Urolithiasis associated with protease inhibitors.

OBJECTIVE: We evaluated the radiographic characteristics as well as the clinical management of urolithiasis induced by systemic therapy with indinavir sulfate, a protease inhibitor utilized in the treatment of HIV infection. PATIENTS AND METHODS: Fifteen consecutive HIV-positive male patients (average age 41.3 years) who presented with urolithiasis while being treated with indinavir sulfate (average time 11.1 months) were studied. RESULTS: All patients presented with flank pain, and eight had gross hematuria. All but one patient had microscopic hematuria. The location of the stones was the kidney in three, the proximal ureter in four, and the distal ureter in nine. One patient had both a renal and a proximal ureteral stone. The stones were radiolucent on CT imaging in five patients and could not be seen in five. In the five cases in which a stone was not definitely identified, a diagnosis of urolithiasis was established on the basis of ureteral obstruction and periureteral/renal streaking noted on CT. Treatment included observation with hydration in eight patients, ureteral stent placement in two patients, ureteroscopy in three patients, and extracorporeal shockwave lithotripsy in two patients. Stones were analyzed in five patients and proved to be 100% indinavir in three and a mixture of indinavir, calcium oxalate monohydrate, and calcium oxalate dihydrate in two. CONCLUSIONS: Urolithiasis is a recognized complication of treatment with indinavir sulfate. Pure indinavir stones cannot be seen on CT unless intravenous contrast medium is utilized. Mixed calcium and indinavir stones can occur and may be radiopaque. The majority of HIV-positive patients with symptomatic urolithiasis can be treated conservatively with hydration. Metabolic evaluation of these patients with identification and correction of factors predisposing to stone formation may minimize future recurrences. Administration of this effective medication thus can continue uninterrupted.     

Frequency of urolithiasis in individuals seropositive for human immunodeficiency virus treated with indinavir is higher than previously assumed

PURPOSE: Indinavir was approved by the Food and Drug Administration in 1996 as a human immunodeficiency type 1 protease inhibitor to treat human immunodeficiency virus infection. Prompted by the high number of patients receiving indinavir who present with renal colic at our institution, we performed a detailed investigation of the true frequency of urolithiasis during indinavir treatment. MATERIALS AND METHODS: We evaluated 105 patients with a mean age of 38.1 years who were treated with indinavir from 1996 to 1997. Before indinavir treatment was initiated all patients underwent renal ultrasonography, urinalysis, and determination of serum sodium, potassium, calcium, uric acid and creatinine. It was recommended that all patients drink 2 l of fluids daily, and all remained under continuous surveillance. RESULTS: Metabolic evaluation and ultrasonography showed no abnormality in any case. A stone episode occurred in 13 men (12.4%) as renal colic during observation. Colic recurred in 1 patient after 2 and 5 months, and in 1 after 2 months. Median duration of indinavir treatment until an acute stone episode was 21.5 weeks (range 6 to 50). A total of 12 stones passed spontaneously. Three patients underwent ureteroscopic calculous removal and 1 was treated with extracorporeal shock wave lithotripsy. CONCLUSIONS: Despite adequate patient information and compliance the rate of nephrolithiasis during indinavir therapy was 12.4%.     

Imaging characteristics of indinavir calculi

PURPOSE: Indinavir sulfate is an effective protease inhibitor of the human immunodeficiency virus type 1. Use is associated with a significant incidence of crystallization and stone formation in the urinary tract, and these calculi are not visible on plain radiographs. Previously all urinary stones, including uric acid and matrix, were believed to be radiodense on computerized tomography (CT). We conducted a retrospective study to evaluate the radiographic appearance of indinavir calculi. MATERIALS AND METHODS: Retrospective chart review of 36 patients taking indinavir sulfate and presenting with renal colic was performed with attention to presentation, urinalysis, radiographic evaluation and management. Specifically, imaging characteristics on CT were addressed. RESULTS: All patients complained of ipsilateral flank pain and 35 had nausea and/or vomiting. Of 30 patients with dysuria or urgency the majority had hematuria, and most had pyuria and/or proteinuria. No stones were visualized on abdominal radiography. Diagnosis was confirmed on 1 of 13 excretory urograms and 4 of 11 renal ultrasounds. None of 12 CT scans was diagnostic of renal lithiasis. CONCLUSIONS: Indinavir sulfate is a protease inhibitor with poor solubility and significant urinary excretion. Crystallization and stone formation are demonstrated in as many as 20% of patients taking the medication. Most patients present with flank pain, nausea or vomiting and hematuria. Previously CT was thought to identify all urinary calculi with clarity but it cannot reliably confirm the presence of indinavir calculi.     

