经皮肾穿刺造瘘在梗阻性肾积水（脓）中的临床价值

目的：探讨经皮肾穿刺造瘘（PCN）在梗阻性肾积水（脓）中的临床应用价值.方法：对86例肾积水（脓）患者先行超声引导经皮肾穿刺造瘘引流.待肾功能改善、机体状况好转或经引流及造影确定诊断,其中结石引起的肾积水（脓）69例.非结石性肾积水（脓）17例,合并脓肾31例.52例行经皮肾镜取石碎石术,17例行后腹腔镜肾盂、输尿管切开取石术,6例行肾盂切开取石术后加行肾盂输尿管成型术;5例行输尿管狭窄段切除端端吻合术;3例行肾下盏-输尿管吻合术;3例行输尿管皮肤造瘘术.结果：86例患者均穿刺成功,及时解除梗阻,71例患者肾功能恢复正常;9例肾功能改善,维持在轻中度氮质血症水平;6例肾功能无改善.结论：PCN所建立的通道为缓解病情、病因诊断和二期手术打开方便之门,尤其是对急性梗阻性脓肾及结石梗阻性肾积水（脓）的诊治具有重要的应用价值.     

手术治疗上尿路结石并发急性肾功能衰竭46例报告

对４６例上尿路结石并发急性肾功能衰竭患者根据结石部位及病人当时情况分别采取输尿管插管引流，经皮肾穿刺造瘘引流，肾输尿管切开取石，一侧输尿管切开取石对侧经皮肾穿刺造瘘引流及急症输尿管镜取石等不同方法进行治疗，结果除３例术扣发生尿瘘外，均治愈，表明：及时手术治疗解除梗阻有利于此类患者康复。文中还讨论了各种治疗方法的适应证。     

肾后性急性肾功能衰竭的微创治疗

目的:总结腔内微创技术治疗肾后性急性肾功能衰竭的临床经验。方法:对48例不同梗阻原因致肾后性急性肾功能衰竭的患者,采用膀胱镜下逆行插管(3例)、输尿管镜下取石/碎石后置管(35例)引流、经皮肾穿刺造瘘引流(10例)解除梗阻,回顾性分析其治疗效果。结果:48例患者均成功解除尿路梗阻,无一例死亡,无尿瘘、输尿管穿孔、肾出血等并发症。结论:上尿路梗阻是肾后性急性肾功能衰竭的主要原因,应首选输尿管镜技术处理。如处理困难,膀胱镜下逆行插管和经皮肾镜穿刺造瘘引流也是可行的有效方法。     

肾积脓的早期诊治分析(附41例报告)

目的提高脓肾的早期诊治水平,挽救及保护肾功能,减少肾切除率.方法综合应用尿常规、血常规、B超、IVU、肾脏核素显像、CT等检查,诊断脓肾患者41例.男17例,女24例,平均年龄49岁.28例先行经皮肾穿刺造瘘引流再行二期手术,2例行输尿管镜放置双J管引流后行二期手术,10例急诊手术,1例抗感染治疗后行体外冲击波碎石.结果术前无创检查明确诊断为脓肾者31例（75.6%）,经皮肾穿刺造瘘引流发现4例,术中发现6例.行保肾35例（85.4%）,行患肾切除手术6例（14.6%）.37例随访3个月～9年,其中保肾者33例均未因患肾功能恶化而切肾,4例患肾切除者血肌酐正常.结论早期诊断,及时引流,解除梗阻是脓肾保肾治疗的关键.B超在脓肾早期诊断中有重要作用,CT诊断脓肾准确率高.经皮肾穿刺造瘘引流后二期手术,可明显降低肾切除率,合并输尿管上段结石或肾结石者可经原造瘘通道行经皮肾取石术.     

上尿路结石并重度肾积水的处理方法

目的:探讨上尿路结石并重度肾积水的处理方法.方法:对79例上尿路结石并重度肾积水患者,先行患侧经皮肾穿刺造瘘解除梗阻,再根据情况择期行微创经皮肾镜取石术(mPCNL)、输尿管镜气压弹道碎石术(URL)、或开放手术取石及肾切除手术.结果:除肾切除患者外,积水肾功能均获不同程度改善,全部患者症状缓解,痊愈出院.结论:对于上尿路结石并重度肾积水,先行积水肾经皮肾穿刺造瘘,根据结石大小、部位、梗阻程度及肾功能情况,择期选PCNL、URL或开放手术取石,安全性好,疗效确切.     

