输尿管软镜联合钬激光碎石术治疗肾和输尿管上段结石:附86例报告

目的 评价输尿管软镜联合钬激光治疗上尿路结石的效果及影响碎石成功的因素和技巧.方法 2008年7月至2011年6月86例输尿管软镜钬激光碎石病例.共104枚结石,结石最大直径10~25 mm.术中使用输尿管硬镜探查患侧输尿管,放置输尿管软镜鞘并换用Storz Flex-X2 F7.5输尿管软镜.若输尿管鞘无法插入,可直接在导丝引导下插入输尿管软镜至肾盂.如果软镜仍不能直接插入,则在放置导丝后留置6 F双J管,1~2周后第二次试行输尿管软镜碎石.术后4周复查KUB或双肾CT平扫,评估碎石效果.结果 软镜一次进镜成功率87.2%(75/86),余11例第二次手术9例成功进镜,总的进镜成功率为97.6%(84/86),钬激光碎石成功率95.3%(82/86).4周后结石清除率为83.7%02/80.12例再次行输尿管软镜碎石,其中9例排净结石.总的结石清除率为94.1%(81/86).平均手术时间为45 min(18-75 min).无严重并发症.结论 输尿管软镜钬激光碎石是治疗10~25mm肾和输尿管上段结石的安全有效的方法.其结石排净率高、并发症低,可以作为体外冲击波碎石失败和经皮肾镜碎石术后残留结石的治疗选择.     

A prospective trial on ureteral stenting combined with secondary ureteroscopy after an initial failed procedure

The aim of this study is to investigate the impact of the intentional ureteral stenting on the success rate of calculus extraction by second ureteroscopy, when the initial ureteroscopy failed. We prospectively enrolled 512 patients with ureteral calculi who underwent ureteroscopies from April 2005 to May 2011. The patients with failed initial ureteroscopies were classified into two groups depending on the stent type: the Double-J stent and the ureteral catheter group. The secondary ureteroscopies were performed in a short period (3–22 days). Data were abstracted on stone size, location, patient demographics, outcome and complications. A total of 453 patients had success after the initial ureteroscopy and the success rate was 88.5 %. Of the 59 failed patients, 40 were managed by reureteroscopy with Double-J stent placement and 19 with ureteral catheters. There were no statistically significant differences between patients in Double-J stent and ureteral catheter group in the aspects of age, primary stone size, gender, stone location and stone-free rate [39/40 (97.5 %) versus 19/19 (100 %), p > 0.05]. Moreover, the mean stents retaining period before the second ureteroscopy was significantly shorter in the ureteral catheter group, when compared with the Double-J stent group (3.9 versus 16.9 days, p < 0.01). The complications were moderate and not significantly different between the two groups (p > 0.05). Indwelling a ureteral stent leads to a high subsequent success rate for second ureteroscopy following an initial failed procedure. In addition to Double-J stent, the ureteral catheter stent was an effective alternative with shorter retaining period, especially for impacted stones.     

