根治性膀胱切除术后输尿管-回肠膀胱吻合口狭窄的分型及腔内处理的疗效  

Classification and minimally invasive management of ureteroileal bladder anastomotic stricture after radical cystectomy

作　　者：陈瑞宝 梅江 尹懿盛 周辉[1] 车悦 李书荣 田逸群 詹鹰 曾晓勇[1] Chen Ruibao;Mei Jiang;Yin Yisheng;Zhou Hui;Che Yue;Li Shurong;Tian Yiqun;Zhan Ying;Zeng Xiaoyong(Department of Urology,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430030,China)

机构地区：[1]华中科技大学同济医学院附属同济医院泌尿外科,武汉430030

出　　处：《中华泌尿外科杂志》2023年第4期265-269,共5页Chinese Journal of Urology

摘　　要：目的探讨根治性膀胱切除术后输尿管-回肠膀胱吻合口狭窄(UAS)的分型及腔内处理的疗效。方法回顾分析2017年1月至2022年1月同济医院收治的34例根治性膀胱切除术后UAS患者的临床资料。男25例,女9例。年龄(66.3±7.7)岁。发生UAS时间为根治性膀胱切除术后(14.7±6.5)个月。单侧肾盂积水32例,双侧肾盂积水2例。2例在外院已行肾造瘘。3例血常规检查白细胞升高,其中2例伴发热,先行积水侧肾造瘘和抗感染治疗,待血常规检查白细胞正常,且停用抗生素24h无发热后再手术。34例术前肾积水(2.7±0.6)cm。本组34例中,5例经术前留置的肾造瘘管注射亚甲蓝,29例用18G穿刺针于超声引导下穿刺肾盂注射亚甲蓝。用输尿管硬镜于回肠膀胱中观察,4例可见亚甲蓝,依亚甲蓝引导寻及狭窄处并置入超滑导丝,其中3例用5mm输尿管扩张球囊导管扩张,1例用F14软镜鞘扩张,然后留置F6单J管。30例未见亚甲蓝,其中16例顺行经肾造瘘口用输尿管软镜寻及狭窄处,用30W钬激光切开,然后9例行球囊扩张、7例行软镜鞘扩张后留置F6单J管。14例顺行方法无法寻及狭窄处,根据手术时间、患者情况等决定即刻或二期行双镜联合手术,经肾造瘘口用软镜沿超滑导丝进镜至狭窄处,经回肠膀胱用输尿管硬镜观察,借助超滑导丝抖动和内镜光点寻找狭窄处。10例寻及狭窄处,用30W钬激光切开,8例行球囊扩张、2例行软镜鞘扩张后留置F6单J管。4例采用双镜联合方法仍无法准确寻及狭窄处(其中1例为双侧狭窄1侧已解除),继续留置肾造瘘管。本研究成功解除狭窄的定义为输尿管可以置入F6单J管。结果根据术中所见严重程度将UAS分成4型:Ⅰ型,狭窄处管腔较正常输尿管缩窄>50%,但亚甲蓝可以成股通过;Ⅱ型,针尖样狭窄,仅允许亚甲蓝细丝样通过;Ⅲ型,膜状闭锁,狭窄段长1~3mm,亚甲蓝无法通过;Ⅳ型,长段狭窄。本组34例中,Ⅰ型4例Objective To discuss the classification and treatment of ureteroileal anastomotic stricture(UAS)after radical cystectomy.Methods The clinical data of 34 patients with UAS after radical cystectomy in the Department of Urology of Tongji Hospital from January 2017 to January 2022 were reviewed and analyzed.There were 25 males and 9 females.The average age was(66.3±7.7)years,including 2 cases of bilateral hydronephrosis and 32 cases of unilateral hydronephrosis.The average time of UAS was detected(14.7±6.5)months after radical cystectomy.There were 32 patients of unilateral hydronephrosis and 2 patients of bilateral hydronephrosis.Two patients had undergone nephrostomy in an external hospital.Three patients had elevated leukocytes in blood routine.Among them,two patients had fever.First,nephrostomy on the hydronephrosis side and anti-infection treatment were performed.After routine blood tests showed that the white blood cells were normal and antibiotics were stopped for 24 hours without fever,the operation was performed.34 patients had preoperative hydronephrosis of(2.7±0.6)cm.Of the 34 cases in this group,5 cases were injected with methylene blue through a preoperative nephrostomy tube,and 29 were injected with methylene blue through the renal pelvis using an 18G puncture needle under ultrasound guidance.Using a ureteroscope to observe in the ileal bladder,methylene blue was seen in 4 cases.Methylene blue was used to guide the search for the stenosis and a super smooth guide wire was inserted.Among them,3 cases were dilated with a 5 mm ureteral dilation balloon catheter,1 case was dilated with a F14 ureteral access sheath,and then a F6 single J stent was inserted.Methylene blue was not seen in the ileal conduit in 30 cases,of which 16 cases were treated with a flexible ureteroscope through the nephrostomy to locate the stenosis,incised with a 30 W holmium laser.9 cases were treated with 5 mm ureteral dilation balloon catheter,and 7 cases were treated with a F14 ureteral access sheath,and then an F6 single J sten

关 键 词：输尿管-回肠膀胱吻合口狭窄 膀胱根治性切除术 膀胱癌 

分 类 号：R699.5[医药卫生—泌尿科学]