Experience with the holmium laser as an endoscopic lithotrite

INTRODUCTION: Holmium laser lithotripsy represents an additional option in the management of urinary tract calculi. We report the results of a cohort of patients with ureteric and bladder calculi treated with this modality. METHODS: Twenty-three patients underwent holmium laser lithotripsy to treat ureteric or bladder calculi. Power settings of 0.5 J to deliver 2.5-4.0 watts were used for the ureteric calculi, and up to 30 watts for the bladder calculi. RESULTS: The mean ureteric stone size was 7.3 mm (range 4-10 mm). One stone was upper ureteric, seven were mid-ureter and nine were lower-ureter. Eighteen of the 19 patients with ureteric calculi were free of stones 28 days postoperatively. The remaining patient was clear by 12 weeks. All patients with bladder calculi were completely cleared of stones. There were no intraoperative complications. DISCUSSION: Ureteric stone position can limit the use of extracorporeal shock wave lithotripsy due to imaging difficulties. Ureteric lithotripsy overcomes this problem. The holmium laser has proven to be safe and effective in clearing urinary stone burdens of a variety of sizes, sites and compositions in this cohort of patients.     

A new transportable shock-wave lithotripsy machine for managing urinary stones: a single-centre experience with a dual-focus lithotripter

OBJECTIVE: To assess the efficacy and safety of a transportable extracorporeal shock wave lithotripsy (ESWL) machine, the Modulith SLX-F2(TM) (Storz Medical Italia, Rome, Italy), in the management of solitary urinary calculi. PATIENTS AND METHODS: The study included 233 patients (mean age 51 years; 172 male, 61 female) with symptomatic solitary renal (group A, 170, mean diameter 15.5 mm) or ureteric stones (group B, 63, mean diameter 9.5 mm) treated in a tertiary care institution. Exclusion criteria for the analysis were: pelvi-ureteric junction obstruction, multiple stones, stone diameter >2 cm, stones in a lower calyx with unfavourable anatomy, active infection, or impacted ureteric stones. Selected patients had ureteric stenting before treatment, and all patients were treated with no anaesthesia. Hospitalization, complications and subsequent auxiliary procedures were evaluated. Patients were assessed after a single ESWL session and after 3 months by a plain abdominal film and renal ultrasonography. Stone-free status was defined as no evidence of calculi, and clinical success as the presence of stone fragments of <4 mm. An efficiency quotient (EQ) was calculated for the ESWL treatment. Pain was assessed using a visual analogue scale. RESULTS: The mean number of shocks used was 3779 and the mean (range) treatment time was 35 (5-55) min. The overall clinical success rate after one ESWL session was 83.7% and 82.5% for renal and ureteric stones, respectively, and the overall 3-month stone-free rate was 77% and 74.6%, respectively; the overall EQ was 0.64. When risk factors for persistent calculi were analysed simultaneously in a logistic regression model, only stones of >1 cm were statistically significant (P < 0.05). Most patients reported that pain during ESWL was mild to moderate and easily tolerated. Only minor complications occurred, with an overall complication rate of 3.8%. CONCLUSIONS: This transportable lithotripter is a safe and effective device for managing solitary stones throughout the urinary tract. Its main advantage is represented by the dual-focus system. Moreover, it shares with other contemporary machines several important features such as outpatient setting, no need for anaesthesia, easy patient positioning, and the capability of ancillary procedures.     