Piezoelectric lithotripsy of radiopaque gallstones: results and six-month follow-up

Sixty-eight patients with radiopaque gallbladder stones (38 with a single stone, 30 with multiple stones) were treated with piezoelectric extracorporeal shock wave lithotripsy (ESWL) and results were compared with those of 69 patients with radiolucent stones (28 with a single stone, 41 with multiple stones). Stones were fragmented to 4 mm or less in 76.8% after 41,466 +/- 36,504 shock waves in the radiolucent stone group and 77.9% after 54,686 +/- 51,024 shock waves in the radiopaque stone group (p = 0.876 and 0.130, respectively). In 137 patients, ten patients were lost to follow-up. Average period of follow-up was 220 +/- 198 days. Six-month clearance rate of the radiolucent stone group was 43.5% and that of the radiopaque stone group was 16.4% (p less than 0.05) Figure 1. Six-month clearance rate of patients with single stones smaller than 2 cm was also significantly higher in the radiolucent stone group than in the radiopaque stone group (69.5% vs 18.6%; p less than 0.01). However, in patients with multiple stones, the presence of calcification did not affect rates of successful fragmentation or 6-month clearance. There was no statistically significant difference in incidence of complications between the radiolucent and radiopaque stone groups. Although the number of cases are small and the follow-up period is short, our results of ESWL on radiopaque gallstones are so far not satisfactory in terms of stone clearance. Strict patient selection is needed unless there is an improvement in the lithotripsy procedure or post-lithotripsy management.     

影响第二次冲击波碎石术治疗上尿路结石患者成功的因素分析

目的 探讨影响第二次冲击波碎石术（extracorporeal shock wave lithotripsy, ESWL）治疗上尿路结石患者成功的因素。方法 回顾性分析2008年1月至2012年12月来本院接受第二次ESWL治疗的上尿路结石患者120例。根据患者上尿路结石有无完全排出分为成功组（n=80）和失败组（n=40）。回顾性分析所有患者的病历资料,相关因素分析包括性别、年龄、病程、BMI、结石侧别、结石位置、结石长度、结石宽度、结石数目、肾绞痛、血尿、肾积水程度、非增强螺旋CT值、冲击次数、冲击能量等指标。应用单因素、多因素非条件Logistic回归分析上尿路结石患者第二次ESWL治疗成功与否的危险因素分析。结果 120例上尿路结石患者临床特征显示,两组在病程、BMI、结石长度、结石宽度、结石数量、肾绞痛、肾积水程度、CT值、冲击次数方面差异有统计学意义（P＜0.05）,在性别、年龄、结石侧别、结石位置、血尿、冲击能量方面差异无统计学意义（P＞0.05）。经单因素、多因素 Logistic 回归分析结果显示,BMI偏高、结石长度＞2 cm、存在肾绞痛、肾积水程度严重、CT值＞750 HU会增加上尿路结石患者第二次ESWL治疗失败的风险（P＜0.05）。结论 临床医师利用ESWL第二次治疗上尿路结石患者过程中,应格外注意患者BMI、结石长度、肾绞痛、肾积水程度、CT值等关键指标。     

