Emphysematous cystitis: from bullae to pneumaturia

A 91-year-old woman with type 2 diabetes presented at the emergency ward subconscious with lower abdominal swelling. Evaluation revealed dehydration and hyperglycaemia, and abdominal x-ray showed an air space surrounding a severely swollen bladder. After excluding enterovesical fistulae, the patient was diagnosed with emphysematous cystitis. Treatment for urinary retention, antibiotic treatment and control of the diabetes mellitus resulted in a rapid recovery. A second patient, a 65-year-old woman with a history of recurrent urinary tract infections and urolithiasis, presented with irritative urinary symptoms and pain in the lower abdomen. Explicit inquiry revealed that she also had intermittent pneumaturia. Urethrocystoscopy revealed submucosal bullae, which are a hallmark of emphysematous cystitis. The patient was given intravenous antibiotic therapy. Diabetes mellitus is a risk factor for emphysematous cystitis. The disorder is treated by draining the bladder with an indwelling catheter and intravenous antibiotic therapy, selected according to the urine culture results. In general, orally administered antibiotics are insufficient.     

经皮肾镜气压弹道联合超声碎石治疗上尿路感染性结石

目的探讨经皮肾镜治疗输尿管上段结石及肾结石并感染的疗效。方法对肾、输尿上段结石并感染较轻者,经控制感染后I期行经皮肾镜气压弹道联合超声碎石术37例;合并较严重感染者先期行经皮肾造瘘、Ⅱ期经皮肾镜气压弹道联合超声碎石术17例。结果 I期行经皮肾镜气压弹道联合超声碎石术37例中,4例术后出现高热(>39℃),7例术后体温在38℃～39℃,其余26例术后体温<38℃。Ⅱ期经皮肾镜气压弹道联合超声碎石术17例,所有病例Ⅱ期经瘘道碎石取石术后体温均<38℃。结论对于输尿管上段及肾结石并感染患者,经抗炎治疗后复查,血象、体温正常,无腰痛,估计手术时间较短者,选择I期经皮肾镜碎石取石术;否则,选择Ⅱ期经皮肾镜术。     

经皮肾镜气压弹道联合超声碎石治疗上尿路感染性结石

目的探讨经皮肾镜治疗输尿管上段结石及肾结石并感染的疗效。方法对肾、输尿上段结石并感染较轻者,经控制感染后I期行经皮肾镜气压弹道联合超声碎石术37例;合并较严重感染者先期行经皮肾造瘘、Ⅱ期经皮肾镜气压弹道联合超声碎石术17例。结果 I期行经皮肾镜气压弹道联合超声碎石术37例中,4例术后出现高热(>39℃),7例术后体温在38℃～39℃,其余26例术后体温<38℃。Ⅱ期经皮肾镜气压弹道联合超声碎石术17例,所有病例Ⅱ期经瘘道碎石取石术后体温均<38℃。结论对于输尿管上段及肾结石并感染患者,经抗炎治疗后复查,血象、体温正常,无腰痛,估计手术时间较短者,选择I期经皮肾镜碎石取石术;否则,选择Ⅱ期经皮肾镜术。     

Spontaneous partial fracture of the catheter of a totally implantable subcutaneous infusion port.

A totally implantable subcutaneous infusion port was inserted via the left subclavian vein with peel-away sheath in a 45-year-old male patient receiving home parenteral nutrition. Sixteen months after implantation, the patient noted pain in his left clavicular region during home infusion. This was found to be due to the leakage of infusion fluid resulting from partial fracture of the catheter at the level where the catheter passed between the clavicle and first rib. Because the fracture was partial, the catheter did not embolize to the heart or large vessels. Although subcutaneous infusion ports afford patients greater freedom and the ability to lead a more active life than do external catheters, it is emphasized that there may be the risk of spontaneous catheter fracture in patients using subcutaneous infusion ports.     

A case of hyperplastic polypoid lesion in the common bile duct hard to differentiate from early bile duct carcinoma

In a 72-year-old male carcinoma of the bile duct was suspected because of an abnormality on laboratory examination. Ultrasound showed the dilatation of extrabiliary duct. Endoscopic ultrasound revealed localized wall thickening of the common bile duct. ERCP demonstrated the dilatation of the CBD. Within the dilated duct a filling defect was present. Histology of the resected specimen disclosed hyperplasia of the epithelium in the CBD.     

A case of bilateral adrenal cortical carcinoma with special reference to image diagnosis

The patient, a 45-year-old male, complained of left flank pain and fever. CT revealed bilateral adrenal tumors, in which MRI disclosed inhomogeneous signal intensity with low signal intensity rim. Arteriography demonstrated bilateral adrenal tumors with moderately rich tumor vessels.     