Ureteroscopy in the management of pediatric urinary tract calculi

PURPOSE: To report our experience with ureteroscopy in the treatment of pediatric urinary tract calculi and present a review of the literature. PATIENTS AND METHODS: Between 1988 and 2003, 52 ureteroscopic procedures were performed in 25 male and 10 female children aged 11 months to 15 years (mean 5.9 years). Using a semirigid 6.8F 43-cm ureteroscope and routine antibiotic prophylaxis, stones were fragmented with a pulsed-dye laser (N = 14; stone size 6-15 mm with a mean of 9.6 mm), electrohydraulic lithotripsy (EHL) (N = 26; stone size 3-20 mm with a mean of 8.4 mm), or a holmium laser (N = 7; stone size 5-15 mm with a mean of 10 mm); removed by basket extraction (N = 5; stone size 5-8 mm with a mean of 7 mm); or both. Stenting or ureteral dilatation was not performed routinely. RESULTS: With the pulsed-dye laser, there was an overall stone-free rate of 72%. Complications consisted of one ureteral perforation and one stenosis of the intramural portion of a megaureter (14% complication rate). With EHL, the overall stone-free rate was 92%. Complications consisted of one case each of ureteral perforation and incipient urinary retention and five of mild fever (27%). With the holmium laser, the overall stone-free rate was 100%, and there were no complications. Basketing likewise produced a 100% stone-free rate, and there was one complication, a mucosal tear in a patient who also underwent pulsed-dye laser lithotripsy. CONCLUSION: Ureteroscopy is a safe and effective means of treating the majority of pediatric ureteral calculi, although retreatment rates are higher with multiple stones and in younger children. Dilatation of the vesicoureteral junction is usually not necessary with ureteroscopes <8F, nor is ureteral drainage required after uncomplicated ureteroscopy. The holmium laser is the most effective and safest method of fragmentation regardless of stone composition. Ureteroscopy for this indication should be performed only by an experienced endoscopist.     

Role of Extracorporeal Shock Wave Lithotripsy in Management of Upper Ureteric Stones

Introduction

The treatment options for upper ureteric stones range from open surgeries to minimally invasive and non invasive techniques. Presently the two most frequently used options for upper ureteric calculi that require intervention are extracorporeal shock wave lithotripsy (ESWL) and ureterorenoscopy (URS) with contact lithotripsy applied by attaining endoscopic access to the calculi.

Holmium:YAG laser for urinary stones

OBJECTIVE: To evaluate the results of Holmium:YAG (Ho:YAG) laser lithotripsy in the treatment of urinary stones. MATERIAL AND METHODS: Between 1993 and 1997, 59 patients with 85 urinary stones were treated with the Ho:YAG laser lithotripsy. Retrospective evaluation was done on the 64 procedures available, comprising 53 ureteric, 8 bladder, and 2 renal calculi, and one stone in a ureterocele. RESULTS: The Ho:YAG laser fragmented all types of calculi. Of 38 patients, 29 (76%) with ureteric stones were stone-free and 7 (18%) had stone fragments smaller than 2 mm left 1-3 months after the lithotripsy, resulting in a total clinical success rate of 95%. The procedure caused four ureteric perforations. One ureteric stricture, after repeated treatments for a Steinstrasse formation, led to nephrectomy. CONCLUSIONS: The Ho:YAG laser was reliable and effective for most of the urinary stones. The largest stones in any location, and stones of hard composition, however, were treated with combined disintegration methods. Four minor ureteric perforations and one ureteric stricture were related to laser use.     

Shock wave lithotripsy is effective and safe for distal ureteral calculi in children

We evaluated the effectiveness of the Siemens Lithostar Modularis lithotriptor for the management of distal ureteric calculi in children. Between 2004 and 2006, 29 children with distal ureteric calculi were treated in our stone center with the Siemens Lithostar Modularis (Siemens Medical Solutions, Inc.) Effectiveness of lithotripsy, retreatment and efficacy quotient rates, and complications were assessed. The series consisted of 18 (62%) boys and 11 (38%) girls with an age range of 1-13 years (average age 7.0 +/- 3.5). Under fluoroscopic guidance, children were treated with a maximum 3,000 shocks at an average of 2.2 +/- 0.3 kV. Mean stone size was 8.2 +/- 3.2 mm (range 4-18). Success was defined as the lack of any visible stone fragments on posttreatment radiological evaluation. The mean number of sessions required was 1.5 +/- 0.8/patient (range 1-4). Complete clearance rate at 3 months was 86.2%. Re-treatment and efficacy quotient rates for distal ureteral stones were 41.4 and 55.6%, respectively. Complications such as urinary tract infection or steinstrasse occurred in 2 (6.9%) patients. Minor complications included petechial skin hemorrhage at the site of entry of shock waves in all patients. Our results show that shock wave lithotripsy for distal ureteral calculi with the Siemens Lithostar Modularis lithotriptor has a high success rate (86.2%) and efficacy quotient (55.6%) with negligible complications in children.     

