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中华腔镜泌尿外科杂志(电子版)

中华腔镜泌尿外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (04) : 366 -371. doi: 10.3877/cma.j.issn.1674-3253.2024.04.011

临床研究

输尿管软镜术后严重出血治疗的初步探索
麦子结1, 曾学晴1, 张乾升1, 刘永达1,†()   
  1. 1. 510500　广东，广州医科大学附属第一医院泌尿外科
  • 收稿日期:2024-05-14 出版日期:2024-08-01
  • 通信作者: 刘永达
  • 基金资助:
    广东省基础与应用基础研究基金(2020A1515011461)

A preliminary study on the treatment of severe bleeding after ureteroscopy

Zijie Mai1, Xueqing Zeng1, Qiansheng Zhang1, Yongda Liu1,†()   

  1. 1. Department of Urology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510500, China.
  • Received:2024-05-14 Published:2024-08-01
  • Corresponding author: Yongda Liu
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麦子结, 曾学晴, 张乾升, 刘永达. 输尿管软镜术后严重出血治疗的初步探索[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 366-371.

Zijie Mai, Xueqing Zeng, Qiansheng Zhang, Yongda Liu. A preliminary study on the treatment of severe bleeding after ureteroscopy[J/OL]. Chinese Journal of Endourology(Electronic Edition), 2024, 18(04): 366-371.

目的

探索输尿管软镜碎石取石术后严重出血的原因，并探讨相关治疗方法与策略的可行性。

方法

回顾性收集分析2022至2023年广州医科大学附属第一医院接受的输尿管软镜术后严重出血患者的一般资料及围手术期相关临床数据，分析相关出血原因及治疗策略的可行性。

结果

5例患者中有3例患者经肾动脉栓塞术治疗后未再发生出血。一例患者肾3次动脉栓塞术后再行肾造瘘治疗后成功止血，另一例患者2次肾动脉栓塞术后仍存在出血，遂行肾造瘘术后再次行栓塞术，后未再发生出血。止血期间联合补液、输血、抗感染、持续膀胱冲洗等治疗，最终所有患者好转出院。

结论

输尿管软镜碎石取石术导致出血的特点是多根血管损伤，目前出血原因未完全明确，考虑可能与肾盂内压升高、假性动脉瘤形成等原因有关。行肾造瘘减轻肾盂内压及加强肾动脉栓塞治疗对软镜术后出血疗效较为明显。

关键词: 输尿管软镜, 出血, 肾盂内压, 肾造瘘, 肾动脉栓塞
Objective

To explore the causes of severe bleeding after retrograde intrarenal surgery and explore the feasibility of related treatment methods and strategies.

Methods

The general data and preoperative and postoperative clinical data of patients with severe bleeding after retrograde intrarenal surgery in the First Affiliated Hospital of Guangzhou Medical University from 2022 to 2023 were retrospectively collected and analyzed, and the causes of bleeding and the feasibility of treatment strategies were analyzed.

Results

Among the 5 patients, 3 cases did not experience any further bleeding after renal artery embolization treatment. One patient who underwent renal artery embolization three times and then underwent nephrostomy successfully stopped bleeding. Another patient continued to experience bleeding after two rounds of renal artery embolization, and underwent another embolization procedure after nephrostomy. No further bleeding occurred thereafter. During the hemostasis period, a combination of fluid replacement, blood transfusion, anti infection, continuous bladder irrigation, and other treatments were used, and ultimately all patients improved and were discharged.

Conclusion

The bleeding after retrograde intrarenal surgery is characterized by multiple blood vessel injuries. The cause of bleeding is not completely clear at present, and may be related to elevated renal pelvis pressure, false aneurysm formation and other reasons. Nephrostomy alleviates the intrarenal pressure and subsequent embolization of renal artery is effective in the treatment of bleeding.

