經皮輸尿管內置管置放治療輸尿管狹窄

The Management of Ureteral Strictures with Percutaneous Ureteral Stent Placement

王家槐(Jia-Hwia Wang)；許重權(Chung-Chuan Hsu)；張遵(Tsuen Chang)；張心湜(Luke S. Chang)

經皮輸尿管內置管置放 ； 輸尿管狹窄 ； 輸尿管內置管 ； 經皮腎造瘻術 ； percutaneous ureteral stent placement ； ureteral stricture ； ureteral stents ； percutaneous nephrostomy

中華放射線醫學雜誌

13卷3期（1988 / 09 / 01）

235 - 242

繁體中文

從民國73年10月至77年6月，共有16位輸尿管狹窄之患者，在接受逆行性輸尿管內置管置放失敗後，接受共17次經皮前行性輸尿管內置管置放。結果有13位患者14次放置成功；而有3位患者3次放置因輸尿管極度狹窄及彎曲而失敗。有1例術後發生敗血症，後經積極性內科治療而加以控制。有1例輸尿管內置管在放置1個月後，在門診追踪發現內置管往上移位，後經泌尿外科醫師以膀胱鏡矯正。對於經皮前行性輸尿管內置管置放成功與否，腎臟之入口非常重要；同時選擇適當之導引鋼絲及導管，加上熟練之血管攝影導管技巧，可提高成功率。假如內置管無法通過輸尿管狹窄處，可以血管擴張氣球導管先行將狹窄處加以擴張，再放置內置管；或可由泌尿外科醫師藉著膀胱鏡經由我們放置於腎與膀胱間之導引鋼絲施行逆行性放置輸尿管內置管。假如導引鋼絲無法通過輸尿管狹窄處，則可放置前頭稍彎之導管於狹窄處上方幾天後，再施行經皮前行性輪尿管內置管置放。如合併泌尿道感染，應在控制感染後，再施行經皮前行性輸尿管內置管置放。最嚴重之併發症是嚴重出血；如果發生，應施以選擇性或超選擇性腎動脈攝影，決定是否施行腎動脈栓塞術。長期放置輸尿管內置管，可能發生覆蓋物或移位，因此定期追踪檢查所放置之輸尿管內置管是必須的。

From Oct. 1984 thru June 1988, 17 percutaneous antegrade ureteral stent placements were tried in 16 patients; in which 14 placements in 13 patients were successfully done, and three placements in three patients failed due to severe stenotic and markedly tortuous ureters. Sepsis occured in one case which was controlled after intensive medical treatment. Upward migration of ureteral stent occurred in one case in OPD follow-up which was corrected cystoscopically. Renal access is very important for successful percutaneous antegrade placement of ureteral stents. Selection of suitable guide wires and stents and well-trained angiographic catheter techniques are also important for successful percutaneous antegrade placement of ureteral stents. If the stents will not pass a stenotic segment, the slightly curved tip catheter should be reinserted and left in place for several days. Alternatively, the stenosis could be dilated with an angioplasty balloon catheter, or the urologist could retrieve the guide wire in the bladder. In cases of superimposed urinary tract infection, percutaneous antegrade ureteral stent placement should be postponed until urinary tract infection has been controlled, and only percutaneous nephrostomy is done. The most frequent severe complication is massive hemorrhage. Significant bleeding may be immediate or delayed with the formation of pesudoaneurysms and arteriovenous fistula. Selective renal arteriography is indicated in cases of post-placement significant bleeding for diagnostic and theurapeutic reasons. Because migration or encurstation of the ureteral stents may occur, periodic check of the ureteral stents is recommended. Infection may occur with long-term indwelling stents, but this can be prevented by use of antibiotics and periodic change of the stents.