Flexible ureterorenoscopy for the treatment of refractory upper urinary tract stones.

OBJECTIVE: To report our experience of using flexible ureterorenoscopy for upper urinary tract stones. PATIENTS AND METHODS: Thirty-seven patients (13 females, 24 males, mean age 48 years, range 10-76) with upper urinary tract stones not responding to other treatments had their residual symptomatic stones treated through a 9.3 F flexible ureterorenoscope. Electrohydraulic lithotripsy (EHL) was used to fragment the stones and a basket or a grasper used to retrieve the fragments. RESULTS: Twenty-three patients were completely freed of stone and a further five had asymptomatic residual fragments of < 5 mm. Of 15 patients with ureteric stones, 14 were rendered stone-free at the end of the procedure and 14 of the 22 patients with kidney stones were treated successfully; 80% of the lower calyceal stones were treated successfully and a firm decision was possible on the further management of the remaining stones. There were no major complications. CONCLUSION: Flexible ureterorenoscopy should be considered in patients with symptomatic upper ureteric or renal stones refractory to other treatments, but the instrumentation is expensive and delicate, and its use should be reserved for such cases.     

妊娠期输尿管结石合并感染的微创处理

目的：探讨利用微创技术治疗妊娠期输尿管结石合并感染的可行性及临床效果。方法：2006年5月～2010年4月对21例妊娠期输尿管结石合并泌尿系感染患者行微创技术治疗。21例患者孕6～36周,平均24周。结石最大径5～15mm。左侧输尿管结石9例,右侧12例。输尿管结石上段5例,中段10例,下段6例。尿常规：白细胞＋＋～＋＋＋＋,伴不同程度发热。单纯留置双J管8例,12例采用输尿管镜下钬激光碎石术,1例行经皮肾穿刺造瘘术。结果：所有患者肾绞痛、发热等急症症状经治疗后消失。结石一次性取净12例,留置双J管及肾造瘘管者至分娩后再行微创手术取石。无一例发生先兆流产或早产等,所有患者均顺利生产,婴儿健康。无输尿管穿孔及其他并发症发生。结论：利用微创技术治疗妊娠期输尿管结石合并感染安全有效。     

Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications

OBJECTIVE: To compare patients with and with no stenting after ureteroscopy for ureteric calculi, as placing such stents is routine, although many patients complain of pain and urinary symptoms. PATIENTS AND METHODS: In all, 45 patients with ureteric calculi amenable to ureteroscopic management were prospectively randomized into a stented (23) or an unstented (22) group. Standard ureteroscopic basketing and lithotripsy was used, through a ureteroscope (8.5 F) with or without ureteric dilatation. Symptom questionnaires were completed by the patients after treatment, and they were followed radiographically to assess stone-free rate and evidence of obstruction. RESULTS: There was no statistically significant difference in age, stone size, operative duration or hospital stay between the groups (P > 0.05). Furthermore, there was no statistical difference in flank pain or urinary symptoms (P > 0.05), except haematuria, between the groups; haematuria was more severe and prolonged in the stented group (P = 0.001). CONCLUSIONS: Uncomplicated ureteroscopy for removing calculi is safe with no stent after treatment, and after considering complications and side-effects we think that the routine use of ureteric stents after uncomplicated ureteroscopy for stone extraction is unnecessary.     

Ureteroscopic management of lower ureteric calculi: a 15-year single-centre experience

OBJECTIVE

To review our 15‐year experience with ureteroscopic treatment of distal ureteric calculi and to determine the impact of improved technology and techniques on the efficacy, success and complications of the procedure.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 4512 patients who underwent 5133 ureteroscopic procedures for the treatment of distal ureteric calculi at our institution from January 1991 to December 2005. The patient and stone characteristics, treatment variables and clinical outcomes were assessed. Factors such as type of ureteroscope, procedure duration, procedure success, complication rate and hospital stay were evaluated. Data obtained from a cohort of patients that underwent the procedure from 1991 to 1995 (group 1) were statistical compared with those obtained from a cohort of patients from 1996 to 2005 (group 2). Logistic regression analysis was used to identify associated factors with the major complications of ureteroscopy.

