低能量体外冲击击波碎石术研究进展

复式脉冲低能量体外冲击波碎石术治疗尿路结石成功率高,复打率低,副作用少,无严重并发症。本文就低能量体外冲击波碎石术提高成功率、减轻结石周围组织损伤及预防结石再复发的研究进展作一综述。     

电磁式体外冲击波碎石的应用体会和输尿管镜碎石治疗输尿管结石的差别

目的比较电磁式体外冲击波碎石与输尿管镜碎石治疗输尿管结石的效果。方法选择我科室2015年7月至2017年10月就诊的150例输尿管结石患者,随机分为2组,体外冲击波组75例采用电磁式体外冲击波碎石术治疗,输尿管镜组75例采用输尿管镜碎石术治疗,对比两组临床疗效、结石大小、手术时间及并发症发生情况。结果体外冲击波组结石直径1 cm碎石成功率为95.24%,输尿管镜组结石直径1 cm为73.33%,差异具有统计学意义(P0.05),结石直径≥1 cm且2 cm和结石直径≥2 cm两组差异无统计学意义(P0.05),体外冲击波组总碎石成功率合计88.00%,输尿管镜组为72.00%,两组差异具有统计学意义(P0.05);体外冲击波组术后并发症发生率为9.33%,输尿管镜组为21.33%,差异具有统计学意义(P0.05)。结论电磁式体外冲击波碎石治疗对于1.0 cm的输尿管结石效果较好,且减少并发症发生。     

Changes in resistive index following extracorporeal shock wave lithotripsy

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) has replaced most surgical and endourologic forms of therapy for upper urinary tract stone disease. Despite its proved safety and efficacy, its adverse effects on renal function are still to be identified. A newer diagnostic technique, color Doppler ultrasonography, has brought a new insight into renal function. It enables precise evaluation of the renal vascular supply. Changes in intrarenal vascular resistance after ESWL were studied with Doppler ultrasound techniques. METHODS: In 70 consecutive patients the resistive index (RI) was measured at an interlober artery before and 30 min after ESWL in the treated and contralateral kidneys. In 17 patients, a follow-up Doppler study was performed 1 week after ESWL. RESULTS: In the treated kidneys, the RI significantly increased from 0.656+/-0.053 (mean +/- SD) at baseline to 0.682+/-0.053 (P<0.0001). There was no significant correlation of increase in RI with patient age (r = 0.010) or with pre-ESWL blood pressure (r = 0.002). Elderly patients (> or =60 years old, n = 31) had higher RI levels on baseline than younger patients (<60 years old, n = 39). In 18 of the 31 (58.1%) elderly cases the RI were elevated to greater than 0.7, indicating pathologic changes. In younger patients, only 9 (23.1%) experienced increase in RI up to 0.7 or greater. The contralateral untreated kidneys showed significant change in RI before (0.664+/-0.045) and after (0.679+/-0.049) lithotripsy in elderly patients (P<0.005). A follow-up Doppler study showed that the mean RI returned to pretreatment levels after 1 week. CONCLUSIONS: Because of higher RI levels on baseline, elderly patients have a higher risk of post-ESWL renal tissue damage than younger patients. Clinical implication of RI change in the contralateral kidneys in this study remains to be answered. The measurement of changes in RI with Doppler ultrasound techniques after ESWL may provide useful information for clinical diagnosis of renal tissue damage.     

坦索罗辛预防肾结石ESWL术后并发症的临床研究

目的探讨坦索罗辛对肾结石体外冲击波碎石（ESWL）术后排石的疗效及对并发症的预防作用。方法120例单纯肾结石行ESWL术患者，结石直径8—22mm，随机分成2组，坦索罗辛组60例，给予氟罗沙星、排石冲剂及坦索罗辛（哈乐），对照组60例，给予氟罗沙星、排石冲剂，治疗时间4周，比较2组之间结石排净率、石街的形成、疼痛评分（VAS）、膀胱刺激症状。结果坦索罗辛组的结石排净率（88．3％）高于对照组（71．7％）（P=0．022），坦索罗辛组石街形成率（6．7％）低于对照组（16．7％）（P=0．040），坦索罗辛组疼痛VAS评分[2（0-7）分]低于对照组[4（0-8）分（P〈0．01）]，坦索罗辛组膀胱刺激症状发生率（10％）低于对照组（21．7％）（P=0．024）。治疗期间2组未出现药物不良反应。结论ESWL术后坦索罗辛能够促进ESWL术后结石排出，预防石街形成，缓解疼痛及膀胱刺激症状，可以作为肾结石ESWL术后排石的辅助用药。     

