小儿输尿管结石的输尿管镜和ESWL治疗

目的 报告小儿输尿管结石URS和ESWL治疗经验，探讨微创治疗的效果和策略。方法 复习了1988～2003年间65例小儿输尿管结石的治疗和结果，其中22例患儿应用ESWL治疗；43例输昧管中、下段结石和5例上段嵌顿结石FSWL失败者进行了输尿管镜治疗，用APL弹道碎石机或钬激光击碎结石并取出，7例联合ESWL；1例接受了开放手术．结果 22例输尿管上段结石经过29次ESWL治疗，随访3个月，结石完全排空16例，完全排空率为72．7%。43例输尿管中、下段结石和5例上段嵌顿结石ESWI．失败者进行了48次输尿管镜治疗，47次进镜治疗成功。30例下段结石URS治疗均成功；13例中段结石，10例URS取石成功。3例中段结石和4例上段结石联合ESWL碎石均成功，45例术后停留引流管1～4周，随访3个月，结石清除率为979％。1例上段结石入镜失败改行开放手术取石。结论 ESWL仍是输尿管上段结石的首选治疗方法；对输尿管中、下段结石特别是下段结石应用小直径输尿管镜则是安全有效的方法；部分中、上段结石采用URS联合ESWL效果可能更好。     

微创经皮肾取石治疗小儿复杂肾结石

目的总结小儿复杂肾结石微创治疗经验，探讨小儿肾结石微创经皮肾取石（mini—PCNL）的治疗效果。方法回顾了10年间（1995-2005年）行mini—PCNL的35例患儿的临床资料，男20例，女15例，平均年龄8岁（3．5～14岁），其中伴尿路畸形8例（22．9%），3例伴UPJ梗阻同时行顺行肾盂输尿管狭窄内切开术，1例UPJ梗阻输尿管镜扩张，4例联合ESWL。结果Ⅰ期mini-PCNL为26例（74．3％），Ⅱ期mini—PCNL为9例（25．7％）；Ⅰ期结石完全清除25例（71．4%），Ⅱ期结石完全清除6例（17．1％），联合ESWL4例（11．4％），总的结石清除率为97．1％。手术时间平均40min（30-120min）；平均住院时间7d（4～15d）。4例UPJ梗阻治疗效果良好。结论微创经皮肾取石治疗小儿复杂肾结石是安全有效的方法，但要根据结石和设备技术情况，联合ESWL成功率更高。     

微创经皮肾输尿管镜取石术治疗幼儿上尿路结石

目的 总结我们应用微创经皮肾输尿管镜取石术治疗幼儿上尿路结石的经验,并且探讨其安全性和有效性.方法 回顾性分析2006年10月到2 009年12月,我们应用微创经皮肾输尿管镜取石术治疗18例幼儿上尿路结石的患儿资料.所有手术均使用8.0/9.8F输尿管镜代替肾镜,12～16F的肾通道,X线定位下完成.结果 其中16例患儿结石完全取净,清除率为88.9%,2例患儿需要联合ESWL治疗.平均手术时间76.5 min,平均血红蛋白下降18.7 g/L.Ⅰ期处理14例,Ⅱ期处理4例.结论 微创经皮肾输尿管镜取石术治疗幼儿上尿路结石安全有效,并发症少,并且可以多次治疗.     

小儿尿路结石的腔内微创治疗

目的探讨小儿尿路结石施行腔内微创治疗的临床价值。方法对79例小儿尿路结石患儿施行腔内微创治疗。男47例，女32例。年龄0．5～14岁，平均7．9岁。肾结石18例；输尿管上段结石14例（阴性结石和多发性结石各1例），输尿管中段结石2例，输尿管下段结石10例，膀胱内型输尿管囊肿内结石1例，肾结石合并输尿管上段结石4例；膀胱结石18例；尿道结石12例（后尿道6例，前尿道6例）。结石横径0．5～2．8cm，长径0．5～1．5cm。上尿路结石中左侧24例，右侧22例，双侧3例。结果30例下尿路结石、13例输尿管中下段结石行经输尿管镜碎石术（URL），1例肾盂结石、4例输尿管上段结石行后腹腔镜肾盂输尿管切开取石术（RPPL／RPUL），31例肾、输尿管上段结石行微创经皮肾镜取石术（MPCNL），手术均获成功。术中、术后无严重不良反应发生。结论综合应用各种腔内治疗技术，小儿尿路结石可以实现现代微创治疗，并可作为一线治疗的选择。     

