硬输尿管镜术并发症及其防治

目的 探讨硬输尿管镜术并发症发生的原因和防治措施。方法 对804例输尿管镜术中发生的并发症进行了回顾性研究。结果 1994年10月前后入镜成功率分别67．07％和96．68‰输尿管口撕裂假道形成12例（1．49％）、浅层撕裂47例（5．85％），无输尿管断裂及黏膜撕脱、输尿管穿孔14例（1．74％）、输尿管嵌顿7例（0．87％），术中因出血中止手术10例（1．24％），术后524例获得随访，输尿管口狭窄5例（0．95％），输尿管狭窄8例（1．53％）。中转开放手术2例。术后行ESWL96例，第2次输尿管镜术47例，输尿管气囊扩张7例，输尿管口再植术2例。榆尿管端端吻合术4例。该组所有并发症患者经过处理后均得到治愈和明显改善。结论 对于严重输尿管镜术并发症应高度重视，采用正确的方法，大部分并发症是可以防治的。     

输尿管镜下阻挡网篮配合双频激光碎石术与ESWL治疗非复杂性输尿管上段结石疗效比较

目的：对体外震波碎石（ESWL）及输尿管镜下阻挡网篮配合双频激光碎石（URL）治疗非复杂性输尿管上段结石进行比较。探讨两种术式的疗效．方法：收治121例非复杂性输尿管上段结石病例。随机分两组．其中63例行ESWL-58例行URL,ESWL组采用多尼尔Cigma双定位体外冲击波碎石机,URL组采用Storz硬性输尿管镜,配用自制阻挡网篮,连接W．O．MU—100双频激光机后进行碎石,术后留置双J管。结果：两组在一次碎石成功率（ESWL93．7％、URI．93．1％）、术后1个月结石清除率（ESWI,90．4％．URI,93．1％）差异无统计学意义（P〈0．05）,治疗时间（ESWI．33．5±6．4、URL15．0±2．3）及术后1周结石清除率（ESWL69．8％、URL93．1％）URL组要优于ESWL组．差异有统计学意义（P〈0．05）。ESWI．组出现l例包膜下血肿。URL组出现1例输尿管穿孔．结论：对非复杂性输尿管上段结石的治疗,我们要根据患者具体情况及要求,科学地制定个体化治疗方案,以减少并发症。     

第4、5腰椎水平难治性输尿管结石的处理

目的：探讨第4、5腰椎水平难治性输尿管结石的处理方法。方法：采用经皮肾穿刺造瘘联合经尿道输尿管镜气压弹道／钬激光碎石术治疗第4、5腰椎水平难治性输尿管结石患者20例。结果：20例均在B超引导下成功穿刺建立经皮肾通道。留置肾造瘘管（气囊型）于肾盂输尿管连接部下方．一期行经尿道输尿管镜碎石术。手术时间平均48min（30~70min）．清石率为100％．未出现严重并发症。结论：经皮肾穿刺造瘘联合经尿道输尿管镜碎石术治疗第4、5腰椎水平难治性输尿管结石安全、有效。     

输尿管镜钬激光碎石术治疗输尿管结石96例分析

目的探讨输尿管硬镜钬激光碎石术治疗输尿管结石的有效性和安全性。方法回顾性分析2006年7月-2010年8月96例输尿管镜下钬激光碎石治疗输尿管结石患者的临床资料,对碎石率、排石率和并发症进行统计分析。结果 96例输尿管结石患者一次手术结石粉碎率为95.8%(92/96),输尿管镜置镜成功率为99.0%,输尿管上、中、下段碎石、排石成功率分别为81.8%(9/11)、97.1%(34/35)和99.0%(49/50)。在输尿管上段碎石过程中并发输尿管穿孔2例。全组均有不同程度的肉眼血尿,无输尿管撕脱、断裂等严重并发症发生。结论输尿管镜下钬激光碎石取石治疗输尿管结石是安全和有效的,尤其对下段输尿管结石,术后常规放置D-J是安全和需要的。     

Treatment of ureteric lithiasis with retrograde ureteroscopy and holmium:YAG laser lithotripsy vs extracorporeal lithotripsy

OBJECTIVE

To analyse the efficiency of extracorporeal shockwave lithotripsy (ESWL) vs retrograde ureteroscopy and holmium:YAG laser lithotripsy, as ESWL is successful in 67–90% of cases but endoscopic lithotripsy with pneumatic lithotrites or lasers is successful in 90–96% of distal ureteric calculi, and holmium:YAG lithotripsy is effective in proximal ureteric calculi.

PATIENTS AND METHODS

From April 2006 to April 2008 we assessed 164 patients undergoing ureteric lithiasis in two homogeneous groups: group A included 83 treated with retrograde ureteroscopy and holmium:YAG endoscopic lithotripsy, and group B, 81 treated by ESWL. For laser lithotripsy we used 2071 mJ pulses at 3–6 Hz, with a mean of 1105 pulses and 2.5 kJ of total energy. ESWL was carried out using 37.5–87.5 mJ shock waves, a mean of 3650 shock waves and 187.6 J, with a radioscopy time of 1–4 min. The results were assessed after 3 weeks with plain films and ultrasonography, or urography. The efficiency of each procedure was assessed by calculating the relative risk, and results compared using the chi‐square or Student’s t‐test. The efficiency quotient (EQ) was determined for both procedures, and the focal applied energy quotient (FAEQ) used to assess ESWL.

