Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf ·...
Transcript of Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf ·...
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DFIR årsmøde 2019
Urologiske Interventioner
Overlæge Arne Hørlyck
Røntgen og Skanning
Århus Universitetshospital
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Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
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Baggrund
180 suprapubisk kateter om året
600 nefrostomier om året
25 antegrad JJ-kateter om året
(stærkt stigende!)
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Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
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Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
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Indikation
• Behov for blærekateter
- uretral-kateter ikke muligt
- uretral-kateter ikke hensigtsmæssigt
• ”Blind” anlæggelse ikke muligt/sikkert
- nedre abdominale operationer
- blærekapacitet < 250 ml
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Forberedelse
Lav-risiko procedure
− kun blodprøver ved mistanke om
blødningsforstyrrelse eller AK-behandling
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Forberedelse
Koagulationsstatus
INR < 2,5
Profylaktisk antibiotika kun til immunsupprimerede
God kontakt til patienten og forklaring om indgrebet
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Forberedelse
Uretral-kateter (hvis muligt)
Lidocain 20 g/l – 100 ml i blæren
Evt. yderligere isoton saltvand
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Udførelse
UL-vejledt lokalanæstesi
1,2 mm nål – Seldinger teknik
Dilatator 8 F – 10 F – 14 F
12 F Silikone ballon-kateter
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Udførelse
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Alternativ akut procedure
UL-vejledt lokalanæstesi
7 F pigtail kateter one-step
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Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
![Page 14: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/14.jpg)
Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
![Page 15: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/15.jpg)
Indikation
• Obstruktion
- okklusion (2 uger => udslukt nyre)
- relativ stenose (infektion, smerte, funktion, bilateralt)
voksne – børn
• Tørlægning
- ureterlæsion
- blærelæsion
- fistler
• Nyregraft
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Indikation
• Obstruktion
- okklusion (2 uger => udslukt nyre)
- relativ stenose (infektion, smerte, funktion, bilateralt)
voksne – børn
• Tørlægning
- ureterlæsion
- blærelæsion
- fistler
• Nyregraft
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Forberedelse
Mange forskellige regimer
Mellem-risiko procedure
− kun blodprøver ved mistanke om
blødningsforstyrrelse eller AK-behandling
− Koagulationsstatus, INR < 2,5
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Forberedelse
Faste 4 timer?
Profylaktisk antibiotika
Præmedicin? (morfin, diazepam)
God kontakt til patienten og forklaring om indgrebet
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Historie
1912: Hugh Hampton Young
Børnecystoskop direkte ind i massiv hydronefrose
1955: Willard Goodwin
Første beskrivelse af systematisk brug af nefrostomi
(trochar teknik, palpation og røntgen)
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Historie
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Historie
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Historie
1912: Hugh Hampton Young
Børnecystoskop direkte ind i massiv hydronefrose
1955: Willard Goodwin
Første beskrivelse af systematisk brug af nefrostomi
(trochar teknik, palpation og røntgen)
1974: Jan Fog Pedersen
Første beskrivelse af UL-vejledt nefrostomi
(Seldinger-teknik)
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Historie
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Historie
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Historie
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Historie
![Page 27: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/27.jpg)
Historie
1912: Hugh Hampton Young
Børnecystoskop direkte ind i massiv hydronefrose
1955: Willard Goodwin
Første beskrivelse af systematisk brug af nefrostomi
(trochar teknik, palpation og røntgen)
1974: Jan Fog Pedersen
Første beskrivelse af UL-vejledt nefrostomi
(Seldinger-teknik)
1999: Montenari (urolog)
Første beskrivelse af kombineret UL- og rtg-vejledt
nefrostomi (Seldinger-teknik)
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Historie
1991: Skejby (UL- og rtg-vejledt, one-step og Seldinger)
1999: Skejby (UL- og rtg-vejledt, Seldinger-teknik)
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Teknik
Mange varianter!
Ultralydvejledt
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Teknik
Hvordan det ikke skal gøres!
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Teknik
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Teknik
Hvordan vi gør det
Overlæger – afdelingslæger – kursister
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Teknik
UL- og rtg-vejledt – Seldinger-teknik
Altid! ”Keep it simple”
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Teknik
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Teknik
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Teknik
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Teknik
Udvælge punktursted og patientlejring
Retroperitonealt indstik – fri af organer
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X-ray
Lejring
Højre nyre Foretrukket
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X-ray
Lejring
Venstre nyre
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Lejring
Venstre nyre
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Lejring
Venstre nyre
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Lejring
Venstre nyre
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X-ray
Lejring
Venstre nyre Foretrukket
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Teknik
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Teknik
Udvælge punktursted og patientlejring
Retroperitonealt indstik – fri af organer
Lokal anæstesi – ultralydvejledt
Punktur – 1,2 mm nål
Kontrastinjektion – guidewire 0,035″
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Teknik
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Teknik
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Teknik
Udvælge punktursted og patientlejring
Retroperitonealt indstik – fri af organer
Lokal anæstesi – ultralydvejledt
Punktur – 1,2 mm nål
Kontrastinjektion – guidewire 0,035″
Kateter – 7 French, hydrofil
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Teknik
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Teknik
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Teknik
Udvælge punktursted og patientlejring
Retroperitonealt indstik – fri af organer
Lokal anæstesi – ultralydvejledt
Punktur – 1,2 mm nål
Kontrastinjektion – guidewire 0,035″
Kateter – 7 French, hydrofil, snoretrækslås
Plasterfixering
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Teknik
Andre mulige teknikker
3 grupper: One-step uden rtg
UL – rtg – Seldinger
Finnål – 2 guides
To-punktur teknik
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Hvordan går det?
