开放手术治疗上尿路结石667例回顾分析

目的 总结开放手术治疗上尿路结石的有效性,探讨在微创时代开放手术治疗上尿路结石的手术适应证.方法 回顾分析1995年1月至2004年12月在四川大学华西医院泌尿外科行开放手术治疗的上尿路结石病例.结果 共667例上尿路结石行开放手术治疗,同期约有9000例上尿路结石病例在我科治疗,开放手术比例约7.4%.开放手术原因包括:复杂结石及巨大结石297例,结石致患肾无功能137例,结石合并上尿路解剖畸形134例,微创治疗失败57例,结石合并各种内科疾病30例,结石合并肾肿瘤5例,结石合并黄色肉芽肿性肾盂肾炎3例,结石合并肾外伤2例,结石合并同侧其他手术2例.145例肾切除病例中共16例出现术中并发症,6例出现术后并发症;522例肾输尿管切开取石病例中,7例出现术中并发症,34例出现术后并发症;术后57例结石残留,总结石清除率为89.1%;围手术期无一例死亡.结论 开放手术在上尿路结石的治疗中仍然有重要作用,结石性无功能肾切除、复杂及巨大肾结石、结石合并解剖畸形、微创治疗失败及合并内科疾病的部分选择性病例适合选择开放手术治疗,治疗效果确切,并发症低.     

纤维膀胱镜在复杂上尿路结石手术中的应用

目的提高复杂泌尿系结石的治疗效果。方法对7例复杂泌尿系结石开放手术中利用纤维膀胱镜取石。结果7例全部成功,无结石残留及并发症出现。结论纤维膀胱镜配合手术治疗复杂尿路结石具有安全、简便、疗效确切的优点。     

尿流改道术后尿路结石的治疗

目的 探讨尿流改道术后尿路结石的治疗方法.方法 选取20例既往因膀胱癌接受尿流改道的尿路结石患者(肾结石6例,输尿管结石5例,储尿囊结石9例),接受个性化的治疗:其中经皮肾取石术8例,经皮肾顺行输尿管软镜碎石术3例,储尿囊流出道入路手术5例,经皮膀胱穿刺人路手术3例,开放取石1例.结果 手术时间60～130min,平均104min;术后结石清除率90％(18/20);术后发热4例(20％o),其中l例经皮肾镜技术(PCNL)术后液胸,行胸腔闭式引流.结论 针对尿流改道术后的尿路结石患者,采取个性化治疗方案,能够有效的清除尿路结石.     

微创经皮肾取石术治疗上尿路结石82例报告

目的探讨微创经皮肾穿刺取石术(微创PCNL)治疗上尿路结石疗效。方法采用微创PCNL治疗82例上尿路结石,其中输尿管上段结石26例,单纯肾盂结石15例,肾盏结石12例,多发性结石10例,肾铸型结石19例。结果82例均行一期穿刺取石,1次取石61例,2次取石21例;中转开放手术2例,单通道77例,双通道5例,结石清除率85%,残石体外冲击波碎石13例,2个月后结石清除率98%,平均手术时间2 h,术后有出血3例,保守治愈。住院时间为7~14 d。结论微创PCNL是一种较佳治疗上尿路手术方法,创伤小,恢复快,疗效佳。     

低龄儿上尿路结石微创手术治疗分析（附39例报告）

目的：总结手术治疗小儿上尿路结石经验,提高小儿上尿路结石微创手术技术。方法：分析总结39例低龄儿上尿路结石的诊断、药物治疗情况、手术指征、手术方法和技巧、治疗结果、并发症情况等,并结合文献进行复习。结果：39例低龄儿上尿路结石患者诊断明确,手术指征明确,充分术前准备后行微创经皮肾碎石取石术和输尿管镜碎石取石术,手术顺利,术后恢复好,无一例残留结石,无并发症发生。结论：微创经皮。肾碎石取石术和输尿镜取石碎石术是治疗低龄儿上尿路结石的重要和有效的方法,技术要求高,须严格把握手术指征。     

开展ESWL及腔内镜取石后上尿路结石开放手术治疗地位的探讨(附88例临床分析)

在开展ESWL及腔内镜取石后一年中共收治上尿路结石1383例,其中行开放手术治疗88例(6.35%),除1例双侧脓肾术后死亡、4例结石残留外,余均取净结石,临床症状明显改善。提示ESWL等非开放性手术不能完全代替开放性手术治疗上尿路结石。通过对开放手术治疗上尿路结石适应证的讨论,认为掌握手术时机及术中充分引流是治疗成功的关键。     