RESULTS

Overall, the stone‐free rate after the procedure was 94.6%, the mean (sd ; range) operative duration was 43 (15.0; 25–120) min, the intraoperative complication rate was 6.67%, the postoperative complication rate was 9.9%, and the mean (sd ) hospital stay was 1.7 (1.1) days. The clinical and radiological follow‐up (mean 36.8 months) for 71.3% of eligible patients detected only 12 ureteric strictures (0.23%). On comparing group 1 with group 2, the overall success of ureteroscopic stone extraction improved from 85.7% to 97.3% (P < 0.001), significant ureteric perforation decreased from 3.3% to 0.5% (P = 0.05), ureteric avulsion decreased from 1.3 to 0.1% (P < 0.05), ureteric stricture decreased from 0.7% to 0.1% (P < 0.007), the mean (sd ) procedure time significantly decreased from 75 (42.9) min to 36.5 (12.5) min (P < 0.001), and the mean hospital stay significantly decreased from 2.5 (1.6) days to 0.5 (1.2) days, with a trend toward outpatient treatment. Logistic regression analysis showed a significant association of the major ureteroscopic complications with increased operative duration, type of ureteroscope used, stone impaction, stone size and surgeon experience.

CONCLUSION

The present series shows the high success rate, with minor complications, that can be achieved with ureteroscopic treatment of distal ureteric calculi. Improvements in ureteroscope design, accessories, technique and experience have led to a significant increase in the success rate and decrease in the complication rate.     

Ureteric calculi in children: preliminary experience with holmium:YAG laser lithotripsy

OBJECTIVE: To determine the efficacy and safety of holmium:YAG laser lithotripsy in children with ureteric calculi. PATIENTS AND METHODS: Between 1999 and 2003, 28 ureteroscopic laser procedures were carried out on 26 children (14 boys and 12 girls, mean age 6.5 years) with ureteric calculi. The mean (range) stone size was 1.21 (0.4-2.2) cm. At ureteroscopy the calculi were in the upper ureter in six (23%), mid-ureter in five (19%) and lower ureter in 15 (58%) patients. A rigid 8 F ureteroscope was used and the Ho:YAG laser energy delivered at 0.6-1.4 J and 6-10 Hz. All patients were evaluated after 3 months with intravenous urography to confirm stone clearance and to exclude ureteric stricture formation. RESULTS: The overall stone-free rate was 92% (24 children) after 28 ureteroscopic procedures. Stones were completely cleared in 83%, 80% and 100% of the procedures in the upper, mid- and lower ureters, respectively. In two children the procedure failed; they were salvaged by ureterolithotomy in one and extracorporeal shockwave lithotripsy in the other. During the procedures, a ureteric perforation was caused by several factors, including a technically difficult procedure and higher laser energy. At the mean (range) follow-up of 18 (3-39) months, low grade vesico-ureteric reflux was detected in two children, and there were no ureteric strictures in any. CONCLUSION: Holmium:YAG laser lithotripsy is an efficient and safe treatment for ureteric calculi in children.     

