【摘要】 目的探讨膀胱镜下输尿管支架置入失败或无法置入的恶性输尿管梗阻患者介入治疗策略。方法收集2016年1月到2019年9月因恶性输尿管梗阻行膀胱镜下输尿管支架置入失败患者18例,共22条梗阻输尿管,先采用经皮穿刺肾盂,常规或改良的微导丝贯通技术建立贯通通道,然后利用交换导管导丝技术,逆行置入输尿管支架,对常规及改良法都无法建立微导丝贯通的患者行经皮肾盂造瘘术。结果所有的22条梗阻输尿管均采用介入方法得到了治疗,18例患者22条梗阻输尿管中,常规微导丝贯通术成功18条,4条常规微导丝贯通失败患者,均行改良微导丝贯通术,成功3例,其中2例为膀胱全切术后回肠代膀胱、回肠造瘘患者,均成功放置输尿管支架,1例改良微导丝贯通术通过输尿管重度狭窄段并成功逆行置入输尿管支架,1例改良微导丝贯通失败患者改行经皮肾盂造瘘术。所有微导丝贯通成功患者术后均未见肉眼血尿;术后第7天所有患者肾盂输尿管扩张较术前明显好转,术后第7天患者肌酐水平(88.89±22.19)μmol/L,较术前(233.44±125.63)μmol/L有明显下降,差异有显著统计学意义(T=5.329 P<0.001)。结论对于膀胱镜下输尿管支架置入失败的恶性输尿管梗阻患者,介入术中首先采用经皮穿刺肾盂,利用常规或者改良微导丝贯通技术逆行置入输尿管支架,若无法行微导丝贯通,则行经皮穿刺肾盂造瘘术。综合介入方法能够解除恶性输尿管梗阻患者的梗阻症状,明显降低患者的肌酐水平,改善患者的肾功能,值得推广。更多还原

【Abstract】 Objective To investigate the interventional therapeutic strategy for patients with malignant ureteral obstruction in whom the ureteral stent implantation under cystoscopy failed. Methods The clinical data of 18 patients with malignant ureteral obstruction, in whom the ureteral stent implantation under cystoscopy failed during the period from January 2016 to September 2019, were collected. A total of 22 obstructed ureters were detected. First, percutaneous renal pelvis puncture was performed, which was followed by the establishment of penetrating route with conventional or modified micro-wire penetration techniques, then, the retrograde implantation of ureteral stent was carried out by using catheter-guide wire exchange technique. For the patients, in whom the penetrating route could not be established with conventional or modified method, percutaneous pyelostomy was carried out. Results All the 22 obstructed ureters were treated with interventional method. Of the 22 obstructed ureters in 18 patients, successful ureteral stent implantation with conventional micro-wire linking technology was accomplished in 18, and conventional micro-wire linking technology failed in 4, for these 4 obstructed ureters modified micro-wire penetration technique was adopted and success of treatment was achieved in 3 of them, including two patients with ileal-replaced bladder after total cystectomy or ileostomy, successful modified microcatheter penetration through severe ureteral stricture together with retrograde ureteral stent implantation was achieved in one case,and percutaneous pyelostomy was successfully accomplished in another case. No postoperative gross hematuria was observed in all patients whose obstructed ureters were successful penetrated. Seven days after treatment, the dilatation of the renal pelvis and ureter was improved, and the serum creatinine level was(88.89±22.19) umol/L,which was significantly lower than preoperative(233.44 ±125.63) umol/L, the difference was statistically significant(T=5.329, P<0.001). Conclusion For patients with malignant ureteral obstruction, in whom ureteral stent implantation under cystoscope failed, percutaneous pyelopelvic puncture should be carried out first when interventional treatment is adopted, and the retrograde ureteral stent implantation with conventional or modified micro-wire penetrating technique should be tested. If the micro-wire penetrating technique could not be accomplished, percutaneous pyelostomy should be carried out. Comprehensive interventional method can relieve the obstruction symptoms of malignant ureteral obstruction, reduce the serum creatinine level, and improve the renal function of patients. Therefore, this therapeutic method is worthy of promotion.(J Intervent Radiol, 2020, 29: 694-697)更多还原