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摘 要 ：目的：探讨输尿管镜钬激光碎石术并发症发生原因及处理措施.
方法：回顾分析2007年6月～2009年12月共开展输尿管镜钬激光手术242例,出现并发症共37例,发生率15.3%.其中输尿管黏膜撕裂1例,予留置双J管；输尿管穿孔并发腹膜炎1例,予开放手术并置管引流；置镜失败13例中11例改开放手术；术后尿路感染16例；结石上移冲入肾盂3例,1例改行经皮肾输尿管镜钬激光碎石术,1例于肾盂内钬激光碎石,另1例留置双J管,行体外震波碎石治疗；结石残留输尿管3例,1例行体外震波碎石治疗,另2例经随访拔除双J管2周后结石自行排出.
结果：37例均获治愈,未发生二次并发症.
结论：了解输尿管镜钬激光碎石手术并发症的原因,提高操作水平,减少并发症的发生.
关 键 词 ：输尿管镜 钬激光 并发症
The treatment and prevention of plications associated with holmium:YAG laser ureterolithotripsy
Ding Yinman Hu Zhihua Zhang Rentao et al
Abstract:Objective:To study the cause and the resolvent of plications associated with holmiu:YAG laser ureterolithotripsy.
Methods:Review242 ureteroscopy holmium:YAG laser surgery cases from June 2007 to December 2009. 37 cases were found with plications , the rate was 15.3%. one patient suffered with Ureteral mucosa tear who retained to double J tube, one patient with Ureteral surgery was peritonitis and treated with open surgery and laid tube drainage, 11 of the 13 cases which failed with installed mirror changed to open surgery. Postoperative urinary tract infections were found in 16 patients , Stone move up to renal pelvis were found in 3 cases which switched to percutaneous renal ureteroscopy holmium:YAG laser lithotripsy, the renal pelvis holmium:YAG laser lithotripsy and the lien double J tube respectively line extracorporeal shock wae lithotripsy treatment, 3 cases with Residual ureteral stones , 1 routine extracorporeal shock wae lithotripsy treatment,the other two cases followed up by pulling out the double J tube,the stones pass spontaneously after 2 weeks.
Result:37 cases were cured, and did not happen secondary plications.
Conclusion:The skilled operation and strict indication are important for reducing plications.
Keywords:Ureteroscope Holmium laster Complication
【中图分类号】R4【文献标识码】A 【文章编号】1008-1879(2012)07-0019-02
近年来,输尿管镜钬激光技术在泌尿外科的广泛应用促进了微创外科及腔内泌尿外科的发展.2007年6月～2009年12月我院共开展输尿管镜钬激光手术242例,出现各类并发症共37例,发生率15.3%.现予分析总结如下.
1.临床资料
本组患者242例,其中男性150例,女性92例.年龄17～84岁,平均年龄44岁.结石直径0.4～2.6cm,平均0.8cm,输尿管上段结石88例,中段25例,下段129例.23例术前合并尿路感染.所有患者术前均行B超,尿路平片及静脉尿路造影等检查,明确诊断为输尿管结石.40例患者术中探查输尿管结石合并有息肉.均选择输尿管镜钬激光碎石术.
2.方法
采用德国产Wolf 8.0／9.8F输尿管硬镜.科医人公司生产的钬激光机,功率60W,550pm钬激光光纤.采用全麻或硬膜外麻醉,截石体位,双下肢尽量下垂,直视下将输尿管硬镜经尿道进入膀胱,找到患侧输尿管开口,插入超滑导丝或斑马导丝,在导丝引导下采用旋转侧入法将输尿管镜置入输尿管腔内,直视下沿导丝将输尿管镜缓缓推进,到达结石下方,观察结石的大小、与输尿管黏膜关系、结石下方是否存在息肉等情况,是否存在结石嵌顿等.进镜过程中采用人工注水法扩张输尿管,较小结石直接用异物钳夹住随镜缓缓取出；较大结石予钬激光碎石.通常设置碎石功率为1.0J～1.5J、20Hz～30Hz.术中尽可能将结石击碎到直径≤2mm,以利直接被水冲出或术后自行排出.术中发现40例结石合并息肉,均予应用钬激光电灼处理.所有病例碎石后常规留置双J管,予术后2～4周拔除.术后3天内复查尿路平片(KUB),了解碎石效果及双J管位置.242例患者中,出现并发症37例.术中输尿管黏膜撕裂1例,予留置双J管；输尿管穿孔并发腹膜炎1例,予开放手术并置管引流；置镜失败13例中11例改开放手术；术后尿路感染16例；结石上移冲入肾盂3例,1例改行经皮肾输尿管镜钬激光碎石术,1例于肾盂内钬激光碎石,另1例留置双J管,行体外震波碎石治疗；结石残留输尿管3例,1例行体外震波碎石治疗,另2例经随访拔除双J管2周后自行排出.