Use of the holmium:YAG laser for ureterolithotripsy in children

OBJECTIVE: To review our experience with rigid ureteroscopy and holmium:YAG laser for treating ureteric calculi in children. PATIENTS AND METHODS: The study included 35 children who were treated with rigid ureteroscopy for ureteric calculi between November 1997 and June 2003 (15 boys and 20 girls; mean age 6.2 years, range 1-14). The mean (range) stone size was 8 (4-15) mm and the duration of anaesthesia 46.6 (15-90) min. The stone was in the distal third of the ureter in 33 children and in the proximal third in two. We used a 7.5/8/10 F rigid ureteroscopes with routine dilatation of the ureteric orifice. For lower ureteric stones, lithotripsy was carried out with holmium:YAG laser in 29 cases, a pneumatic impactor in two and forceps extraction in two. Both stones in the proximal ureter were pushed back into the collecting system. All the ureters were stented using JJ stents in 31 and ureteric catheters in four cases. The mean postoperative follow-up was 12 (2-30) months. RESULTS: Excluding the two stones pushed back, the stone-free rate after a one-stage procedure was 82% (27/33). With repeated procedures in the six (ESWL in two) remaining cases the success rate was 97% (32/33). The ureter was perforated in two patients within the first five in the series. There was no pyelonephritis or gross haematuria after surgery. CONCLUSION: Ureteroscopy and lithotripsy using the holmium:YAG laser is effective and safe for treating ureteric stones in children, in experienced hands. The results would be even better using smaller and flexible ureteroscopes.     

EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY FOR DISTAL URETERIC CALCULI

The results of 67 consecutive patients referred to the New South Wales Lithotripter Centre with distal ureteric calculi were evaluated. All these patients were treated on the Dornier HM3 Lithotripter. Distal ureteric calculi were classified as those at, or distal to, the proximal margin of the sacro-iliac joint. Eleven patients with stones overlying the sacro-iliac joint were treated in the prone position, while 56 patients with stones distal to the sacro-iliac joint, were treated in the saddle (astride) position. Of the 64 patients in whom follow-up was available, 44 (69%) were rendered totally stone free by extracorporeal shock-wave lithotripsy (ESWL). Lithotripsy has proved an effective treatment for distal ureteric calculi and has rendered 69% of patients stone free with minimal morbidity. Stones overlying the sacro-iliac joint can be successfully treated in the prone position.     

A comparison of holmium:YAG laser with Lithoclast lithotripsy in ureteral calculi fragmentation

PURPOSE: Among various intracorporeal lithotriptors, Lithoclast (EMS, Switzerland) has become the widely used tool for the treatment of urinary stones. Recently, the holmium:YAG laser has been used with a wide range of potential urological applications, including intracorporeal lithotripsy of urinary calculi. The purpose of the present study is to compare Lithoclast with holmium:YAG laser lithotripsy in ureteral calculi fragmentation. METHODS: Out of 51 patients with ureteral calculi, 26 underwent Lithoclast lithotripsy and 25 holmium:YAG lithotripsy using a 8/9.8F rigid ureteroscope. There were no changes to the ureteroscopes, video monitors, baskets or irrigation devices during the study period. RESULTS: There were no differences in patient age, sex, stone size and location of stones between these groups. The immediate stone-free rates were 96.0% in the holmium:YAG group and 73.1% in the Lithoclast group (P < 0.05). The 3-month stone-free rates were 96.0% and 84.6%, respectively (P = 0.350). The mean operation time and mean period of postoperative hospitalization in the holmium:YAG group (49.8 min and 1.0 days, respectively) were shorter than those of the Lithoclast counterpart (76.9 min and 2.5 days, respectively). Post-treatment complications, such as ureteral perforation, were encountered in only two patients who underwent Lithoclast. CONCLUSIONS: Holmium:YAG lithotripsy was associated with shorter operation time and postoperative hospitalization period. These data also suggest that holmium:YAG lithotripsy was safe and more effective than Lithoclast lithotripsy in the aspect of immediate stone free rate. We believe that holmium:YAG laser is an excellent treatment modality for managing ureteral calculi.     

Electrokinetic lithotripsy: safety, efficacy and limitations of a new form of ballistic lithotripsy.