小儿输尿管结石体外震波碎石:十年经验

目的报告小儿结石ESWL治疗的10年经验，探讨ESWL治疗的效果和策略。方法回顾性研究67例小儿输尿管结石行ESWL治疗的结果，检测及记录患儿的代谢情况、生理解剖、结石的大小、位置以及各种并发症；其中术前置人输尿管导管52例；术后随访3～9个月。结果67例输尿管结石，首次碎石后，43例（64．2％）结石完全排空；7例（10．4％）经2次ESWL结石完全排空；2例（2．9％）经3次碎石结石完全排空；总结石完全排空率为77．6％。小于10mm结石首次碎石后的完全排空率为100％，37例大于10mm的结石患儿中，23例（62．2％）首次碎石后完全排空。上段结石的完全排空率为92．0％，而中下段结石的完全排空率仅为69．0％。其中11例输尿管中、下段结石和1例上段嵌顿结石ESWL失败者进行了输尿管镜治疗，用APL弹道碎石机击碎结石并取出；3例改行开放手术。结论ESWL是小儿输尿管结石的安全有效的治疗方法；对输尿管中、下段结石应用输尿管镜是ESWL的有效补充治疗；部分结石采用输尿管镜联合ESWL可获得较好的效果。     

输尿管软镜在小儿多发性肾结石治疗中的应用

目的 探讨输尿管软镜在小儿多发性肾结石经肾盂切开取石术治疗中的应用价值。方法 将输尿管软镜用于小儿肾多发性结石经肾盂切开取石术，术中经输尿管软镜配合气压弹道碎石，以及钳夹冲洗等方法取出结石。结果 全部一次性取尽结石。输尿管软镜对肾盂肾盏内其他病变也能起到检查及治疗作用，具有对肾脏损伤小，恢复快，并发症少等优点。结论 小儿多发性肾结石经肾盂切开并配合输尿管软镜治疗是一种安全有效的方法。     

经皮肾镜取石术治疗小儿复杂肾结石合并上尿路梗阻

目的探讨微创经皮肾镜取石术(MPCNL)治疗小儿复杂肾结石合并上尿道梗阻的疗效和临床应用价值。方法回顾性分析我们于2006年6月至2009年6月采用微创经皮肾镜取石术(MPCNL)治疗的20例小儿复杂肾结石合并上尿路梗阻患儿临床资料,其中男14例,女6例,年龄8个月至11岁,平均年龄4.5岁。结果全部患儿平均住院时间6 d,20例中,16例一期全部取净,4例行二期取净,一期结石清除率为80.0%(16/20),术中未见肾盂大穿孔或肾皮质撕裂的并发症,无一例需术中输血,所有患儿术后随访6~12个月,未见输尿管狭窄或闭锁等并发症。结论微创经皮肾镜取石术(MPCNL)治疗小儿复杂肾结石合并上尿路梗阻安全有效,值得在临床上推广。     

学龄儿童肾结石经皮肾取石术疗效评估

目的 评价经皮肾取石术(PCNL)治疗学龄儿童肾结石的疗效与安全性.方法 2006年8月至2011年8月对25例7～12岁学龄儿童肾结石患者接受经皮肾取石术治疗.X线定位穿刺,建立16F经皮肾通道,8/9.8F输尿管镜下碎石取石.结果 平均手术时间74 min.20例肾结石患儿I期PCNL取出结石,2例患儿接受Ⅱ期pCNL治疗并取净结石,结石清除率88％(22/25).无严重并发症发生.结论 对有手术指征的学龄儿童肾结石,采用经皮肾取石术治疗是安全有效的.     