输尿管镜取石手术后不留置支架管的探讨

目的探讨输尿管镜取石术后不留置支架管的可行性，气压弹道碎石或钬激光碎石及输尿管镜取石，可根据指征术后留置支架管。结果不留置支架管指征包括大部分患者恢复顺利，平均住院4．2天，X平片或B超随访结石消失；并发症主要表现为轻度肉眼血尿21例，占26．9％；一过性下尿路症状16例，占20．5％；与上尿路梗阻有关的腰痛13例，占16．7％，其中5例腰部症状明显给予重新置入支架管，占6．4％；与泌尿系统感染相关的发热9例，占11．5％。上述并发症常发生在术后短期．多可自行消失，部分患者服用奥昔布宁、坦素罗辛后缓解。结论输尿管镜术后不留置支架管是可行和安全的，有助于减少留置支架管所导致的并发症及降低患者治疗费用。     

经皮肾微造瘘输尿管镜术治疗复杂性上尿路结石

目的　探讨经皮肾微造瘘输尿管镜术治疗复杂性上尿路结石的效果。方法　采用经皮肾微造瘘输尿管镜术配合气压弹道碎石治疗 70 0例 80 0侧肾铸型结石或多发性结石和输尿管上段结石 ,共进行 130 2次取石手术 ,其中 1次取石 382侧 ,2次取石 334侧 ,3次取石 84侧。结果　结石全部取干净 74 3侧 ,5 7侧有残石未能取出 ,结石取净率达 92 %。结论　该方法优点在于穿刺通道细小 ,创伤小 ,病人痛苦轻 ,术中出血及并发症少 ,可重复手术取石 ,结石清除率高 ,可代替经皮肾镜术成为新的治疗复杂性上尿路结石的微创治疗手段。     

Percutaneous embolization of hemorrhaging renal arteriovenous fistula]

A 67 year old male patient with macroscopic hematuria was treated by percutaneous intraarterial embolization with Gianturco-coil (Cook). The patient had a percutaneous stone removal from the left kidney two weeks before the bleeding. The emergency angiography showed an arteriovenous shunt in the left kidney. A superselective embolization was performed. There was no bleeding on the control angiography. The embolization was performed without complication.     

Unavoidable surgical intervention in two women with severe actinomycosis during IUD use

Extensive abdominal infections with Actinomyces were diagnosed in two women aged 35 and 33 years respectively, who suffered from the nonspecific symptoms fever and abdominal pain. These infections occur more often in women with an intrauterine device. Development of an abdominal mass with ureter or bowel obstruction may cause hydronephrosis and mechanical ileus. The patients underwent a laparotomy and a double-J catheter was inserted, which could be removed later on (temporary stoma). Treatment included high-dose penicillin i.v. followed by oral amoxicillin. Both patients recovered. It may be difficult to establish this diagnosis: the first patient was diagnosed by histopathological examination, in the second Actinomyces had been found in a routine cervical smear a few years earlier.     

Urolithiasis in adolescent children

Idiopathic urolithiasis in children has become more frequent in the past few decades as a result of increasing affluence and rapid change in our society's dietary habits. In Western societies, calcium stones in the kidney and ureter predominate. Pediatric urolithiases, unlike the adult form, require a comprehensive metabolic evaluation, because metabolic and enzymatic derangements play an important role in their pathogenesis. The recent advancements in endoscopic procedures, interventional radiology, and lithotripsy have allowed children to be managed effectively without open surgery. Pediatric urolithiasis requires a close working relationship between the urologist for acute surgical management of urolithiasis and the nephrologists for prevention of stone formation. In many children and adolescents with urolithiasis, a nonpharmacologic approach involving the adoption of healthy nutrition habits may suffice.     

新型肾造瘘管固定装置对经皮肾造瘘管固定作用的前瞻性随机对照研究

目的:研究探讨新型肾造瘘管固定装置对经皮肾镜穿刺造瘘术后肾造瘘管固定的临床疗效及安全性。方法:选取在医院行经皮肾镜造瘘留置肾造瘘管的284例患者,按照随机数表法将其分为观察组和对照组,每组142例,对照组患者的肾造瘘管采用常规缝合固定,观察组采用自制的新型肾造瘘管固定装置进行固定。对比两组患者的主观舒适度、并发症及意外脱管;通过视觉模拟评分法(VAS)评估患者留置伤口局部疼痛和取出肾造瘘管时疼痛等指标,评估新型固定装置的疗效及安全性。结果:术后对照组肾造瘘管脱出、皮肤瘙痒和肉芽肿形成分别占3.62%、9.28%和2.71%,观察组分别占0.68%、1.81%和0.45%,两组比较差异有统计学意义(x^2=6.24,x^2=20.10,x^2=8.35;P<0.01);对照组患者对医疗护理技术满意率为36.61%,观察组患者满意率为64.78%(x^2=17.56,P<0.01);VAS局部疼痛和VAS取管疼痛两组比较差异有统计学意义(x^2=8.58,x^2=7.10;P<0.05)。结论:新型肾造瘘管固定装置可降低肾造瘘管脱落、皮肤瘙痒和切口肉芽肿形成等不良护理事件的发生率,降低患者疼痛,提高患者对医疗护理技术的满意度。     

