数字减影血管造影在恶性输尿管梗阻治疗中的应用

A comparative study of DSA-guided percutaneous antegrade ureteral stent placement vs. percutaneous nephrostomy in malignant ureteral tract obstruction

目的:回顾性分析无法耐受逆行输尿管支架置入或操作失败的恶性输尿管梗阻患者的临床资料,比较数字减影血管造影(DSA)引导下顺行输尿管支架置入与经皮肾造瘘治疗的临床疗效。方法:收集2014月5月-2018年5月辽宁省肿瘤医院收治的逆行膀胱镜或输尿管镜下输尿管支架置入失败的恶性输尿管梗阻的病例。分别采用DSA引导下经皮顺行输尿管支架置入术(输尿管支架组,32例)与经皮肾造瘘术(造瘘组,39例),统计两组病例血清肌酐指标、术中置管成功率、术后并发症等资料;并进行6个月随访,比较两组肾皮质厚度、血清肌酐值、导管堵塞率、导管更换成功率。结果:两患者均未观察到与操作相关的并发症导致死亡的病例。输尿管支架组中5例患者由于梗阻严重导致导丝未能通过梗阻段,转行肾造瘘,成功率84.3%;造瘘组成功率100%。梗阻伴肾功能不全的病例(42例)中,术后1周血清肌酐水平均较术前有明显改善(P<0.05)。术后随访1个月,输尿管支架组及造瘘组肾皮质厚度较同组术前明显增加(P<0.05);随访3个月,输尿管支架组导管堵塞率为11.6%,高于造瘘组的0%(P<0.05);随访6个月,输尿管支架组导管更换成功率97.7%,高于造瘘组的85.7%(P<0.05)。结论:DSA引导下经皮顺行输尿管支架置入与经皮肾造瘘在治疗恶性输尿管梗阻中均安全、有效,可作为膀胱镜或输尿管镜下逆行输尿管支架置入失败的补充治疗方法。

Objective:To compare the clinical efficacy of anterograde ureteral stent placement vs.percutaneous nephrostomy in the treatment of ureteral obstruction caused by failure of retrograde ureteral stent placement under cystoscope or ureteroscope.Methods:Malignant ureteral obstruction cases admitted to Liaoning Cancer Hospital from May 2014 to May 2018 were collected.All cases failed to insert ureteral stent under retrograde cystoscope or ureteroscope.The patients were divided into ureteral stent group(32 cases)and fistula group(39 cases).The data of serum creatinine index,success rate of catheterization and complications were collected before and after operation.The renal cortex thickness,serum creatinine value,catheter blockage rate and success rate of catheter replacement were com-pared between the two groups after 6 months of follow-up.Results:No operative complications resulted in deaths in 71 patients.Among them,5 patients in ureteral stent group were converted to nephrostomy because of the failure of guide wire opening during operation;the power of ureterostomy was 100%,higher than that of ureteral stent(84.3%,P<0.05);in 42 patients with obstruction and renal insufficiency,the serum creatinine levels in ureteral stent group and ureterostomy group were significantly reduced one week after operation(P<0.05).During the postoperative follow-up period of 1 month,the thickness of renal cortex in both groups was significantly increased as compared with that before operation(P<0.05).During the postoperative follow-up period of 3 months,the catheter blockage rate in the ureteral stent group was 11.6%,significantly higher than that in the nephrostomy group(0,P<0.05).The catheter replacement success rate in the ureteral stent group was 97.7%,and it was 85.7%in the nephrostomy group.Conclusions:Percutaneous anterograde ureteral stent placement and percutaneous nephrostomy are both safe and effective in the clinical application of alleviating malignant urinary tract obstruction,and can be used as a supplementary treatment for the failure of retrograde ureteral stent placement under cystoscopy or ureteroscopy.