Therapeutic options in lithiasis of the lumbar ureter

INTRODUCTION: In the past 25 years, the treatment of lithiasis of the lumbar ureter has evolved from ureterolithotomy to extracorporeal shockwave lithotripsy and/or endoscopic lithotripsy. Our objective has been to analyse the results of extracorporeal lithotripsy and endoscopic surgery in lithiasis of the lumbar ureter. MATERIALS AND METHODS: We have analysed 734 single calculi of the lumbar ureter treated during the decade 1990-2000, excluding patients with lithiasis in other locations in order to avoid bias in the assessment of the results. Extracorporeal shockwave lithotripsy (ESWL) was carried out using a Siemens Lithostar, urinary diversion with a double pigtail ureteric catheter or percutaneous nephrostomy, semi-rigid ureteroscopy and electrokinetic contact lithotripsy.The patient were divided into six groups. We assessed complete and partial success, the fragmentation index, and complications, analysing the results using a test for the comparison of proportions. RESULTS: In group A, non-obstructive lithiasis treated by in situ ESWL, complete success was achieved in 95.5%. In group B, obstructed lithiasis treated by in situ ESWL, 93.15%. In group C, obstructive lithiasis treated with a double pigtail catheter and ESWL, 81.11%. In group D, obstructive lithiasis treated with percutaneous nephrostomy and ESWL, 93.75%. In group E, ureteric lithiasis <1cm, treated by retrograde displacement to the renal cavities and ESWL, 82.3%. In group F, lithiasis of the lumbar ureter treated by ureteroscopy, 91%. CONCLUSIONS: The primary therapeutic option for the treatment lithiasis of the lumbar ureter, in the absence of criteria for urinary diversion, is in situ ESWL. We consider the criteria for urinary diversion prior to ESWL to be severe obstruction, obstruction associated with urinary tract infection, and obstruction caused by a proximal ureteric calculus adjacent to the inferior renal pole.Ureteroscopy and/or contact lithotripsy is the technique of choice in lithiasis of the lumbar ureter resistant to ESWL due to non-fragmentation or to the persistence of impacted fragments. Ureteroscopy may be the first choice of therapy in obstructive lithiasis, substituting urinary diversion plus ESWL.     

经尿道输尿管镜379输尿管疾病的临床应用

目的　探讨经尿道输尿管镜处理输尿管疾病的临床价值。　方法　回顾分析 1990年 1月～ 2 0 0 0年 4月的 3 79例输尿管结石、异物、尿漏以及原因不明的血尿、肾积水采用经尿道输尿管镜技术诊治的临床资料。　结果　经尿道输尿管镜检查输尿管 19例全部成功 ;治疗输尿管结石成功率 94% (3 15 /3 3 5 ) ;取双J管成功率 96 4% (2 7/2 8) ;放置双J管治疗尿漏 6例全部成功。发生并发症 9例 ,占 2 4%。　结论　输尿管镜治疗输尿管结石的成功率与操作经验、技术熟练程度及与适应证的选择有关。用输尿管镜取输尿管异物安全、方便     

输尿管软镜联合钬激光碎石术治疗上段尿路结石的疗效观察

目的 探讨输尿管软镜联合钬激光治疗上段尿路结石的疗效.方法 回顾性分析2013年1月至2015年3月期间本院采用输尿管软镜联合钬激光碎石术治疗的43例上尿路结石患者临床资料.结石最大直径12 ～27mm.12例患者术前1周留置患侧双J管,术中先经F8/9.8输尿管硬镜镜检留置导丝,沿导丝放置Cook外鞘,再引入奥林巴斯纤维输尿管软镜联合钬激光,尽可能将结石粉碎化,必要时辅助使用套石篮套取出较大的结石碎屑.术后4周复查KUB或双肾CT平扫,评估碎石效果结果.结果 术前留置患侧双J管1周的12例患者均成功一次性进镜;经输尿管硬镜扩张后的软镜一次进镜成功率90.3％ (28/31),余3例留置双J管2周后行第二次手术全部成功进镜;总进镜成功率为100％(43/43).总的结石寻及率95.3％(41/43),钬激光碎石成功率97.6％ (40/41),4周后结石清除率为70％ (28/40).平均手术时间为65min(35～150min).无严重并发症发生.结论 输尿管软镜联合钬激光治疗上尿路结石微创、安全,疗效确切,并发症少,具有良好的应用的前景.     

经皮肾通道顺行输尿管软/硬镜联合输尿管镜治疗恶性输尿管梗阻

目的探讨斜仰卧截石位经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤致输尿管梗阻的安全性及临床效果。 方法回顾性收集并分析2016年10月至2019年1月我院收治的25例恶性肿瘤引起的输尿管梗阻患者的资料,上述患者均因常规逆行膀胱镜或输尿管镜置双J管失败,进而以斜仰卧截石位利用经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管。 结果25例患者（32侧输尿管梗阻）中,1例因肿瘤侵犯输尿管造成双侧输尿管管腔完全闭塞,双J管置入失败。其余24例均成功放置双J管（成功率93.7%）。手术时间平均（57.4±22.4）min,平均住院时间（5.5±1.9）d,术中无严重肾出血,无输尿管穿孔及撕脱。术后6~14 d拔除肾造瘘管,拔除肾造瘘管后随访12个月,肾积水缓解。 结论斜仰卧截石位皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤引起的输尿管梗阻安全、有效,值得临床推广。     