Extracorporeal shock wave lithotripsy in children

PURPOSE: We analyzed the efficacy of extracorporeal shock wave lithotripsy in children. MATERIALS AND METHODS: Between 1987 and 2000, 15,423 patients with urinary calculi were treated at our institution, of whom 86 (0.56%) children 3 to 14 years old underwent lithotripsy using the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, New Jersey). A total of 121 calculi in 90 urinary tracts were treated requiring 149 extracorporeal shock wave lithotripsy sessions. The stones were caliceal in 62 cases, renal pelvic in 35, ureteral in 18 and staghorn in 6. Followup consisted of nephrotomogram or ultrasound 1 day and 1 to 3 months postoperatively. RESULTS: Complete removal of all stone fragments was achieved in 97.6% of the stones after 3 months. Re-treatment was necessary in 24 patients (27.9%). All patients were treated as outpatients with intravenous sedation in 54 (62.8%), general anesthesia in 13 (15.1%) and no anesthesia in 19 (22.1%). Complications were present in 8 patients (10.7%) who had colic and received medical treatment followed by uneventful recovery. CONCLUSIONS: Extracorporeal shock wave lithotripsy using the Lithostar Plus has been demonstrated to be an effective noninvasive procedure to treat radiopaque and even radiolucent or slightly opaque urinary calculi in children.     

The etiology of urolithiasis in HIV infected patients

PURPOSE: It is commonly thought that urinary lithiasis in HIV infected patients on protease inhibitor therapy is composed primarily of the protease inhibitor itself. Since many HIV infected patients on protease inhibitors presenting to our institution had nonprotease inhibitor stones, we investigated potential underlying metabolic abnormalities that may account for the lithogenesis. MATERIALS AND METHODS: We retrospectively reviewed all HIV infected patients on protease inhibitors with renal colic and evidence of nephrolithiasis who presented to our institution between June 1996 and January 2001. Patients were evaluated for stone composition and metabolic abnormalities of blood and urine when possible. RESULTS: A total of 24 patients were identified, and all were or had been on protease inhibitors (indinavir 14, ritonavir 3, nelfnavir 2, unspecified 5). Of the 14 patients on indinavir only 4 (28.6%) had indinavir containing stones. The remaining stones in this group and in those not on indinavir contained various amounts of calcium oxalate monohydrate and dihydrate, ammonium acid urate and uric acid. Of 10 patients who underwent 24-hour urine collection for metabolic evaluation 8 (80%) had abnormalities, including hypocitraturia in 5, hyperoxaluria in 4, hypomagnesuria in 4, hypercalciuria in 3, increased supersaturation of calcium oxalate in 3 and hyperuricosuria in 2. Abnormalities in the levels of urinary phosphate and sodium were also observed. CONCLUSIONS: HIV infected patients form many types of stones, which probably are attributable to underlying metabolic abnormalities rather than the use of protease inhibitors. A complete metabolic evaluation is warranted in these patients, as a means of guiding treatment to prevent future stone episodes, while avoiding the need to alter antiretroviral regimens.     

妊娠期顽固性肾绞痛的腔内处理

目的探讨腔内诊治妊娠期肾积水合并顽固性肾绞痛的安全性和有效性。 方法回顾性分析2017年3月至2018年9月我院收治的78例妊娠期肾积水合并顽固性肾绞痛患者的病例资料。根据顽固性肾绞痛持续时间将患者分为A组（6 h以内16例）,B组（6～12 h 53例）和C组（12 h以上9例）。 结果58例术中发现输尿管结石,16例（27.6%）术前彩超未见输尿管结石,行输尿管镜碎石取石和留置输尿管双J管。输尿管结石清除率87.9%（51/58）。20例未发现输尿管结石但合并肾盂结石患者,术中留置输尿管双J管。9例（11.5%）有先兆流产表现,其中A组1例（6.25%）,B组4例（7.55%）,C组4例（44.4%）。C组先兆流产的发生率高于A和B组（P<0.05）。1例（6.25%）患者出现尿源性脓毒血症,抗感染等对症处理后痊愈。所有患者均成功通过围产期并生产健康婴儿。 结论对于妊娠期肾积水合并顽固性肾绞痛的患者,早期输尿管镜腔内处理是有效安全的诊断和治疗手段,可降低孕妇和胎儿的风险。     

Renal scintigraphy in initial evaluation of renal colic.