影响体外冲击波碎石术疗效的因素分析

目的　探讨影响体外冲击波碎石术(ESWL)疗效的因素。　方法　回顾ESWL治疗尿路结石患者234例的临床资料。分析患者性别、年龄、病程、结石大小、位置、X线形态及合并肾积水情况等因素与治疗成功率的关系。ESWL术后3个月接受KUB、IVU和B超检查,剩余结石<2mm为碎石成功, >2mm为治疗不成功。　结果　234例碎石成功率78. 6% (184 /234)。男性组和女性组治疗成功率分别为80. 3% (122 /152)和75. 6% (62 /82),P>0. 05。治疗不成功组与成功组病程分别为(1262. 6±1742. 1)d、(722. 9±1364. 6)d,P>0. 05;结石直径分别为(1. 1±0. 6)cm、(1. 0±0. 4)cm,P>0. 05;年龄分别为(58. 8±13. 6)岁、(42. 8±12. 2)岁,P<0. 05。肾盂结石(22. 7%, 10 /44)与肾盏结石(40. 0%, 8 /20),肾盂结石与输尿管结石( 18. 8%, 32 /170 ),输尿管上段结石( 15. 8%, 18 /114)与下段结石(25. 0%, 14 /56)间不成功率比较,差异无统计学意义(P>0. 05)。均匀高密度结石(20. 0%, 6 /30)与杂色结石(21. 6%, 44 /204)不成功率两组比较差异无统计学意义(P>0. 05)。结石直径0. 3~1. 0cm者(1. 9%, 2 /108), 1. 0 ~2. 0cm者(29. 8%, 28 /94), >2. 0cm者(62. 5%, 20 /32)不成功率3组两两比较P<0. 05。结石大小与治疗剂量呈正相关(r=0.28,P=0. 006)。     

体外冲击波碎石治疗单发输尿管结石及疗效预测

目的探讨体外冲击波碎石术（ESWL）治疗输尿管结石疗效的影响因素,并建立预测模型。方法2008年1月至2011年2月接受ESWL治疗的输尿管结石患者1116例,随访3个月。用X^2检验或t检验、秩和检验进行单因素分析来研究患者性别、年龄、身高、体重、病程、临床症状和结石特征等因素与疗效的关系,多因素分析采用Logistic逐步回归分析（Forward：LR法）,建立Logistic回归预测模型。结果ESWL单次治疗输尿管结石成功率84．3％（941／1116）。单因素分析发现结石部位、结石长短径及肾绞痛对疗效均有影响。Logistic回归分析则显示结石部位、结石长短径及肾绞痛决定治疗的成功率,预测模型对碎石成功率的解释力良好（X^2=117．434,P〈0．001）,并通过拟合优度检验（X^2=5．261,P=0．729）,预测总体准确率为83．8％。结论结石部位、结石长短径及肾绞痛是ESWL治疗输尿管结石成功率的重要决定因素。     

Anaesthesia for extracorporeal shock wave lithotripsy

The anaesthetic considerations of patients presenting for extracorporeal shock wave lithotripsy are described. Regional anaesthesia with sedation may be preferable to general anaesthesia for patients undergoing this form of therapy. If regional anaesthesia is contra-indicated, general anaesthesia using controlled ventilation with muscle relaxation, supplemented with a narcotic and a low concentration of volatile anaesthetic has been found to be a suitable alternative. The additional epidural preparation time has to be balanced against the benefits of easier patient transfer, especially during multi-stage procedures, and better postoperative analgesia. The epidural catheter can be left in situ in patients who require multiple treatments or who may experience severe ureteric pain as the resulting 'sand mass' is passed. Epidural space localisation using a 'loss of resistance to saline' technique is recommended, in order to avoid the possible risk of damage to the spinal cord and emerging nerves (due to the presence of an air-water interface). Patients with cardiac insufficiency need special consideration, in view of the effects of immersion on right and left heart filling pressures.     

