恶性输尿管梗阻的综合介入治疗18例

【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。     

Self-expanding metal stents for palliative treatment of malignant ureteral obstruction.

OBJECTIVE. We studied the immediate and long-term efficacy of the Wallstent device in the treatment of ureteral obstruction caused by malignant disease. SUBJECTS AND METHODS. In 23 patients (30 ureters), self-expanding metal stents were implanted endoscopically (n = 23), percutaneously (n = 5), or bidirectionally (n = 2) because of extrinsic malignant ureteral obstruction. Patients who met the following criteria were selected for stent implantation: (1) life expectancy of at least 6 months, (2) current polychemotherapy, (3) increasing levels of serum creatinine, and (4) severe clinical signs and symptoms associated with hydronephrosis. Obstruction was diagnosed by using sonography and excretory urography. After radiologic localization and dilatation of the stenosis, the Wallstent device was inserted. For 4 weeks, a double-J catheter inserted through the stent was kept in place in order to prevent obstruction by reversible hyperplastic reaction of the urothelium. Patients were followed up for 31 weeks (range, 3-75 weeks). Follow-up included sonography, excretory urography, and determination of serum levels of creatinine in all cases and furosemide scintigraphy and the Whitaker test in selected cases. RESULTS: Implantation of the Wallstent device was successful in 30 (97%) of 31 cases attempted. The survival rate was 81% after 6 months and 61% after 8 months. The primary patency was 83% after 30 weeks. Complications were macrohematuria (one patient) and incrustation (two patients). No infection and no migration or compression of the stent were observed. CONCLUSION. Implantation of a Wallstent device is a safe and effective alternative to double-J catheter placement in tumor-associated ureteral obstruction.     

Cutting Balloon angioplasty for the treatment of haemodyalisis vascular accesses: midterm results

PURPOSE: The purpose of this study was to assess the effectiveness of Cutting Balloon angioplasty in the treatment of stenoses in haemodialysis arteriovenous accesses. MATERIALS AND METHODS: Over the past 2 years, we have observed 80 patients with stenotic haemodialysis accesses; 24 of these (mean age 66.4 years, range 50-81) with 26 stenoses of 24 accesses (21 Cimino-Brescia fistulas and 3 dialysis loops) were selected for Cutting Balloon angioplasty. In 11 cases, the Cutting Balloon device was used after failure to dilate the access with a high-pressure balloon whereas in 15 cases (10 focal stenoses and 5 restenoses), it was used as a first choice. Two Cutting Balloon devices had a diameter of 8 mm, two of 7 mm, 11 of 6 mm, eight of 5 mm and one of 4 mm. The follow-up was performed by colour Doppler ultrasound (CDUS) and clinical assessment at 1, 3, 6, 12, 18 and 24 months. RESULTS: In all patients, postprocedure angiography demonstrated immediate technical success. No periprocedural complications occurred. Follow-up examinations (range 3-24 months, mean 18.2 months) demonstrated patency of the vascular access and its good functioning during dialysis in 23/24 cases (95%). Only in one case did we observe a haemodynamically significant restenosis, which was treated again with Cutting Balloon angioplasty. CONCLUSIONS: Cutting Balloon angioplasty is safe and effective in the treatment of haemodialysis access stenosis, especially in cases of severe stenosis, with low restenosis rate both in the short and medium term.     

Direct percutaneous ureteral approach for the treatment of ureteral stenosis or obstruction.

Two cases are presented in which conventional approaches did not permit dilation of and stent placement in obstructed ureters. In patients with iatrogenic ureteral laceration or rigid ureteral kinking, direct percutaneous translumbar puncture may provide a safe alternative. The authors' technique is described.     

Maintaining quality of life after palliative diversion for malignant ureteral obstruction

The records of 71 consecutive patients who underwent percutaneous nephrostomy for malignant ureteral obstruction were reviewed. The average post-nephrostomy survival time was seven months, of which 25% was spent in the hospital. When comparing these figures to older studies of open nephrostomy, the percutaneous procedure is associated with less morbidity and an increased percentage of time spent at home (75% compared to 36%). Long-term survival, however, is still poor, with only 25% of patients alive at one year. We suggest that the criteria previously adopted for open nephrostomy generally remain appropriate for patients being considered for percutaneous urinary diversion.     

