2016-08-012024-05-14https://scholars.lib.ntu.edu.tw/handle/123456789/660651摘要：惡性腫瘤造成輸尿管阻塞的治療目前仍是棘手的問題，傳統上可利用經皮腎臟造瘻 〔PCN〕提供尿液引流，經皮腎臟造瘻具有較高的成功率，但會影響病人的生活品質，也比 較容易造成感染。另外的治療方式為體内放置輸尿管支架〔ureteral stent〕，但是，放置支架 仍有10%至30%的失敗率。此外，根據文獻報導，即使成功放置輸尿管支架，還是有一些病 患，引流尿液的效果不好，約有20%至60%的病人仍然有阻塞的問題。一般而言，泌尿科的 逆行性〔retrograde〕置放支架具有較高失敗率，而放射科的順行性〔antegrade〕支架置放提 供另一個可行方法，以增加成功放置的機會。然而，即使成功放置了輸尿管支架，是否臨床 上尿液引流就成功了呢？答案當然是否定的，尤其是癌症病患的惡性阻塞，即使是千辛萬苦 放置成功，臨床卻還是失敗。有鑑於此，如何改善輸尿管支架放置後尿液引流的成功率及效 果，目前仍是臨床上是一個非常重要的課題，也是我們想要改善的目標。可能的解決方式包括同時放置兩隻輸尿管支架，理論上可以增加支架管腔的截面積，並 可以利用支架間的空隙提供尿液流動，一些小規模回溯式病例報告有初步的報告，並顯示會 比單獨放置一隻支架有較佳的結果。另外就是利用特殊設計的材質，以增加支撐及引流的效 果，傳統的輸尿管支架是聚氨酯（polyurethane)的材質，現在也發展出腫瘤用的輸尿管導管， 商品名稱為 Angiomed UROSOFT tumor stent (Bard-Angiomed; Karlsruhe, Germany)，外層是聚 胺基曱酸乙酯〔pellethane〕，而内層是聚亞醯胺（polyamide)的輸尿管支架；另外則是金屬 材質支架，商品名稱為Resonance Stent (Cook Medical, Bloomington, USA)。這兩者皆較能抵抗 外界的壓迫，達到較好的引流效果的。另外的考量是不同置放方式的醫療成本，以目前給付 方式，一條polyurethane材質的輸尿管支架的成本約為1,500元，而此新型腫瘤專用的輸尿管 支架則要價8,120元，金屬材質的支架則為31,875元。這個研究主要收集嚴重腫瘤壓迫造成輸尿管狹窄及腎水腫的病患，若無法經由泌尿科採 逆行性方式放置輸尿管支架，則進行順行性輸尿管支架放置，並利用前瞻式隨機的設計，隨 機分派放置兩隻輸尿管支架，放置腫瘤用的輸尿管導管，或是放置金屬材質的支架，比較其 置放的可行性，並評估其引流尿液的效果，以及放置後病患的可能症狀，包括以血液和影像 學檢查評估腎功能變化（血清肌酸酐及估計之GFR值），和腎水腫的改善程度，包括核醫腎臟掃描（Tc99m DTPA diuretic renal scan)及腎臟超音波以評估其阻塞程度改善情況，尿液感 染情況，也利用定型化問卷，評估病人因輸尿管導管引發的臨床不適症狀及生活品質。希望 能藉由比較各種輸尿管支架的放置方式的臨床效果，找出較佳的治療方式，也達成節省醫療經費的目的。<br> Abstract: The treatment of malignant ureteral obstruction (MUO) is still a challenge. Percutaneous nephrostomy (PCN) has traditionally been used to provide urinary drainage. Percutaneous nephrostomy tubes are associated with a high success rate but may impair quality of life and have higher risk of infection compared to internal ureteral stent. Internal ureteral stenting for long-term urinary drainage in these patients is now widely accepted in clinical practice. Initial attempts at stent placement are unsuccessful in 10-30% of such patients. Even when they are initially placed successfully, these ureteral stents are destined to fail in 20-60% of such patients. Till now, stent failure has been a dilemma encountered frequently by clinicians.Some strategies have been adopted to solve the tough problem. The first alternative option is to place double ureteral stents (double DBJ) simultaneously. Theoretically, double ureteral stents may increase the cross-sectional area of the stent lumen and provide space between the stents to facilitate urine flow. However, placement of double ureteral stents for relief of MUO was described in small retrospective series despite the results showed promising.The second option is to use the specially designed tumor stent with the brand name Angiomed UROSOFT tumor stent (Bard-Angiomed; Karlsruhe, Germany). Compared to conventional ureteral stone made of polyurethane, tumor stent is made of pellethane in outer layer and polyamide in inner layer. The third option is metallic stent (Resonance Stent; Cook Medical, Bloomington, USA). Both tumor stent and metallic stent provide increased capacity to resist external compression on ureter. In terms of medical cost, one polyurethane stent cost 1,500 NTD, the tumor stent costs 8,120 NTD, and the metallic stent costs 31,875 NTD.Traditional retrograde placement of ureteral stent yields a high failure rate in MUO and percutaneous antegrade placement is a practicable approach. In this study, patients with severe MUO who failed to place the ureteral stent by traditional retrograde manner were recruited. All patients were randomized to double ureteral stents group (Group 1), single tumor stent group (Group 2), or single metallic stent group (Group 3). We compare the efficacy and safety of these treatmentmodalities via evaluation of stent-related symptoms by validated questionnaire, patient-reportedquality-of-life (QOL), risk of urinary tract infection, renal function, improvement of obstruction by (Tc99m DTPA diuretic renal scan and renal ultrasound/ or CT/ or MR). We look forward to find better method for the treatment of severe MUO and achieve the goal of reducing medical costs.惡性腫瘤輸尿管阻塞輸尿管支架雙重輸尿管支架腫瘤輸尿管支架金屬輸尿管支架malignant ureteral obstructionureteral stentdouble ureteral stentsmetallic ureteral stent