微创外科治疗合并临床症状的肾盏憩室结石

目的 探讨合并临床症状的肾盏憩室结石的微创治疗方法及安全性.方法 合并临床症状的肾盏憩室结石患者21例.男9例,女12例.平均年龄39(22～57)岁.憩室平均直径3.7(2.5～7.0)cm,结石平均直径为2.3(0.8～3.5)cm.患者临床表现为血尿、腰痛、泌尿系感染.均经影像学检查诊断,分别采用逆行输尿管软镜碎石4例、PCNL 7例、腹腔镜下手术取石9例、腹腔镜联合PCNL取石1例.结果 21例手术顺利,无中转开放手术、穿孔、周围脏器损伤等并发症.术后1周出现医源性动静脉瘘合并迟发性出血1例,2 d后自发形成血栓治愈;结石残留但临床症状明显缓解2例.19例无残留结石随访6～12个月结石无复发.结果 有效地选择适应证和建立合理治疗方案的前提下,微创外科治疗合并临床症状的肾盏憩室结石安全有效.     

输尿管结石三种治疗方法的疗效比较

目的:探讨对输尿管结石治疗方法如何进行选择.方法:对经ESWL、输尿管镜下气压弹道碎石术(URSL)及输尿管切开取石术3种方法、治疗的360例输尿管结石患者的疗效进行比较.结果:ESWL174例,碎石率为90.3%,URSL150例,一次碎石率为92.2%,手术切开输尿管取石36例,取石成功率100%.输尿管镜失败改切开取石12例(8%);ESWL失败改切开取石或输尿管镜下气压弹道碎石56例(32.2%).结论:URSL治疗输尿管结石可以避免开放手术对患者造成的痛苦,减少术后并发症,但也不能盲目采用;对于复杂性输尿管结石,开放手术仍是可供选择的重要的治疗手段.     

微创经皮肾镜气压弹道碎石取石术治疗上尿路结石的临床分析

目的 探讨微创经皮肾镜下气压弹道碎石取石术治疗上尿路结石的疗效及安全性.方法 回顾性分析258 例微创经皮肾镜下气压弹道碎石术治疗上尿路结石的临床资料,分析围手术期数据,评估手术疗效.结果 258 例手术中单通道取石251 例,双通道取石7 例;一期穿刺取石成功196 例,二期取石成功29 例,三期取石成功4 例,结石总清除率88.8%.留置造瘘管者平均6.8 d 拔管,平均住院时间12.5 d.未置造瘘管者28 例,该无管化患者平均住院时间9 d.无胸膜、肝脏和肠管等损伤及中转开放手术发生.结论 微创经皮肾镜下气压弹道碎石取石术治疗上尿路结石具有微创、安全、出血少、结石清除率高等优点,是治疗上尿路结石的理想方法.无管化能减轻痛苦、加快恢复、缩短住院时间.     

肾移植病人尿路结石的诊治(附五例报告)

目的：探讨肾移植术后尿路结石的诊断与治疗。方法：对5例肾移植并发泌尿系结石病人进行诊治。其中供肾内残留结石1例,膀胱输尿管吻合口处狭窄并发结石3例,肾移植后内置支架管形成结石1例。予以观察排石治疗2例,输尿管取石、输尿管膀胱再吻合术3例次,ESWL1例次。结果：5例病人均人肾存活,随访1－13年。1例未行手术处理者已存活13年。结论：肾移植术后尿路结石的治疗与常人相同,但应注意尿酸盐结石的成因治疗。     

钬激光治疗泌尿系结石(附155例报告)

目的：探讨钬激光治疗泌尿系结石的疗效。方法：总结利用Versa Pulse Select钬激光机经输尿管镜或膀胱镜治疗155例泌尿系结石患者的临床资料。结果：8例肾结石和7例膀胱结石均1次碎石成功;140例输尿管结石患者单次手术结石粉碎率为95．7％（134／140）,平均结石排净时间2．5周;平均手术时间25min、平均术后住院天数2．5d。术中无输尿管穿孔、撕裂等并发症。结论：钬激光治疗泌尿结石是一种有效的腔道泌尿外科碎石方法。     

钬激光腔内治疗泌尿系结石(附126例报告)

目的：探讨泌尿系结石腔内钬激光治疗效果及安全性。方法：总结钬激光结合腔内泌尿外科技术治疗126例泌尿系结石的临床资料。结果：5例肾结石和11例膀胱结石，均一次碎石成功，109例输尿管结石，单次碎石率为96.3%(105/109)，复杂结石1例数次行输尿管腔镜下碎石。平均结石排净时间2.8周，平均手术时间30min，平均术后住院2d。术中除1例输尿管穿孔外，无其他并发症。结论：钬激光结合腔内泌尿外科技术治疗泌尿系结石，是一种较新的、安全的、有效的方法。     

