经皮肾镜取石术后严重出血的介入治疗

Interventional treatment of massive hemorrhage after percutaneous nephrolithotomy

目的 探讨经皮肾镜碎石取石术（PCNL）术后严重出血经保守治疗无效患者的进一步诊断和治疗措施.方法 回顾性分析我院2010年1月至2014年1月收治的经皮肾镜取石术后严重出血的36例患者的临床资料.其中,男21例,女15例,左侧22例,右侧14例,平均年龄46.7岁.严重出血发生于PCNL术后1～7d,平均3～4d,主要表现为经肾造瘘管引流出鲜红色血性液体,同时伴有鲜红色肉眼血尿,均经保守治疗无效后实施介入治疗.结果 36例患者均给予肾动脉CT血管造影（CTA）检查,结果发现22例假性动脉瘤,5例动静脉瘘,予以急诊行数字减影血管造影（DSA）检查＋栓塞治疗并获成功;其余9例未发现明显出血点,考虑为静脉性出血,予以保守治疗成功.栓塞患者术后1～3d尿液及肾造瘘管引流液均逐渐变澄清.术后3个月复诊,上述患者无再次发生出血,肾功能正常.结论 对于PCNL术后严重出血经保守治疗无效的患者,肾动脉CTA检查可作为首选检查项目,DSA检查和栓塞术可作为首选治疗方法.

Objective To explore the diagnostic and therapeutic measures of massive hemorrhage after percutaneous nephrolithotomy （PCNL） unresponsive to conservative treatment.Methods The clinical data of 36 cases of massive hemorrhage occurring after PCNL from January 2010 to January 2014 at our hospital were analyzed.There were 21 males and 15 females with an average age of 46.7 years.There were left （n =22） and right （n =14） cases.Severe hemorrhage had an average onset of Days 3-4 （range,1 to 7） after PCNL.Clinical manifestations included a drainage of fresh red blood liquids out of kidney fistula accompanied by red gross hematuria.Conservative measures were ineffective.Results On computed tomography angiography （CTA）,pseudoaneurysm （n =22） and arteriovenous fistula （n =5） were found.Digital subtraction angiography （DSA） and coil embolization were successfully performed in 27 cases whose hemorrhage stopped in 1-3 days after embolization and kidney function returned to normal.Another 9 cases had no obvious hemorrhage on CTA.And venous hemorrhage was considered and conservative treatment succeeded.Conclusions Renal arterial CTA is an ideal for assessing massive hemorrhage after PCNL unresponsive to conservative treatment.DSA and coil embolization are the preferred treatments.