同期微创经皮肾取石术治疗双侧上尿路结石(附54例报告)

目的：探讨同期微创经皮肾取石术治疗双侧上尿路结石的疗效和安全性。方法：回顾性总结同期微创经皮肾取石术治疗54例双侧上尿路结石患者的效果和并发症。结果：术后3天复查,27例双侧肾脏结石的结石清除率为85．2％（23／27）;16例一侧肾脏结石对侧输尿管上段结石的结石清除率为87．5％（14／16）;11例双侧输尿管上段结石的结石清除率为90．9％（10／11）。术后27．8％（15／54）的患者出现超过38．5℃的发热,66．7％（36／54）的患者因手术部位疼痛,需要口服或肌肉注射非甾体类镇痛药物。1例双侧肾脏结石患者术后因为失血过多需要输血治疗。结论：对于部分身体状况较好、结石清除相对容易的上尿路结石患者,采用同期双侧微创经皮肾取石手术安全、可靠,并可减少患者的住院时间和住院费用。     

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.     

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.     

免疫性血小板减少症(ITP)合并胸闷1例

免疫性血小板减少症（immune thrombocytopenia,ITP）是一种因免疫系统介导的血小板破坏过多进而导致血小板减少的疾病,具有高出血风险。冠心病（coronary artery disease,CAD）和经皮冠状动脉介入（percutaneous coronary intervention,PCI）术后的患者需要常规抗血小板治疗,与ITP的治疗相矛盾。本文报道1例ITP合并急性冠脉综合征（acute coronary syndrome,ACS）行PCI术的老年男性,因血小板数量低下、出血风险高而未行充分抗血小板治疗,导致ACS数次发作,于原冠脉支架内形成血栓,病程中数次行PCI术并调整抗血小板治疗方案和激素治疗剂量,以期为这类患者的临床处理提供参考。     

经皮肾镜去石术后出血的介入治疗

目的: 研究超选择性肾动脉栓塞在治疗经皮肾镜术后出血中的效果及失败原因。方法: 对65例伴有血液动力学改变的经皮肾镜术后出血患者行肾动脉造影,用微导管行超选择性插管,用微弹簧圈栓塞损伤动脉。若首次肾动脉造影无阳性发现,则采用以下措施以防止遗漏病灶:(1)腹主动脉造影;(2)重复肾动脉造影;(3)造瘘管走行区域肾动脉分支超选择造影;(4)保留穿刺通道,拔除肾造瘘管后造影。对肾动脉出血的造影表现进行总结,并对栓塞止血失败的原因进行分析。结果: 65例患者中,造影有阳性发现的60例(62个肾脏), 均经超选择性栓塞成功止血。肾动脉造影的阳性表现包括:假性动脉瘤形成、斑片状造影剂外溢、假性动脉瘤合并动静脉瘘、造影剂进入集合系统、造影剂弥散至肾被膜下。一次栓塞成功53例(55个肾脏), 成功率88.71%,两次栓塞成功率96.77%。首次栓塞失败的原因主要是遗漏病灶(4例,57.10%)和栓塞的受损血管再通(2例,28.57%)。5例患者肾动脉造影无阳性发现,经保守治疗血尿停止。所有患者介入治疗后3、6、12个月随访,均未再次出现血尿,且未发生持续、严重的肾功能损害。结论: 超选择肾动脉栓塞是治疗经皮肾镜术后出血的有效方法,肾动脉造影遗漏病灶是造成止血失败的主要原因。     

RPLU、FURL及PCNL治疗输尿管上段嵌顿性结石的疗效研究

目的探讨后腹腔镜切开取石术（retroperitoneal laparoscopic lithotomy,RPLU）、输尿管软镜碎石清石术（lithotripsy with flexible ureteroscope,FURL）及经皮肾镜碎石清石术（percutaneous nephrolithotomy,PCNL）种不同方法治疗输尿管上段嵌顿性结石的疗效,以明确直径大于1.5 cm的输尿管上段嵌顿性结石的最佳处理方案。方法回顾性分析159例输尿管上段嵌顿性结石,收集其术前术中资料,按术式不同分为RPLU组56例、FURL组55例、PCNL组48例。对手术时间、术后住院时间、结石清除率、术后并发症等数据进行统计学分析。结果FURL组手术时间和术后住院时间明显短于RPLU组和PCNL组,差异均有统计学意义（P＜0.05）。RPLU组术后3 d和术后1个月的结石清除率（100%,100%）稍高于FURL组（90.9%,94.5%）和PCNL组（93.8%,93.8%）,3组患者术后无严重并发症出现,差异均无统计学意义（P＞0.05）。结论3种不同手术方法治疗嵌顿性输尿管上段结石均安全有效,FURL组手术时间及住院时间更短,患者术后恢复更快,更具有优势。     

微创经皮手术与开放手术椎弓根钉内固定治疗胸腰椎骨折的临床疗效对比

为了对比微创经皮手术与开放手术椎弓根钉内固定治疗胸腰椎骨折的临床疗效,收集了104例胸腰椎骨折患者的临床资料进行回顾性分析。患者均采取椎弓根钉内固定术治疗,按采取的手术方法分为微创经皮手术组和开放手术组。所有患者术后均获得12~18个月的随访。结果显示,微创经皮手术组的切口长度、手术时间、出血量、术后3天VAS评分和不良切口愈合率均显著低于开放手术组,但术中X线透视次数显著多于开放手术组;两组术后1年骨折椎体前缘高度比值、Cobb''s角、Oswestry功能障碍指数和内固定失败率无显著差异(P＞0.05)。因此微创经皮手术与开放手术椎弓根钉内固定治疗胸腰椎骨折,都可以获得满意的临床疗效。前者虽然存在较多的X线暴露的缺点,但创伤更小,适合在临床上推广应用。     

