微创经皮肾镜取石术后迟发大出血的原因及防治策略

Cause and management of delayed hemorrhage after minimally invasive percutaneous nephrolithotomy

目的 分析微创经皮肾镜取石（PCNL）术后迟发大出血的原因并探讨防治措施,评价介入栓塞止血的疗效.方法 回顾性分析2004-2009年13例PCNL术后迟发出血患者的临床资料.男10例,女3例.平均年龄47（35～68）岁.其中肾内多发结石8例,肾巨大铸型结石5例.患者出现严重肉眼血尿的时间为术后5～40 d.13例血红蛋白〈80 g/L,其中6例〈60 g/L,分析和总结迟发出血的原因、防治方法及超选择肾动脉造影及栓塞止血治疗的疗效.结果 13例中7例经过绝对卧床休息、止血药物、夹闭肾造瘘管、肾造瘘管球囊压迫牵引等保守治疗10～20 d,出血得到控制;6例经保守治疗无效者行肾动脉造影检查,其中假性动脉瘤4例、动静脉瘘2例,经超选择性栓塞止血治疗1～3 d后血尿逐渐消失.随访3～24个月IVU检查示患肾功能良好.结论 术后迟发性大出血是PCNL严重并发症之一,出血原因为肾穿刺通道的动脉损伤并且形成假性动脉瘤或动静脉瘘,肾动脉造影及超选择肾动脉栓塞是治疗迟发大出血安全有效的方法.

Objective To discuss the cause and management of delayed hemorrhage after minimally invasive percutaneous nephrolithotomy （PCNL）. Methods From 2004 to 2009,there were 13 cases （10 men and 3 women, mean age 47 years） developed severe bleeding following PCNL. The cause of hemorrhage and treatments were retrospectively analyzed and summarized. Results The time of hemorrhage was 5-40 d. In 7 of 13 cases, the bleeding were was controlled by complete bed rest,hemostatic,balloon compression and clamped nephrostomy tube. Six of 13 underwent selective renal arteriography after ineffective with conservative treatment. The DSA showed 4 were false aneurysm and 2 were arteriovenous fistula. All the 6 cases were treated by the super-selective arteriolar embolization. The hematuria was disappeared 1- 3 d later. The intravenous pyelogram revealed the renal function kept well during follow-up visit. Conclusions Delayed hemorrhage is one of the severe complications, which may be caused when the renal puncture passage established as forming false aneurysm and arteriovenous fistula. The renal arteriography and super-selective arteriolar embolization could be a safe and effective treatment for the severe hemorrhage after PCNL.