体外冲击波碎石治疗儿童尿路结石的疗效观察(附62例报告）

目的：探讨体外冲击波碎石(ESWL)治疗儿童尿路结石的有效性和安全性。方法：采用ESWL治疗儿童尿路结石患者62例，其中肾盂肾盏结石35例，输尿管结石22例，膀胱结石4例，移植肾结石1例。结果：62例随访3个月，结石排净59例(95．2％)，结石残留2例(3．2％)，1例无效(1．6％)，改用手术治疗。结论：ESWL治疗儿童尿路结石安全、有效，是儿童尿路结石的首选治疗方法。     

输尿管软镜钬激光碎石术治疗24例肾盏憩室结石

目的 探讨输尿管软镜钬激光碎石治疗肾盏憩室结石的临床治疗效果.方法 2011年3月至2013年1月收治肾盏憩室结石24例,均行输尿管软镜钬激光碎石治疗,对碎石成功率、手术时间、并发症及复发等情况进行分析.结果 一次性碎石成功19例,碎石成功率为79.1％,20例患者症状消失,平均手术时间（80±21）mm,结石直径平均为（11.5±4.1）mm.分析24例患者的结石成分,其中草酸钙＋碳酸磷灰石结石占50.0％（12例）,草酸钙结石占41.7％（10例）,六水磷酸镁铵结石占8.3％（2例）.所有患者术后均无并发症发生.随访1～6个月,未见结石复发及其他症状出现.结论 输尿管软镜钬激光碎石是治疗肾盏憩室结石安全、有效的方法之一.     

Management of pediatric urolithiasis in Pakistan: experience with 1,440 children

PURPOSE: We evaluated the efficacy and safety of different modalities for pediatric urolithiasis in a developing country in 2 eras, namely before and after the advent of minimally invasive surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of 1,440 children younger than 14 years treated with various modalities during a 14-year period. From 1987 to 1995, 486 and 50 patients were treated with open surgery, and extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) and minimally invasive methods, respectively. Between 1996 and 2000, 518 and 386 children were treated with surgery and minimally invasive methods, respectively. RESULTS: Of the 1,440 children 795 (55.2%) had renal, 198 (13.8%) had ureteral and 447 (31%) had bladder calculi. Of the renal stones 556 (70%), 177 (22%) and 62 (7.8%) were treated with open surgery, ESWL and percutaneous nephrolithotomy, respectively. Of the ureteral calculi 85 (43%), 37 (18.6%) and 76 (38%) were managed by ESWL, ureterorenoscopy and open surgery, respectively. Of the bladder calculi 307 (68%), 77 (17.2%) and 63 (14%) were treated with open vesicolithotomy, transurethral pneumatic cystolithotripsy and ESWL, respectively. The renal stone clearance rate was 98% after open surgery, 84% after ESWL and 68% after percutaneous nephrolithotomy monotherapy at 3 months of followup. Similarly the ureteral stone-free rate was 54% after ESWL and 86.9% after ureterorenoscopy. Of the patients with bladder calculi 48% and 93% become stone-free after ESWL and transurethral pneumatic cystolithotripsy, respectively. CONCLUSIONS: The use of ESWL, percutaneous nephrolithotomy and ureterorenoscopy has resulted in treating a large number of children with a short hospital stay and early return to school. Open surgery is reserved only for complex stones.     

输尿管软镜处理大于3 cm肾结石的有效性和安全性评价

目的探讨应用输尿管软镜(flexible ureterorenoscopy,FURS)处理直径>3 cm肾结石的有效性和安全性。 方法回顾性分析2017年1月至2021年1月采用FURS下激光碎石取石术治疗直径>3 cm肾结石52例,其中单侧肾结石42例、双侧肾结石10例;下盏铸形结石24例、鹿角形结石5例,结石直径3.2~6.0 cm。所有患者均预留置单侧或双侧输尿管支架管至少10 d后行FURS手术。术后1 d及术后4周时行影像学(KUB)复查,评估碎石后效果。 结果52例患者单次手术成功率100%,手术时间60~305 min,平均135.4 min;术后无发热,无严重并发症,术后1 d复查结石清除率86.5%,术后1个月复查结石清除率100%。 结论对于熟练掌握FURS的中心,FURS单次手术治疗直径>3 cm的肾结石是一种相对安全、有效的临床方法。     

Idiopathic hypercalciuria of childhood: response to oral calcium loading in children with and without urolithiasis

Fifteen children with episodes of painless hematuria without calculi and 8 others with calcareous urolithiasis were examined for hypercalciuria. All patients were normocalcemic and excreted excessive amounts of urinary calcium (greater than 4 mg. per kg. per day). A familial history for renal calculi was noted in 8 children with hematuria and in 5 with urolithiasis. Children with hematuria excreted greater amounts of calcium and presented at an earlier age compared to patients with renal calculi. After 7 days of a low calcium diet an oral calcium loading test was performed in children from both groups. Urinary calcium excretion and parathyroid activity were not different in the 2 clinical groups while fasting or after an oral calcium load. