经皮肾穿刺微造瘘术在上尿路梗阻的应用

目的介绍B超引导下经皮肾穿刺微造瘘术（mPCN）在上尿路梗阻性疾病的临床应用。方法 54例上尿路梗阻的患者采用B超经皮肾穿刺微造瘘术（mPCN）引流尿液后,再根据病因、梗阻部位、肾功能状态、有无继发感染、患者的基本状态等进一步决定治疗方案。结果 14例肾功能衰竭患者肾功能明显改善,46例通过手术取出结石,3例矫形解除狭窄,5例患肾无功能采取肾切除术。结论 B超引导经皮肾微造瘘术可以迅速引流尿液,改善肾功能,控制感染,有助于进一步完善检查,判断患肾的功能及预后,为制定治疗方案提供依据,用于早期处理上尿路梗阻性病变是一种安全、有效、简单、经济的方法。     

选择性标准通道经皮肾镜Ⅰ期治疗结石性脓肾

目的 探讨标准通道经皮肾镜Ⅰ期治疗结石性脓肾的安全性和有效性.方法 2006年8月至2012年10月,有选择性对146例术前均未进行引流的结石性脓肾患者,围手术期在给予抗感染等综合干预措施下采用EMS三代碎石清石系统行彩超引导下标准通道经皮肾镜Ⅰ期治疗,对齐临床资料进行回顾性分析.结果 146例结石性脓肾患者均顺利完成手术.一次手术1 15例,二次手术31例.单标准通道110例,双标准通道36例.手术时间18～69 min,平均（43±7） min;出血量20～96 ml,平均出血量约（39±8）ml.无肾切除、介入栓塞、感染性休克、大出血、大血管和胸腹腔脏器损伤等严重并发症发生.12例残余结石直径≥0.6 cm（0.6～0.8 cm）,行体外冲击波碎石治疗,结石清除率91.8％.14例患者失访.132例患者随访6～61个月,129例肾功能不同程度恢复,3例肾萎缩.结论 彩超引导下标准通道经皮肾镜Ⅰ期治疗结石性脓肾安全有效,保肾率高,注意病例应有选择性且围手术期应采取抗感染等综合干预措施.     

A Case of Pyonephrosis Secondary to Ureteral Stent Calculus

Ureteric stents, a good solution to many urologic problems, can lead to significant morbidity if left in situ longer than required. Our case is that of an elderly male with a history of intractable hypertension presenting with urosepsis, anemia, diabetes and chronic renal failure. His work-up revealed a stent in the right kidney with secondary staghorn calcification in the renal pelvis and a large vesical calculus. He had apparently undergone stent placement 12 years previously, but was lost to follow-up due to relocation. A nuclear scan revealed a complete loss of renal function. Cystoscopic stent removal was futile, so he underwent an elective right subcapsular nephrectomy. The specimen revealed pyonephrosis with loculations of pus. Postoperatively his course was uneventful, with the hypertension resolving in 4 weeks.     

Percutaneous nephrostomy in pyonephrosis

A series of 76 pyonephrotic kidneys in 73 patients were drained by percutaneous nephrostomy (PN) tube and examined to evaluate the contribution of this technique to the treatment of pyonephrosis. In 71 patients, clinical symptoms disappeared 24–48 h after the procedure. Two patients died from sepsis subsequent to anuria and underlying malignancy. Once the acute phase had remitted, interventional procedures were carried out in 39 cases, and constituted the definitive therapy in 36. In 32 cases, elective surgery was the definitive therapy, including the 3 cases not resolved after interventional procedures. Three patients in whom the obstruction cleared spontaneously following PN needed no additional treatment. Major complications included 6 cases of sepsis, all of which resolved satisfactorily with proper medical therapy.     

上尿路结石合并脓肾的治疗观察

目的 探讨上尿路结石合并脓肾的治疗方法及疗效.方法 选择2004年5月至2010年2月在我科接受诊治的49例上尿路结石梗阻性脓肾患者,采用经尿道输尿管镜碎石取石术并置管内引流22例,经皮肾穿刺造瘘外引流术27例.结果 采用微创内、外引流术中均未出现败血症、感染性休克症状.Ⅱ期行经皮肾镜取石术或开放肾盂、输尿管切开取石术,术中出现寒战、发热等菌血症状者3例(8.3%),3例肾切除术.33例随访3个月～5.5年,所有患肾功能均有不同程度的恢复,未发现患侧肾无功能而采取切肾者.结论 早期诊断、及时引流、解除梗阻是上尿路结石合并脓肾保肾治疗的关键.输尿管镜碎石并留置双J导管及经皮肾穿刺造瘘引流是较好的解除梗阻的方法,安全、并发症较少且为Ⅱ期手术治疗创造良好的条件.

Abstract：

Objective To improve the treatment of pyonephrosis with upper urinary tract calculi (UTC).Methods A total of 49 UTC patients with pyonephrosis were selected at our hospital during May 2004 to February 2010. Among them,22 cases were treated with transurethral ureteroscope lithotripsy followed by tube internal drainage while another 27 cases underwent percutaneous nephrolithotomy.Results No such complications as septicemia and septic shock occurred during the first stage of external and internal drainage.The bacteremic symptoms of chill or fever occurred in 3 cases during the second stage of percutaneous nephrolithotomy and pyelolithotomy/ureterolithotomy(11.1%). There were 3 cases of nephrectomy.A follow-up period of 3 months to 5.5 years showed that all 33 cases had a varying degree of recovered renal functions.And there was no ephrectomy.Conclusion The keys to a successful surgical treatment of pyonephrosis with upper urinary tract calculi are early diagnosis,timely drainage and relief of obstruction. Ureteroscopic lithotripsy,double-J placement and percutaneous nephrostomy drainage are excellent for relieving obstruction.As a safe procedure with minor complications,it creates proper conditions for a second stage operation.     

