微创经皮肾镜碎石术并发大出血影响因素及临床处理分析
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摘要
目的:
分析微创经皮肾镜碎石取石术(mPCNL)大出血的影响因素,并探讨出血的预防与控制,及介入栓塞术对止血的效果及相关经验。
方法:
回顾性分析本院2002年9月至2008年12月收集的4538例MPCNL患者临床资料,发生大出血者28例,作为出血观察组,同时在4510例未大出血患者中随机抽取200例患者,作为对照组,以可能影响MPCNL手术出血的因素(结石情况、高血压、糖尿病、肝功能不全、肾功能不全、泌尿系感染、肾脏既往手术史、肾积水情况、是否为多通道穿刺、是否为分期取石)作为变量,对比分析两组间各变量间的统计学关系,以找出可能引起大出血发生率增大的因素,对出血的预防与控制提供临床参考,并对介入栓塞止血治疗的效果以及时机的把握进行分析和探讨。
结果:
出血组28例患者,总出血量900-3100ml,平均1200ml。术中及术后24h内出血1例,术后2-7天内出血17例,术后7天以后者10例。肾积水情况及程度(P=0.016＜0.05)、合并泌尿系感染(P=0.003＜0.05)、结石大小(P＜0.001)、糖尿病(P=0.002＜0.05)、穿刺通道数量(P=0.000＜0.05)、手术分期(P=0.024＜0.05)及手术时间(P＜0.05)对大出血的发生有影响,采用输血、药物止血、局部压迫,夹闭肾造瘘管等保守治疗者13例,14例患者在保守治疗失败或出血量大急诊行介入栓塞治疗,均取得良好效果。
结论:
结石体积过大、多通道取石、术前合并泌尿系感染或糖尿病以及手术时间过长均能增大MPCNL术大出血的发生,分期手术及肾积水患者出血量减少,并发大出血概率降低。术前控制感染及糖尿病,提高手术熟练度,减少手术时间,对于大体积结石的患者选择分期手术有助于降低大出血的发生。对于并发大出血患者,可以先行夹闭肾造瘘管、输血、应用止血药、甚至更换气囊肾造瘘管、利用水囊压迫等措施予以止血,若仍出血不止,应尽快行介入栓塞止血,介入止血栓塞肾出血动脉分支,选择性高,不会造成肾功能的损害,是PCNL术后反复大出血首选的治疗方法。
Objective:
To analyze the factors affecting severe hemorrhage with minimally invasive percutaneous nephrolithotomy, and to explore the prevention and control of the hemorrhage, summarize the experience in the interventional treatment of severe bleeding after MPCNL by superselective arteriolar embolization.
Method:
4538 cases of MPCNL in our hospital from September 2002 to December 2008 were retrospectively analyzed, 28 cases who occurred severe hemorrhage were defined as the the hemorrhage group; 200 cases of randomly selected patients in 4502 cases of non-bleeding were defined as the control group. Various patient related factors, as calculus situation, hypertension, diabetes, liver dysfunction, renal insufficiency, urinary tract infection, kidney history of previous surgery, hydronephrosis cases, whether multi-channel puncture, whether the stone in phases, were analyzed statistically, for the sake of identing the impact factors increased the rate of severe hemorrhage, and providing clinical experience to prevent and control the severe hemorrhage. And to analyze and approach the effect and the time of the arteriolar embolization.
Result:
Group of 28 cases of bleeding with a total amount of bleeding 900-3100ml, an average of 1200ml. 1 cases occurred in or 24h after operation, 17 cases occurred 2-7 days after, 10 cases occurred 7 days after, the degree of hydronephrosis, urinary system infection, stone surface area, diabetes, the number of puncture channel, surgical staging and surgery affect the incidence of bleeding, the use of blood transfusion, drug to stop bleeding, and local oppression, such as clipping of renal fistula made 13 cases of conservative treatment, 14 patients of conservative treatment failured or large amount of bleeding emergencyly got interventional treatment, and achieved good results.
Conclusion:
The huge stone, multi-channel stones removal, the complicated pre-operative urinary tract infection or diabetes, as well as prolonged operative time can arise the severe hemorrhage rate of MPCNL, severe hydronephrosis and staging the procedure are associated with reduced blood loss, as well as decrease the severe hemorrhage rate. To control the pre-operative infection and diabetes, improve the surgical skills to reduce the operative time , and for the large or complex stones or the cases with intraoperative technical complications choosing to operate in stages can help reduce the occurrence of bleeding. To whom with severe hemorrhage, we can clamp the renal fistula, give blood transfusion and hemostatic. And even the replacement nephrostomy balloon fistula, if still bleeding, interventional embolization should be as soon as possible to stop bleeding. Interventional embolization is highly selective and will not cause renal damage, is the preferred method of treatment of severe bleeding with MPCNL.