经皮肾穿刺微造瘘取石术治疗儿童肾结石

目的探讨经皮肾穿刺微造瘘取石术（mini—PCNL）治疗儿童肾结石的手术技巧及临床应用价值。方法回顾性分析总结35例儿童肾结石患儿采用mini—PCNL术治疗的临床资料。结果22例I期取净结石，12例经二次取石，9例取净，另有1例经三次取石仍未取净。4例有残石者术后配合ESWL治疗，2例排净。随访2～32个月，患儿肾积水明显好转，结石无复发，7例肾盏颈部扩张者狭窄消失。1例有少许残石患儿结石体积有增大。结论mini—PCNL治疗儿童肾结石创伤小，安全、有效。结合术后ESWL治疗可以代替开放手术而成为儿童肾复杂结石、鹿角形结石以及合并肾内狭窄的首选治疗方法。     

钬激光微创治疗儿童体外冲击波碎石术后输尿管石街

目的探讨输尿管镜下钬激光（URSHolL）微创技术在处理儿童体外冲击波碎石术（ESWL）后长段石街方面的优越性。方法回顾性分析26例儿童肾、输尿管结石患儿在ESWL术后形成输尿管石街改行URSHolL治疗的临床疗效。结果全部病例除2例因输尿管狭窄改行开放手术外，其余病例均在输尿管镜下采用钬激光碎石成功，结石排净率达90％。结论肾、输尿管结石经ESWL治疗后在排石过程中由于部分结石嵌顿或粘附在输尿管黏膜表面易形成石街并发息肉，而儿童由于输尿管本身较细不易排尽结石，应尽早改行URSHolL。采用钬激光碎石术能同时处理息肉和疏通石街，在临床上是一种有效的处理儿童输尿管石街的方法。     

经皮肾穿刺碎石取石术治疗婴幼儿肾结石

目的探讨微创经皮肾穿刺碎石取石术（MPCNL）治疗婴幼儿肾结石的疗效与安全性。方法回顾性分析湖南省儿童医院2008年10月至2011年2月,应用经皮肾穿刺术钬激光治疗婴幼儿肾结石47例的临床资料。结果47例患儿50个肾脏行50次mini—PCNL治疗,其中一期碎石取石成功46个肾脏,二期碎石取石成功3个。肾脏,结石残留1例。单通道取石49个肾脏,双通道取石1个。肾脏。3例肾盂输尿管交界处狭窄（UPJO）患儿经钬激光内切开,8例息肉切除。术中通道迷失1例,经再穿刺成功。术后血红蛋白浓度平均下降2．5g／dL。2例肾功能异常者术后1—3d恢复正常。术后拔出DJ管后4周复查B超或X线平片,结石排尽率94％（47／50）,术后3个月复查,除1例结石残余外,其余均排尽。手术肾脏未见缩小,IVU检查提示8例双肾显影正常。38例肾积水患儿中,30例肾积水消失,8例由中重度肾积水转为轻度肾积水。47例术后随访2个月至1年6个月,无其他并发症。结论在明确掌握适应证和操作熟练的情况下,经皮肾穿刺碎石取石术治疗婴幼儿肾结石安全、有效,是一种较为理想的方法。     

微造瘘经皮肾镜碎石术治疗学龄前儿童上尿路结石

目的 评价微造瘘经皮肾镜碎石术在治疗学龄前儿童上尿路结石的安全性和有效性.方法 应用B超引导穿刺的微造瘘(16F)经皮肾镜碎石术治疗平均年龄46个月的学龄前患儿35例共42侧上尿路结石,其中肾结石34侧,上段输尿管结石8侧,结石平均长径(16.9±9.2)mm.结果 所有病例均I期成功建立通道并处理结石,手术时间平均为(35.4±14.9)min.手术清除率分别为92.9%,术后血红蛋白含量下降了12.7%,术后感染率5.0%,没有需要输血.毗邻脏器损伤或循环超负荷的病例.结论 微创经皮肾镜碎石术治疗学龄前儿童上尿路结石是安全、有效的.     