To determine the role of renal scintigraphy (RS) in patients with suspected acute urinary tract obstruction, a prospective study was performed comparing RS with emergency intravenous excretory urography (IVU) in 36 examinations. Thirty patients were diagnosed as having renal colic: 28 had dilation of the urinary tracts with (89%) or without (11%) visualized stone; 2 patients with stones did not have stasis at the IVU. An abnormal RS was found in 28 patients with abnormal IVU, while it was normal in the 2 nonobstructed patients (sensitivity = 93%). The radiopaque stones in these 2 patients were seen on plain x-ray film of the abdomen. The results of this study support the use of RS combined with a plain film of the abdomen in the initial evaluation of renal colic.     

Emergency extracorporeal shockwave lithotripsy for acute renal colic caused by upper urinary-tract stones

PURPOSE: To evaluate emergency SWL for the treatment of upper urinary-tract stones causing renal colic. PATIENTS AND METHODS: Between January 1999 and June 2003, 53 patients with a mean age of 46.6 years (range 22-65 years) were enrolled. The inclusion criteria were acute renal colic, radiopaque 5-mm to 1.5-cm calculi in the ureteropelvic junction (N=10) or upper ureter (N=43), and no evidence of urinary-tract infection or acute renal failure. The mean stone size was 7.14 mm (range 5-13 mm). Patients were randomly assigned to the control (N=28) and study (N=25) groups using previously prepared cards in envelopes. Patients in the study group underwent emergency SWL, while patients in the control group underwent scheduled SWL within 30 days. Stone status was evaluated 4 weeks after lithotripsy. There was no significant difference between the control and study groups with respect to age, sex, stone location or volume, renal obstruction, or days spent in the hospital for pain control. Available fragments of stones were sent for infrared spectroscopy. Preoperative and postoperative data were compared in the two groups using SPSS 10.0 statistical software. RESULTS: The SWL treatment lasted 50+/-11 minutes. The stone-free rates were 72% and 64% and the efficiency quotients were 53% and 44% in study and control groups, respectively. Patients in the control group spent more time in the hospital (P=0.014) and in recovery at home (P=0.011). CONCLUSION: Emergency SWL for acute renal colic caused by upper-ureteral stones is a safe procedure and offers effective release from pain and obstruction. It also decreases hospitalization days and hastens return to normal activity.     

Antegrade pyelography versus unenhanced multidetector CT in the assessment of urinary-tract stones after percutaneous nephrostomy insertion: a prospective blinded study

BACKGROUND AND PURPOSE: In patients with a percutaneous nephrostomy tube (PCN) inserted for symptomatic stone disease, antegrade pyelography is an accepted modality to assess the collecting system and residual stone status prior to PCN removal. Recently, unenhanced multidetector CT (UMDCT) has shown its superiority for the assessment of urinary-tract stones. Comparison of UMDCT with antegrade pyelography has never been done; hence, our aim was to compare the two methods for the assessment of urinary stones in patients with a PCN. PATIENTS AND METHODS: Between July 2004 and July 2005, we prospectively imaged 49 consecutive patients with known urinary-tract stone disease who had PCN (27 men and 22 women; average age 57 +/- 20 years; range 4-88 years). All patients underwent UMDCT and antegrade pyelography within 24 hours. Both examinations were prospectively and blindly evaluated by two attending radiologists for the presence, location, and size of urinary-tract stones. RESULTS: According to the findings of both imaging modalities, 18 patients were stone free, and 31 patients had urinary stones. In 20 of the latter 31 patients (64.5%), the urinary stones were diagnosed only by UMDCT. Antegrade pyelography missed renal as well as ureteral stones, with a significant mean size (5.1 x 6.2 mm, and 6 x 5.3 mm, respectively). Antegrade pyelography missed radiolucent (8/20) as well as radiopaque (12/20) stones. In 11 of the 31 patients (35.5%), urinary stones were diagnosed by both UMDCT and antegrade pyelography. The average size of these renal stones was 6 x 11 mm, and the mean ureteral stone size was 11 x 13 mm. In 64% (7/11), the stones were radiolucent and in 36% (4/11) radiopaque. There was no patient in whom urinary stones were diagnosed by antegrade pyelography but missed by UMDCT. CONCLUSIONS: Unenhanced multidetector CT is more accurate than antegrade pyelography via a PCN for the assessment of urinary-tract stones, with the advantage of reducing the risks of contrast injection side effects.     

