fù)雜性腎結(jié)石,由于出血、感染或取石時間長等原因,需及時終止手術(shù),分期取石[6]。在此情況下常難以順行留置雙J管。若僅留置腎造瘺管,術(shù)后為達(dá)止血目的夾閉腎造瘺管時可導(dǎo)致腰痛、發(fā)熱、漏尿等;開放腎造瘺管則出血明顯。我們于去頂輸尿管導(dǎo)管內(nèi)逆行留置斑馬導(dǎo)絲,拔除輸尿管導(dǎo)管,男性患者取平臥位重新消毒尿道口,循導(dǎo)絲逆行留置雙J管。女性患者可不改變體位即可成功留置,方便省時。
術(shù)中輸尿管導(dǎo)管阻塞,常系凝血塊阻塞引起。此時可將輸尿管導(dǎo)管向體外抽出2~3 cm,再用生理鹽水沖洗或斑馬導(dǎo)絲逆行插入即可達(dá)到疏通輸尿管導(dǎo)管的目的。本組1例輸尿管導(dǎo)管術(shù)中無法逆行注入生理鹽水,經(jīng)斑馬導(dǎo)絲疏通后通暢。而復(fù)雜性腎結(jié)石患者若輸尿管條件允許,可放置1根去頂輸尿管導(dǎo)管和1根非去頂輸尿管導(dǎo)管,既能防止結(jié)石碎屑落入輸尿管,又可保證人工腎積水的成功建立。
總之,PCNL術(shù)中預(yù)留去頂輸尿管導(dǎo)管既可防止術(shù)中損傷腎實質(zhì),又可為各種不同情況的處理提供便利,從而提高手術(shù)成功率、縮短手術(shù)時間,值得臨床應(yīng)用。
[1]Cracco CM, Scofone CM, Searpa RM. New developments in percutaneous techniques for simple and complex branched renal stones. Curr Opin Urol, 2011, 21(2): 154-160.
[2]Ghani KR, Sammon JD, Bhojani N, et al. Trends in percutaneous nephrolithotomy use and outcomes in the United States. J Urol, 2013,190(2): 558-564.
[3]鄒曉峰,袁源湖,肖日海,等.小兒尿路結(jié)石的腔內(nèi)微創(chuàng)治療.中華小兒外科雜志, 2007, 28(9): 458-461.
[4]鄒曉峰,黃明,李遜,等.經(jīng)皮腎微造瘺輸尿管鏡取石術(shù)治療上尿路結(jié)石.中華泌尿外科雜志, 2003, 24(10): 693-693.
[5]劉佛林,鄒曉峰,肖日海,等.即刻二期不置腎造瘺管微創(chuàng)經(jīng)皮腎鏡取石術(shù)療效評價.中國內(nèi)鏡雜志, 2012, 18(10): 1050-1053.
[6]鐘辛,徐瑞權(quán),鄒曉峰,等.微創(chuàng)經(jīng)皮腎鏡取石術(shù)出血影響因素的臨床分析.微創(chuàng)泌尿外科雜志,2014, 3(4): 236-239.
Application of decapitating ureteral catheter in percutaneous nephrolithotomy
ZouYuhua1XieKunlin1ZhangGuoxi1YuanYuanhu1XiaoRihai1XueYijun1LiuFolin1LiuQuanliang1LiaoYunfeng1JiangBo1XuRuiquan1XuGang1ZouXiaofeng1
(1Department of Urology, Affiliated Hospital of Gannan Medical University; Institute of Urology, Gannan Medical University, Ganzhou 341000, China)
Corresponding author: Zhang Guoxi, zgx8778@163.com; Zou xiaofeng, gyfyurology@126.com
Objective: To evaluate the clinical value of decapitating ureteral catheter in percutaneous nephrolithotomy (PCNL). Methods: A total of 126 cases including 73 males and 53 females underwent PCNL for upper urinary tract calculi. The mean age was 43.2 years, range 25 to 72. The calculi were found on left side in 65 cases, right side in 53, and both sides in 8. A decapitating ureteral catheter was inserted into the ureter with the guidance of a guide wire. A PCNL was performed in the prone position. Results: All the procedures were successful. There was no complication of the renal injury caused by the decapitating ureteral catheter. The mean operative time for was 60 (range 20 to 100) mins. The antegrade double J stents were directly placed in 74 patients. With the help of the guide wire inserted through the decapitating ureteral catheter, the renal pelvic orifices were found and the antegrade double J stents was successfully inserted in 20 patients, the antegrade double J stents were successfully placed in 21 patients, and the retrograde double J stents were successfully placed in 11 patients. Conclusions: The decapitating ureteral catheter appears to be safe and convenient for PCNL, which can help improve the success rate and reduce the operative time of PCNL. This technique is worthy of popularization and application in PCNL.
percutaneous nephrolithotomy; ureteral catheter; double-J stent
張國璽,zgx8778@163.com;鄒曉峰,gyfyurology@126.com
2014-10-23
R692.4
A
2095-5146(2014)06-354-03
江西省科技廳科技支撐計劃項目(20132BBG70089);江西省“贛鄱英才555工程”領(lǐng)軍人才培養(yǎng)計劃項目;江西省科技廳科技支撐計劃重點項目(2010BSA14500);江西省衛(wèi)生廳重大科技計劃項目(20084010)