输尿管狭窄疑难病例的输尿管肾镜硬镜下处理技巧

Management skills of intractable ureterostenosis under ureteroscope

目的:探讨输尿管狭窄疑难病例的输尿管硬镜下处理原则与技巧。方法:回顾分析81例输尿管狭窄病例中19例疑难患者的处理情况。19例中包括泌尿系结核所致输尿管多处狭窄、肠道肿瘤与妇科肿瘤压迫致双输尿管狭窄、UPJ狭窄成形术3～12年后吻合口再狭窄、输尿管切开取石术后手术部位狭窄、双输尿管反流伴双输尿管狭窄、肾实质切开取石术后未置双J管致PUJ闭锁、输尿管中上段结石ESWL后3个月输尿管中上段闭锁、肾移植术后输尿管膀胱吻合口狭窄、输尿管末端狭窄行输尿管膀胱吻合术后再狭窄等。病例采用输尿管肾镜硬镜下处理,方法包括:结合使用粗、细输尿管镜,完全依靠输尿管镜本身将狭窄部位扩张;输尿管镜下气囊扩张管将狭窄段扩张;输尿管镜下使用输尿管抓钳将狭窄部位向多个方向撑开;输尿管镜下使用切开刀将狭窄部位切开;输尿管管腔小于最小型号的输尿管镜口径者,输尿管镜下盲插引导导丝后插入F4.5或F3双J管,2～3周待输尿管管径扩张后再用细输尿管镜进入输尿管将狭窄部位扩张并置入较粗双J管或两根双J管。结果:2例未能完成输尿管镜下处理,其条病例成功行狭窄扩张,随访2个月至3年效果良好;3例患者发生穿孔,改变方向后均成功扩张,术后予对症处理,未发生感染及严重血尿,预后较好。结论:输尿管肾镜硬镜下处理输尿管狭窄疑难病例,难度大,在熟练掌握常见输尿管镜下操作基础上,认真、仔细、因人而异地综合应用各种技巧可保证多数病例得到成功处理。

Objective： To discuss the management principles and skills for treatment of intractable ureterostenosis under ureteroscope. Methods： Our management experience on 19 patients with intractable ureteral stenosis was retrospectively analyzed. The 19 cases included urological TB-caused multiple ureteral stenosis, oncothlipsis to ureters from intestinal tract or gynecology, restenosis 3 months to 12 years after pelviureteric junction plasty, operative site stenosis after ureterolithotomy,double ureter back flow accompanied by stenosis, ureter imperforation after renal parenchyma lithotomy without placing double ＂J＂, ureter imperforation 3 months after extracorporeal shock-wave lithotripsy due to ureterolith, tubal bladder stoma stenosis after renal transplantation, restenosis after tubal bladder stoma due to distal ureterostenosis, and so on. All the patients were treated under ureteroscope, The management methods included,, the Wolf 8/9, 8 CH12^＋ and Wolf 6/7.6 CH5^＋ ureteroscope was used as a dilator to dilate the stenoses; balloon expanding under ureteroscope was used to dilate the stenoses; the ureter pliers was used to expand the stenoses to different directions; the cold knife was used to open the stenoses; if the diameter of stenoses were smaller than the that of the ureteroscopes, F4, 5 or F3 double ＂J＂ tubes were inserted guided by a wire under ureteroscope; and 2 or 3 weeks later, a larger tube or two tubes were introduced into the stenoses already dilated partly by the former tube. Results： Ureteroscopic method failed in treating 2 patients in our group and succeeded in treating all the other patients. The outcomes of patient were fine during 2 months to 3 years~ follow-up, Conclusion： It is difficult to treat patients with intractable ureterostenoses. With good experience in manipulation of ureteroscope, the flexible application of several techniques according to the different conditions of different patients can guarantee successful treatment in most patients.