摘要
目的探讨F4.8可视肾镜治疗女性输尿管下段结石合并狭窄的临床疗效和安全性。方法回顾性分析2017年6月至2019年12月武警河南省总队医院收治的32例女性输尿管下段结石合并狭窄患者的病例资料,中位年龄(16~75)(35±10)岁。术前经彩色多普勒超声、静脉尿路造影、CT等检查确诊。结石直径平均(13.0±3.6)(3~20)mm。结石梗阻时间平均(5±17)(2~35)d。单侧输尿管结石27例,双侧输尿管结石5例。所有患者术前均有肾积水,集合系统分离平均(23±15)(15~45)mm。17例术前接受过体外冲击波碎石(ESWL)治疗>2周;6例结石直径<6 mm者接受排石药物治疗>7 d。本组32例均拟行输尿管镜碎石术,术中因输尿管狭窄,输尿管镜(F8/9.8或F6.5/8.5)置镜失败。更换F4.8可视肾镜进行手术。患者取截石位,F4.8可视肾镜接生理盐水,直视下经尿道进入膀胱后,观察输尿管开口情况,21例输尿管开口狭窄,其中8例行输尿管镜手术时造成假道、部分撕脱,F4.8可视肾镜进镜时,利用手控推水压力,配合间断、持续等方式适当加大水流压力,冲开输尿管口和壁内段输尿管后,直接进镜至输尿管管腔。9例为输尿管壁内段走向异常、下段狭窄,F4.8肾镜配合水流压力变化,循管腔缓慢轻柔顺势进入并上行至输尿管管腔。F4.8肾镜通过狭窄处后找到结石,用钬激光将结石粉碎。其中1例钬激光碎石过程中出现结石上移,F4.8肾镜难以触及,留置斑马导丝后退镜并更换F6.5/8.5输尿管镜,在导丝引导下硬性扩张并通过狭窄处输尿管,找到结石并粉碎。2例为输尿管壁内段鸟粪样或泥沙样感染性结石,梗阻重且局部水肿明显,管腔狭窄,斑马导丝无法置入,F4.8可视肾镜进入输尿管,用镜体将梗阻的结石破坏后退镜,结石排入膀胱。碎石结束后留置F4.7双J管和尿管。结果本组32例均一期顺利完成碎石,手术时间平均(35.0±8.7)(15~43)min。住院时间平均5.3(4~7)d。术后3例出现发热,体温>38.5℃,根据血、尿细菌培养结果应用敏感抗生素后体温正常。应用F4.8肾镜手术均未发生输尿管穿孔、假道、撕脱等并发症。术后3 d复查腹部X线片,24例结石排净,8例有结石残留,净石率为75%。术后1个月拔除双J管,复查彩色多普勒超声、静脉尿路造影提示均无结石残留;集合系统分离平均(12±9)(0~35)mm。静脉肾盂造影检查示造影剂均能通过输尿管。结论采用F4.8可视肾镜治疗女性输尿管下段结石合并狭窄安全、有效,在常规输尿管镜进镜困难时可尝试使用。
Objective To evaluate the clinical efficacy and safety of using the F4.8 Visual Puncture Micro-percutaneous nephrolithotomy to treat the female distal calculi associated with stricture.Methods From June 2017 to December 2019,32 female patients with distal ureteric calculi associated with stricture,aged(35.0±10.3)years(range from 16 to 75 years)old,were enrolled into this retrospective study.They were diagnosed by colour doppler ultrasound,IVU(intravenous Urography),or CT,et al.The average stone size was(13.0±3.6)mm in diameter(range from 3 to 20 mm),and the stone obstruction duration was from 2 to 35 days,with average of(5±17)days.Twenty-seven cases were on the unilateral ureter and 5 cases were on the bilateral ureters.There were 17 cases undergoing ESWL 2 weeks before.Six cases of stone diameter less than 6 mm were administered medical therapy for more than 7 days.All the 32 case underwent ureteroscopic lithotripsy but failed because of the ureter stricture.They all suffered from hydronephrosis,with the diameter of renal collecting system from 15 to 45 mm,with(23±15)mm on average.The lithotomy position was taken,and the F4.8 Visual Micro-percutaneous nephrolithotomy using 0.9%Sodium chloride was applied to enter into ureter through urethra.There were 21 cases of ureter orifice stricture,including 8 cases associated with avulsion or perforation,9 cases associated with intramural ureter abnormality and stricture,the zebra guidewire being failed to enter.The F4.8 Visual Micro-percutaneous nephrolithotomy cooperated with water pressure modulation was used to flush and open the ureter orifice and intramural ureter for entering.Holmium lase was used for lithotripsy.Two cases stone were infective and obstructed seriously.F4.8 Visual Micro-percutaneous nephrolithotriptor entered the ureter and destroyed the stones,and the stone fragments were discharged.Stone migrated upward and escaped occurred in 1 case,then the zebra guidewire was indwelled and ureteroscope was used for lithotripsy successfully.All cases were indewelled F4.7 doubld-J tube and urethral catheter after operation.Result All the 32 patients underwent lithotripsy successful by one-stage.The operation time was 15-43 min[averaged(35.0±8.7)min].All patients were recovered and discharged 4-7(averaged 5.3)days after operation.Three patients occured fever,T>38.5℃,and they recovered by using sensitive antibiotics according to the blood and urine culture.No severe complications occurred,such as ureteral perforation or extravasation.All patients were reviewed by ultrasound and KUB 3 days after operation,finding 24 cases with stone free,and 8 cases of a little residual stone,with the stone free rate of 75%.One month later,ultrasound and IVU was performed,and no residual stone was detected,with the stone free rate of 100%.The hydronephrosis alleviated by varying degrees.The diameter of the renal collecting system was from 0 to 35 mm,with(12±9)mm on average.The IVU showed the ureter was unobstructed.Conclusions The F4.8 Visual Micro-percutaneous nephrolithotomy is safe and effective for the female distal calculi associated with stricture,when routine ureteroscopic lithotripsy failed.
作者
张文涛
秦海生
杨胜进
陈俊明
赵胜利
余朝辉
段彩莲
Zhang Wentao;Qin Haisheng;Yang Shengjin;Chen Junming;Zhao Shengli;Yu Zhaohui;Duan Cailian(Department of Urology,Armed Police Forces Hospital of Henan,Zhengzhou 450052,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2021年第6期468-471,共4页
Chinese Journal of Urology
关键词
输尿管结石
可视
肾镜
狭窄
Ureteral calculi
Visual puncture
Nephrolithotomy
Narrow
作者简介
通信作者:张文涛,Email:zhangwt2059@126.com。
