微通道经皮肾镜取石术严重出血的原因及治疗策略

Causes and treatment strategies of severe hemorrhage in mini-percutaneous nephrolithotomy

目的:分析微通道经皮肾镜取石术(mPCNL)治疗上尿路结石出现严重出血的原因及治疗策略。方法:回顾分析2016年6月至2023年5月收治的23例mPCNL术后出现严重出血的上尿路结石患者的临床资料。结果:3例(13.04%)为术中出血,其中1例术中因重要血管损伤行肾切除术;20例为术后出血(86.96%)。6例(26.09%)经保守治疗治愈,出血停止时间平均(3.17±1.72)d。16例(69.57%)行选择性介入栓塞治疗,术后出血停止时间平均(2.25±1.66)d,其中13例经1次选择性介入栓塞治疗成功止血,3例经2次选择性介入栓塞治疗后成功止血。4例患者术后出现恶心、腹胀、低热等栓塞后综合征表现。肾动脉血管造影显示肾小动脉分支损伤10例,肾动静脉瘘3例,肾假性动脉瘤3例。结论:mPCNL术中及术后出血是最常见且难以避免的手术并发症,预防严重出血的关键是严格把握手术指征、规范手术操作。轻度出血经保守治疗多可成功止血,保守治疗失败需行选择性肾动脉栓塞术。严格把握介入栓塞治疗时机是成功止血的关键。

Objective:To analyze the causes and treatment strategies of severe hemorrhage in minimally invasive percutaneous nephrolithotomy(mPCNL)for the treatment of upper urinary tract calculi.Methods:Clinical data were analyzed retrospectively in 23 upper urinary tract calculi patients who complicated with severe hemorrhage after mPCNL between Jun.2016 and May 2023.Results:There were 3 cases of intraoperative hemorrhage(13.04%),in which one case was performed nephrectomy due to important vascular injury;20 cases were postoperative hemorrhage(86.96%).6 cases(26.09%)cured after conservative treatment,and the average time of hemostasis in conservative treatment was(3.17±1.72)d.16 cases(69.57%)were treated by selective interventional embolization,and the average time of hemostasis was(2.25±1.66)d after selective embolization,of which 13 cases were cured after one selective embolization,and 3 cases were treated by selective embolization twice.Postembolization syndrome was found in 4 cases,including n ausea,abdominal distension and low fever.Renal artery angiography showed 10 cases of renal arteriolar branch injury,3 cases of renal arteriovenous fistula,and 3 cases of renal pseudoaneurysm.Conclusions:Intraoperative and postoperative hemorrhage is the most common and unavoidable complication of mPCNL.The key to prevention of severe hemorrhage is strict grasping the operative indication and standard surgical procedure during mPCNL.Most mild hemorrhage can be successfully treated by conservative treatment.If conservative treatment fails,selective renal artery embolization should be performed to control hemorrhage.Strict grasping the timing of interventional embolization is the key to successful hemostasis.