输尿管镜技术治疗输尿管膀胱壁间段结石的疗效观察

目的 探讨输尿管镜技术治疗输尿管膀胱壁间段结石安全性和有效性.方法 回顾性分析我院近10年采取输尿管镜技术治疗的输尿管膀胱壁问段结石患者86例.结果 全部患者成功碎石并留置双J管,术后4周拔除.术后6个月复查超声与尿常规未见同侧肾积水、输尿管开口狭窄和尿路感染.结论 输尿管镜技术治疗输尿管壁间段结石安全有效,具有创伤小、安全性高、疗效确切等优点,具有很强的实用性及可操作性.     

Ureterolithotripsy: report of 1000 cases

A series of 1000 patients with calculi of the ureter at various levels were treated by ureteroscopy and lithotripsy over a period of 27 months. The overall success rate was 88.8%. Stones in the upper third of the ureter were removed in 15 of 39 patients. Calculi in the middle third were successfully removed in 52 of 102 patients. A success rate of 95.5% was achieved for calculi of the lower ureter. Per-operative complications included 10 ureteric perforations, 4 of which were treated surgically and 6 conservatively. Urography, performed in 520 patients 3 months post-operatively, showed 12 ureteric strictures; 9 of these were treated by insertion of a self-retaining pig-tail catheter and 3 required an operation. Ureterolithotripsy appears to be the method of choice in the management of ureteric calculi.     

The impact of extracorporeal piezoelectric lithotripsy on the management of ureteric calculi: an audit

The presentation and management of 153 patients with ureteric calculi requiring active treatment over a 12-month period were reviewed; 74% of patients had primary ureteric calculi and 26% had ureteric calculi composed of fragments resulting from extracorporeal piezoelectric shockwave lithotripsy (EPL) to renal calculi; 32 patients (21%) had more than 1 calculus or a steinstrasse. The primary procedures included were in situ EPL (n = 54), push-bang (44), retrograde ureteroscopy (40), Dormia basket extraction (6), push-pull (1), antegrade ureteroscopy (1) and combinations of these (7). The success of the primary procedure could not be predicted from stone size, site or duration in the ureter, but upper tract dilatation was significantly less (p less than 0.01) in the successful group. The overall success rate for complete stone extraction was 97%, but 54 patients (35%) required more than 1 procedure to achieve this. In situ EPL and push-bang, as either primary or secondary procedures, were successful in treating 79 patients (52%); 2 patients required ureterolithotomy (1.3%). The overall complication rate was 18%. Since EPL is only successful in treating approximately half of ureteric calculi, a range of other treatments should be available to maintain a low rate of open surgery.     

Ureteroscopic treatment of lower pole calculi: comparison of lithotripsy in situ and after displacement

PURPOSE: Ureteroscopic management is a viable option for lower pole calculi less than 2 cm. Recently a technique was described to displace the calculus into a more accessible calix using a nitinol basket or grasper before lithotripsy. We compared the efficacy and safety of this technique with in situ treatment of small and intermediate lower pole calculi. MATERIALS AND METHODS: We retrospectively reviewed the records of 95 ureteroscopy cases performed at our institution from January 1997 through August 2001 for renal calculi located only in the lower pole. Preoperative patient characteristics, stone size, operative details, complications and outcomes were compared for calculi treated in situ and those displaced before treatment. RESULTS: Adequate followup was available on 78 patients. Patients in the displacement group were statistically older, more often had a preoperative indwelling ureteral stent and had a mean operative time that was 16 minutes longer (p = 0.04). Average stone diameter in the in situ and displacement groups was 8 and 10.3 mm., respectively (p = 0.04). In patients with radiographic followup greater than 1 month complete success was obtained for 77% of stones 1 cm. or less treated in situ versus 89% treated with displacement first (p = 0.43). For calculi greater than 1 cm. complete success was obtained for 2 of the 7 (29%) treated in situ versus all 7 (100%) treated with displacement (p = 0.005). CONCLUSIONS: When treating lower pole calculi 1 to 2 cm. via ureteroscopy, a higher success rate can be obtained with displacement into a more accessible calix before treatment.     

