输尿管通道鞘状态与鞘内流速变化分析*

目的探讨输尿管通道鞘(UAS)的不同状态与鞘内灌注液流出速度的变化关系,了解限压150 mmHg Wolf泵灌注时肾盂内的压力。方法 18例输尿管软镜手术患者根据UAS(F12/14)的3种状态分成A、B和C 3组,各6例,分别测定URF-P5软镜进入肾盂寻找结石时和置入200μm光纤碎石时UAS鞘内灌注液的流出速度,C组患者采用"鞘内导丝法"提高鞘内流速,对其中1例有肾瘘管的患者进行肾盂内压力测定。结果限压150 mmHg Wolf泵灌注下,URF-P5软镜进入肾盂寻找结石时,3组鞘内流速分别为(54.22±2.14)、(47.32±2.39)和(25.01±2.54)ml/min;置入200μm光纤碎石时,鞘内流速分别为(32.68±2.23)、(30.44±2.58)和(24.15±2.22)ml/min;鞘内放置导丝后,C组的流速为(28.64±2.18)ml/min,与放置导丝前相比,流速增加13.0%～21.0%,平均流速增加18.6%。测压患者静息状态下肾盂内压为11 mmHg;软镜进入肾盂后,肾盂内压28～51 mmHg,中位值38 mmHg;钬激光碎石时肾盂内压55～72 mmHg,中位值68 mmHg;鞘内置入导丝后肾盂内压下降至38～61 mmHg,中位值50 mmHg。结论 UAS的不同状态导致了不同的鞘内灌注液的流出速度,通过观察鞘内流速的变化,可以间接判断肾盂内的压力情况;使用F12/14 UAS、URF-P5软镜和Wolf泵灌注限压150 mmHg是相对安全的;当UAS的状态评估不满意时,术者应控制手术时间,可以采用"鞘内导丝法"增加鞘内流速,降低肾盂内压力。

Analysis of ureteral access sheath status and intrathecal flow velocity*

Abstract: Objectives To investigate the relationship between the status of ureteral access sheath (UAS) and the flow rate of perfusion fluid in the sheath, discovering the pressure in the renal pelvis at 150mmHg Wolf pump perfusion. Methods 18 patients with flexible ureteroscope operations were divided into three groups: A, B and C, according to the three states of UAS (F12/14), 6 cases in each group. We detected the intrathecal flow velocity after URF-P5 flexible ureteroscope were placing into the renal pelvis and when placing 200 um fiber crushed stone. In group C which the UAS condition assessment is not satisfying, intrathecal guidewire was applied to improve the intrathecal velocity. We measured the internal pressure of the renal pelvis 1 case with renal fistula. Results The intrathecal velocity of URF-P5 in group A, B and C was (54.22 ± 2.14) ml/min, (47.32 ± 2.39) ml/min, and (25.01 ± 2.54) ml/min, respectively, after perfusion with 150 mmHg Wolf pump. The intrathecal flow rate was (32.68 ± 2.23) ml/min, (30.44 ± 2.58) ml/min, and (24.15 ± 2.22) ml/min, respectively. The flow rate of intrathecal guidewire placement in group C was (28.64 ± 2.18) ml/min, which increased by 13.0% ~ 21.0% and the average flow rate increased by 18.6% compared with that before guide wire placement. The renal pelvic pressure was 11 mmHg at rest. After entering the renal pelvis, the renal pelvic pressure was 28 ~ 51 mmHg with a median value of 38 mmHg. The renal pelvic pressure was 55 ~ 72 mmHg and the median value was 68 mmHg at holmium laser lithotripsy. The renal pelvic pressure decreased to 38 ~ 61 mmHg and the median value was 50 mmHg after intrathecal guidewire. Conclusions Different states of UAS lead to different outflow rates of perfusion fluid, and outflow rates could reflect the pressure of renal pelvis indirectly. It is relatively safe to use F12/14 UAS, URF-P5 flexible ureteroscope, Wolf pump perfusion pressure limit of 150 mmHg. The operation time should be controlled when the condition assessment of UAS is not satisfying and intrathecal guidewire is needed to reduce renal pelvic pressure through increasing intrathecal flow rate.