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妊娠合并输尿管结石并发顽固性肾绞痛的急诊处理

来源:《中华现代外科学杂志》
摘要:【摘要】目的探讨妊娠合并输尿管结石并发顽固性肾绞痛安全有效的急诊处理方法。方法1997~2006年妊娠合并输尿管结石致肾绞痛经解痉镇痛治疗无效患者16例,年龄22~36岁,平均27岁,初诊时孕7~35周,平均27周。结石最大径4~15。其中1例为独肾,1例并发发热,1例为双侧输尿管下段结石,患侧轻度肾积水8例,中度肾......

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【摘要】    目的 探讨妊娠合并输尿管结石并发顽固性肾绞痛安全有效的急诊处理方法。方法 1997~2006年妊娠合并输尿管结石致肾绞痛经解痉镇痛治疗无效患者16例,年龄22~36岁,平均27岁,初诊时孕7~35周,平均27周。结石最大径4~15.5 cm。其中1例为独肾,1例并发发热,1例为双侧输尿管下段结石,患侧轻度肾积水8例,中度肾积水9例,均在局麻下在膀胱镜或输尿管镜下逆行置入输尿管双J管治疗。结果 15例患者在置入输尿管双J管后肾绞痛症状均缓解,1例出现间歇性肉眼血尿,有间断轻微肾绞痛,予解痉治疗可缓解,1例患者双J管自动滑出,反复置管2次。16例孕妇均顺利分娩。结论 妊娠合并输尿管结石并发顽固性肾绞痛,采用放置输尿管双J管治疗,安全有效。

【关键词】  妊娠 输尿管结石 肾绞痛

  Emergency treatment of refractory renal colic due to ureteric calculi during pregnancy

    GAO Jian,GONG Jing,YANG Yong,et al.Department of Urology,The Affiliated Hospital of Wuhan University of Science & Technology,Wuhan 430064,China

    [Abstract] Objective To evaluate the safety and efficacy of emergency treatment of refractory renal colic due to ureteric calculi during pregnancy.Methods From 1997 to 2006,this series included 16 pregnant women (mean age was 27 years,and age ranged form 22 to 36 years old) with renal colic had not responded to conservative measures of antispasmodics and analgesics.The mean(range) gestation time was 27(7~35) weeks at diagnosis.The ureteric calculi were 4~15.5 cm in greatest dimension.All these cases presented with symptoms such as solitary kidney (1 case),fever (1 case),bilateral lower ureter calculus(1 case),8 cases of mild hydronephrosis and 9 cases moderate hydronephrosis were observed,all of them received treatment of placing of double-J-catheter under the cystoscope or ureteroscope under local anesthesia.Results Renal colic was relieved by placing double-J-catheter under the cystoscope or ureteroscope in 15 cases,in which one case had intermittent gross hematuria and mild intermittent renal colic,which could be reliered by antispasmodics and analgesics.Double-J- catheters slid out in 1 case and was placed repeatedly.All 16 pregnant women had normal delivery.Conclusion For pregnant women with refractory renal colic due to ureteric calculi,placing double-J-catheter is safe and effective.

    [Key words] pregnancy;ureteral calculi;renal colic;double-J-catheter

    1997~2006年,笔者对16例妊娠合并输尿管结石并顽固性肾绞痛患者,采用了放置输尿管双J管的急诊处理,效果满意,现报告如下。

    1 资料与方法

    1.1 一般资料 本组16例,年龄22~36岁,平均27岁。初诊时孕7~35周,平均27周,结石最大径4~15.5 cm,16例患者均有典型肾绞痛(其中肾绞痛反复发作10例),4例伴尿频、尿急、尿痛,7例出现间断性肉眼血尿,畏寒、发热1例(体温38.2 ℃~39.3 ℃),其中1例为独肾,发生急性梗阻性无尿(血尿素氮 18.2~23.3 mmol/L,血肌酐501~729 μmol/L),其余15例患者肾功能正常,16例患者均行B超检查,2例经KUB检查,确诊为输尿管结石,1例为双侧输尿管结石,其中患侧轻度肾积水8例,中度肾积水9例,均行尿常规检查,12例患者镜下可见红细胞,1例尿培养提示大肠埃希菌生长。

    1.2 治疗方法 患者予利多卡因局麻后,取截石位,13例经膀胱镜放置输尿管双J管,3例膀胱镜下置管失败,改为经输尿管镜放置双J管,双J管为5F~6F型号。其中泌尿系感染者给予青霉素400万u/次,2次/d治疗。

