患者坐位超声引导下经皮肾穿刺造瘘术的临床应用

柴军 刘春林 渠渊 张进生

[摘要] 目的 对患者坐位超声引导下行经皮肾穿刺造瘘术（Percutaneous nephrostomy，PCN）的临床资料进行总结，探讨患者坐位超声引导下PCN的可行性。 方法 回顾性分析2017年1月～2018年12月对上尿路积水患者16例（27侧）进行PCN治疗，对比PCN前、后肾功能的变化。 结果 对梗阻性肾积水（Hydronephrosis），嘱患者取坐位，超声引导下PCN，满意放置UrovisionR造瘘管，成功率96.3%（26/27）。局麻下操作，对患者的呼吸、血流动力学影响小，未出现严重并发症，患者容易耐受，PCN前、后肾功能变化差异有统计学意义（P<0.05）。 结论 坐位实时超声引导PCN成功率高、安全、可靠，手术操作者更舒适，患者也更容易耐受，合理选择PCN通道是操作成功的关键。

[关键词] 坐位;尿路梗阻;肾积水;肾穿刺造瘘;超声

[中图分类号] R692.2          [文献标识码] A          [文章编号] 1673-9701（2020）18-0001-04

Clinical application of ultrasound-guided percutaneous nephrostomy in patients' sitting position

CHAI Jun   LIU Chunlin   QU Yuan   ZHANG Jinsheng

Department of Urology， Fuxing Hospital Affiliated to Capital Medical University， Beijing   100038， China

[Abstract] Objective To summarize the clinical data of ultrasound-guided percutaneous nephrostomy（PCN） in patients' sitting position， and discuss the feasibility of ultrasound-guided PCN in patients' sitting position. Methods 16 patients with upper hydroureterosis（27 sides） from January 2017 to December 2018 were retrospectively analyzed and treated with PCN， and renal function before and after PCN was compared. Results For obstructive hydronephrosis， patients were instructed to adopt sitting position， ultrasound-guided PCN was conducted， UrovisionR fistulation tube was satisfactorily placed， and the success rate was 96.3%（26/27）. The operation under local anesthesia exerted little respiratory and hemodynamic influence on the patients， saw no occurrence of serious complications， and the patients had good tolerance. There was statistically significant difference in the renal function before and after PCN（P<0.05）. Conclusion   PCN guided by real-time ultrasound in patients' sitting position has high success rate， and it is safe and reliable. With it， the operator will be more comfortable and the patient will be more tolerant. Reasonable selection of PCN channel is the key to successful operation.

[Key words] Sitting position; Urinary tract obstruction; Hydronephrosis; Nephrostomy; Ultrasound

經皮肾穿刺造瘘术（Percutaneous nephrostomy，PCN）引流肾盂尿液，可以在X线透视或者超声引导下进行，嘱患者俯卧位，腹部下方垫高，使肾脏与皮肤距离变短。我科在给患者进行穿刺过程中，观察多例患者由于肾功能不全、钠水潴留、低蛋白血症、贫血，合并心功能不全，出现心肾综合征表现。患者肾功能不全，俯卧位时回心血流量增加、呼吸频率加快无法耐受俯卧位。同时患者腹部垫高，也增加了患者的不适，故我们尝试让患者采取坐位[1]（类胸穿体位）。患者坐位，回心血流量减少，肺部充血和心功能不全症状减轻。另外肾脏位置因自身重量自行下降、肾脏上下移动幅度变小，尤其在吸气末时肾脏在肋缘下更易暴露，有利于超声引导下穿刺肾盂或肾盏。操作者一手固定超声探头，另一只手持穿刺针穿刺。2017年1月～2018年12月我院在超声引导下施行PCN患者16例（27侧），取得满意的疗效，现报道如下。……