数字减影血管造影引导经皮肾穿刺入路联合膀胱镜下输尿管支架置入在妇科手术后医源性输尿管损伤中的临床应用

doi:10.19558/j.cnki.10-1020/r.2019.02.005

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摘要 目的：探讨临床应用数字减影血管造影（DSA）引导经皮肾穿刺入路联合膀胱镜行输尿管支架置入术治疗妇科手术后医源性输尿管损伤的安全性、可行性。方法：收集辽宁省肿瘤医院2015年8月–2017年9月妇科腹腔镜术后单侧输尿管下段损伤、临床出现阴道尿瘘的患者资料（7例,年龄38~62岁）,对所有患者采用DSA引导经皮肾穿刺入路联合膀胱镜置入输尿管支架。置管操作按以下步骤进行：①先尝试经膀胱镜引导将导丝逆行由患侧输尿管膀胱入口通过病损区域;②如果步骤1失败,则由膀胱镜下置入造影导管,标记损伤段以下输尿管,并尝试通过经皮肾盂穿刺顺行开通病损区域;③如果步骤1、2均失败,将顺行入路及逆行入路的导丝均经阴道残端在体外汇合,并沿逆行入路置入交换导管,从体外将顺行导丝置入交换导管,实现病损区域开通。结果：7例患者均成功置入输尿管支架,术后1~3 d阴道漏尿停止。其中步骤1成功0例,步骤2成功者1例,步骤3成功者6例。未见操作相关的感染、支架管移位脱落、大出血等并发症。所有患者随访12个月,术后3个月患者尿瘘均愈合。5例患者接受Ⅱ期输尿管修复手术治疗,术后恢复良好;2例患者拒绝修复手术,定期行膀胱镜下支架导管更换。结论：妇科手术后医源性输尿管损伤的病例中,应用经皮肾盂穿刺入路联合DSA引导膀胱镜下行输尿管支架置入技术可优化操作流程,创伤小,费用低,具有一定的临床应用价值。

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	郑文恒
	于韬
	罗娅红
	毕缓
	张朝赫
	黄焱
	穆中一

关键词 ：经皮肾造瘘术, 医源性输尿管损伤, 膀胱镜, 输尿管支架置入术, 阴道尿瘘, 妇科手术, 数字减影血管造影

Abstract：Objective： To study the safety and feasibility of percutaneous nephrostomy combined with cystoscopy for ureteral stent placement in iatrogenic ureteral injury after gynecological surgery. Methods: Seven cases of ureteral injury after gynecological surgery at the Liaoning Provincial Cancer Hospital from August 2015 to September 2017 (aged 38-62 years) were included. The vaginal urinary fistulae were observed after gynecologic laparoscopic surgery. The operation of percutaneous nephrostomy puncture was performed under ultrasound guidance in all cases, and the operation of guide wire was guided by X-ray fluoroscopy. The surgical procedures were as follows: (1) The wire guided by the cystoscopy was tried to pass through the lesion area of the ureter retrogradely. (2) If the procedure 1 was failed, the catheter was placed under the cystoscope to mark the lesion. Percutaneous nephrostomy puncture was performed and the wire was tried to pass through the lesion area through this pathway. (3) If the procedures 1 and 2 were failed, the wire of the antegrade approach and the retrograde approach was circumscribed out of the body through the vaginal stump, and the catheters were exchanged. After the guide wire passed though the lesion area, the ureteral stent was placed under the cystoscope. Results: The ureteral stents were successfully placed in the 7 cases of ureteral injury, and vaginal leakage stopped after 1-3 days. No complications such as operation-related infection, stent displacement, and severe bleeding were observed. During the follow-up period of 12 months, 5 of them underwent stage II ureter repair surgery and recovered well; 2 patients refused to undergo repair surgery, and stent catheter was replaced under regular cystoscopy every 3 months. No vaginal urinary fistula was seen after 3 months. Conclusions: The operation of ureteral stent placement through percutaneous nephroscopy combined with cystoscopy is safe and minimally invasive method with lower medical expense, and may be useful for iatrogenic ureteral injury.

Key words： percutaneous nephrostomy iatrogenic ureteral injury cystoscopy ureteral stenting vaginal fistula gynecological surgery digital subtraction angiography

收稿日期: 2019-02-11

ZTFLH:

R693

通讯作者: 于韬,yutao@cancerhosp-ln-cmu.com

引用本文:

郑文恒, 于韬, 罗娅红, 毕缓, 张朝赫, 黄焱, 穆中一. 数字减影血管造影引导经皮肾穿刺入路联合膀胱镜下输尿管支架置入在妇科手术后医源性输尿管损伤中的临床应用[J]. 微创泌尿外科杂志, 2019, 8(2): 93-98.
ZHENG Wenheng, YU Tao, LUO Yahong, BI Huan, ZHANG Zhaohe, HUANG Yan, MU Zhongyi. Clinical application of DSA-guided percutaneous nephrostomy combined with cystoscopy for ureteral stent placement in iatrogenic ureteral injury after gynecological surgery. JOURNAL OF MINIMALLY INVASIVE UROLOGY, 2019, 8(2): 93-98.

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