500 konsekutive nefrostomier (2006 – 2007)
61 ”ikke dilaterede”
353 patienter, heraf 21 børn
Kursister (max. 2 stik), afdelingslæger, overlæger
![Page 54: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/54.jpg)
Hvordan går det?
Succesrate:
98,52% (dilaterede)
82% (ikke dilaterede)
alle ”uden succes” (19) fik ”succes” i løbet af 24 timer
Noget bedre end SIR anbefalinger
Komplikationer:
Major: 0,45% (blødning) (SIR 4%), ingen †
Minor: 14,2% (SIR 15%)
![Page 55: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/55.jpg)
Hvordan går det?
![Page 56: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/56.jpg)
Hvordan går det?
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Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
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Dagsorden
• Suprapubisk kateter
• Nefrostomi
• Antegrad JJ-kateter
• Diskussion
![Page 59: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/59.jpg)
Indikation
Behov for længere tids aflastning med JJ
Generel anæstesi kontra stik i nyreparenkym (blødning)
• Retrograd JJ ikke muligt
− Blæretumor (anden svær obstruktion)
− Stor prostata
− Neoblære
− Ureterreimplantation (nyregraft)
• Eksisterende nefrostomi
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Forberedelse
Som nefrostomi
Mellem-risiko procedure
− kun blodprøver ved mistanke om
blødningsforstyrrelse eller AK-behandling
− Koagulationsstatus, INR < 2,5
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Forberedelse
Faste 4 timer
Profylaktisk antibiotika
Skylning af blæren med 100 ml Lidokain 2%
Præmedicin (morfin, diazepam, paracetamol)
God kontakt til patienten og forklaring om indgrebet
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Teknik
Brickerblære – bilateral ureterstenose
Dybt spaltet pelvis dxt. med nefrostomi x 2
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Teknik
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Teknik
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Teknik
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Teknik
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Teknik
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Teknik
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Teknik
Brickerblære – højresidig ureterstenose
![Page 70: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/70.jpg)
Teknik
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Teknik
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Teknik
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Teknik
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Teknik
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Teknik
Brickerblære – højresidig ureterstenose
Guidewire ud gennem stomi
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Teknik
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Teknik
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Teknik
Brickerblære – venstresidig ureterstenose
Ingen nefrostomi anlagt tidligere
Blødning
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Teknik
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Hvordan går det?
Succesrate 125/130 (96%)
Komplikationer 8/130 (6%)
(6 infektioner, 1 via falsa, 1 fejlplacering)
![Page 81: Urologiske Interventioner - DFIRdfir.dk/wp-content/uploads/2019/06/Urologiske-interventioner.pdf · nefrostomi (Seldinger-teknik) Historie 1991: Skejby (UL- og rtg-vejledt, one-step](https://reader031.fdocument.pub/reader031/viewer/2022041621/5e3efc7efdddc27aec70037c/html5/thumbnails/81.jpg)
DFIR årsmøde 2019
Overlæge Arne Hørlyck
Røntgen og Skanning
Århus Universitetshospital
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Nefrostomi – Komplikationer
• Blødning
observation – transfusion – embolisering – operation
• Infektion – sepsis
antibiotika – symptomatisk behandling
• Organskader
lever – milt – colon – (nyre)
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
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Komplikationer – colon
Let feber – behandlet med antibiotika
Ny nefrostomi efter 2 dage – gamle fjernet over guide
Ingen gener
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Komplikationer – nyre
Bilateral nefrostomi
Henvist p.gr.a. dårlig funktion af højre kateter,
sivning langs kateter
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
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Komplikationer – nyre
Anlagt nyt kateter
Gamle fjernet over guide
Ingen komplikationer
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Displaceret nefrostomi
Nedsat, men ikke ophørt funktion af hø-sidig nefrostomi
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Displaceret nefrostomi
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Displaceret nefrostomi
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Nefrostomi og JJ-kateter
7-årigt barn opereret for UPS (Hynes-Anderson)
Operativt anlagt JJ-kateter
Smerter efter 2 dage
Ultralyd viser balloneret nyrepelves med JJ-kat.
Generel anæstesi
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Nefrostomi og JJ-kateter
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Nefrostomi og JJ-kateter
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Tak for opmærksomheden
Overlæge Arne Hørlyck
Billeddiagnostisk afdeling
Århus Universitetshospital