经皮肾镜术中上尿路狭窄的处理对策及疗效分析

Treatment Strategy and Curative Effect Analysis of Upper Urinary Tract Stenosis During Percutaneous Nephrolithotomy

目的探讨经皮肾镜术中发现上尿路狭窄的处理对策及疗效分析。方法回顾性分析我院2002年1月-2015年11月经皮肾镜手术6825例资料,术中发现上尿路狭窄84例,其中肾盏颈狭窄37例,肾盂输尿管连接部（ureteropelvic junction,UPJ）狭窄28例,输尿管上段狭窄19例。术中根据狭窄的程度、部位,采用不同的治疗方案,完全闭锁4例及狭窄接近闭锁斑马导丝不能通过者8例,用钬激光或柱状电极打出通道,筋膜扩张器扩张狭窄9例,高压球囊扩张狭窄3例;严重狭窄斑马导丝能通过者45例,直接予以筋膜扩张器扩张34例,高压球囊扩张11例;27例轻度狭窄输尿管镜不能通过者,直接用筋膜扩张器扩张。结果 84例手术均顺利,无中转开放手术。手术时间39～195 min,平均112 min。术中8例集合系统黏膜出血致术野不清,5例盏颈撕裂,2例出血明显终止手术。1例术后出血行超选择肾动脉栓塞。所有患者均痊愈出院。术后随访6个月～3年,平均14个月,治愈71例,有效6例,无效4例,失访3例。结论经皮肾镜术中发现上尿路狭窄,应遵循先处理结石,后处理狭窄的原则,采用内切开、经皮肾镜扩张器或高压球囊扩张是安全有效的方法。

Objective To discuss the treatment strategy and curative effect analysis of upper urinary tract stenosis in the course of percutaneous nephrolithotomy. Methods A total of 6825 cases of percutaneous nephrolithotomy（ PCNL） in our hospital from January 2002 to November 2015 were studied. During the operation,there were 84 cases of upper urinary tract stenosis,including37 cases of renal calyx stenosis,28 cases of ureteropelvic junction obstruction（ UPJO）,and 19 cases of upper ureteral stenosis.According to the location and degree of stenosis,we used different treatments. For 4 cases of complete atresia and 8 cases of near atesia with the Zebra Urological Guidewire failed passing through,a tunnel was made with holmium laser or cylindrical electrode and then the dilatation was completed with a nephroscope dilator in 9 cases or a high pressure balloon in 3 cases. For 45 cases of severe stenosis with the Zebra Urological Guidewire passing through successfully,the dilatation was completed with a nephroscope dilator in 34 cases or a high pressure balloon in 11 cases. For 27 cases of mild stenosis through which a ureteroscope failed to pass through,the dilatation was completed directly with a nephroscope dilator. Results The operations were completed successfully in all the 84 cases. No conversion to open surgery was required. The operation times was 39- 195 min（ mean,112 min）. Intraoperative field was not clear because of mucosal bleeding in 8 cases. Calyx neck rupture occurred in 6 cases. The operation was terminated in 2 cases because of bleeding. There was 1 case of postoperative renal hemorrhage,which was controlled with superselective renal artery embolization. All the patients were cured to discharge. The patients were followed up for 6- 36 months（ mean,14 months）. There were 71 cases of cure,6 cases of effective,4 cases of ineffective,and 3 cases of lost to follow-up. Conclusions To handle with upper urinary tract stenosis in the course of PCNL is complicated. The principle of ＂ stone removal first,stenosis dilatation later＂ should be followed. It is safe and effective to utilize percutaneous nephroscope dilator or high pressure balloon dilatation.