OBJECTIVE: To investigate the safety and efficacy of electrokinetic lithotripsy (EKL), a ballistic lithotripter which uses high-energy magnetic fields to propel an impactor to fragment calculi. PATIENTS AND METHODS: The records and radiographs of 121 patients who underwent ureteroscopy using the EKL for stones in the upper (26), mid (28) or lower (67) ureter were reviewed retrospectively. Ureteroscopy was performed with an 8.5 F semi-rigid ureteroscope, through which a 3 F EKL probe was passed. RESULTS: A total of 148 stones (mean stone size 11.5 mm, range 6-40) in 121 patients were treated using the EKL. One patient was lost to follow-up. Of 148 stones, 147 (99.3%) were fragmented, including five that had resisted fragmentation with either pulsed-dye laser or electrohydraulic lithotripsy. Despite this, only 45 of 56 patients (80%) with a single stone in the lower ureter were rendered stone-free after a single ureteroscopic procedure. Seven patients in this group (12%) required shock-wave lithotripsy for fragments that had been propelled into the kidney, while four patients (7%) required repeat ureteroscopy for retained ureteric fragments. Complications were limited to minor ureteric perforations in two patients, both of which were treated with a stent. CONCLUSION: EKL is an inexpensive and reliable endoscopic method which fragments nearly all urinary calculi. Its limitations include the propulsion of fragments and the need to use an offset, semi-rigid ureteroscope. We recommend the use of a basket or graspers to remove fragments of >/=4 mm after EKL.     

Extracorporeal shock wave lithotripsy with the Storz Modulith SL20: the first 500 patients.

Our initial experience of extracorporeal shock wave lithotripsy (ESWL) with the Storz Modulith SL20 is reported. A total of 500 patients with 551 renal and 120 ureteric stones, mean diameter 11.9 mm, underwent 746 treatments; 68.2% of patients required a single treatment. The mean treatment rate for renal calculi was 1.4 and for ureteric calculi it was 1.5, rising to 4.2 for staghorns; 62.2% of treatments were performed on an out-patient basis. Analgesia (intravenous fentanyl) was required in 60.9% of treatments for renal calculi but in only 38.2% of those for ureteric calculi. The overall stone-free rate at 3 months was 77.6%, with a further 14.7% of patients having fragments less than 3 mm in diameter that required no further treatment. The stone-free rate was dependent on the site of the stone, with the majority of residual fragments lying in a lower pole calix. There were few complications. The Modulith is an efficient and safe lithotripter capable of treating stones in the kidney and throughout the ureter.     

The impact of the Dornier Compact Delta lithotriptor on the management of primary ureteric calculi

OBJECTIVE: To assess the effectiveness of the Dornier Compact Delta lithotriptor on the management of in situ primary ureteric stones. PATIENTS AND METHODS: 137 patients with primary ureteric stones were treated at a tertiary urological center using the latest Dornier Compact Delta lithotriptor between January 1999 and January 2002. Effectiveness of lithotripsy, retreatment rate, reasons for failure and complications were assessed. RESULTS: 102 males and 35 females with primary ureteric stones underwent ESWL treatment at our center. 74 patients had upper, 37 middle and 26 lower ureteric locations respectively.Mean stone size was 10 mm (range 8-25 mm). Mean numbers of sessions required were 1.8 (range 1-3). The retreatment rate was 33% in upper ureteric, 29% in mid ureteric and 26% in lower ureteric locations respectively. Complete clearance rate at 3 months was 86% for upper ureteric, 79% for mid ureteric and 79% for lower ureteric. 29 patients had auxiliary treatment in the form of double J ureteric stenting or percutaneous nephrostomies. 26 patients failed treatment and underwent ureteroscopic or ante grade percutaneous removal. Stone size was the only significant factor correlating with failure. The mean size of stones in the successful group was 12 mm as compared to 17 mm in failure group. The likelihood of success following a failed second session (no disintegration or disintegration with fragments more than 6 mm) of treatment was 13.4%. Complications including, steinstrasse, colic, UTI and petechial haemorrhage were seen in 35 patients. One patient developed pyonephrosis and subsequently required nephrectomy. CONCLUSION: An electromagnetic shock wave lithotriptor using the EMSE-150 shock wave emitter is an effective in situ treatment of primary ureteric stones. Patients with large stone size are likely to have a higher retreatment rate, more auxiliary procedures and complications. Having a failed second treatment session, the likelihood of a successful outcome after third session of ESWL is poor.     