Extracorporeal shock wave lithotripsy for lower pole calculi: Our experience

INTRODUCTION: This study was performed in order to evaluate the immediate and long-term outcome of patients undergoing extracorporeal shock wave lithotripsy (ESWL) for isolated lower pole calculi. METHODS: Three hundred and seventy renal units of 350 patients (240 men and 110 women; mean age 55 years) with isolated lower pole renal stones of smaller than 2 cm2 were studied. Follow up ranged from 1 to 52 months (mean, 15 months) to time of censorship, significant period of secondary urologic evaluation. RESULTS: Out of 370 renal units in 350 patients, 212 (57, 29%) were stone-free 1 month after ESWL and 21 (5.67%) spontaneously became stone-free within another 1-52 months (mean, 15 months). Intervention was required after 1-52 months (mean, 17.5 months) and accomplished by ESWL alone (30/350 patients 8.57%) or combined with retrograde endoscopy (10/350 patients 2.85%) while retrograde manipulation was necessary in two of the 350 patients (0.57%). CONCLUSION: Extracorporeal shock wave lithotripsy is the initial treatment of choice in patients with lower pole stones < 2 cm2, because the overall stone-free rate is acceptable and because even in the residual calculi, the risk of suffering symptomatic episodes requiring secondary intervention is low.     

Acute pancreatitis caused by extracorporeal shock wave lithotripsy for bilateral renal pelvic calculi

An elderly woman with a history of cholecystectomy and a re-operation for postoperative peritonitis underwent extracorporeal shock wave lithotripsy (ESWL) for right and left renal pelvic calculi, 11 x 6 and 12 x 5 mm in size, to which 2400 and 1400 shots at 20 kV were given, respectively, on the same day. During the evening after the operation, the patient started to complain of upper abdominal pain. Laboratory examination on the next day revealed elevations in blood and urine amylase levels and a diagnosis of pancreatitis was made. Conservative treatment, including administration of protease inhibitor, did not improve her symptoms; abdominal distension became marked and she underwent laparotomy. Necrosection and indwelling of several drain tubes in abdomen were performed with an operative diagnosis of acute necrotic pancreatitis. With daily irrigation of drain tubes and treatment for methicillin-resistant Staphyloococcus aureus infection of the lungs and abdominal cavity, septicemia and duodenal fistula, the patient gradually recovered and was discharged on postoperative day 151. It was suggested that ESWL was responsible for the acute pancreatitis. Either an obstruction of the pancreatic duct by fragments of common duct stone, or mechanical injury of the pancreas due to adhesion between the pancreas and surrounding tissue caused by the lapalotomy, was considered as a possible cause of pancreatitis. To our knowledge, there has been no previous report of severe acute pancreatitis and the present case suggests that ESWL may cause severe pancreatic even in cases without stone shadow in the bile, common duct or pancreatic duct.     

Chronic kidney disease affects the stone‐free rate after extracorporeal shock wave lithotripsy for proximal ureteric stones

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To investigate the effect of renal function on the stone‐free rate (SFR) of proximal ureteric stones (PUS) after extracorporeal shock wave lithotripsy (ESWL), as urinary obstruction caused by PUS can impair renal function, and elevated serum creatinine levels are associated with decreased ureteric stone passage.

PATIENTS AND METHODS

From January 2005 to December 2007, 1534 patients had ESWL for urolithiasis, 319 having ESWL in situ for PUS; they were reviewed retrospectively. Patients requiring simultaneous treatment of kidney stones, placement of a double pigtail stent, or percutaneous pigtail nephrostomy tube were excluded. We divided patients into groups by chronic kidney disease (CKD) stage according to the estimated glomerular filtration rate (eGFR) of ≥60 and <60 mL/min/1.73 m². Stone‐free status was defined as no visible stone fragments on a plain abdominal film at 3 months after ESWL. A logistic regression model was used to evaluate the possible significant factors that influenced the SFR of PUS after ESWL, and to develop a prediction model.