The double wire technique: an alternative method for difficult ureteroscopic access

We read with great interest the study report by Ji et al. (Urol Res, doi:10.1007/s00240-012-0476-0, 2012) about the impact of the intentional ureteral stenting on the success rate of calculus extraction by second ureteroscopy, when the initial ureteroscopy failed. Actually, sometimes ureteral stone treatment pose challenging problems for the urologists. This study has filled an important gap on this field. If flexible ureteroscopy and laser lithotripter are not available pre-existing stent may improve the success rate of a subsequent ureteroscopy for impacted ureteral stones. Because, post-stent ureteroscopy has the advantage of working through a dilated ureter. We would like to add some additional comments and suggestions in addition to the authors’ discussion, which is noteworthy in several respects.     

Transurethral ureteroscopy. Safety guide wire as an aid to a more aggressive approach

In an unselected, consecutive series of patients, ureteroscopy was carried out for removal or manipulation of stones in 48 patients and for evaluation of suspected ureteric tumours in two. A success rate of 92% was achieved. The use of an intra-ureteric safety guide wire, indwelling throughout the procedure, facilitated ureteroscopic manipulation, minimised complications, reduced the need for subsequent open surgery and has been a prerequisite for our comparatively aggressive approach to ureteric disorders. The procedure may be time-consuming but prolonged manipulation within the ureter seems to carry little morbidity.     

Two pelvises,one stone: A different approach for management of calculi in a duplex renal collecting system

Duplex renal collecting systems are a common congenital abnormality. Management of renal calculi in patients with this abnormality is complex. We describe a patient with a duplex collecting system presenting with a renal calculus. Initial flexible ureteroscopy failed to reach the collecting system containing the stone due to inability to visualize an additional ureteric orifice. The patient then underwent percutaneous puncture of the stone containing moiety, followed by antegrade stent insertion. This allowed for guidewire-assisted passage of a ureteroscope into the duplex collecting system, where the calculi were identified and fragmented.     

输尿管良性狭窄内切开前行球囊扩张的临床研究

目的 探讨输尿管良性狭窄内切开前使用球囊扩张的必要性.方法 16例输尿管良性狭窄患者行钬激光输尿管内切开前,6例采用球囊扩张狭窄段,10例采用输尿管硬镜扩张狭窄段.回顾性分析其临床资料和随访结果,包括病因、狭窄部位、诊断方法和超声等随访情况.结果 输尿管硬镜扩张者3例失败,改用球囊扩张成功;使用球囊扩张的患者均扩张成功.狭窄长度为0.8～1.4 cm.用球囊扩张的手术时间短于用输尿管硬镜扩张,但手术费用高于用输尿管硬镜扩张,差异均有统计学意义(P<0.05).随访3～28个月,无围手术期并发症,2例用输尿管硬镜扩张患者出现再狭窄.结论 输尿管良性狭窄内切开前使用球囊扩张安全、有效,但费用较高.     

Morbidity associated with surgical treatment of ureteric calculi in a teaching hospital in Kuwait

