X线引导下输尿管内梗阻双J管的更换方法探讨

Investigation of the replacement of obstructed double J tube in ureter under X-ray guidance

目的探讨X线引导下行输尿管内梗阻双J管更换的可行性及安全性。方法回顾性分析2016年4月至2019年8月所有接受双J管更换术并存在双J管梗阻的44例患者的临床资料。44例中,男性3例,女性41例,年龄27.0~70.0(54.6±11.2)岁,分析距上次双J管置入的时间、经尿道将双J管取出的方法、双J管更换方法、双J管梗阻位置及术后并发症等,并计算手术成功率。根据钙盐在双J管沉积的位置不同,将梗阻双J管分为:膀胱端型、肾盂端型、两端型和全阶段型。不同的双J管梗阻类型,其更换方法不同:剪末端法是应用剪刀剪去双J管膀胱端末端,可见到内部通畅的双J管,经双J管引入导丝至肾盂,更换新的双J管即可,此法仅用于膀胱端型双J管梗阻;细导丝法是将不能通过肾盂端梗阻的普通导丝更换为微导丝,使其通过肾盂端型梗阻的双J管末端或从侧孔穿出,进入肾盂内,撤出原有双J管,即可更换新的双J管,此法适用于肾盂端型双J管梗阻,或联合剪末端法应用于两端型双J管梗阻;辅助鞘管法是以梗阻的双J管作支撑,送血管鞘管至输尿管内,经鞘管送入导丝至肾盂,更换新的双J管。此法适用于所有类型双J管梗阻。结果 44例患者共接受47例次X线引导下双J管更换术。在双J管取出中,应用直接法37例次,应用间接法10例次,双J管取出的总体成功率为100%(47/47)。距离上次双J管置入的时间为(4.2±1.3)个月。23例次为膀胱端型双J管梗阻,8例次为肾盂端型双J管梗阻,5例次为两端型双J管梗阻,11例次为全阶段型双J管梗阻。应用剪末端法更换双J管的成功率为76.0%(19/25);应用细导丝法的成功率为50.0%(2/4);应用辅助鞘管法的成功率为77.8%(14/18)。在剪末端法或细导丝法失败后,4例次又进一步分别应用细导丝法或辅助鞘管法更换,3例次取得成功。双J管更换的总体成功率为80.9%(38/47)。未成功更换双J管的9例次均通过再次行经皮穿刺肾盂造瘘术置入输尿管双J管。44例中,术后发生尿道口疼痛不适4例次,肉眼血尿2例次,均自行缓解。结论 X线引导下输尿管内梗阻双J管更换安全、可行。

Objective To investigate the feasibility and safety of the X-ray guided obstructive double J tube replacement in ureter.Methods The clinical data of 44 patients with double J tube obstruction who underwent double J tube replacement from April 2016 to August 2019 were analyzed retrospectively.Among the 44 cases,there were 3 males and 41 females,aged from 27.0 to 70.0(54.6±11.2)years.The time since last double J tube placement,the method of transurethral remove of double J tube,the method of double J tube replacement,the location of double J tube obstruction and postoperative complications were collected,and the success rate of operation was calculated.According to the different positions of calcium salt deposition in double J tubes,the obstructive double J tubes were divided into bladder end type,renal pelvis end type,two-end type and whole partial type.The replacement method was differentiated according to different types of double J tube obstruction.The cut-off end method was to cut off the obstructed bladder end of double J tube by scissors,and the internal unobstructed double J tube could be seen.The guide wire could be introduced into the renal pelvis through the double J tube,and the new double J tube could be replaced.This method was only used for bladder end type double J tube obstruction.The thine guide wire method was to replace the common guide wire which could not pass through the renal pelvis end obstruction with the microguide wire,so that it could pass through the end of the double J tube of the renal pelvis end obstruction or through the side hole,enter into the renal pelvis,withdraw the original double J tube,and then replace the new double J tube.This method was suitable for renal pelvis end type double J tube obstruction,or combined with cut-off end method for two-end type double J tube obstruction.In the auxiliary sheath method,the obstructed double J tube was used as the support,the vascular sheath tube was sent into the ureter,and the guide wire was sent to the renal pelvis through the sheath tube to replace the new double J tube.This method was suitable for all types of double J tube obstruction.Results A total of 47 X-ray-guided double J tube replacements were performed in 44 patients.In the removal of double J tube,37 cases of direct method and 10 cases of indirect method were used,and the overall success rate of double J tube removal was 100%(47/47).The time from the last double J tube placement was(4.2±1.3)months.There were 23 cases of bladder end type obstruction,8 cases of renal pelvis end obstruction,5 cases of two-end type obstruction,and 11 cases of whole partial type obstruction.The success rate of replacing double J tubes by cut-off end method,thin guide wire method and auxiliary sheath method was 76.0%(19/25),50.0%(2/4)and 77.8%(14/18),respectively.After the failure of the cut-off end method or the thin guide wire method,4 cases were further replaced by the thin guide wire method or auxiliary sheath method,and 3 cases were successful.Therefore,the overall success rate of double J tube replacement was 80.9%(38/47).The double J tubes were inserted by percutanous pyelostomy in 9 patients who failed to replace double J tube successfully.Among the 44 cases,there were 4 cases of urethral orifice pain and discomfort,and 2 cases of gross hematuria,all of which relieved spontaneously.Conclusion It is feasible and safe to replace the obstructive double J tube in ureter under X-ray guidance.