RESULTS

The overall SFR of PUS (276/319 patients) was 86.5%; the SFR was 93% in patients with an eGFR of ≥60 and 50% in those with an eGFR of <60 (P < 0.001). After univariate and multivariate analysis, the three significant factors affecting SFR were an eGFR of ≥60, stone width, and gender, with odds ratios (95% confidence intervals) of 19.54 (8.25–46.30) (P < 0.001), 0.67 (0.55–0.82) (P < 0.001) and 0.16 (0.05–0.50 (P = 0.002), respectively. A logistic regression model was developed to estimate the probability of SFR after ESWL, the equation being 1/(1 + exp [?(3.8137 ? 0.3967 × (stone width) + 2.9724 × eGFR ? 1.8120 × Male)]), where stone width is the observed value (mm), eGFR = 1 for eGFR ≥60 and 0 for <60, and male = 1 for male, 0 for female.

CONCLUSIONS

Gender, eGFR ≥60 and a stone width of >7 mm were significant predictors affecting the SFR after one session of ESWL for PUS.     

钬激光碎石术与体外冲击波碎石术治疗输尿管结石的疗效比较

目的　比较输尿管镜钬激光碎石术与体外冲击波碎石术 (ESWL)治疗输尿管结石的有效性和安全性。　方法　采用输尿管镜钬激光碎石术治疗输尿管结石 15 9例 16 8侧 ,其中结石直径≥ 1cm者 76侧 ,<1cm者 92侧。ESWL治疗输尿管结石 319例 334侧 ,其中结石直径≥ 1cm者 14 3侧 ,<1cm者 191侧。比较两组手术时间 结石排净率 手术并发症发生率指标的差异。　结果　对直径≥ 1cm和 <1cm的输尿管结石钬激光碎石术治疗平均手术时间分别为 5 8min和 4 3min ,短于ESWL的平均手术时间 6 8min和 5 6min(P <0 .0 1) ;钬激光碎石术对直径≥ 1cm的输尿管结石 3个月结石排净率为 92 % ,高于ESWL的 6 1% (P <0 .0 1) ;对直径 <1cm的输尿管结石钬激光碎石术和ESWL的 3个月结石排净率分别为 95 %和 85 % (P >0 .0 5 )。钬激光碎石术组并发症发生率为 4 .8%( 8/ 16 8) ,ESWL组无明显并发症发生。　结论　输尿管镜钬激光碎石术治疗直径≥ 1cm的输尿管结石疗效明显优于ESWL ,而直径 <1cm的结石二者疗效差异无显著性 ,ESWL为直径 <1cm结石的首选治疗方法     

Fate of residual fragments after successful extracorporeal shock wave lithotripsy

PURPOSE: The aim of the present study was to investigate the reason residual fragments from upper urinary tract calculi failed to clear after successful extracorporeal shock wave lithotripsy (ESWL). METHODS: Risk factors were analyzed in 161 patients with residual fragments (< or = 4 mm) that had remained for more than 3 months after ESWL. The factors examined in the present study were gender, a history of urolithiasis, the number, location and size of stones, hydronephrosis 3 months after ESWL and bacteriuria before ESWL. The mean follow-up period was 20.0 months (range 6-69 months). RESULTS: The overall stone-free rate was 14.3%. The stone-free rate in patients with multiple stones or hydronephrosis 3 months after ESWL was significantly lower than that in patients without these conditions (P < 0.05 and P < 0.01, respectively). The cumulative non-clearance rate in patients with hydronephrosis was significantly higher than in patients without this condition (P < 0.05). Results of Cox's proportional hazards model indicated that hydronephrosis was the most important and only significant factor for failure to clear of the seven factors investigated (P < 0.05). CONCLUSION: Hydronephrosis was most highly correlated with the fate of residual fragments after ESWL.     