    置管成功后,患者每月复查B超,观察肾积水及双J管的位置,3~6个月更换一次双J管,直至分娩。

    2 结果

    15例患者在置入输尿管双J管后肾绞痛症状均缓解,1例出现间歇性肉眼肉尿,伴间断轻微肾绞痛,予解痉对症治疗后可缓解。1例患者双J管自动滑出,反复置管2次,导管未脱出。发热及尿培养阳性患者经双J管引流及抗感染治疗,感染及肾绞痛症状均得到控制,1例独肾、急性梗阻性无尿患者置管引流后,症状缓解,尿量及肾功能(血尿素氮、血肌酐)均恢复正常,16例患者置管后每月复查B超直至分娩,15例患者的肾积水均得到不同程度的改善。16例患者均未出现先兆流产等产科异常,均足月分娩,产下健康婴儿,分娩时间孕37~41周。分娩后,经B超、腹部平片等检查,5例患者的结石已自行排出,7例经体外冲击波碎石治疗,4例行输尿管镜取石治疗,输尿管结石均被清除。

    3 讨论

    妊娠合并泌尿系结石的发病率约4~50/万[1],妊娠期尤其是妊娠中晚期的解剖和生理变化很大,可出现肾盂和输尿管扩张[2],合并输尿管结石并顽固性肾绞痛发作,易误诊漏诊,如处理不当,可危及母婴生命[3]。除了患者的病史、症状、体征、实验室检查,B超是临床首选诊断方法。虽然其敏感性和特异性只有74%和67%[4],但副作用小,且可直接发现结石和肾积水。X线照射对胎儿有潜在致畸和影响发育的可能,应尽量避免,但也有研究KUB或限制性IVU对胎儿的照射量很少,造成不良后果的几率很低[5]。

    妊娠尤其是中晚期合并输尿管结石急症总的治疗原则为:解除梗阻,防治感染,确保母婴安全[6]。且70%~80%孕妇的泌尿系结石可以自然排出,所以我们首先考虑保守治疗,失败后再考虑外科手段干预。我们考虑外科治疗的适应证是:(1)肾绞痛反复发作,保守治疗无效者。(2)双侧输尿管梗阻或孤立肾合并梗阻影响肾功能者。(3)泌尿系结石梗阻性肾积水并感染,在没有控制感染的情况下,应避免逆行输尿管镜操作。置入输尿管双J管对缓解保守治疗无效的孕妇肾绞痛、解除泌尿系梗阻、挽救受损的肾功能具有重要作用[7]。且有的进口双J管经特殊亲水处理,对人体组织刺激性小,可留置 6个月甚至以上,从而避免频繁更换双J管。

    经皮肾穿刺造瘘被认为是一种有效引流肾积水的方法,但需长期更换,预防感染,且外置肾造瘘管会给孕妇生活带来麻烦[8]。ESWL可致先兆流产,对胎儿有影响,视为禁忌证。Scarpa等[9]和Shokeir等[10]及国内的袁坚等[11]报道可采用逆行输尿管镜碎石或取石治疗,但也有学者认为有并发输尿管穿孔、输尿管狭窄、先兆流产可能。

    本组16例患者经置入输尿管双J管(有的给予适当的抗感染治疗),肾绞痛、发热等症状得到缓解,1例患者的肾功能得到恢复,复查B超15例患者肾积水有所减轻。因此,我们认为妊娠合并输尿管结石并发顽固性肾绞痛,采用放置输尿管双J管治疗,安全有效。

【参考文献】
  1 Corton E,Whitfied HN.Renal calculi in pregnancy.Br J Urol,1997,80(Suppl 1):4-9.

2 吴阶平.泌尿外科学.济南:山东科学技术出版社,2001,773.

3 Watterson JD,Girvan AR,Beiko DT,et al.Ureteroscopy and holmium:YAG laser lithotripsy:an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy.Urology,2002,60:383-387.

4 Webb JA.Ultrasonography and Doppler studies in the diagnosis of renal obstruction.BJU Int,2000,86:25-32.

5 Swanson SK,Heilman RL,Eversman Wg.Urinary tractin pregnancy.Surg Clin North Am,1995,75:123-142.

6 Webb JAW.Ultrasonography and Doppler studies in the diagnosis of renal obstruction.BJU Int,2006,86(Suppl 1):25-32.

7 Delakas D,Karyotis I,Loumbakis P,et al.Ureteral drainage by double-J-catheters during pregnancy.Clin Exp Obstet Gynecol,2000,27:200-202.

8 Kavousi LR,Albaia DM,Elasier JW,et al.Percutaneous management of urolithasis during pregnancy.J Urol,1992,148:1069-1071.

9 Scarpa RM,De Lisa A,Usai E.Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes.J Urol,1996,77:17-20.

10 Shokeir AA,Mutabagani H.Rigid ureteroscopy in pregnant women.Br J Urol,1998,81:678-681.

11 袁坚.妊娠合并输尿管结石致顽固性肾绞痛的临床处理.中华泌尿外科杂志,2005,26:324-326.

(编辑:许 忆)


作者单位:430064 湖北武汉,武汉科技大学附属医院泌尿外科

作者: 高剑 宫敬 杨勇 罗冬喜 曾斌 陈磊 钱芳 孙建萍 2008-6-13
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