Maintaining quality of life after palliative diversion for malignant ureteral obstruction

The records of 71 consecutive patients who underwent percutaneous nephrostomy for malignant ureteral obstruction were reviewed. The average post-nephrostomy survival time was seven months, of which 25% was spent in the hospital. When comparing these figures to older studies of open nephrostomy, the percutaneous procedure is associated with less morbidity and an increased percentage of time spent at home (75% compared to 36%). Long-term survival, however, is still poor, with only 25% of patients alive at one year. We suggest that the criteria previously adopted for open nephrostomy generally remain appropriate for patients being considered for percutaneous urinary diversion.     

Endovascular stent-graft treatment for thoracic aortic aneurysms: short- to midterm results

PURPOSE: To evaluate short- and midterm results of the endovascular repair of thoracic aortic aneurysm (TAA) with the use of custom-made stent-grafts. MATERIALS AND METHODS: Between May 1997 and May 2003, 40 patients with TAA (26 degenerative/atherosclerotic, seven dissection-related, three traumatic, two mycotic, one anastomotic, and one penetrating ulcer) underwent endovascular stent-graft placement. The mean age of the patients (29 male and 11 female) was 67.2 years. Twenty-four of the 40 patients (60%) were judged not to be good candidates for conventional open repair. Stent-graft placement was performed in the angiography suite with general anesthesia and transient cardiac arrest or induced hypotension. Custom-made stent-grafts were used in all patients. Four of the 40 patients (10%) underwent preliminary extra-anatomic bypass surgery to provide a sufficiently long landing zone. The mean follow-up period was 16.7 months (range, 1-65 months). RESULTS: The technical success rate was 97.5% and the early mortality rate was 2.5% (one out of 40 patients). There were four late deaths (two procedure-related). Survival rates were 84.2%+/-6.6% at 1 year and 84.2%+/-6.6% at 2 years. Survival rates were not significantly different between surgical candidates and non-surgical candidates (P =.423). Intraprocedural complications included access artery complications in nine patients and bleeding in three patients. Postoperative complications included early aneurysmal expansion in one patient, pneumonia in one patient, wound infection in one patient, stroke in three patients, paraplegia in one patient, respiratory insufficiency in two patients, aortoesophageal fistula in one patient, and late aneurysmal expansion in three patients. The rates of freedom from first additional intervention were 91.0%+/-6.7% at 1 year and 74.5%+/-11.9% at 2 years. The rates of freedom from second additional intervention was 100% at 2 years. The rates of freedom from treatment failure were 84.7%+/-7.6% at 1 year and 69.3%+/-11.6% at 2 years. CONCLUSION: Endovascular repair of TAA with a custom-made stent-graft is a safe and effective alternative to open repair and continues to play an important role. However, careful follow-up is mandatory to manage complications.     

Uterine artery embolization for the treatment of uterine leiomyomata midterm results.

INTRODUCTION: The authors review their midterm experience with uterine artery embolization for the treatment of uterine fibroids. MATERIALS AND METHODS: Sixty patients were referred for permanent polyvinyl alcohol (PVA) foam particle uterine artery embolization during an 18-month period. Detailed clinical follow-up and ultrasound follow-up were obtained. RESULTS: Bleeding was a presenting symptom in 56 patients and pain was a presenting symptom in 47 patients. All patients underwent a technically successful embolization. One of the patients underwent unilateral embolization. Fifty-nine patients underwent bilateral embolization. Of all patients undergoing bilateral embolization, at last follow-up (mean, 16.3 months), 81% had their uterus and had moderate or better improvement in their symptoms. Ninety-two percent of these patients also had reductions in uterine and dominant fibroid volumes. Overall, the mean uterine and dominant fibroid volume reduction were 42.8% and 48.8%, respectively (mean follow-up, 10.2 months). One infectious complication that necessitated hysterectomy occurred. CONCLUSION: Uterine artery embolization for the treatment of uterine fibroids is a minimally invasive technique with low complication rates and very good clinical efficacy.     