In situ extracorporeal shock wave lithotripsy with Booster technique in the treatment of ureteral stones

Summary After treatment of more than 3000 kidney and ureteral stones with the Siemens Lithostar Multiline the results of the first 1400 ureteral stone treatments using the “Booster technique” and 3-month follow-up findings are reported. There was a disintegration rate of 98 % directly after treatment; 1 week after “Booster technique” treatment 96 % of the patients were free of stones and without any symptoms. The 3-month follow-up showed a stone-free rate of 97 %. Only in 13 % of the cases auxiliary procedures were neccessary, 7 % of them before extracorporeal shock wave lithotripsy (ESWL) and 6 % after ESWL. 43 % of the treatments were performed without any premedication, anaesthesia or sedoanalgesia. Our data even prove that in situ ESWL is a safe and effective method for the treatment of ureteral stones. In comparison to endoscopic procedures, it is superior in regard to invasivity, side effects, complications and neccessity of analgesia, while being just as efficient. Therefore it is recommended as first choice method in the treatment of ureteral stones.      

输尿管结石行体外冲击波碎石治疗后发生输尿管狭窄的危险因素分析

目的探讨输尿管结石经体外冲击波碎石治疗后发生狭窄的危险因素。方法收集2006年7月至2011年7月就诊于我院首次行体外冲击波碎石治疗的输尿管结石患者的临床资料,先对所取临床指标进行单因素分析,然后进行Logistic多因素回归分析。结果共收集行体外冲击波碎石的输尿管结石患者174例,其中发生术后输尿管狭窄的患者15例,狭窄发生率为8.62%,单因素分析显示:结石长径、肾积水程度、结石嵌顿时间以及碎石次数与术后输尿管狭窄发生相关,多因素Logistic回归分析结果显示:结石长径、肾积水程度以及碎石次数是患者发生输尿管狭窄的独立危险因素。结论对于肾积水程度较重、结石长径较大、预期碎石次数较多的输尿管结石患者,行体外冲击波碎石后发生狭窄的可能性相对较高,在治疗选择上应更加慎重,提倡选择体外冲击波碎石之外更加安全有效的治疗方式。     

Complicating risk factors for pyelonephritis after extracorporeal shock wave lithotripsy

PURPOSE: The score to predict the risk of post-extracorporeal shock wave lithotripsy (ESWL) pyelonephritis was evaluated. The score was based on the multivariate analysis of risk factors available pre-operatively. Stone size, pyuria, bacteriuria, previous pyelonephritis and other adjunctive procedures had been selected and scored. METHODS: Three-hundred and forty-eight adult patients without active urinary infection undergoing ESWL therapy were studied. One of three regimens were selected by either doctor or patient: (i) no antimicrobial treatment; (ii) one dose of levofloxacin; or (iii) 1 week course of levofloxacin. Who and why selected it were described. Post-ESWL fever over 38 degrees C was defined as the unfavorable event. RESULTS/CONCLUSION: With increasing score, doctors recommend taking an antimicrobial. There were 11 bacteriuric patients and post-ESWL pyelonephritis developed in one of them. Bacteria within the stone and post-ESWL ureteral obstruction caused by the stone fragments were considered to be important in developing pyelonephritis. However, multiple factors were related with it. Although their decision was not based simply on the score, the score was confirmed to be useful in identifying the high-risk patients and, therefore, to implement cost-effective antimicrobial use.     

Acute necrotizing pancreatitis as a rare complication of extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is considered the standard treatment for most renal and upper ureteral stones. Some centers use ESWL to treat bile duct stones and pancreatic calculi. Although ESWL is generally considered safe and effective, major complications, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, rupture of an aortic aneurysm and intracranial hemorrhage, have been reported to occur in less than 1% of patients. Here, we present an extremely rare case of acute necrotizing pancreatitis occurring after ESWL for a right-sided urinary stone, which was treated by non-operative percutaneous interventions.     