腹腔镜和输尿管镜治疗脓肾合并输尿管上段结石的对照分析

目的 探讨比较腹腔镜输尿管切开取石术与输尿管镜钬激光碎石术治疗脓肾合并输尿管上段结石的疗效.方法 分别对筛选患者采用输尿管镜钬激光碎石术21例,腹腔镜下输尿管切开取石术20例;采集有无术中结石滑脱及术后感染性休克等资料,定期随访尿常规、泌尿系彩超、患肾功能、输尿管狭窄等.结果 41例患者均康复满意;腹腔镜组手术及住院时间稍长于输尿管镜组(P＜0.05);腹腔镜组结石滑脱及感染性休克发生率明显低于输尿管镜组,差异有统计学意义(P＜0.05);术后随访示,尿白细胞、肾皮质厚度、患肾功能较术前均明显改善(P＜0.05),两组之间差异无统计学意义(P＞0.05).结论 腹腔镜输尿管切开取石术是相对安全有效地治疗脓肾合并输尿管上段结石的方法,是对输尿管镜技术的有效补充和支持.     

蕈状肾盂输尿管支架管在治疗脓肾中的应用

目的观察蕈状肾盂输尿管支架管治疗脓肾的效果。方法通过蕈状肾盂输尿管支架管,应用有效抗生素,经过肾盂、输尿管、膀胱进行持续性冲洗、引流脓液,解除梗阻。结果本组28例患肾的功能全部或部分肾功能恢复,切口I期愈合。结论能有效地控制感染,解除梗阻,保留患肾,降低了脓肾的切除率及Ⅱ期手术率。     

腔内泌尿技术Ⅰ期或Ⅱ期手术治疗结石性脓肾

目的:探讨运用腔内泌尿外科技术治疗结石性脓肾的疗效和价值.方法:对52例结石性脓肾患者,14例行Ⅰ期手术(包括4例行经皮肾镜取石术;6例经尿道输尿管镜取石术;4例行经皮穿刺肾造瘘引流联合经尿道输尿管镜取石术);38例行Ⅱ期手术,即Ⅰ期经皮肾穿刺造瘘引流,Ⅱ期腔内技术取石术或肾切除术.结果:48例患者肾盂、肾盏漏斗和输尿管梗阻部结石均被取净,6例行肾切除术;无术后大出血和感染性休克等严重并发症;36例随访1～12个月,34例肾功能得到不同程度的恢复.结论:腔内技术安全、有效、微创,保肾率高,应作为结石性脓肾的首选治疗方法,应根据具体情况选择Ⅰ期还是Ⅱ期手术.     

一期输尿管软镜联合经皮肾镜治疗鹿角形结石合并脓肾的疗效和安全性

目的探讨一期输尿管软镜(FURS)联合经皮肾镜取石术(PCNL)治疗鹿角形结石合并脓肾的可行性、有效性和安全性。方法回顾性分析北京大学第三医院2017年5月至2019年12月采用一期FURS联合PCNL治疗的13例鹿角形结石合并脓肾患者的病例资料,男7例,女6例。年龄52.5(33~68)岁。临床表现为间断发热9例,腰部不适6例,肉眼血尿1例,2例无明显临床表现。8例合并糖尿病。CT检查示完全型鹿角形结石6例,部分型7例;结石位于左侧7例,右侧6例;4例伴中/重度肾积水,9例伴轻度肾积水。影像学检查评估结石负荷(1070.9±397.0)(507.4~1809.5)mm^2。13例术前均行尿细菌培养及药敏试验。4例住院时有发热症状者术前留置患侧输尿管支架管≥1周。所有病例术前应用抗菌药物≥1周,待感染症状及感染相关指标恢复正常后接受手术治疗。手术采用全麻,患者取改良Valdivia体位。先经尿道置入FURS到达患侧肾盂,B超及FURS引导下在患侧腋中线和肩胛旁线之间、12肋下建立经皮肾标准通道,单通道PCNL下采用负压吸引装置吸出脓液并处理视野范围内的结石,再联合FURS处理其他肾盏结石。术中PCNL穿刺成功后,均可见肾内浑浊脓性尿液排出,留取肾内尿液送检细菌培养及药敏试验。本组13例均经术中肾盂尿细菌培养结果确诊为脓肾。术后常规留置输尿管支架管和肾造瘘管,继续抗感染治疗。术后第1~3天行影像学检查,评估结石清除率,残留结石≥4 mm为有意义的结石残留。结果本组13例手术均顺利完成,手术时间(94.2±21.8)(65~135)min。一期结石清除率76.9%(10/13)。术后6例出现全身炎症反应综合征,无脓毒血症及≥Clavien-DindoⅢ级并发症发生。术后中位随访12(3~24)个月,4例患侧结石复发,2例患侧轻度肾萎缩,随访期间无患侧上尿路感染复发。结论FURS联合PCNL是治疗鹿角形结石合并脓肾的有效方法,具有良好的疗效和安全性。     

Sepsis due to pyonephrosis: an adult with pelvic–ureteric junction obstruction (PUJO) in a duplex kidney

We present the case of a 75-year-old woman with sepsis. She was evaluated with bedside ultrasound with a diagnosis of pyonephrosis, and subsequently underwent a TC scan that showed a pelvic–ureteric junction obstruction (PUJO) in a duplicated renal system. PUJO associated with duplex kidney, while relatively frequent in children, is a rare condition in adults, and may lead to severe complications as in this case.