“无管化”微通道经皮肾镜取石术治疗上尿路结石68例临床观察

目的 评价“无管化”微通道经皮肾镜取石术(MPCNL)治疗上尿路结石临床疗效、安全性和可行性.方法 用“无管化”MPCNL方法治疗上尿路结石患者68例,其中肾结石患者41例和输尿管上段结石27例,结石最大直径均≤3 cm,术后不留置肾造瘘管,取石后常规留置双“J”管和导尿管.结果 68例患者术中出血量约30～80 mL,平均55 mL,手术时间35～75 min,平均(52.5±3.3)min,结石清除率为95.6％(65/68),3例结石残留(术后2d复查B超提示残留结石直径为3.1、2.8、2.5 mm),术后未出现尿外渗、肾周血肿、感染等并发症;术后住院时间3～5d,平均(4.0±1.2)d,出院后1个月和3个月复查,无结石复发,肾周无肾性囊肿,肾积水均有不同程度减轻.结论 “无管化”MPCNL由于选择了合适的患者,降低了术中的风险性,结石清除率高、术中出血量少、术后并发症少、恢复快,因此是安全有效且可行的,具有非常肯定的临床应用价值,值得进一步推广应用.     

输尿管硬镜下钬激光碎石取石术治疗输尿管上段结石112例

【摘要】〓目的〓探讨输尿管硬镜下钬激光碎石取石术治疗输尿管上段结石的临床效果及安全性。 方法〓应用输尿管硬镜下钬激光碎石取石术治疗112例输尿管上段结石患者。男63例,女49例,年龄18~87岁(46.7±13.6岁),左侧61例,右侧46例,双侧5例。结石长径0.7~2.2 cm(1.2±0.5 cm)。26例合并输尿管息肉,31例曾行体外冲击波碎石术,所有患侧肾脏均合并不同程度肾积水。 结果〓手术成功率88.4%(99/112),手术时间15~80 min(33.6±16.8 min),术后住院天数3~14天(4.7±2.1天)。所有患者均无严重肉眼血尿、输尿管穿孔、粘膜撕裂、输尿管镜石街形成等并发症。3例患者出现畏寒、高热,其中1例发展为尿源性脓毒血症,予以积极抗感染治疗后,症状逐渐缓解。结论〓输尿管硬镜下钬激光碎石取石术治疗输尿管上段结石是安全,有效的治疗方法。     

Combined Treatment of Staghorn Calculi by Fiberoptic Transurethral Nephrolithotripsy and Extracorporeal Shock Wave Lithotripsy

Background:
Although various strategies have been proposed, the treatment of staghorn calculi is still controversial. We report on the treatment of 27 staghorn calculi using fiberoptic transurethral nephrolithotripsy (f-TUL) combined with extracorporeal shock wave lithotripsy (ESWL).
Methods:
Stones were initially disintegrated by f-TUL as an inpatient procedure. For stone fragmentation, we originally used an electrohydraulic lithotriptor (EHL) but changed to a pulsed-dye laser in 1993. After the stones were disintegrated as much as possible, a double-J ureteral stent was inserted and the patient was discharged. ESWL for the residual fragments was begun on an outpatient basis at 1 or 2 weeks after f-TUL and repeated until the residual fragments were smaller than 4 mm.
Results:
Since 1989, 27 staghorn calculi in 26 patients have been treated. Among them, 21 were successfully fragmented using this combined treatment regimen. From 3 to 26 ESWL sessions (mean, 8.4 sessions) were required to disintegrate the staghorn calculi. Auxiliary percutaneous endourological procedures were necessary in 2 cases due to ureteral obstruction. The other 4 patients are still receiving ESWL for residual fragments. Urinary tract injury occurred in 2 patients early in this series when an EHL was used, but was managed without any surgical procedures. A fever greater than 38^°C developed in 9 patients.
Conclusion:
Combining f-TUL with ESWL provides an alternative treatment option for staghorn calculi. The use of a small caliber fiberscope (2.6 mm in diameter) and a laser for fragmentation decreased the risk of complications.