[耻骨上膀胱穿刺微造瘘输尿管镜碎石术在儿童下尿路结石中的应用]输尿管造瘘
[摘要] 目的 探讨耻骨上膀胱穿刺微造瘘输尿管镜碎石术治疗儿童下尿路结石的方法和疗效。 方法 采用耻骨上膀胱穿刺微造瘘输尿管镜碎石术治疗儿童下尿路结石12例。 结果 12例患者均一次手术成功，无大出血，造瘘口无尿瘘，拔除尿管后均排尿顺畅，术后复查KUB或B超无结石残留，随访患者未发生尿道狭窄等并发症。 结论 采用耻骨上膀胱穿刺微造瘘输尿管镜碎石术治疗儿童下尿路结石具有手术损伤小、并发症少、操作简单、疗效佳的优点，值得推广。
[关键词] 膀胱穿刺；输尿管镜；弹道碎石；儿童；下尿路结石
[中图分类号] R322.63 [文献标识码] C [文章编号] 1673-7210（2012）07（b）-0167-02
Application of percutaneous ureteroscopic lithotripsy in the treatment of lower urinary calculi in children
FENG Zhenhua HUANG Qiang QIU Guangjin PENG Yeping CHEN Xianguo WU Fuguang
Department of Urology Surgery, the People"s Hospital of Gaozhou City, Guangdong Province, Gaozhou 525200, China
[Abstract] Objective To investigate the methods and the clinical value of percutaneous ureteroscopic lithotripsy in the treatment of lower urinary calculi in children. Methods Percutaneous ureteroscopic lithotripsy were performed on 12 children. Results All the operations were completed successfully, with no severe bleeding and urethrocutaneous fistula occurring. After removing urethral catheter urination of all the children became smooth. By postoperative re-examination of KUB or ultrasound lower urinary calculi were found cleaned thoroughly in all cases. All the patients followed up had no such complications as urethrostenosis. Conclusion Percutaneous ureteroscopic lithotripsy in the treatment of lower urinary calculi in children is a simple and efficient method with advantages of mini-invasion, which is worth of application generally.
[Key words] Vesicopuncture; Ureteroscope; Lithotripsy; Children; Lower urinary calculi
我院自2008年7月～2011年7月采用耻骨上膀胱穿刺微造瘘输尿管镜碎石术治疗儿童下尿路结石12例，疗效满意。现报道如下：
1 资料与方法
1.1 一般资料
本组12例，年龄3～13岁，平均6.5岁；男童11例，女童1例；其中膀胱结石7例，后尿道结石5例；结石单发9例，多发3例。结石直径4～25 mm。合并急性尿潴留者3例，11例男童中有7例合并包茎。所有患儿均有不同程度的排尿痛、排尿困难症状，尿常规可见红细胞、白细胞。术前均行B超、膀胱区片明确诊断，排除合并其他尿路畸形。
1.2 治疗方法
本组患者术前半小时应用抗生素预防感染。6岁以下患儿采用静脉全麻，6岁以上患儿采用硬膜外麻醉，均取平卧位，适当垫高臀部，经尿道置入6F或8F气囊尿管致膀胱，包茎者可先予小分离钳撑开包皮口，后尿道结石导致尿管受阻者，可先予8F金属尿道探子将结石推入膀胱内。经尿管向膀胱注水约100 mL，见膀胱区稍隆起即可。取耻骨联合以上1 cm作穿刺点，做一约5 mm小切口，深达腹白线，取14F筋膜扩张器，外套peel-away鞘，垂直腹壁穿刺，有明显落空感后拔出筋膜扩张器，见有尿液经peel-away鞘涌出证实已进入膀胱。8/9.8F输尿管镜连接电视摄像系统，经peel-away鞘进入膀胱观察，通过气压弹道碎石后将碎石钳出或水冲出体外。本组1例女童膀胱结石因膀胱内小橡胶管异物引起，粉碎结石后将小橡胶管钳出。检查无结石残留、无活动出血，无合并下尿路畸形后退镜，留置14F膀胱造瘘管。术后预防性应用抗生素3 d，生理盐水间断冲洗膀胱1～2 d，术后1～2 d观察尿液澄清后可拔除尿管，患儿排尿顺畅，B超复查无结石残留后，第2天可拔除膀胱造瘘管，再观察1 d，如造瘘口无尿瘘，无肉眼血尿，无排尿困难，即可出院。
2 结果
12例患者均一次手术成功，手术时间为20～65 min，平均30 min。住院5～7 d，平均6 d。所有患者术中没有出现大出血、膀胱穿孔、腹腔脏器损伤等并发症。拔除尿管后均能自行排尿，无明显排尿痛或血尿；拔除膀胱造瘘管后，均没有出现尿瘘，造瘘口1周左右完全愈合。经随访2个月～3年，未出现尿道狭窄、排尿困难。