分析微创经皮肾镜碎石取石术(mPCNL)大出血的影响因素,并探讨出血的预防与控制,及介入栓塞术对止血的效果及相关经验。
方法:
回顾性分析本院2002年9月至2008年12月收集的4538例MPCNL患者临床资料,发生大出血者28例,作为出血观察组,同时在4510例未大出血患者中随机抽取200例患者,作为对照组,以可能影响MPCNL手术出血的因素(结石情况、高血压、糖尿病、肝功能不全、肾功能不全、泌尿系感染、肾脏既往手术史、肾积水情况、是否为多通道穿刺、是否为分期取石)作为变量,对比分析两组间各变量间的统计学关系,以找出可能引起大出血发生率增大的因素,对出血的预防与控制提供临床参考,并对介入栓塞止血治疗的效果以及时机的把握进行分析和探讨。
结果:
出血组28例患者,总出血量900-3100ml,平均1200ml。术中及术后24h内出血1例,术后2-7天内出血17例,术后7天以后者10例。肾积水情况及程度(P=0.016＜0.05)、合并泌尿系感染(P=0.003＜0.05)、结石大小(P＜0.001)、糖尿病(P=0.002＜0.05)、穿刺通道数量(P=0.000＜0.05)、手术分期(P=0.024＜0.05)及手术时间(P＜0.05)对大出血的发生有影响,采用输血、药物止血、局部压迫,夹闭肾造瘘管等保守治疗者13例,14例患者在保守治疗失败或出血量大急诊行介入栓塞治疗,均取得良好效果。
结论:
结石体积过大、多通道取石、术前合并泌尿系感染或糖尿病以及手术时间过长均能增大MPCNL术大出血的发生,分期手术及肾积水患者出血量减少,并发大出血概率降低。术前控制感染及糖尿病,提高手术熟练度,减少手术时间,对于大体积结石的患者选择分期手术有助于降低大出血的发生。对于并发大出血患者,可以先行夹闭肾造瘘管、输血、应用止血药、甚至更换气囊肾造瘘管、利用水囊压迫等措施予以止血,若仍出血不止,应尽快行介入栓塞止血,介入止血栓塞肾出血动脉分支,选择性高,不会造成肾功能的损害,是PCNL术后反复大出血首选的治疗方法。
Objective:
To analyze the factors affecting severe hemorrhage with minimally invasive percutaneous nephrolithotomy, and to explore the prevention and control of the hemorrhage, summarize the experience in the interventional treatment of severe bleeding after MPCNL by superselective arteriolar embolization.
Method:
4538 cases of MPCNL in our hospital from September 2002 to December 2008 were retrospectively analyzed, 28 cases who occurred severe hemorrhage were defined as the the hemorrhage group; 200 cases of randomly selected patients in 4502 cases of non-bleeding were defined as the control group. Various patient related factors, as calculus situation, hypertension, diabetes, liver dysfunction, renal insufficiency, urinary tract infection, kidney history of previous surgery, hydronephrosis cases, whether multi-channel puncture, whether the stone in phases, were analyzed statistically, for the sake of identing the impact factors increased the rate of severe hemorrhage, and providing clinical experience to prevent and control the severe hemorrhage. And to analyze and approach the effect and the time of the arteriolar embolization.
Result:
Group of 28 cases of bleeding with a total amount of bleeding 900-3100ml, an average of 1200ml. 1 cases occurred in or 24h after operation, 17 cases occurred 2-7 days after, 10 cases occurred 7 days after, the degree of hydronephrosis, urinary system infection, stone surface area, diabetes, the number of puncture channel, surgical staging and surgery affect the incidence of bleeding, the use of blood transfusion, drug to stop bleeding, and local oppression, such as clipping of renal fistula made 13 cases of conservative treatment, 14 patients of conservative treatment failured or large amount of bleeding emergencyly got interventional treatment, and achieved good results.
Conclusion:
The huge stone, multi-channel stones removal, the complicated pre-operative urinary tract infection or diabetes, as well as prolonged operative time can arise the severe hemorrhage rate of MPCNL, severe hydronephrosis and staging the procedure are associated with reduced blood loss, as well as decrease the severe hemorrhage rate. To control the pre-operative infection and diabetes, improve the surgical skills to reduce the operative time , and for the large or complex stones or the cases with intraoperative technical complications choosing to operate in stages can help reduce the occurrence of bleeding. To whom with severe hemorrhage, we can clamp the renal fistula, give blood transfusion and hemostatic. And even the replacement nephrostomy balloon fistula, if still bleeding, interventional embolization should be as soon as possible to stop bleeding. Interventional embolization is highly selective and will not cause renal damage, is the preferred method of treatment of severe bleeding with MPCNL.
引文
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[2]Jaekman SV,Hedican SP,Peters CA,et al.Percutaneous nephrolithotomy in infants and preschool age children:experience with a new technique[J].Urology.1998,52(4),697-701.
[3]Jaekman SV,Docimo SG,Cadeddu JA,et al.The"mini-perc"technique:a less invasive alternative to percutaneous nephrolithotomy[J].World J Urol.1998,1(6):371-374.
[4]李逊,曾国华,袁坚,等.经皮肾穿刺取石术治疗上尿路结石(20年经验)[J]。北京大学学报(医学版),2004,36(2):124-126.
[5]陈合群,廖锦堂,齐范等.经皮肾镜取石术处理肾结石[J].中华泌尿外科杂志,2006,27(6)374-376
[6]燕翔,郭宏骞,李笑弓等.经皮肾微造瘘输尿管镜碎石术失血因素分析[J].中华泌尿外科杂志,2008,29(4)254-258
[7]王宇雄,李逊,吴开俊,等.经皮肾穿刺取石术并发大出血的分析及对策[J]。临床泌尿外科杂志,2006,27(2):96-97.
[8]梁卓寅,梁志雄.超选择性肾动脉栓塞治疗微创经皮肾穿刺取石术后出血[J].国际泌尿系统杂志,2006,26(6)725-727
[9]袁坚,吴开俊.经皮肾镜术并发大出血16例报告.中华泌尿外科杂志,1995,16:530-531.
[10]Gremmo E,Bakkanger P,Dore B,et al.Hemorrhagic complications during percutaneous nephrolithotomy.Retrospective studies of 772 cases.Prol Urol,1999,9:460-463.
[11]Nguyen HC,Tan YH,Wong MY,et al.Percutaneous nephrolithotomy in the management of complex upper urinary tract calculi:the Singapore Genenal Hospital experience.Ann Acad Med Singapore,2003,32:570.
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