B超定位下经皮肾造瘘术并发肾静脉损伤三例报告

Renal vein trauma in the echo-guide percutaneous nephrostomy（3 cases report）

目的总结经皮肾造瘘术（PCN）中肾静脉损伤的处理方法。方法PCN术中发生肾静脉损伤3例。男2例，女1例。年龄分别为43、55及72岁。例1因左肾鹿角形铸型结石行左肾经皮肾镜取石术（PCNL），术中穿刺扩张后出现大出血，留置肾造瘘管并夹闭。CT检查提示肾造瘘管进入下腔静脉，并通过右心房进入右颈内静脉。例2因右肾下盏结石行右肾PCNL，B超定位穿刺成功后有少量出血，扩张至16F鞘后出现大出血，KUB示肾造瘘管进入肾静脉。例3因胃癌晚期肿瘤侵犯双侧输尿管，导致双肾积水、肾衰竭，行右肾PCN术引流尿液。穿刺后出现静脉性出血，放置肾造瘘管并夹闭，KUB示肾造瘘管部分进入下腔静脉。3例患者术后48h内在X线监视下逐次将肾造瘘管退至肾静脉破口处，24-48h后再退至集合系统。每次退管3～4cm。结果3例出血均控制，血液动力学状态稳定。拔管后均未出现再出血，未行外科手术干预，未出现肾功能进一步损害。结论PCN术中肾静脉损伤及其导致的严重静脉性出血可以通过留置并夹闭肾造瘘管，分次逐渐退出肾造瘘管而愈合。该方法可以避免外科手术干预，不会对患肾功能造成进一步损害。

Objective To discuss the management of renal vein trauma in the percutaneous nephrostomy （PCN） procedure. Methods Three cases with renal vein trauma by PCN or malposition of nephrostomic catheter were reviewed. Case 1 was a patient with staghorn calculi. There was massive hemorrhage after the puncture and the dilatation during PCN. Then the nephrostomy catheter was clamped. The post-operative CT scan showed the nephrostomy catheter passed the inferior vena cava to the right external jugular vein. Case 2 was a patient with a 3 cm calculus in the inferior calice of the right kidney. A massive haemorrage occurred after the dilatation by the 16 F sheath guided by ultrasound during PCN. The nephrostomic catheter was found in the renal vein by X-ray film. Case 3 was a patient with bilateral hydronephrosis complicating chronic renal failure, which caused by the metastatic of the gastric carcinoma. After the puncture, the massive hemorrage appeared and a nephrostomic catheter was placed and then clamped. The catheter was seen in the renal vein confirmed by the X-ray. For all 3 patients, the catheter was withdrawn carefully monitored by the X-ray until the place of the renal vein perforation during the first 24--48 h. Then it was withdrawn 3 to 4 cm each time un- til reach the pelvic. Results The hemorrhage was well controlled and nobody needed the surgical in- tervention. There was no renal function aggravation in these 3 patients. Conclusions The renal vein trauma during the echo-guide PCN procedure can be treated by clamping the nephrostomy catheter and withdrawing it gradually. Thus, the surgical intervention can be avoided and this method will not impair the renal function.