肾移植术后上尿路结石个体化治疗策略

目的:探讨肾移植术后移植肾上尿路结石的个体化治疗策略。方法:回顾性分析2003年12月~2017年9月于我院泌尿与碎石中心治疗肾移植后移植肾上尿路结石10例患者的临床资料。其中男6例,女4例,平均年龄(42.1±8.6)岁。6例移植肾及输尿管上段结石,4例移植肾输尿管中下段结石。单发结石4例,多发结石6例,平均结石负荷(1.0±0.6)cm。所有患者均有不同程度肾积水,8例肾功能异常,4例尿路感染。结果:6例移植肾及输尿管上段结石患者中,1例行体外冲击波碎石(ESWL)成功;5例行经皮肾镜取石术(PCNL)成功。4例移植肾输尿管中下段结石患者,1例输尿管支架更换术中膀胱镜下活检钳取石成功;1例输尿管镜取石术(URS)成功;1例URS失败改PCNL成功;1例URS和PCNL处理结石均失败,留置造瘘、透析治疗。所有患者术后肾积水得到缓解,肾功能恢复,感染得到纠正。无患者出现术后发热。3例患者接受输血治疗。结论:肾移植结石患者情况特殊且病情相对复杂,术者应根据患者具体情况决定个体化的治疗策略,从处理结石的多种方法中选择最适合患者的手术方式和治疗方案。虽然清除结石是重要治疗目标,但应充分考虑患者身体耐受程度,不可盲目追求结石的清除效果。

Individual treatment strategy for upper urinary tract calculi after renal transplantation

Objective:To discuss the individual treatment strategy for upper urinary tract calculi in transplanted kidneys.Method:From December 2003 to September 2017,10 patients with upper urinary tract calculi in transplanted kidneys who received treatment at Urological and Lithotriptic Center in Peking University People’s Hospital were retrospectively analyzed.There were 6 males and 4 females with the mean age of(42.1±8.6)years old.Six cases had renal or upper ureteral calculi and 4 cases had middle-lower ureteral calculi.Four cases had solitary stone and 6 cases had multiple stones,and the mean stone burden was(1.0±0.6)cm.All the cases suffered from varying degrees of hydronephrosis.Eight cases had abnormal renal function and 4 cases had urinary tract infection.Result:Of the 6 cases with renal or upper ureteral calculi,1 case was successfully treated by extracorporeal shockwave lithotripsy(ESWL),and other 5 cases were successfully treated by percutaneous nephrolithotomy(PCNL).Of the 4 cases with middle-lower ureteral calculi,1 case’s calculus was successfully removed by biopsy forcep under cystoscope during ureteral stent replacement,1 case was successfully treated by ureteroscopic(URS)lithotomy,1 case was successfully treated by PCNL after the failure of URS during surgery and 1 case was treated by dialysis with nephrostomy tube after the failure of URS and PCNL.The hydronephrosis was alleviated,renal function recovered and infection was corrected after treatments.No patient developed postoperative fever and 3 patients received blood transfusion.Conclusion:Renal transplant patients with upper urinary tract calculi have special and complex conditions,therefore,urologists should implement individual treatment strategy on the basis of different physical situations and calculi conditions of patients and choose the optimal surgical methods and treatment schemes from multiple methods treating calculi.Though the clearance of calculi is a critical therapeutic goal,the patients’ surgical tolerance level should be given considerable thought,not blindly pursuing the removal effect of stones.