中华泌尿外科杂志
中華泌尿外科雜誌
중화비뇨외과잡지
CHINESE JOURNAL OF UROLOGY
2015年
1期
54-58
,共5页
李俊%何银志%邓观云%旷淼%韩斌%卢俊锦%毛兴会%朱向会%陈唐兵
李俊%何銀誌%鄧觀雲%曠淼%韓斌%盧俊錦%毛興會%硃嚮會%陳唐兵
리준%하은지%산관운%광묘%한빈%로준금%모흥회%주향회%진당병
微创经皮肾镜取石术%右心房%腔静脉
微創經皮腎鏡取石術%右心房%腔靜脈
미창경피신경취석술%우심방%강정맥
Mininimally invasive nephlithotomy%Right atrium%Vena cava
目的 探讨肥胖患者行B超引导下侧卧位微创经皮肾镜取石术(mininimally invasive percutaneous nephrolithotomy,MPCNL)中肾静脉损伤导致造瘘管置入腔静脉、导丝进入右心房的处理方法. 方法 回顾性分析2014年5月收治的1例左输尿管结石左肾积水男性患者的临床资料.年龄30岁.因反复左侧腰部疼痛5年,检查发现左肾结石伴左肾积水入院.患者有大量饮酒史3年,高血压病、糖尿病史6个月.体质指数35.9 kg/m2.查体:血压150/110 mmHg(1 mmHg=0.133 kPa).左肾区叩痛明显.B超检查:左侧肾盂输尿管连接处见约1.5 cm×1.0 cm强光团,后伴声影,左肾中度积水.CT检查:左侧输尿管上段结石伴左肾中度积水,增强扫描左肾皮质CT值100 HU.全麻下行B超引导下侧卧位MPCNL.术中建立经皮肾通道时因出血导致视野不清,留置斑马导丝及肾造瘘管准备二期行MPCNL. 结果 术后第7天复查CT发现导丝位于右心房,肾造瘘管位于腔静脉内达肝门水平.在CT引导下拔出导丝,每次约10 cm,观察5 min,患者无不良反应则再拔出10 cm,共5次将斑马导丝退入肾造瘘管内,将肾造瘘管退至肾分支静脉内距肾盂1 cm处停止,待分支肾静脉穿刺口血栓形成和愈合.术后第9天再次在CT监视下将肾造瘘管退入肾盂内,引流出清亮黄色尿液.术后第14天在全麻下经原通道行MPCNL,于肾盂输尿管连接处寻及约1.5 cm×1.0 cm结石,在输尿管镜下行气压弹道碎石术,检查各肾盏及输尿管上段无残石后,留置双J管及肾造瘘管,术中及术后无血尿,患者无不适.二次手术后3d拔除肾造瘘管.二次手术后1个月拔除双J管,患者无特殊不适. 结论 肥胖患者行B超引导下侧卧位MPCNL时经皮肾通道建立难度大,术中穿刺深度与术前CT检查测量的距离存在误差,易导致损伤.术中肾静脉损伤及肾造瘘管误入腔静脉时,可以通过夹闭造瘘管进行止血.在充分做好抢救准备的前提下,可在CT引导下分次逐步拔除导丝及造瘘管.
目的 探討肥胖患者行B超引導下側臥位微創經皮腎鏡取石術(mininimally invasive percutaneous nephrolithotomy,MPCNL)中腎靜脈損傷導緻造瘺管置入腔靜脈、導絲進入右心房的處理方法. 方法 迴顧性分析2014年5月收治的1例左輸尿管結石左腎積水男性患者的臨床資料.年齡30歲.因反複左側腰部疼痛5年,檢查髮現左腎結石伴左腎積水入院.患者有大量飲酒史3年,高血壓病、糖尿病史6箇月.體質指數35.9 kg/m2.查體:血壓150/110 mmHg(1 mmHg=0.133 kPa).左腎區叩痛明顯.B超檢查:左側腎盂輸尿管連接處見約1.5 cm×1.0 cm彊光糰,後伴聲影,左腎中度積水.CT檢查:左側輸尿管上段結石伴左腎中度積水,增彊掃描左腎皮質CT值100 HU.全痳下行B超引導下側臥位MPCNL.術中建立經皮腎通道時因齣血導緻視野不清,留置斑馬導絲及腎造瘺管準備二期行MPCNL. 結果 術後第7天複查CT髮現導絲位于右心房,腎造瘺管位于腔靜脈內達肝門水平.在CT引導下拔齣導絲,每次約10 cm,觀察5 min,患者無不良反應則再拔齣10 cm,共5次將斑馬導絲退入腎造瘺管內,將腎造瘺管退至腎分支靜脈內距腎盂1 cm處停止,待分支腎靜脈穿刺口血栓形成和愈閤.術後第9天再次在CT鑑視下將腎造瘺管退入腎盂內,引流齣清亮黃色尿液.術後第14天在全痳下經原通道行MPCNL,于腎盂輸尿管連接處尋及約1.5 cm×1.0 cm結石,在輸尿管鏡下行氣壓彈道碎石術,檢查各腎盞及輸尿管上段無殘石後,留置雙J管及腎造瘺管,術中及術後無血尿,患者無不適.二次手術後3d拔除腎造瘺管.二次手術後1箇月拔除雙J管,患者無特殊不適. 結論 肥胖患者行B超引導下側臥位MPCNL時經皮腎通道建立難度大,術中穿刺深度與術前CT檢查測量的距離存在誤差,易導緻損傷.術中腎靜脈損傷及腎造瘺管誤入腔靜脈時,可以通過夾閉造瘺管進行止血.在充分做好搶救準備的前提下,可在CT引導下分次逐步拔除導絲及造瘺管.