移植肾尿路结石的腔内治疗

目的探讨腔内治疗移植。肾尿路结石的效果和策略。方法采用腔内技术治疗13例移植。肾尿路结石，其中。肾结石3例，金属支架结石1例，输尿管结石9例，合并输尿管口狭窄2例。结石最大直径8～48mm，接受肾移植的时间1个月～8年。结果3例。肾结石和1例金属支架结石行经皮微造瘘输尿管镜取石术成功取石。4例输尿管结石行逆行输尿管镜取石治疗；3例行经皮顺行输尿管镜取石成功，其中1例合并移植输尿管口狭窄者同时行内切开取石；1例移植输尿管口狭窄合并下端结石者，改行开放手术；1例输尿管结石直接行体外冲击波碎石术2次后排净结石。术后随访1～8年，人肾存活均良好，12例患者。肾功能恢复正常，无结石复发。结论移植肾尿路结石处理应选择创伤小、效果好的腔内微创治疗，尽可能保护。肾功能。     

复杂性肾结石的早期诊断及预防

目的通过分析复杂性肾结石病史,结石成分等临床特点,为其诊疗及预防提供帮助。方法回顾性研究2009年8月至2010年5月于北京大学人民医院进修期间118例复杂性肾结石病例,对患者病史、既往史、结石化学成分及尿常规、肾功能等临床资料进行总结分析。结果118例患者中,7例(5.9%)接受过定期规律体检,97例(82.2%)从未曾接受过健康体检,64例(54.2%)曾有结石病史,86例(72.9%)以疼痛、血尿及发热等不适症状为主诉,92例(78.0%)伴有泌尿系感染,18例(15.3%)伴有肾功能不全,结石成分中含钙结石94例(79.7%),感染石55例(46.6%),含尿酸结石28例(23.7%)。结石以混合成分为主,其中感染石与草酸钙的混合成分所占比例最大,共51例(43.2%)。结论应通过定期规律体检提高早期诊断比例,控制结石进展,根据不同结石成分,采取有针对性的预防措施,同时必须重视抗感染治疗,以减少患者损伤,降低结石复发率。     

Shock wave lithotripsy treatment of radiolucent ureteric calculi with the help of contrast medium

OBJECTIVE: Extracorporeal shock wave lithotripsy (SWL) treatment of radiolucent ureteric calculi (UC) is hampered by the reduced visibility of the stone. Intravenous contrast medium (IV-CM) administration may overcome this problem by indirectly depicting the localisation of the stone. However, IV-CM administration bears known risks. The aim of this study was to compare the clinical outcome after SWL in two representative groups of patients with either radiolucent or radio-opaque UC. METHODS: Two groups of patients, 156 with a radiolucent UC and 203 with a radio-opaque UC, were assessed with regard to age, gender, treatment modalities, auxiliary measures, complications, stone properties and stone-free rate 3 months after treatment. RESULTS: Both groups were comparable with regard to epidemiology, treatment and clinical outcome. In both groups, stone-free rates were well within the percentages described by other investigators. There were no adverse reactions to CM. CONCLUSIONS: The clinical outcome of SWL treatment for radiolucent ureter stones does not differ from that for radio-opaque ureter stones. Being a non-invasive treatment, SWL with the help of IV-CM administration should be the first-line therapy for radiolucent ureter stones. Although awareness of possible adverse reactions to CM is mandatory, the risk remains small.     