上尿路结石并重度肾积水的治疗(附56例报告)

目的 探讨上尿路结石并重度肾积水的治疗方法.方法 对56例上尿路结石并重度肾积水患者,先行患侧经皮肾穿刺造瘘解除梗阻,再根据病情择期行微创经皮肾取石术(m PCNL),输尿管镜气压弹道碎石术(URL),切开取石术或肾切除术.结果 除肾切除患者外,积水肾功能明显改善,全部患者症状缓解,痊愈出院.结论 上尿路结石并重度肾积水,先行积水肾经皮肾穿刺造瘘,再根据病情(结石大小、部位、肾功能、全身状况)择期选择适宜手术方式,安全,效果好.     

经皮肾穿刺造瘘在急性肾后性肾衰诊治中的作用

目的:探讨经皮肾穿刺造瘘术在急性肾后性肾衰患者诊治中的作用。方法:回顾性总结28例肾后性急性肾衰的临床资料。14例行ESWL,6例行输尿管镜治疗,开放手术2例,保守治疗4例。在B超引导下肾脏穿刺造瘘25例。结果:24例为上尿路结石引起;14例为功能性孤立肾。引流后2~7天,28例肾功能均恢复正常。本组26例治愈,2例长期留置肾造瘘管,均无造瘘后出血和感染发生。结论:经皮肾穿刺造瘘对急性肾后性肾衰患者挽救肾脏功能有重要价值,B超定位可以显著增加成功率。     

经皮肾穿刺微造瘘输尿管镜治疗上尿路结石

目的 探讨经皮肾穿刺微造瘘输尿管镜治疗上尿路结石的方法及疗效。方法 采用经皮肾穿刺微造瘘输尿管镜下气压弹道碎石处理肾和输尿管结石20例。结果 20例均一期手术取石，单通道取石18例。双通道取石2例；其中1次取石12例，2次取石7例，3次取石1例。15例结石全部取尽，余5例有少许残留。术后行ESWL，结石基本排出。平均手术时间85min，平均出血量50mL，术后平均住院时间8．5d。所有病例均无明显并发症。结论 经皮肾穿刺微造瘘取石术治疗肾及输尿管上段结石具有创伤小、并发症少、疗效好、恢复快等优点，值得推广应用。     

经皮肾镜取石治疗结石性脓肾

目的 探讨微创经皮肾穿刺取石术（MPCNL）治疗结石性脓肾的安全性和有效性.方法 对24例结石性脓肾患者（其中6例为孤立肾并肾功能衰竭患者）,18例先一期行微创经皮肾穿刺造瘘引流,二期经皮肾取石.6例行一期或分期经皮肾钬激光碎石.结果 24例均成功行经皮肾穿刺敛激光碎石,解除梗阻,肾功能均不同程度恢复.无感染性休克、邻近器官损伤等严重并发症,无1例行患肾切除.结论 微创经皮肾穿刺取石安全、有效,可及时解除梗阻,通畅引流,有效控制感染,最大程度恢复肾功能,可作为结石性脓肾首选方法,但应根据具体情况选择一期或二期手术.     

盆腔器官肿瘤浸润或术后放疗致输尿管梗阻的处理

目的探讨盆腔器官肿瘤浸润或术后放疗致输尿管梗阻的诊治方法。方法回顾性分析1990年6月至2000年5月经临床处理的15例本病的临床资料,其中双J管内引流或输尿管导管引流术6例,经皮肾穿刺造瘘术4例。行开放性肾造瘘术3例,输尿管皮肤造瘘术2例。结果本组15例经尿流改道或内引流后全身状况及尿毒症症状很快好转,其中7例肾功能恢复正常,8例肾功能改善。结论B超、输尿管逆行插管和／或磁共振尿路水成像(MRU)检查是较好的诊断手段。输尿管插管引流或双J管内引流和经皮肾穿刺造瘘术。具有损伤小、对患影响轻的优点,是解除梗阻的首选方法。     

Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management

OBJECTIVE: To determine the causes of steinstrasse, methods of prevention and treatment strategies. PATIENTS AND METHODS: Fifty-two patients with steinstrasse were identified and treated: all patients were initially treated conservatively but when there was obstruction, infection or no progression of the stone fragments, further treatment was used, ranging from repeated extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrostomy (PCN), endoscopic manipulations and finally open surgery, depending on the degree of obstruction, infection, renal function and response to each kind of therapy. RESULTS: Conservative management was successful in 25 patients (48%), repeated ESWL in 12 (23%), PCN in 10 (19%), ureteroscopy in three (6%) and open surgery in two (4%). CONCLUSION: As many patients, and particularly those with larger stones, are treated by ESWL, the risk of developing steinstrasse will increase, with associated patient discomfort, infection or impaired renal function. The optimum selection of cases (aiming to pulverize the stones rather than fragment them) and accurate stone targeting are essential to minimise the development of steinstrasse. The meticulous follow-up of patients with steinstrasse should prevent any loss of renal function. When there is obstruction and/or infection or renal damage, active treatment is indicated, of which ESWL and PCN are the most effective, with ureteroscopy and open surgery reserved for difficult cases.     

急性上尿路梗阻性无尿的治疗方法探讨(附58例报告)

目的：探讨急性上尿路梗阻性无尿的应急治疗、病因治疗的方法及效果。方法：对58例确诊为急性上尿路梗阻性无尿患者的应急治疗、病因治疗的方法以及治疗后肾功能恢复情况进行回顾性分析，应急治疗主要为输尿管插管、经皮肾穿刺引流（PCN）、开放性肾造瘘、输尿管腹壁造口和血液透析；病因治疗根据不同病因采取不同方法。结果：应急治疗：39例急诊解除梗阻患者3个月后，24例（61．5％）肾功能恢复正常，12例（30．8％）肾功能明显改善，3例（7．7％）肾功能无改善。病因治疗：27例上尿路结石和4例输尿管狭窄患者成功去除结石和狭窄；14例肿瘤转移侵犯或压迫输尿管和3例腹膜后纤维化患者无法去除病因；3例药物结晶和结核患者均行保守治疗而愈。3例放弃治疗。3个月后，34例（61．8％）肾功能恢复正常，12例（21．8％）肾功能明显改善；9例（16．4％）肾功能无改善。结论：急性上尿路梗阻性无尿的应急治疗顺序依次为输尿管插管、肾造瘘（经皮或开放）及输尿管腹壁造口，尽早解除梗阻可获得较好疗效。上尿路结石、输尿管狭窄、药物结晶、结核等病因可得到解除，腹膜后纤维化、恶性肿瘤等无法去除病因，可行尿流改道。     

恶性肿瘤致输尿管梗阻治疗方法的选择及疗效观察

目的 探讨恶性肿瘤引起的输尿管梗阻治疗方法的选择并观察其疗效.方法 回顾性分析2011年6月至2013年12月中山大学附属第六医院泌尿外科收治的因恶性肿瘤引起的输尿管梗阻患者32例,行逆/顺行输尿管金属支架置入术或经皮肾穿刺造瘘术,分析治疗过程的临床资料.结果 32例患者均先行逆行输尿管金属支架置入手术,成功17例（53.1％）,失败15例（46.9％）,失败15例患者再行顺行输尿管金属支架置入手术,成功10例（66.7％）,失败5例（33.3％）,失败5例患者最后行经皮肾穿刺造瘘术,全部成功.所有患者治疗后临床症状明显改善,肌酐（Cr）,血尿素氮（BUN）及肾盂分离值三种指标均较治疗前有显著性改善（P＜0.05）.经皮肾穿刺造瘘术患者慢性疼痛发生率显著高于输尿管金属支架置入术患者（P＜0.05）.所有患者均无严重并发症.结论 输尿管金属支架逆/顺行置入术或经皮肾穿刺造瘘术治疗恶性肿瘤引起的输尿管梗阻临床疗效满意,可根据不同情况灵活选择术式.     

Therapie der Harnleiterobstruktion

Ureteral obstruction represents a heterogeneous disease pattern and is treated by ureteral stenting or percutaneous nephrostomy (PCN) depending on the necessity. The benefits of urinary diversion with ureteral stenting or PCN in malignant ureteral obstruction (MUO) for patient survival are only moderate. No differences have been found between ureteral stenting and PCN in MUO with regard to median patient survival and complication rates. In cases of MUO there is currently no evidence that urinary diversion improves the quality of life. Alternative concepts of ureteral stenting, such as tandem ureteral stents, metallic ureteral stents or metal mesh ureteral stents have not yet shown clear benefits. In benign ureteral obstruction, prospective randomized studies have demonstrated comparable quality of life after PCN or ureteral stenting. The method of choice for urinary diversion is influenced by the recommendations, personal experience of the clinician and the availability of the method.     