목적 탐토비반환자행B초인도하측와위미창경피신경취석술(mininimally invasive percutaneous nephrolithotomy,MPCNL)중신정맥손상도치조루관치입강정맥、도사진입우심방적처리방법. 방법 회고성분석2014년5월수치적1례좌수뇨관결석좌신적수남성환자적림상자료.년령30세.인반복좌측요부동통5년,검사발현좌신결석반좌신적수입원.환자유대량음주사3년,고혈압병、당뇨병사6개월.체질지수35.9 kg/m2.사체:혈압150/110 mmHg(1 mmHg=0.133 kPa).좌신구고통명현.B초검사:좌측신우수뇨관련접처견약1.5 cm×1.0 cm강광단,후반성영,좌신중도적수.CT검사:좌측수뇨관상단결석반좌신중도적수,증강소묘좌신피질CT치100 HU.전마하행B초인도하측와위MPCNL.술중건립경피신통도시인출혈도치시야불청,류치반마도사급신조루관준비이기행MPCNL. 결과 술후제7천복사CT발현도사위우우심방,신조루관위우강정맥내체간문수평.재CT인도하발출도사,매차약10 cm,관찰5 min,환자무불량반응칙재발출10 cm,공5차장반마도사퇴입신조루관내,장신조루관퇴지신분지정맥내거신우1 cm처정지,대분지신정맥천자구혈전형성화유합.술후제9천재차재CT감시하장신조루관퇴입신우내,인류출청량황색뇨액.술후제14천재전마하경원통도행MPCNL,우신우수뇨관련접처심급약1.5 cm×1.0 cm결석,재수뇨관경하행기압탄도쇄석술,검사각신잔급수뇨관상단무잔석후,류치쌍J관급신조루관,술중급술후무혈뇨,환자무불괄.이차수술후3d발제신조루관.이차수술후1개월발제쌍J관,환자무특수불괄. 결론 비반환자행B초인도하측와위MPCNL시경피신통도건립난도대,술중천자심도여술전CT검사측량적거리존재오차,역도치손상.술중신정맥손상급신조루관오입강정맥시,가이통과협폐조루관진행지혈.재충분주호창구준비적전제하,가재CT인도하분차축보발제도사급조루관.
Objective To investigate the management of misguiding the guide wire into right atrium and nephrostomy tube into the vena cava in obese patient with mininimally invasive percutaneous nephrolithotomy under lateral position.Methods In May 2014,the clinic data of one 30 years old male case with left ureter stone and hydronephrosis was retrospectively studied.The patient was admitted to our hospital due to the repeated left flank pain for five years.The left kidney stones and hydronephrosis were found before admission.The patient has the history of alcohol abusing for drinking 3 years.A 6 months history of hypertension and diabetes mellitus were also recorded.His BMI index was 35.9 kg/m2.During physical examination,an obvious left kidney region percussion pain was noticed.The ultrasound examination showed that the high echo region (1.5 cm× 1.0 cm) existed in the left ureteropelvic junction with moderate hydronephrosis.The enhancement CT scan demonstrated the left upper ureteral calculi with moderate hydronephrosis.The CT value of left kidney cortex in enhanced phase was 100 HU.The patient was accepted the general anesthesia and the downlink lateral position MPCNL.During establishing the channel,the bleeding caused the poor vision,which could not continue the operation.Then the zebra guide wire and nephrostomy tube were left for second stage operation.Results 7 days after the operation,the CT scan showed that the guide wire located in the right atrium.And the nephrostomy tube was placed into the vena cava,which located at level of hepatic hilum.Under CT guidance,the guide wire was pulled out about 10 cm at each time and then observed for 5 min.If there was no adverse reaction,the procedure would be repeated.After repeating those procedures for five times,the guide wire was pulled back into nephrostomy tube.Then,the tube was pulled back into branched renal vein,which was 1cm close to the pelvis,and waiting for the thrombosis formation and healing of puncture site in renal vein.9 days post-operatively,the tube was pulled back in the pelvis under the monitoring of CT scan.The drainage of translucent yellow urine achieved successfully.Another MPCNL was performed via original channel under general anesthesia 14 days later.A 1.5 cm× 1.0 cm stone was found in ureteropelvic junction.The EMS lithotripsy was performed.After confirming the free stone in renal calices and upper ureter,the double J stent and nephrostomy tube was left.The nephrostomy tube and double stent were removed 3 and 30 days after the second operation,respectively.No special discomfort was complained from this patient.Conclusions To obese patient,it is difficult to establish the channel during mininimally invasive percutaneous nephrolithotomy under lateral position.The bias between puncture depth and preoperative CT inspection may lead to the injury.Intraoperative renal vein injury and nephrostomy tube into vena cava can be treated by clipping the tube to stop the bleeding.After carefully preparation,the guide wire and tube could be pulled out gradually under CT guided.