PTED与FD治疗腰椎间盘突出症的效果比较

为探讨经皮椎间孔镜椎间盘切除术(PTED)和椎板开窗椎间盘切除术(FD)在腰椎间盘突出症(LDH)患者治疗中的临床效果差异。94例LDH患者,根据手术方法分为PTED组和FD组各47例。结果表明,与FD组相比,PTED组的手术切口长度、手术出血量、住院时间降低,术后7天,血清白细胞介素-1β(IL-1β)、白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、前列腺素-E2(PGE2)水平也显著降低;与术前比较,术后3个月、术后6个月,两组患者的ODI指数均显著降低。结果说明,PTED与FD治疗LDH患者均具有较好的效果,但是PTED手术较FD手术创伤更小、能更及时有效的降低血清疼痛相关因子。     

动脉溶栓联合血管内支架成形术对急性脑梗死的治疗作用

目的评价动脉溶栓联合血管内支架成型术治疗急性颈内动脉系统脑梗死的疗效与安全性。方法22例动脉溶栓后遗有血管狭窄的急性脑梗死患者,男性10例,女12例,平均年龄(66.18±11.49)岁,均在发病6 h内接受治疗。分为治疗组10例和对照组12例,分别给予支架治疗和常规药物治疗,于术后第1天和30天比较两组NIHSS评分及病死率。结果与对照组相比,治疗组患者临床症状明显改善,术后1 d和30 d的NIHSS评分都显著降低(P<0.05)。治疗组无1例死亡。结论动脉溶栓联合血管内支架成型术治疗急性脑梗死较单纯动脉溶栓疗效好,而且较为安全。     

Effect of intracoronary administration of anisodamine on slow reflow phenomenon following primary percutaneous coronary intervention in patients with acute myocardial infarction

Background Many basic and clinical studies have proved that anisodamine can produce significant effect on relieving microvascular spasm, improving and dredging the coronary microcirculation. It may be beneficial to the improvement of slow-reflow phenomenon (SRP) following percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). So we investigated the effect of intracoronary administration of anisodamine on SRP of infarct related artery (IRA) following primary PCI in patients with ST segment elevated acute myocardial infarction (STEAMI). Methods Twenty-one patients with SRP from a total of 148 STEAMI patients accepted primary PCI were enrolled into this study from September 2004 to December 2005. When SRP happened, nitroglycerin (200 &micro;g) was “bolus” injected firstly into IRA to exclude the spasm of epicardial artery and identify SRP as well as a baseline and self-control agent following PCI. Ten minutes later, 1000 &micro;g of anisodamine was injected into IRA with SRP at 200 &micro;g/s, while the coronary angiography (CAG) was taken before and at 1st, 3rd and 10th minute after administration of nitroglycerin or anisodamine, respectively. The corrected TIMI frame count (cTFC), TIMI myocardial perfusion grade (TMPG) and the diameter of IRA were calculated and analyzed by Gibson’s TIMI frame count method using quantitative computer angiography (QCA) system to evaluate the influence of anisodamine on coronary flow and vessel lumen. In the meantime the invasive hemodynamic parameters of intracoronary and systemic artery (systolic, diastolic and mean pressure) and electrocardiogram (ECG) were measured and monitored. The changes of ventricular performance parameters and the adverse reaction were evaluated and followed-up at 1 month post-PCI. Results No significant changes in cTFCs and TMPGs were found at 1st, 3rd and 10th minute after intracoronary administration of nitroglycerin as compared with the baseline control (P＞0.05). cTFCs were decreased by 58.3%, 56.2%, and 54.6%, respectively (P&lt;0.001), and TMPGs were increased from 1.13±0.21 grade to 2.03±0.32, 2.65±0.45 and 2.51±0.57 grades (P&lt;0.05) at 1st, 3rd and 10th minute after intracoronary administration of anisodamine as compared with those after intracoronary administration of nitroglycerine, respectively. The average coronary blood flow of TIMI grade was improved from 1.76±0.43 to 2.71±0.46 (P&lt;0.05) while the diameter of middle segment in re-patented coronary artery was slightly increased from (3.20±0.40) mm to (3.40±0.50) mm at the 3rd minute after intracoronary administration of anisodamine (P＞0.05) as compared with those of nitroglycerine control. The systolic, diastolic and mean pressures of intracoronary artery after intracoronary administration of anisodamine increased from 115 to 123, 75 to 84, 88 to 95 mmHg (P&lt;0.05), respectively, along with the rise of heart rate from 68 to 84 beats per minute (P&lt;0.05). There were no significant changes in intervals of PR, QT and QRS (P＞0.05) and no any severe fast arrhythmia after intracoronary administration of anisodamine. The ventricular performance parameters were significantly improved and no major adverse cardiovascular events (MACE) were found during follow-up at 1 month post-PCI. Conclusions Intracoronary administration of 1000 &micro;g anisodamine is effictive in reversing SRP following PCI in STEAMI patients, especially it is suitable for SRP patients with bradycardia or hypotension.