经皮肾微造瘘输尿管镜下钬激光碎石术治疗儿童上尿路结石

目的 探讨经皮肾微造瘘输尿管镜下钬激光碎石术治疗儿童上尿路结石的疗效与安全性.方法 上尿路结石患儿51例,平均年龄5.6岁,均为14岁以下.其中肾结石41例,结石平均大小16.8 mm（11～28 mm）,输尿管结石10例,结石平均大小11.5 mm（10～16 mm）.全部病例使用全身麻醉下经皮肾微造瘘输尿管镜下钬激光碎石术治疗.术后行超声或X线摄片观察疗效,术后随访2～20个月.结果 51例患儿中,单通道取石49例（96%）,双通道取石2例（3%）.一期取石46例（90%）,二期取石5例（9%）.结石排尽率96%（49/51）.平均手术时间85.5 min.一期取净结石者住院时间7～10 d,平均8 d.术中操作鞘脱出腹膜后渗液1例,置腹膜后引流管后渗液消失.术后发热4例（7%）;1例（2%）术后大出血予输血及超选择性肾动脉栓塞后治愈.4例残石患儿,2例二期行原窦道或再次穿刺取石取净;1例一期取石术后ESWL治疗仍有残石,1例一期取石术后出血放弃再次取石.全部病例术后半年复查彩超,49例肾积水消失,2例重度肾积水转为轻度肾积水,手术肾脏未见缩小.结论 经皮肾微造瘘输尿管镜下钬激光碎石术并发症少,净石率高,可重复取石,是治疗儿童上尿路结石安全有效的手段.     

Management of urinary calculi using endourology and extracorporeal shock wave lithotripsy (ESWL)

Childhood urolithiasis is uncommon, comprising 2% – 3% of urinary calculi. This paper presents our initial experience in the endourological (EU) treatment of 23 children with urinary calculi presenting to the Royal Childrens' Hospital. Twenty-seven renal, ureteric, and vesical calculi were treated. Three strictures were divided endoscopically synchronously with calculus removal. Twenty-three calculi were renal (6 staghorn, 3 cystine), 2 ureteric, and 2 vesical. In 12 patients (mean age 17.5 years, range 5–24), the underlying cause was a neuropathic bladder secondary to spina bifida. Ten of these had ileal conduits, 1 was successfully undiverted, and 1 previously undiagnosed (all infected). The second group of 11 patients (mean age 10.1 years, range 5–16) had normal renal anatomy. Seventeen (63%) were treated by percutaneous nephrolithotomy (PCNL) or endoscopic lithotripsy via their conduit (n = 1) or bladder (n = 2). Three (11%) underwent combined extracorporeal shock wave lithotripsy (ESWL) and PCNL and 7 (26%) were treated by ESWL alone. Twenty-one (77%) were cleared of stone by their primary procedure. Four patients with residual calculi following ESWL have a decreased volume of stone and 2 patients with staghorn calculi treated by PCNL have peripheral fragments only (1 bilateral). There was no mortality or significant morbidity except sepsis in 4 patients, which was treated medically. This series demonstrates that EU and ESWL techniques are safe and effective in children and patients with spina bifida, who often have marked scoliosis, urinary diversion, and difficulties in access. In our experience, paediatric calculi were associated with infection, metabolic disorders, urinary diversion, and patient deformities, and so the majority were more appropriately treated by endourological techniques. ESWL was effective for small stones and in combination with EU for complex stones. By using EU and ESWL alone or in combination, we have avoided open surgery in all patients with urinary calculi treated so far. Offprint requests to: H. L. Tan     

小儿后腹腔镜输尿管切开取石术及其疗效观察

目的 探讨小儿后腹腔镜输尿管切开取石术的技术要点及临床应用价值.方法 采用后腹腔镜技术行4qL输尿管切开取石术16例,其中9例分别于术前行体外冲击波碎石术(ESWL)、输尿管镜取石术(URL)或二者结合而失败,7例术前未行其他治疗;结石直径1.2～2.2 cm,平均(1.62±0.35)cm.输尿管上段结石12例,输尿管中段结石4例,右侧4例,左侧12例,男11例,女5例.年龄3～14岁,平均7岁.结果 16例患儿取石均成功.手术时间40～150 min,平均(61.31±29.51)min,术中出血量5～25 ml,平均(12.19±7.06)ml;术中无脏器损伤及气体栓塞等严重并发症.患儿均于术后1～2 d恢复饮食和下床活动.3～5 d拔引流管,1周出院,术后漏尿1例.平均随访8个月(3～36个月),患儿肾输尿管积水均明显好转,无结石复发和输尿管吻合处狭窄.结论 小儿后腹腔镜输尿管切开取石术是安全有效的方法,可部分代替传统开放性手术,对于较大的输尿管上段结石可作为首选的治疗方法.     