Outcome of percutaneous nephrostomy for the management of pyonephrosis

OBJECTIVE: The aim of this study was to evaluate the efficacy of percutaneous nephrostomy (PCN) drainage for the interim management of pyonephrosis. METHODS: Ninety-two consecutive patients [29 men, 63 women; mean age, 57 years; range, 23 to 88] who underwent PCN for the treatment of pyonephrosis from 1996 to 1999 were evaluated retrospectively. The clinical presentation, bacteriology and patient outcomes were analyzed. RESULTS: The majority [77%] of patients had underlying obstructing urinary calculi. Other causes of obstruction included strictures [9%], papillary necrosis [7%], pelvi-ureteric junction obstruction [4%] and malignant stricture [3%]. The microorganisms cultured were Escherichia coli [30%], Klebsiella [19%], Proteus [8%], Pseudomonas [5%], Enterococcus [5%], and Candida spp [5%]. The microorganisms were sensitive to gentamicin [79%], ceftriaxone [71%], cephalexin [54%], nitrofurantoin [40%], cotrimoxazole [35%], nalidixic acid [32%] and ampicillin [29%]. Only 30% of bladder urine cultures were positive for microorganisms; the addition of PCN cultures improved this yield to 58%. The antibiotic regimen was revised according to the PCN culture whenever there was a discrepancy. After PCN, 69% of patients underwent minimally invasive procedures as definitive treatment of the obstructing lesion. Only 14% of patients required open surgery. There was low procedure-related morbidity [14%] and low overall mortality [2%]. CONCLUSIONS: PCN cultures yield important bacteriological information. The procedure is associated with minimal morbidity, facilitates definitive treatment and provides therapeutic benefit.     

The management of malignant ureteral obstruction treated with ureteral stents

PURPOSE: We developed an algorithm for the management of ureteral obstruction due to malignant extrinsic compression. MATERIALS AND METHODS: We retrospectively reviewed all ureteral stents placed for noncalculous reasons at our institution from January 1, 1990 to January 1, 2004. Further clinical information was gathered from 157 patients with malignant extrinsic ureteral compression. Failure was defined as recurrent ureteral obstruction or an inability to place stents cystoscopically. RESULTS: A total of 157 patients underwent retrograde ureteral stent attempt for malignant extrinsic ureteral obstruction. Mean patient age was 54.7 years (range 23 to 83) and average followup was 13.6 months. Of our patients 61% were women, and the most common cancer diagnoses were ovarian cancer (in 26), lymphoma (17) and cervical cancer (16). A total of 24 patients required immediate percutaneous nephrostomy (PCN) referral. There were 32 patients who experienced a late failure and required PCN (average 180 days after initial stent), and 83 patients in our series (52.9%) who experienced 110 major complications. Type of cancer did not predict need for PCN. However, when invasion into the bladder was noted on cystoscopy, 55.9% (19 of 34, p = 0.008) progressed to PCN referral. A total of 77 patients underwent stent replacement on average 2.8 times and with an interval of 95 days. CONCLUSIONS: In our series patients with malignant extrinsic ureteral compression presenting for ureteral stent(s) experienced a failure rate of 35.7% (56 of 157). Invasion at cystoscopy had a significant predictive value for progression to PCN. We present an algorithm on the management of extrinsic malignant ureteral obstruction.     