输尿管上段结石的微创外科治疗（附146例报告）

目的探讨输尿管上段结石的微创外科治疗方法。方法146例输尿管上段结石患者，根据病史及影像学检查分析是单纯性结石还是复杂性结石。采用体外冲击波碎石术（ESWL）治疗单纯性结石，治疗无效的患者按复杂性结石处理。采用输尿管镜下碎石术（URL）及URL联合ESWL治疗复杂性结石。URL失败的患者改行微创经皮肾穿刺取石术（MPCNL）。结果初步诊断单纯性结石97例，复杂性结石49例。ESWL治疗输尿管上段单纯性结石成功率为90．7％（88／97）。9例ESWL无效改行URL。URL及URL＋ESWL治疗输尿管上段复杂性结石的成功率为86．2％（50／58）。8例URL失败改行MPCNL，治疗成功率为100．0％（8／8）。结论应当充分尊重患者本人的意愿，从经济、安全、有效的角度，按无创-微创-轻创的顺序选择治疗输尿管上段结石的方法。     

The value of antegrade stenting for lower ureteric obstruction.

Eleven kidneys in 10 patients (mean age 80 years) presenting over a period of 1 year with obstruction of the lower ureter secondary to malignant obstruction (8 patients), stone disease (1 patient), and bladder wall hypertrophy (1 patient) underwent nephrostomy with subsequent immediate or delayed antegrade stenting. An antegrade placement of the stent was achieved in 10 of the 11 kidneys (90% success). In three cases a combined procedure was performed with cystoscopic assistance. In most cases there was rapid improvement of renal function following stenting. Insertion of ureteric stents in patients admitted to hospital with malignant ureteric obstruction allowed treatment of their renal failure and subsequent discharge without use of permanent external urinary diversion appliances. No significant complications of the procedure were encountered. Medium term follow-up of patients stented for malignant ureteric obstruction suggests that the stents can be left in place without replacement for up to 20 months.     

妊娠期有症状的泌尿系结石46例临床分析

目的对妊娠期有症状的泌尿系结石病例进行分析,以提高该病的诊治水平。方法回顾分析2007年1月至2011年10月在佛山市第二人民医院收治的46例妊娠期有症状的泌尿系结石患者的临床资料。结果妊娠期有症状的泌尿系结石引起绞痛发作以妊娠中晚期多见,临床表现主要为腰腹部绞痛,伴肉眼或镜下血尿;合并感染者有发热、尿中见白细胞、血白细胞计数升高;B超对妊娠期泌尿系结石的检出率为91.3%。约84.8%的患者经解痉、镇痛、抗感染等保守治疗后疼痛缓解,热退,白细胞计数正常,无严重并发症,但少数病例也可出现胎儿窘迫、脓毒败血症等严重并发症。约15.2%的患者需手术治疗。结论对妊娠中晚期腰腹部绞痛的孕妇应高度警惕泌尿系结石的可能,尽早确诊及治疗。治疗以保守治疗为主,积极解痉、镇痛、抗感染,预防脓毒败血症及胎儿窘迫等并发症的发生,恰当及时的外科手术干预是获得良好妊娠结局的关键。     

徒手超声引导下经皮肾输尿管镜碎石术治疗肾结石的探讨

目的 探讨徒手超声引导及输尿管镜替代肾镜进行经皮肾镜手术的可行性.方法 采用徒手超声引导下进行术中定位、穿刺,输尿管镜替代肾镜行经皮肾镜碎石术治疗肾结石35例,对其临床资料进行回顾性分析.结果 35例均成功建立皮肾通道并一期手术,其中单通道清除结石34例,双通道1例.2例行二期碎石清石术.总手术时间50～130min,建立通道时间15～25 min,一期手术结石清除率为94.28％ (33/35),无大出血、感染性休克等严重并发症.结论 徒手B超引导下输尿管镜替代肾镜的经皮肾镜碎石术治疗肾结石安全、有效并且是可行的.     

