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Allium覆膜金属输尿管支架长期留置治疗放疗后输尿管狭窄的有效性和安全性

Allium coated metal ureteral stent for the treatment of radiation induced ureteral stricture

摘要:

目的:探讨Allium覆膜金属输尿管支架长期留置治疗放疗后输尿管狭窄(RIUS)的有效性和安全性。方法:回顾性分析北京大学人民医院2018年10月至2019年12月采用Allium输尿管支架治疗的23例(34侧)RIUS患者的病例资料,男1例(1侧),女22例(33侧)。平均年龄(57.4±11.5)岁。术前中位血肌酐96.0(47.0~421.0)μmol/L。单侧输尿管狭窄12例,双侧狭窄11例。排尿后肾脏超声或CT检查评估患侧肾积水程度,平均肾盂宽度(2.3±1.1)cm。原发疾病包括宫颈癌17例,直肠癌3例,子宫内膜癌2例和输尿管癌1例;肿瘤治疗方式包括根治性放疗2例,手术联合放化疗21例。术前留置肾造瘘管5例(7侧);留置双J管18例(27侧),中位留置时间18.0(2.0~84.0)个月,更换间隔时间5.0(1.0~12.0)个月/次。输尿管支架症状问卷(USSQ)总分99.0(59.0~126.0)分。Allium输尿管支架置入手术采用蛛网膜下腔麻醉或全麻,患者取截石位,逆行尿路造影检查确定输尿管全长狭窄8侧,中下段狭窄20侧,中段狭窄1侧,下段狭窄5侧;平均狭窄长度(15.9±5.9)cm。先行输尿管球囊扩张狭窄段[球囊压力2 533.1kPa(25ATM),时间3 min],当狭窄长度>6 cm时由上至下依次扩张,根据狭窄长度置入1~3根Allium输尿管支架。单侧输尿管置入3根支架6侧、2根支架18侧、1根支架10侧。X线下放置支架到位后释放,行逆行造影观察输尿管通畅性,术毕留置导尿管。术后第1天复查血肌酐和腹平片,术后每6个月复查血肌酐、排尿后肾脏超声和腹平片,评估患者肾功能、支架位置和通畅性,记录患者USSQ以评估患者生活质量。采用Clavien-Dindo分级系统评估术后并发症。结果:本组23例手术均顺利完成,平均手术时间(100.7±37.2)min。支架置入成功率为100%。术后6个月血肌酐93.5(54.0~289.0)μmol/L,较术前显著降低( P=0.005);肾盂宽度和USSQ总分较术前差异无统计学意义( P>0.05);末次随访血肌酐89.0(45.0~342.0)μmol/L,肾盂宽度(1.6±0.6)cm,USSQ总分66.0(50.0~105.0)分,均较术前显著降低( P>0.05)。术后发生Clavien-Dindo Ⅰ级并发症3例(13.0%),为支架相关症状如腰腹痛、血尿和下尿路刺激症状,保守治疗后均好转;Clavien-Dindo Ⅲ级4例(17.4%),分别为支架移位2例和支架结壳2例,行内镜手术治疗后2例支架移位患者好转,余2例因反复结壳拔除Allium输尿管支架并留置双J管。术后中位随访16.5(11.0~24.0)个月,21例(32侧,94.1%)保持输尿管通畅。 结论:采用Allium覆膜金属输尿管支架长期留置治疗RIUS是安全、有效的,术后可以较长期保持较高的输尿管通畅率和较低的并发症发生率,可以明显改善患者的肾功能和生活质量。

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abstracts:

Objective:To discuss the efficacy and safety of Allium coated metal ureteral stent in the treatment of radiation induced ureteral stricture (RIUS).Methods:The data of 23 patients (34 sides) with RIUS treated with Allium coated metal ureteral stent from October 2018 to December 2019 in Peking University People's Hospital were retrospectively analyzed, including 1 male (1 side) and 22 female (33 sides). The mean age was (57.4±11.5) years old. The preoperative median serum creatinine was 96.0(47.0-421.0) μmol/L. Unilateral ureteral stricture was observed in 12 cases and bilateral stricture in 11 cases. The average width of the renal pelvis was (2.3±1.1) cm. The primary diseases included cervical cancer (17 cases), rectal cancer (3 cases), endometrial cancer (2 case) and ureteral cancer (1 case). There were 2 cases treated with radical radiotherapy and 21 cases with operation combined with chemoradiotherapy. Preoperative percutaneous nephrostomy tube was observed in 5 cases (7 sides). 18 patients (27 sides) had ureteral stents. Median indwelling time of D-J stent was 18.0 (2.0-84.0) months, replacement every 5.0(1.0-12.0) months, and the total score of the ureteral stent symptom questionnaire (USSQ) 99.0 (59.0-126.0). The location and length of ureteral stricture were measured by retrograde urography. Then ureteral balloon dilatation [2 533.1kPa(25ATM), 3 min]was performed. According to the length of ureteral stricture, 1-3 Allium stents were inserted under X-ray and released after in place, and finally urography was done again to confirm. The serum creatinine, ultrasonography and abdominal X-ray were reviewed in the first day, every 6 months after the operation to evaluate the renal function, location and patency of Allium stent, USSQ were recorded to evaluate quality of life. Postoperative complications were assessed by Clavien-Dindo system.Results:All the 23 cases in this group were successfully operated, with an average operation time of (100.7±37.2) min. Retrograde urography revealed 8 full-length ureteral strictures, 20 cases in the middle and lower segments, 5 in the lower segments and 1 in the middle segments. The mean stenosis length was (15.9±5.9) cm. Three Allium stents unilaterally were placed on 6 sides, 2 stents on 18 sides and 1 stent on 10 sides. The success rate of indwelling is 100%. Compared with preoperative data, serum creatinine was 93.5 (54.0-289.0) μmol/L in 6 months after surgery, significantly lower than that before surgery ( P=0.005), but there was no significant difference in renal pelvis width and USSQ total score. Serum creatinine 89.0 (45.0-342.0) μmol/L, renal pelvis width (1.6±0.6) cm and USSQ total score of 66.0 (50.0-105.0) in the last follow-up after surgery were significantly reduced. Postoperative Clavien-Dindo Ⅰ complications occurred in 3 patients (13.0%), presenting stent related symptoms such as flank and abdominal pain, hematuria and lower urinary tract symptoms, which were all improved after conservative treatment. There were 4 patients (17.4%) with Clavien-Dindo Ⅲ complications, including Allium ureteral stent displacement in 2 cases and stent encrustation in 2 cases. After endoscopic surgery, Allium ureteral stent was removed and D-J stents were inserted in 2 cases due to repeated encrustation. The median follow-up was 16.5 (11.0-24.0) months. Allium ureteral stent was effective in 21 patients (32 sides, 94.1%). Conclusions:Allium ureteral stent used for the treatment of RIUS could be safe and effective. Patient’s renal function and quality of life could be improved.

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作者: 王明瑞 [1] 胡浩 [1] 王起 [1] 赖金惠 [1] 刘献辉 [1] 熊杰 [1] 许克新 [1] 徐涛 [1]
期刊: 《中华泌尿外科杂志》2020年41卷12期 921-926页 ISTICPKUCSCDCA
栏目名称: 临床研究
DOI: 10.3760/cma.j.cn112330-20200623-00488
发布时间: 2021-01-11
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