The role of percutaneous nephrostomy in malignant ureteric obstruction

OBJECTIVES: Uraemia as a result of malignant ureteric obstruction is a recognised event in those with advanced malignancy, usually of pelvic origin, which, if left untreated, is quickly a terminal event. Palliative decompression of the obstructed urinary system, either by percutaneous nephrostomy (PCN), ureteric stent or a combination of both is a recognised method of improving renal function, with presumed low morbidity. The aims of the study were to assess whether PCN placement in malignant ureteric obstruction provided any additional survival benefit or patient morbidity. PATIENTS AND METHODS: The case notes of 32 patients with a mean age of 68.1 years (16 male, 16 female) who underwent PCN drainage for malignant ureteric obstruction were retrospectively analysed. Data on the site of primary malignancy, mode of presentation, improvement in renal function, median survival, conversion to internal ureteric stents and intervention-related complications were collected for analysis. RESULTS: The median survival following PCN insertion was 87 days and was unrelated to the patient's age and renal function. Those patients with primary underlying gynaecological malignancies appeared to survive almost 4 times as long as those with underlying primary bladder cancer. Renal function took a mean of 16.8 days to reach a nadir. Almost 79% of patients were able to be discharged from hospital--each patient, however, being re-admitted back to hospital on average 1.6 times prior to their death through PCN or internal ureteric stent related events. Retrospective "useful quality of life" was seen in less than half of the patient cohort. CONCLUSIONS: In the presence of malignant ureteric obstruction, palliative percutaneous urinary diversion may be performed and is effective in improving renal function. However, long-term survival is limited and should, therefore, be performed only when the views and wishes of the patient and carers are taken into account and if there is a definitive treatment plan available for the patient as quality of life can be suboptimal.     

A comparative analysis of nephrostomy, JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones.

OBJECTIVES: To determine the optimal method of treatment for ureteric stones causing complete obstruction, treated by insertion of a JJ stent or a nephrostomy tube, followed by extracorporeal shock wave lithotripsy (ESWL) or by urgent in situ ESWL if readily available. PATIENTS AND METHODS: The study comprised a retrospective analysis of 82 consecutive patients who presented with ureteric stones causing complete obstruction. Twenty-six had a percutaneous nephrostomy (PCN, group 1) and 40 had a JJ stent (group 2) placed to relieve the obstruction, and the stones were subsequently treated by ESWL. Sixteen patients underwent urgent in situ ESWL without recourse to either a JJ stent or a PCN (group 3). The choice of the procedure was not determined by stone size, site or other factors, but mainly by the attending surgeon's preference or the availability of urgent ESWL. The success rate was measured by the disintegration of the stone and spontaneous passage after ESWL; failure was defined as the need for additional procedure(s) for stone extraction. RESULTS: Urgent in situ ESWL (group 3) had a median (95% confidence interval) success rate of 81 (54-96)%, compared with 70 (53-83)% in group 2 and 54 (33-73)% in group 1. CONCLUSION: If facilities are available, urgent in situ ESWL appears to be the choice of treatment for obstructing ureteric stones. If such facilities are not available, a JJ stent may offer better success than a PCN. A prospective controlled trial is necessary to confirm these findings.     

Nephrostomy tube or 'JJ' ureteric stent in ureteric obstruction: assessment of patient perspectives using quality-of-life survey and utility analysis.

INTRODUCTION: Upper urinary tract obstruction is often relieved by either a percutaneous nephrostomy tube (PCN) or a ureteric stent. Both can cause considerable morbidity and reduce patient's health-related quality of life (QoL). We have compared the QoL in these 2 groups. PATIENTS AND METHODS: 34 patients (21 stent and 13 PCN) with unilateral ureteric obstruction were prospectively studied. Each patient completed a questionnaire, which included a common single health index (EuroQol EQ-5D) and intervention-specific questions to assess pain, urinary symptoms and day-to-day problems. RESULTS: There were 22 male and 12 female patients [mean age 56+/-9 years (PCN) and 55+/-14 years (stent)]. The mean duration between the intervention and conduct of the survey was 12+/-5 days for PCN and 28+/-14 days for stent. There was no different in the mean EuroQol score (p = 0.199) and analogue score (p = 0.596) indicating no differences in the gross defects in physical and psychosocial function and the utility between the 2 groups. There was a significant difference in the urinary symptoms (p<0.0001) with patients who had a stent experiencing significantly more irritative urinary symptoms. This group also suffered discomfort for a greater duration and in various postures requiring more analgesia (although not significant with Bonferroni correction). Patients with PCN required more help in the daily care of the nephrostomy tube. There was no difference in the incidence of infections and the need for antibiotics. CONCLUSIONS: Patients with 'JJ' stents have significantly more irritative urinary symptoms and a high chance of local discomfort than patients with nephrostomy tubes (PCN). However, based on the EuroQol analysis, there is no significant difference in the gross impact on the health-related QoL or the utility between these groups indicating no patient preference for either modality of treatment.