A boy with cyclic vomiting and an alleged furosemide allergy on the basis of a subpelvic stenosis

An 8-year-old boy, known with a Diamond-Blackfan anaemia, was admitted to the hospital because of frequent vomiting since 3 days and loin pain. In previous years, he had been admitted several times for the same complaints but no cause had been identified. Ultrasound examination of the abdomen performed at admittance showed dilatation of the left renal pelvis. A renal scintigraphy was discussed with the mother, and she refused the injection of furosemide, because her son was allegedly allergic to furosemide: previous furosemide treatments during blood transfusions for his anaemia had always resulted in stomach-ache and vomiting, which may be attributed, however, to an acute dilatation of the renal pelvis due to the diuretic effect of furosemide. Scintigraphy without furosemide showed a significant obstruction and asymmetric renal function, so a pyeloplasty was performed after which he has been symptom-free. In patients with cyclic vomiting, an intermittent uretero-pelvic junction obstruction should be considered and can only be ruled out when ultrasound during the complaints and renal scintigraphy under adequate hydration and after furosemide are normal.     

The role of multidetector computed tomography in the diagnosis in 3 patients with ischaemic heart complaints

Multidetector CT (MDCT) can provide important information before or after coronary angiography (CAG). This is illustrated by three cases. In a 21-year-old female with ventricle fibrillation CAG demonstrated an anomalous right coronary artery, the exact course of which could not be evaluated. MDCT demonstrated a course between the aorta and pulmonary trunk with vessel compression during systole. After a bypass operation and subsequent pacemaker implantation, she was asymptomatic at follow-up six weeks after hospital discharge. In a 46-year-old male with chest pain, MDCT showed triple vessel disease after which percutaneous coronary intervention (PCI) with stent implantation of the three main branches was performed. Two months after discharge, the patient did not report any complaints. In a 51-year-old male scheduled for PCI of the left anterior descending coronary artery (LAD), MDCT detected a LAD thrombus with 90% occlusion prior to PCI. The occlusion was confirmed during CAG and treated with angioplasty. The next day he was discharged. MDCT offers a practical solution for different cardiac problems through its high diagnostic value.     

泌尿系结石临床诊治与护理体会

尿道结石患者要及时接受治疗，否者会引发其他痰病，给患者身。健康造成等大危害。本文阐述了临床采用ESWL体外冲击波碎石术，安全、无痛苦；一次性治疗、节省费用、不影响工作和生活。加之中药汤剂辅助治疗，确保排石彻底以及预防术后并发症的发生；医护人员要耐心向患者及家属讲解相关医学知识以治疗方法，取得信任感；围手术期密切观察记录疼痛部位、性质、程度等体征变化；发作期采取镇捅措施；做好院外康复指导工作。确保患者早期康复。     

Ambulatory laparoscopic cholecystectomy is as effective as hospitalization and from a social perspective less expensive: a randomized study]

OBJECTIVE: To compare the effects and costs of an ambulatory treatment versus an overnight stay for laparoscopic cholecystectomy. DESIGN: Prospective, randomised. METHOD: In the St Antonius hospital, Nieuwegein, the Netherlands, 86 patients with symptomatic cholelithiasis without comorbidity underwent either ambulatory (AM: 42 patients: 8 men and 36 women; mean age: 48.9 years (SD: 11.9)) or overnight stay (OS: 44 patients: 10 men and 32 women; mean age: 44.9 years (SD: 11.8)) laparoscopic cholecystectomy in the period 1 November 1997-30 September 1999. The following were registered: operative time, complications, hospital stay and readmissions, as well as reported pain, nausea, activity resumption, quality of life and patient satisfaction. The cost analysis was performed from a societal and hospital perspective. RESULTS: In the OS group one laparoscopic procedure was converted to open cholecystectomy, two relaparotomies were performed due to intra-abdominal haemorrhage and 1 patient had a catheter inserted due to urine retention. Two patients were readmitted, one for postoperative pancreatitis and the other for a retained bile duct stone. In the AM group one laparoscopic procedure was converted to open cholecystectomy, in 1 patient a wound abscess was treated with drainage in the outpatient clinic, in 1 patient there was peroperative stone loss without further complications and in 1 patient a catheter was placed to drain peroperative bile and blood loss. In the AM group 11 (26%) patients were kept overnight due to nausea and/or pain (n = 7) or one of the aforementioned complications (n = 4). Two patients were readmitted within 24 hours of being discharged due to abdominal pain. The average hospital stay was 3.1 (OS) versus 1.7 (AM) days. The quality of life, pain, nausea and activity resumption were comparable for both groups. Due to the difference in hospital stay, costs for the ambulatory procedure were lower. CONCLUSION: Laparoscopic cholecystectomy was successfully performed as an ambulatory surgery procedure in 69% of the patients. The quality of life, patient satisfaction and resumption of activities in both groups were comparable. The ambulatory treatment was less expensive.