BACKGROUND: Ureteric lithiasis is a common urological problem in Kuwait. Because of the different interventional approaches, we carried out an audit on the morbidity associated with the surgical management of the disorder. PATIENTS AND METHODS: The surgical records were reviewed of all patients with the diagnosis of ureteric lithiasis that were managed surgically by ureteroscopy or ureterolithotomy in Mubarak Al-Kabeer Hospital in Kuwait between January 1996 and December 1999. Patients' bio-data, location of calculi, indications for surgical intervention, types of therapeutic interventions, operating surgeon and complications were analysed. Patients managed primarily and successfully by extracorporeal shockwave lithotripsy were excluded from this analysis. RESULTS: A total of 1383 patients with ureteric calculus were managed in the period under review--775 (56%), 567 (41%), and 41 (3%) patients were managed by extracorporeal shockwave lithotripsy, ureteroscopy and ureterolithotomy, respectively. The 608 patients managed by ureteroscopy or ureterolithotomy had a total of 710 operations. The commonest surgical procedure performed was ureteroscopy with Dormia basket with or without double 'J' stenting and this accounted for 418 (58.9%) operations. The least common procedure was ureteric meatotomy with Dormia basket and with or without double 'J' stenting in 9 (1.3%) patients. The overall complication rate was 110 out of 710 (15.5%) operations. Of the complications, 101 (92%) were minor (e.g. haematuria, fever, and mucosal injury). Nine (8%) complications were major complications (e.g. ureteric perforation and ureteric avulsions). Ureterolithotomy and ureteroscopy with intracorporeal lithotripsy were associated with the highest complication rates. CONCLUSIONS: This analysis has shown that with technological advances, the treatment of ureteric lithiasis has improved and major complications have decreased. However, with so many therapeutic options to choose from, there is a need to audit the various therapeutic options and select those associated with the least morbidity rates in each urology unit.     

输尿管镜钬激光联合两重双J管引流术处理ESWL治疗失败的输尿管结石

目的：评价输尿管镜钬激光碎石联合腔内两重双J管引流术处理ESWL治疗失败输尿管结石的临床疗效,并探讨其影响因素。方法：2005年1月～2010年6月对ESWL失败的21例输尿管结石患者行输尿管镜钬激光碎石术,碎石后置入两根双J管,术后常规留置2～4周后拔除。结石合并息肉形成的13例患者均同期采用钬激光汽化切割息肉。结果：21例输尿管结石行钬激光碎石成功率达95．2%（20／21）,手术时间10～70min,平均（40．4±10．3）min;术后住院时间1～7天,平均（3．1土1．2）天。结论：输尿管镜钬激光碎石联合腔内两重双J管引流术处理ESWL治疗失败输尿管结石是安全可行的,保证结石清除率的同时不增加并发症发生率。     

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.     

输尿管镜操作技巧及医源性损伤的临床分析(附372例报告)

目的:分析输尿管镜医原性损伤的原因、治疗和预防措施。方法:回顾两家医院自2007年1月～2009年8月所行的372例输尿管镜手术,男141例,女231例;年龄15～87岁,中位年龄42岁;输尿管镜结合钬激光碎石267例;输尿管镜检查术83例;输尿管镜下输尿管狭窄内切开术10例;输尿管镜下放置双J管9例;输尿管镜下拔出双J管3例。结果:发生输尿管损伤有18例(4.8%)。其中,输尿管口严重撕裂2例(11.1%),输尿管穿孔9例(50%),假道形成4例(22.2%),输尿管断裂2例(11.1%),输尿管全层撕脱1例(5.5%)。留置双J管保守治疗13例,开放手术5例。随访3个月～1年,2例轻度肾盂积水,其余病例恢复良好。结论:严格把握输尿管镜手术适应证,不断提高操作技巧可减少对输尿管医原性损伤,及时发现并妥善处理可明显改善患者预后。     

输尿管镜术后双J管引流无效原因分析

目的　总结输尿管镜手术后应用双J管引流无效的原因。　方法　回顾性分析 2 0 0 0年 6月至 2 0 0 3年 3月输尿管镜手术后放置双J管引流的 3972例患者拔管前进行追踪观察。男 2 184例 ,女 1788例 ,共放置双J管 4 6 35例次 ,其中经尿道逆行放置者 3138例次 ,经皮肾造瘘口顺行放置者14 97例次。　结果　全组双J管引流无效者 115例次 ,占 2 .4 8%。常见原因有严重腔外梗阻、严重输尿管石街、严重输尿管狭窄和支架管过期留置。　结论　严格掌握输尿镜手术及双J管放置适应证和术后紧密追踪观察是减少发生输尿管镜术后双J管引流无效的关键