Is intravenous urography a prerequisite for renal shockwave lithotripsy?

PURPOSE: To determine whether intravenous urography (IVU) is a prerequisite for shockwave lithotripsy (SWL) of renal stones by addressing whether using non-contrast-enhanced CT (NCCT) instead of IVU for delineating urinary tract anatomy is associated with post-SWL complications. PATIENTS AND METHODS: Thirty-eight patients treated by SWL (Econolith 2000) for radiopaque renal stones underwent either IVU or NCCT. Twenty patients with normal urinary tracts or with mild hydronephrosis proximal to the stone on urography comprised the IVU group. Eighteen patients who underwent NCCT and plain abdominal (KUB) films and had urinary tract systems similar in appearance to the IVU group comprised the NCCT group. The two groups were of similar mean age (45.75 years, range 24-73 years; and 49.0 years, range 26-72 years, respectively) and had a similar mean stone size (10.1-10.2 mm). Patients with internal ureteral or nephrostomy catheters were excluded. Information on episodes of intractable renal colic, urinary tract infections, and hospitalization was recorded at follow-up 2 to 6 weeks post-SWL. RESULTS: The IVU and NCCT patients had similar mean stone fragmentation rates (80% and 74%, respectively) at 2 to 6 weeks post-SWL. Four IVU patients (20%) had intractable renal colic. One NCCT patient (5.5%) had a urinary infection. Complication and hospitalization rates in the two groups were not significantly different (P = 0.34; Fisher' exact test). CONCLUSIONS: Using only NCCT before SWL was not associated with higher complication rates. Thus, IVU is not a prerequisite for SWL of radiopaque renal stones in patients with a normal urinary tract anatomy as seen on NCCT.     

Retrograde ureteropyeloscopic holmium laser lithotripsy for large renal calculi

OBJECTIVE: To assess the efficacy and safety of the retrograde ureteropyeloscopic holmium laser for treating renal stones that are too large to treat with extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHODS: Thirty patients (22 men and eight women, mean age 43 years, range 18-62) with a renal stone burden of > 2 cm were selected for laser treatment. The stones were in the renal pelvis in 16 patients, lower calyx in five, middle calyx in two, upper calyx in one and multiple pelvic and calyceal in six. Lithotripsy was undertaken using a holmium laser through 550 microm and 200 microm laser fibres passed through a semi-rigid fibre-optic long ureteroscope or the actively deflectable flexible ureteropyeloscope, respectively. Success was defined as total fragmentation of the stone to < 2 mm in diameter and/or clear imaging on renal ultrasonography and plain films within the 3-month follow-up. Patients in whom the treatment failed received either alternative therapy or complementary ESWL. RESULTS: Endoscopic access and complete stone fragmentation was achieved in 23 of the 30 patients (77%). The treatment failed in seven patients because of poor visualization, the initial presence of stones in, or migration of their large fragments to, an inaccessible calyx. There were no major intraoperative complications. Minor complications after treatment included haematuria that persisted for 2 days in one patient and high-grade fever in two patients; all were treated conservatively. CONCLUSION: Large renal calculi that are not amenable to ESWL monotherapy can be safely and effectively treated with a retrograde endoscopic technique that seems to compete well with the more invasive percutaneous or open surgical manoeuvres.     

Experience with extracorporeal shock-wave lithotripsy (ESWL) for urinary calculi

Over a 36-month period 2800 patients were subjected to extracorporeal shock-wave lithotripsy (ESWL). A total of 5154 procedures were done. Best results were seen with renal pelvic calculi (not larger than 2.5 cm in diameter). Fragments of crushed lower calyceal calculi proved the most difficult to eliminate. As ureteral stone localization approached the bladder, the ESWL results were poorer. Post-ESWL complications were proportional to the stone mass; the higher the mass the more numerous the complications tended to be. Besides erythrocyturia and gross haematuria renal colic was the most frequent complication in almost 60% of the patients. Less prevalent were impacted ureteral stones, subcapsular haematoma and fever. At our institution, thanks to the ESWL method about 80% of the patients were spared surgery.     

