经皮顺行输尿管软镜在Bricker术后输尿管梗阻中的应用

发布时间：2018-05-24 14:59

本文选题：Bricker术 + 输尿管-肠吻合口狭窄　；参考：《浙江大学》2014年硕士论文

【摘要】：目的：探讨经皮顺行输尿管软镜联合钬激光,球囊扩张导管在Bricker术后输尿管梗阻中的应用价值,为该病的微创处理提供一个新的思路。方法：2010.10-2013.9期间邵逸夫医院收治了5例膀胱全切,Bricker回肠膀胱术后出现输尿管梗阻的患者。5例均为男性,年龄57-77岁,平均64岁,术后8～168个月(平均66个月)出现梗阻。单侧输尿管-回肠吻合口狭窄3例,其中左侧2例,右侧1例,其中1例合并右输尿管中下段结石；双侧输尿管-回肠吻合口狭窄1例,伴双侧输尿管下段结石；右侧输尿管-回肠吻合口完全梗阻(闭锁)1例。术前均在B超或CT引导下行经皮肾穿刺造瘘,置入F8或F12造瘘管引流肾积水2周。通过B超、CT、KUB+IVP.顺行尿路造影检查明确梗阻部位、长度及伴发结石数量。术中用Peel-away筋膜扩张器扩张至F14或F16,通过扩张鞘置入输尿管软镜,输尿管软镜沿输尿管下行至回肠-输尿管吻合处,在梗阻远端用膀胱软镜或输尿管硬镜直视观察下采用顺行结合逆行方式行腔内钬激光碎石,狭窄段内切开联合球囊扩张导管扩张。术后留置F6D-J管于8周后拔除,并定期随访肾积水及结石情况。结果：平均手术时间95min,术中失血5-20m1,术后平均住院天数2.5d。5例患者均一期处理吻合口狭窄或闭锁并留置D-J管,伴发结石者同时处理结石,随访3-18月(平均9月),所有病例肾功能恢复正常,无结石复发,3例术后无肾积水,1例遗留轻度肾积水,1例拔除D-J管4月后肾积水进行性加重,考虑吻合口狭窄复发予膀胱软镜下逆行留置D-J管并予每3月更换D-J管后肾积水明显消退。结论：经皮肾穿刺顺行输尿管软镜联合钬激光及球囊扩张治疗Bricker术后输尿管-肠段吻合口梗阻安全,有效,短期效果确切,可减少创伤,减轻患者痛苦,可望替代开放手术或长期肾造瘘,为该病的微创治疗提供一个新的思路。
[Abstract]:Objective: to explore the value of percutaneous anterograde ureteroscopy combined with holmium laser and balloon dilation catheter in the treatment of ureteral obstruction after Bricker, and to provide a new idea for minimally invasive management of ureteral obstruction. Methods five patients with ureteral obstruction after cystectomy Bricker ileal bladder operation were admitted to run Shaw Hospital from October to March 2010..5 cases were male, aged 57-77 years (mean 64 years). Obstruction occurred in 8 ~ 168 months (average 66 months) after operation. There were 3 cases of unilateral uretero-ileal anastomotic stricture, including 2 cases on left side and 1 case on right side, in which 1 case was complicated with middle and lower ureteral calculi, 1 case had bilateral uretero-ileal anastomotic stoma stricture, 1 case had bilateral distal ureteral calculi. Complete obstruction of right uretero-ileal anastomosis (1 case with atresia). Percutaneous nephrostomy was performed under the guidance of B-ultrasound or CT before operation, and F8 or F12 fistula tube was placed to drain hydronephrosis for 2 weeks. KUB IVP. Anterograde urography was used to determine the location, length and number of stones associated with obstruction. The Peel-away fascia expander was used to expand to F14 or F16 during the operation. The soft ureteroscope was inserted into the ureteroscope through the dilatation sheath, and the soft ureteroscope went down to the ileo-ureteral anastomosis along the ureter. Endovascular holmium laser lithotripsy was performed in the distal part of the obstruction with direct observation of soft cystoscopy or ureteroscopy, and dilatation of balloon dilatation catheter was performed in the narrow segment with anterograde combined with retrograde method of holmium laser lithotripsy. The F6D-J tube was removed after 8 weeks and the hydronephrosis and calculi were followed up regularly. Results: the average operation time was 95 min, the blood loss was 5-20 m ~ (1) during operation, and the average days of hospitalization after operation were 2.5d.5. All patients with anastomotic stoma stenosis or atresia were treated with D-J tube in one stage, and the patients with stones were treated with stones at the same time. All cases were followed up for 3 to 18 months (mean September), all cases recovered normal renal function, 3 cases without recurrence of stone and 1 case with mild hydronephrosis after removal of D-J tube, 1 case had progressive aggravation of hydronephrosis after removal of D-J tube for 4 months. After retrograde indwelling D-J tube under soft cystoscopy and replacement of D-J tube every 3 months, hydronephrosis disappeared obviously. Conclusion: percutaneous renal puncture combined with holmium laser and balloon dilatation is safe, effective and effective in the treatment of uretero-intestinal anastomotic obstruction after Bricker. It can reduce the trauma and alleviate the pain of the patients. It is expected to replace open surgery or long-term nephrostomy and provide a new idea for minimally invasive treatment of the disease.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R699

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