Key words: Flexible ureteroscope, Bleeding, Renal pelvic pressure, Nephrostomy, Embolization of renal artery
表1 5例输尿管软镜碎石术后严重出血患者一般资料
项目 病例1 病例2 病例3 病例4 病例5
年龄(岁) 58 46 37 58 70
BMI（kg/m2) 23 24 25 22 26
住院天数(d) 44 11 9 3 8
随访时间(d) 32 83 44 16 539
结石最长径(mm) 10 8 12 20 18
结石负荷(mm2) 48 100 212 158 350
结石CT值(Hu) 1 035 950 675 1 153 1 380
输尿管软镜碎石手术时间(min) 42 85 70 145 40
图1　五例患者输尿管软镜术后出血行肾动脉栓塞术造影图片　 图2　病例5输尿管软镜术后出血行肾动脉栓塞术造影图片注：1a～1b示病例1左肾后干分支末梢、左肾中下部3个小点状对比剂滞留，局部伴小片浓染色，供血动脉包括左肾下前段动脉的2个分支及上前段动脉的1个分支，1c示病例1另左肾后干一分支末梢，左肾上前段、下前段各一动脉分支末梢对比剂外溢，1d示病例1左肾中部两个小点状对比剂外溢，供血动脉为左肾上前段动脉的两个纤细分支；1e～1g示病例2左肾中下部见一椭圆形假性脉瘤，供血动脉来源于左肾动脉后干分支；1h～1i示病例3左肾下部可疑小假性动脉瘤，供血动脉为左肾下段动脉分支；1j示病例3左肾下部数个可疑小假性动脉瘤，供血动脉为左肾下段、下前段动脉分支；1k示病例3左肾动脉局部栓塞术后改变，左肾下段动脉原栓塞分支主干旁局部可见点状对比剂浓聚；1l～1o示病例4左侧主肾动脉造影，上部、下部各一动脉分支出血不均，局部可见点状、小片状对比剂浓聚；2a～2d造影显示左肾下极一支纤细动脉末梢可见对比剂外溢至左侧肾盂输尿管移行部，出血动脉为左肾下段一动脉分支，另一支动脉分支末梢可见少量对比剂
表2 五例输尿管软镜碎石术后严重出血患者第一次肾动脉栓塞前后相关临床资料
第一次肾动脉栓塞术前 病例1 病例2 病例3 病例4 病例5
术前白细胞(109/L) 6.66 5.52 15.59 10.83 13.29
术前肌酐(μmol/L) 198 83 76 65 145
术前APTT(s) 38 29 34 34 41
术前PT(s) 14.9 12.9 13.4 13.8 13.1
术前血小板(109/L) 77 304 450 135 180
术前血红蛋白(g/L) 68 70 110 90 70
介入时间(min) 60 85 122 145 40
第一次肾动脉栓塞术后          
术后白细胞(109/L) 14.79 5.97 15.09 8.15 9.96
术后肌酐(μmol/L) 114 74 175 77 96
术后APTT(s) 38 31 43 37 40
术后PT(s) 14.6 12.0 14.2 14.1 13.7
术后血小板(109/L) 64 290 351 130 172
术后血红蛋白(g/L) 65 67 92 83 69
输血量(ml) 800 600 1 600 800 800
表3 病例1和3第二、三次行肾动脉栓塞术前后相关临床资料
第二次肾动脉栓塞术前 病例1 病例3
术前APTT(s) 29 37.5
术前PT(s) 13.5 13.5
术前血小板(109/L) 67 559
术前血红蛋白(g/L) 67 63
介入时间(min) 80 124
第二次肾动脉栓塞术后    
术后APTT(s) 39.5 34.4
术后PT(s) 13.1 13.4
术后血小板(109/L) 59 409
术后血红蛋白(g/L) 75 72
输血量(ml) 1 400 1 200
第三次肾动脉栓塞术前    
术前APTT(s) 48.7 36.7
术前PT(s) 13.6 13.9
术前血小板(109/L) 80 417
术前血红蛋白(g/L) 75 56
介入时间(min) 100 70
第三次肾动脉栓塞术后    
术后APTT(s) 47.6 36
术后PT(s) 13.2 13.5
术后血小板(109/L) 69 356
术后血红蛋白(g/L) 77 65
输血量(ml) 0 1 200
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