Comparison of conventional radiography combined with ultrasonography versus nonenhanced helical computed tomography in evaluation of patients with renal colic

The aim of this study is to determine whether kidneys ureters bladder X-ray (KUB) film combined with ultrasound (US) can be effectively used in evaluation of renal colic and miss stones with clinically significant size identified on nonenhanced computed tomography (NECT) in patients with urolithiasis. This retrospective study evaluated the clinical and radiological records of 300 patients at our institution undergoing KUB and/or US and/or NECT for the evaluation of renal colic from June 2007 to December 2010. Of patients with negative findings on KUB and/or US, 22 had renal stones on NECT (mean size 4.4?mm, range 3-8), 3 had lower ureteral stone (mean size 3.3?mm, range 2-5). In patients with isolated suspicious renal ectasia without stone image, two had renal stone on NECT (mean size 4?mm, range 2-6), 5 had upper ureteral stone (mean size 4.4?mm, range 4-6), 7 had middle ureteral stone (mean size 3.7?mm, range 3-4) and 14 had lower ureteral stone (mean size 4?mm, range 2-6). The cost-effective and almost radiation-free combination of KUB and US should be preferred for diagnosis of urolithiasis, as it detects most of the ureteral and renal calculi which are clinically significant.     

经皮肾镜取石术治疗肾脏感染性结石的疗效分析(附127例报告)

目的:评价经皮肾镜取石术(PCNL)治疗肾脏感染性结石的方法和疗效。方法:对我院2009年1月~2013年6月127例肾感染性结石患者行PCNL的临床资料进行回顾分析,男52例,女75例,结石直径为2~5cm,均为鹿角形或多发性结石。结果:在B超引导下穿刺建立F20~22通道,采用输尿管镜钬激光碎石,105例一次取净结石,平均手术时间为134min,10例结石残余直径1cm,1周后经原通道取石,12例结石残余直径1cm,选择联合体外冲击波碎石术(ESWL)治疗或药物排石治疗,总住院时间10~17d,平均为13d,1个月后复查KUB,116例未见明显结石残余,结石总清除率91.3%。22例患者术后出现发热,其中8例为寒颤高热(39.5℃),6例为低热(38.0℃),2例为菌血症,1例患者术后出现肾脏持续性出血行栓塞治疗,1例出现尿瘘,未出现脓毒血症、腹腔脏器损伤、腹腔积液、胸腔积液、气胸、肾动静脉瘘等严重并发症发生。结论:通过充分的术前准备,改进术中操作细节,有效的术后护理及抗感染治疗,认为PCNL采用输尿管镜钬激光碎石术具有结石排净率高、创伤小、恢复快、并发症少等优点,是治疗肾脏感染性结石的一种安全有效的方法。     

Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management

OBJECTIVE: To determine the causes of steinstrasse, methods of prevention and treatment strategies. PATIENTS AND METHODS: Fifty-two patients with steinstrasse were identified and treated: all patients were initially treated conservatively but when there was obstruction, infection or no progression of the stone fragments, further treatment was used, ranging from repeated extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrostomy (PCN), endoscopic manipulations and finally open surgery, depending on the degree of obstruction, infection, renal function and response to each kind of therapy. RESULTS: Conservative management was successful in 25 patients (48%), repeated ESWL in 12 (23%), PCN in 10 (19%), ureteroscopy in three (6%) and open surgery in two (4%). CONCLUSION: As many patients, and particularly those with larger stones, are treated by ESWL, the risk of developing steinstrasse will increase, with associated patient discomfort, infection or impaired renal function. The optimum selection of cases (aiming to pulverize the stones rather than fragment them) and accurate stone targeting are essential to minimise the development of steinstrasse. The meticulous follow-up of patients with steinstrasse should prevent any loss of renal function. When there is obstruction and/or infection or renal damage, active treatment is indicated, of which ESWL and PCN are the most effective, with ureteroscopy and open surgery reserved for difficult cases.