Polyurethane-covered self-expandable nitinol stent for malignant biliary obstruction: preliminary results

Purpose: To evaluate the immediate and long-term results in ten patients with malignant biliary obstruction using a polyurethane-covered, self-expandable nitinol stent. Methods: A nitinol stent, fully covered with high-elasticity polyurethane, with an unconstrained diameter of 10 mm and a total length of 60–80 mm, was placed transhepatically under fluoroscopic guidance in ten patients. The length of the biliary obstruction varied between 30–50 mm. The follow-up examination included a clinical assessment, serum bilirubin measurement, and ultrasound examinations at one-month intervals in all patients. Results: Initial stent deployment was successful in eight patients. Two patients experienced proximal migration, which was solved by insertion of two, uncovered Wallstents. One patient had the stent removed after two weeks because of severe nausea and vomiting. One patient had delayed migration of the covered stent after 40 weeks. The follow-up duration was 3–40 weeks (Mean: 16.9 weeks). Seven patients died (3–26 weeks) and three patients survived (24–40 weeks). The bilirubin measurements in all patients had significantly decreased one week after stent insertion. The levels of amylase and lipase had did not increase after stent insertion. Conclusions: A polyurethane-covered, self-expandable nitinol stent can be used effectively and safely in the treatment of malignant biliary obstruction. The preliminary results are favorable, but there is a need for further large studies to determine both long-term survival and patency.     

输尿管旁路支架肾盂膀胱分流术在输尿管梗阻患者中的应用

目的 探讨皮下潜行输尿管旁路支架肾盂膀胱分流术在晚期肿瘤致输尿管梗阻患者中的应用效果.方法 选择因输尿管膀胱晚期肿瘤或腹膜后病变造成输尿管梗阻的12例患者(共16侧输尿管:单侧8例、双侧4例),在超声加C型臂X线机的引导下,采用经皮穿刺肾造瘘,支架管在输尿管旁路皮下潜行,膀胱穿刺造瘘完成上尿路内引流,术后对肾盂形态及肾...     

Urothelial hyperplasia complicating use of metal stents in malignant ureteral obstruction

Self-expandable metal stents (7 mm in diameter) combined with coaxial double-j stents were placed in 10 ureters in ten patients with malignant ureteral obstruction. After 2 and 3 months, when the double-j stents were removed in seven patients, six patients developed hydronephrosis and one patient tolerated removal of the double-j stent and had no signs of urinary obstruction until she died in the fifth month. A double-j stent was inserted again in six patients who developed hydronephrosis. Endoscopy performed during insertion of the double-j stents showed urothelial hyperplasia and incrustations which reduced the lumen of the metal stent. Their double-j stents were exchanged with new ones every 3 months. In the last three patients, double-j stents were not removed, but exchanged with new ones every 3 months. Endoscopy performed regularly during the exchange of the double-j stents in the follow-up of nine patients showed that urothelial hyperplasia, although mild, persisted until the sixth month in three patients. We conclude that urothelial hyperplasia and incrustations limit the use of metal stents in malignant ureteral obstruction. Metal stents, however, when used together with the coaxially placed double-j stents, contributed to the achievement of internal urinary drainage in this study. Since a metal stent provides a buttress for the previously obstructed segment of the ureter, the lumen, although decreased by hyperplasia and incrustations, is held open, which allows an easy exchange of the double-j stent. Regarding the high cost of metal stent, use of it with a coaxial double-j stent should be spared for the malignant ureteral obstructions when a previously placed double-j stent alone fails to achieve efficient drainage. Correspondence to: S. Men     

内膜下成形术治疗股浅动脉长段闭塞

目的 探讨内膜下血管成形术(SIA)治疗长段股浅动脉闭塞的临床价值及中期随访结果.方法 采用SIA治疗45例临床表现为间歇性跛行和重症下肢缺血的长段股浅动脉闭塞患者,对中远期通畅率、保肢率及其影响因素进行统计学分析.结果 45例中,SIA成功治疗43例,其中36例经股浅动脉顺行成功再通,技术成功率为80.0%,另7例...