Minimally invasive percutaneous nephrolithotomy in preschool age children with kidney calculi (including stones induced by melamine-contaminated milk powder)

Purpose

This study was undertaken to assess the safety and efficacy of minimally invasive percutaneous nephrolithotomy (mini-PCNL) using ureteroscope and pneumatic intracorporeal lithotripsy in preschool age children with kidney calculi.

Methods

We studied 27 renal units in 20 patients of preschool age (≤6?years) who underwent mini-PCNL at our institute. The mean age was 42.6?months (range 14–68?months). The average stone burden was 1.85?cm (range 0.9–2.8?cm). Eight patients aged 14 to 58?months had been exposed to melamine-tainted powdered formula. The mini-PCNL was performed with an X-ray-guided peripheral puncture. Minimal tract dilatation was undertaken to fit a 14–16?Fr peel-away sheath. Ureteroscope and pneumatic intracorporeal lithotripsy were used to fragment the stones.

Results

Complete clearance was achieved in 23 renal units (85.2?%) with mini-PCNL monotherapy. This has increased to 92.6?% after adjunctive ESWL. The average fall in hemoglobin was 1.28?g/dL. None of the patients required blood transfusion. The median length of hospital stay was 8.2?days. Patients were followed up every 6?months for 2?years. There has been only one recurrence of stone and no long-term complications.

Conclusion

Mini-PCNL is a effective treatment for pediatric kidney stones refractory to extracorporeal shock wave lithotripsy, including stones induced by melamine-contaminated milk powder. The “mini-PCNL” technique, which uses ureteroscope and pneumatic intracorporeal lithotripsy, is a safe and feasible modality for treating renal calculi in preschool age children.     

Urolithiasis in children: surgical approach

Over the past 3 decades, minimally invasive stone surgery has completely overtaken open surgical approaches to upper tract pediatric urolithiasis. Progressing from least to most minimally invasive, extracorporeal shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy are the surgical methods of today for kidney and ureteral stones. The choice of treatment modality is individualized in children, considering patient age, stone size, number, location, and anatomic and clinical contributing factors. The purpose of this article is to review these techniques for pediatric upper urinary tract stones and summarize outcomes and complications.     

Treatment of paediatric urolithiasis by extracorporeal shock-wave lithotripsy

Non-surgical removal of renal and ureteral stones has proven successful in adults. In this study, 21 paediatric patients have been treated with the first generation extracorporeal shock-wave lithotriptor and an additional 13 children with a second generation local shock-wave lithotriptor. A total of 47 stones was treated. Treatment-related complications such as colics (17%/18.8%) or fever (8.3%/6.2%) were minimal. Stone passage occurred in 93% and 100%, respectively of each group. Open surgery is still the treatment of choice for large staghorn calculi. Extracorporeal shock-wave lithotripsy can be performed successfully in paediatric nephrolithiasis with stones of limited size.Abbreviations PNL percutaneous nephrolithotomy - ESWL extracorporeal shock-wave lithotripsy - LS local shock-wave lithotripsy     

Epidemiology of paediatric renal stone disease in the UK

Background: The previous epidemiological study of paediatric nephrolithiasis in Britain was conducted more than 30 years ago. Aims: To examine the presenting features, predisposing factors, and treatment strategies used in paediatric stones presenting to a British centre over the past five years. Methods: A total of 121 children presented with a urinary tract renal stone, to one adult and one paediatric centre, over a five year period (1997–2001). All children were reviewed in a dedicated stone clinic and had a full infective and metabolic stone investigative work up. Treatment was assessed by retrospective hospital note review. Results: A metabolic abnormality was found in 44% of children, 30% were classified as infective, and 26% idiopathic. Bilateral stones on presentation occurred in 26% of the metabolic group compared to 12% in the infective/idiopathic group (odds ratio 2.7, 95% CI 1.03 to 7.02). Coexisting urinary tract infection was common (49%) in the metabolic group. Surgically, minimally invasive techniques (lithotripsy, percutaneous nephrolithotomy, and endoscopy) were used in 68% of patients. Conclusions: There has been a shift in the epidemiology of paediatric renal stone disease in the UK over the past 30 years. Underlying metabolic causes are now the most common but can be masked by coexisting urinary tract infection. Treatment has progressed, especially surgically, with sophisticated minimally invasive techniques now employed. All children with renal stones should have a metabolic screen.