CAJ | 학술논문

背景输尿管结石合并尿脓毒血症所致的血小板减少患者，病情危重，需要急诊引流。如何选择手术方式，保证患者生命安全，对医生是一个很大的挑战。目的探讨对输尿管结石合并尿脓毒血症致血小板减少患者外科手术治疗的有效性和安全性。方法选取本院2011年1月-2013年5月收治的输尿管结石合并尿脓毒血症致血小板减少患者23例，均给予外科手术治疗。手术治疗流程：（1）局麻下急诊试行双 J 管内引流或输尿管导管引流；（2）如不成功者，对中下段结石行急诊输尿管镜下钬激光碎石术，中上段结石行输尿管切开取石手术；对于中重度积水合并脓肾患者行一期经皮肾造瘘术，二期处理输尿管结石；（3）对于严重肾功能不全患者，不能耐受外科手术者，先行急诊透析后再行外科干预；血小板过少有自发性出血倾向者则先输血小板等处理。结果23例患者中，行一期输尿管开放切开取石术3例（13.0%），试行留置双 J 管或输尿管导管20例（87.0%），其中置管失败4例（20.0%），改为一期输尿管镜下钬激光碎石术3例和一期肾造瘘术1例，间隔5~7 d 后行二期经皮肾镜碎石术；置管成功16例（80.0%），间隔7~30 d 后行二期输尿管镜下钬激光碎石术13例、经皮肾镜碎石术2例、腹腔镜下输尿管切开取石术1例。血小板计数在术后1~7 d 恢复至正常，术后3~7 d 血尿消失，术后临床症状不同程度缓解，无麻醉相关并发症，无患者死亡。结论输尿管结石合并尿脓毒血症致血小板减少患者需要急诊处理，准确评估病情，完善术前准备后，微创手术和开放手术均是安全有效的。
배경수뇨관결석합병뇨농독혈증소치적혈소판감소환자，병정위중，수요급진인류。여하선택수술방식，보증환자생명안전，대의생시일개흔대적도전。목적탐토대수뇨관결석합병뇨농독혈증치혈소판감소환자외과수술치료적유효성화안전성。방법선취본원2011년1월-2013년5월수치적수뇨관결석합병뇨농독혈증치혈소판감소환자23례，균급여외과수술치료。수술치료류정：（1）국마하급진시행쌍 J 관내인류혹수뇨관도관인류；（2）여불성공자，대중하단결석행급진수뇨관경하화격광쇄석술，중상단결석행수뇨관절개취석수술；대우중중도적수합병농신환자행일기경피신조루술，이기처리수뇨관결석；（3）대우엄중신공능불전환자，불능내수외과수술자，선행급진투석후재행외과간예；혈소판과소유자발성출혈경향자칙선수혈소판등처리。결과23례환자중，행일기수뇨관개방절개취석술3례（13.0%），시행류치쌍 J 관혹수뇨관도관20례（87.0%），기중치관실패4례（20.0%），개위일기수뇨관경하화격광쇄석술3례화일기신조루술1례，간격5~7 d 후행이기경피신경쇄석술；치관성공16례（80.0%），간격7~30 d 후행이기수뇨관경하화격광쇄석술13례、경피신경쇄석술2례、복강경하수뇨관절개취석술1례。혈소판계수재술후1~7 d 회복지정상，술후3~7 d 혈뇨소실，술후림상증상불동정도완해，무마취상관병발증，무환자사망。결론수뇨관결석합병뇨농독혈증치혈소판감소환자수요급진처리，준학평고병정，완선술전준비후，미창수술화개방수술균시안전유효적。
Background Patients with thrombocytopenia induced by ureteral calculi and urine sepsis are in a critical condition,these severe patients need emergency drainage. Choosing the proper surgical procedures,and ensuring patients safety, are great challenges to doctors. Objective To evaluate the efficacy and safety of surgical management in treatment of patients with thrombocytopenia induced by ureteral calculi and urine sepsis. Methods A total of 23 patients with thrombocytopenia induced by ureteral calculi and urine sepsis who were treated in our hospital from January 2011 to May 2013,were selected as study subjects, all of them received surgical treatment. The course of surgical treatment:emergency double J tube internal drainage or ureteral catheter drainage under local anesthesia;If step 1 was unsuccessful,holmium laser lithotripsy under ureteroscope was used to treat middle - lower ureter,ureterolithotomy was used to treat middle - upper ureter. Patients with moderate to severe hydrops and pyonephrosis received one - stage percutaneous nephrostomy first,then ureteral calculus was treated;Patients with severe renal dysfunction,and patients who can not tolerate surgery,emergency dialysis was used before performing surgery. Platelet transfu-sions were traditionally given to those patients with too few platelets. Results Among 23 cases,3(13. 0% )cases received uret-erolithotomy,among 20(87. 0% )cases who received double J tube internal drainage or ureteral catheter,tube insertion failed in 4(20. 0% )cases,among these 4 cases,3 cases received one - stage holmium laser lithotripsy under ureteroscope,1 case received one - stage percutaneous nephrostomy,they received two - stage percutaneous nephrolithotripsy after 5 - 7 days;Cathe-terization was done successfully in 16(80. 0% )cases,among these 16 cases,7 - 30 days later,13 cases received two - stage holmium laser lithotripsy under ureteroscope,2 cases received percutaneous nephrolithotripsy,1 case received laparoscopic uret-erolithotomy. Blood platelet count went back to normal 1 - 7 days after surgery,hematuresis disappeared 3 - 7 days after surgery, symptoms had improved in varying degrees,anesthesia related complication was not found,and no patient dead. Conclusion Patients with thrombocytopenia induced by ureteral calculi and urine sepsis need emergency treatment,both minimally invasive surgery and open operation are safe and effective on the basis of accurate disease evaluation and careful preoperative preparation.