输尿管镜术中输尿管口丢失的应对策略

目的探讨输尿管镜术中输尿管口丢失的应对方法。方法报告输尿管镜术中因输尿管口丢失而进镜失败的14例患者的处理过程及结果。先采用斜仰卧截石位,实时超声定位下以G18穿刺针朝向肾盂输尿管连接部穿刺患肾中上盏,从针芯中顺行向输尿管内推置亲水导丝,如可见导丝进入膀胱,则沿导丝径路进镜;如导丝无法顺行进入膀胱,则换用经尿道电切镜,薄层电切患侧输尿管口对应部位,显露输尿管壁内段断端,置入亲水导丝后换用输尿管镜进镜。所有患者术后均留置F7双J管1~2根。结果11例肾穿刺顺行置入导丝可见进入膀胱,沿导丝成功进镜入输尿管;3例此法失败者采用输尿管口部位电切法成功进镜。所有患者肾穿刺针和导丝拔除后无大出血,无输尿管穿孔、撕脱等严重并发症,术后2~3个月拔除双J管后未发生输尿管口狭窄。结论输尿管镜术中发生输尿管口丢失,依次采用肾穿刺顺行导丝置入法和输尿管口部位电切法寻找输尿管口成功率高,创伤小,无严重并发症发生。

Rescue managements of damaged and invisible ureteral orifices in ureteroscopic surgery

Objective To evaluate the rescue managements of invisible ureteral orifices damaged and invisible in ureteroscopic surgery.Methods During ureteroscopic surgery,14 ureteral orifices were damaged and became invisible when the rigid ureteroscope was inserted into ureter.The upper or middle calyx of the involved kidney was punctured toward the pyeloureteral junction with an G18 needle under real-time ultrasound guidance after the patients were placed in the position of oblique supine lithotomy.A hydrophilic guide wire was then pushed through the core of the needle into ureter.If the guide wire entered the bladder successfully,the ureteroscope was then placed through the orifice following the wire.If the guide wire was not observed in the bladder,we then performed transurethral thin-layer resection of the inner wall of bladder at the corresponding site of the affected ureteral orifice.Once the mucosa of the terminal ureter was exposed,we inserted the ureteroscope into the ureter successfully with the aid of a retrograde insertion of a hydrophilic guide wire.One or two F7 double-J ureteral stents were indwelt in each patient after the operation.Results Of all 14 patients,11 were successful treated using guide wire anterogradely inserted into bladder through the renal puncture needle.The other 3 cases were successfuly managed through transurethral thin-layer resection of the ureteral orifice as a substitute procedure.No massive hemorrhage or severe complications such as perforation or avulsion of the ureter were observed.After removal of the double-J stents 2-3 months after operation,no stricture of ureteral orifice occurred.Conclusion Once the ureteral orifice is damaged and invisible in ureteroscopic surgery,anterograde insertion of a hydrophilic guide wire via a renal puncture needle or substitute transurethral resection of the ureteral orifice may be a salvage procedure to find the missed ureteral orifice with advantages of a high success rate,minimal invasiveness and no serious complications.