24例输尿管软镜工作鞘放置困难原因分析及对策

Causes and countermeasures for the difficulty in placing the working sheath of flexible ureteroscope:an analysis of 24 cases

目的:探讨输尿管软镜手术时工作鞘置入困难的常见原因及临床处理方法。方法:该院2016年7月至2018年12月行软镜结石手术的235例患者中,对24例出现置入工作鞘困难,患者的临床病例资料进行分析。结果:一期113例输尿管软镜手术,工作鞘置入困难21例,占18.58%(21/113),通过术中技术处理成功19例,2例留置输尿管支架二期手术成功,预留置输尿管支架二期手术122例,置入软镜工作鞘困难3例,占2.45%(3/122)。手术并发症发生率,一期并发症2级以下的10例,3级1例;二期手术并发症1例为1级。有2例尿源性脓毒血症发生在一期术后,3月后复查一期手术结石清除率86.7%,二期结石清除率为93.3%,术后6月随访IVP,一期手术发生输尿管狭窄有2例,二期无输尿管狭窄病例发生。结论:输尿管软镜碎石术前留置输尿管支架可有效减少工作鞘置入困难病例发生,提高手术的安全性和碎石的有效性。

Qbjective:To explore the common causes and treatment of difficult insertion of working sheath in flexible ureteroscopic surgey.Methds:From July 2016 to December 2018,among which 24 cases had the difficulty in placing the working sheath of flexible ureteroscope were analyzed.Results:One-stage flexible ureteroscopic surgery was performed for 113 cases,and there were 21 cases(18.58%,21/113)with the difficulty in placing the working sheath,among which 19 cases were successfully treated by intraoperative techniques and 2 cases were successfully treated by indwelling ureteral stent and second-stage surgery.Second-stage surgery with reserved ureteral stent was performed for 122 cases,among which there were 3 cases(2.45%,3/122)with the difficulty in placing the working sheath.As for the incidence rate of surgical complications,there were 10 cases of grade 1 or 2 complications and 1 case of grade 3 complication in the one-stage surgery,while there was 1 case of grade 1 complication in the second-stage surgery.Two cases of urinary sepsis were observed after the one-stage surgery,and reexamination at 3 months after surgery showed a stone clearance rate of 86.7%in the one-stage surgery and 93.3%in the second-stage surgery.Intravenous pyelography performed at 6 months after surgery showed 2 cases of ureteral stricture in the one-stage surgery,while no case of ureteral stricture was observed in the second-stage surgery.Conclusions:Ureteral stent placement before flexible ureteroscopic lithotripsy can effectively reduce the number of cases with difficulty in working sheath placement and improve surgical safety and stone clearance rate.