RESULTS

The overall success rate for retrograde ureteroscopy and laser lithotripsy was 96.4% (80/83 patients), with an EQ of 0.52; a JJ catheter was placed in 67 patients. The success rate for the first ESWL session was 48%, and after repeat ESWL was 64% (52/81 patients), giving an EQ of 0.39. For successful treatments the FAEQ was 9.22, vs 6.47 for the failures (P < 0.005). There was a significant difference (P < 0.001) favouring laser lithotripsy, with an absolute benefit of 46% (95% confidence interval 33.8–57.9%), and number needed to treat of 2 (2–3), but no significant differences for lumbar ureteric calculi.

CONCLUSIONS

Endoscopic lithotripsy with the holmium laser is more effective than ESWL, but for lumbar ureteric calculi ESWL is therapeutically recommended as it is less invasive.     

输尿管镜下钬激光治疗合并息肉的输尿管上段阴性结石（附60例报告）

目的探讨输尿管镜下钬激光治疗合并息肉的输尿管上段阴性结石的疗效。方法2008年1-12月采用输尿管镜下钬激光（美国科以人公司PowerSuite 20 W激光系统,光纤500μm）治疗合并息肉的输尿管上段阴性结石60例。经尿道输尿管镜直视下到达结石部位,采用钬激光腔内碎石治疗,同时消融息肉。结果手术时间15-70 min,平均21 min。60例息肉均一次治疗成功;除4例上段结石被冲入肾盂外,其余56例均单次原位碎石成功。术中未发生输尿管黏膜撕脱、输尿管穿孔、输尿管黏膜隧道等严重并发症。术后仅有轻微血尿,无低热、肾区疼痛等不适。60例随访3-12个月,平均5个月,均未发现结石残留及输尿管狭窄。结论输尿管镜下钬激光治疗合并息肉的输尿管上段阴性结石安全,疗效满意。     

输尿管镜下钬激光碎石术138例并发症分析

目的分析输尿管镜下钬激光碎石术并发症的发生原因,探讨其防治方法。方法回顾分析138例输尿管结石患者行输尿管镜下钬激光碎石术的临床资料。结果6例输尿管镜下钬激光碎石术失败,其中5例改开放手术（3．42％）。另有2例术后发生严重尿瘘行腹腔内及腹膜后引流。结论输尿管硬镜下钬激光碎石术治疗输尿管结石安全、微创,但也可能导致严重并发症。手术技巧等对有效降低其并发症具有重要意义。     

经尿道输尿管镜气压弹道碎石治疗的护理

目的探讨经尿道输尿管镜弹道碎石治疗的护理方法。方法回顾性总结和分析经尿道输尿管镜弹道碎石的260例病人围手术期的心理护理、术后并发症的观察和护理及饮食指导。结果260例患者中1例发生输尿管损伤,两例出院后一周内出现血尿。结论做好围手术期的心理护理、术后并发症的观察和护理及饮食指导是降低并发症、提高手术成功率、防止结石复发的有效方法。     

输尿管镜钬激光碎石术治疗输尿管结石

目的：探讨输尿管镜钬激光碎石术治疗输尿管结石的有效性和安全性。方法：回顾性分析216例应用经输尿管镜钬激光碎石术治疗的输尿管结石患者资料。男133例,女83例;年龄20～68岁,平均49岁。上段结石48例,中段58例,下段110例。结石直径0．7～2．6cm,平均1．4cm。结果：单次碎石成功率为98．1％（212／216）,其中上段结石单次碎石成功率为91．6％（44／48）,中、下段为100％（168／168）。平均手术时间29min,212例术后平均住院3．5天。术后随访2周～3个月,结石排净率99％（210／212）。结论：输尿管镜钬激光碎石术治疗输尿管结石高效、安全,可作为输尿管结石特别是中下段结石首选的治疗方法。     

Combined electrohydraulic and holmium:YAG laser ureteroscopic nephrolithotripsy of large (greater than 4 cm) renal calculi

PURPOSE: Percutaneous nephrolithotripsy is standard treatment for renal calculi larger than 2 cm. Modern flexible ureteroscopes and accessories using the complimentary effects of electrohydraulic lithotripsy and holmium:YAG laser lithotrites can treat large (greater than 4 cm) branched renal calculi in a minimally invasive fashion with similar or superior results. This report is an assessment of the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for the management of large (greater than 4 cm) branched renal calculi in the community setting. MATERIALS AND METHODS: A total of 16 patients with 17 branched renal calculi ranging from 41 to 97 mm (mean 65) in length and 560 to 2,425 mm2 (mean 1,169) in area underwent staged ureteroscopic nephrolithotripsy monotherapy. Obesity (body mass index greater than 30) was present in 81% and 38% were morbidly obese (body mass index greater than 40). An infectious etiology was present in 81% and hard stone components were present in 94%. All patients presented with hematuria, pain and/or recurrent urinary tract infection. Lithotripsy was performed with a single deflection flexible ureteroscope and predominantly electrohydraulic lithotripsy. Laser drilling was used (in 4) to weaken hard stones before electrohydraulic lithotripsy. Low intrarenal pressure was maintained by continuous bladder drainage and placement of a stiff safety wire. Visibility was maintained using manual pulsatile irrigation. RESULTS: All patients were rendered pain and infection-free. No patient required a blood transfusion and there was no change in serum creatinine. Mobile stone-free status was achieved in 15 of 17 renal units (88%) with a mean of 2.4 stages and 36 of 40 (90%) procedures performed on an outpatient basis. Operative time averaged 49 minutes per stage and 115 minutes per calculus. There were 3 patients admitted for fever and 1 patient (90 years old) admitted for pneumonia 3 days postoperatively. There were also 3 patients with calculi larger than 75 mm who required ureteroscopic management of steinstrasse. CONCLUSIONS: Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with percutaneous nephrolithotripsy.