坦索罗辛在输尿管下段结石ESWL后辅助排石中的作用

目的:探讨α1肾上腺素能受体阻滞剂坦索罗辛在输尿管下段结石ESWL后辅助排石中的效果.方法:64例输尿管下段结石患者随机分成两组,组Ⅰ为对照组,ESWL后应用消炎痛25 mg,3次/d,排石颗粒5 g,3次/d,未应用输尿管平滑肌松弛剂;组Ⅱ为实验组,ESWL后在对照组治疗方案基础上予以口服坦索罗辛0.4mg,1次/d.每例患者观察时间不超过2周.结果:在观察时间内两组排石率分别为42.3%和78.9%.两组比较差异有统计学意义(P＜0.01).观察时间内两组再次发生肾绞痛而需要镇痛药治疗的患者分别为15.4%和7.9%,两组比较差异有统计学意义(P＜0.01).组Ⅱ除1例发生头晕外,无其他不良反应发生.结论:坦索罗辛能提高输尿管下段结石ESWL后的排石率,减少再发生肾绞痛的机率.且安全有效.可作为输尿管下段结石ES-WL后的辅助排石方法.     

肾结石ESWL后肾脏血肿的原因分析

目的:探讨肾结石ESWL后肾脏血肿的原因。方法:对2008年5月~2012年6月5例肾结石ESWL后肾脏血肿的临床资料进行分析并文献复习。结果:采用上海交通大学JDPN-ⅤB型液电式碎石机治疗后引起肾脏血肿3例,深圳惠康HK.ESWL-109型电磁式碎石机治疗引起2例。体型肥胖并高血压2例(其中1例糖尿病)。2例因输尿管结石梗阻感染行输尿管镜取石术后行同侧肾结石ESWL后出现肾脏血肿,2例行一侧输尿管结石ESWL后行对侧肾结石ESWL后出现肾脏血肿,1例右输尿管上段结石ESWL后部分结石上移肾内行肾结石ESWL后出现肾脏血肿。4例保守治疗痊愈(肾包膜下血肿2例,肾包膜破裂肾周血肿2例);1例肾周大血肿腹膜后扩散,输血3 500ml,行高选择性肾动脉分支栓塞治愈。结论:ESWL并非绝对安全、没有重大并发症,只有掌握合适的适应证才安全可靠,在治疗前后需要仔细观察和评估。导致肾脏血肿的易患因素有凝血功能异常、抗凝药物的使用、糖尿病、高血压、老年患者、心脏病、肥胖等因素。高低能量冲击波的交替使用,有助于提高碎石的成功率及安全性。绝大多数患者可以通过保守治疗治愈,少数需要肾动脉栓塞治疗,个别严重患者需要肾切除来挽救生命。     

The efficacy of extracorporeal shock wave lithotripsy on single dense calcified gallstones according to computed tomography

The efficacy and complications of extracorporeal shock wave lithotripsy (ESWL) for single gallstones were compared between 15 patients with a CT-lucent stone and 18 patients with a dense calcified stone. In all of five patients with a stone smaller than 10 mm in diameter, complete or sufficient clearance was observed, regardless of calcification. However, in 28 patients with a stone larger than 11 mm in diameter, the rates of complete or sufficient clearance were lower in those with a dense calcified stone (64%) than in those with a computed tomography (CT) lucent stone (93%). There was no difference in the rate of complications between patients with a CT-lucent stone and those with a dense calcified stone. These results thus suggest that extracorporeal shock wave lithotripsy may be safely employed for patients with a single calcified gallstone.     

ESWL治疗儿童尿路结石的临床效果和远期随访(附54例报告)

为探讨体外冲击波碎石术（ESWL）治疗儿童尿路结石的远期效果，采用ESWL治疗儿童尿路结石54例，成功率为96．3％，术后无严重并发症。并对其中16例患儿进行了24～91个月（平均56．5个月）的远期随访，结果尿常规、尿素氮、肾功能及形态均正常，仅14．3％的患儿有结石复发，另外2例未排净的残石中有1例再生。由此表明，ESWL对患儿的血压远期影响不大，亦不影响患儿的肾脏功能及其生长发育。