Ятрогенные травмы при перкутанной нефролитотрипсии и современные подходы к их диагностике, лечению и профилактике
DOI:
https://doi.org/10.52889/1684-9280-2026-77-5-jto070Ключевые слова:
перкутанная нефролитотрипсия, ятрогенная травма, кровотечение, повреждение соседних органов, ангиоэмболизация, профилактика осложненийАннотация
Перкутанная нефролитотрипсия является ведущим методом хирургического лечения крупных, множественных и сложных камней почки, однако формирование чрескожного доступа и выполнение внутрипочечных манипуляций сопряжены с риском ятрогенной травмы.
Цель обзора: систематизировать современные данные о механизмах, факторах риска, диагностике, лечении и профилактике травматических осложнений перкутанной нефролитотрипсии.
Проведен целевой поиск клинических рекомендаций, систематических обзоров, метаанализов, многоцентровых исследований и репрезентативных клинических серий в базах PubMed, Scopus и Web of Science.
Рассмотрены травмы почечной паренхимы и чашечно-лоханочной системы, артериальное и венозное кровотечение, псевдоаневризма, артериовенозная фистула, повреждения плевры, легкого, толстой кишки, печени, селезенки и других соседних структур. Наиболее значимыми предикторами осложнений являются неправильная траектория пункции, верхнеполюсный надреберный доступ, множественные пункционные тракты, большая каменная нагрузка, активная инфекция мочевых путей, аномальная анатомия почки, сопутствующая патология и недостаточный опыт хирурга. Ранняя диагностика основывается на комплексной оценке интраоперационных признаков, гемодинамических показателей, динамики гемоглобина, данных ультразвукового исследования и контрастной компьютерной томографии.
Большинство ограниченных травм успешно устраняется адекватным дренированием, гемостатической терапией, антибактериальным лечением и динамическим наблюдением. Продолжающееся или отсроченное артериальное кровотечение требует селективной ангиографии и суперселективной эмболизации поврежденного сосуда. Открытое хирургическое вмешательство применяется редко, преимущественно при нестабильной гемодинамике или неэффективности малоинвазивных методов. Профилактика предусматривает тщательную предоперационную визуализацию, индивидуальное планирование безопасного доступа, использование ультразвуковой и комбинированной навигации, контроль внутрипочечного давления, ограничение количества трактов и стандартизацию хирургической техники. Особое значение имеют командное взаимодействие, готовность к немедленной конверсии лечебной тактики, доступность интервенционной радиологии и четкие алгоритмы послеоперационного мониторинга пациентов с повышенным риском кровотечения и повреждения смежных органов в раннем послеоперационном периоде.
Комплексный подход позволяет своевременно распознавать травму, выбирать органосохраняющую тактику и снижать частоту тяжелых осложнений.
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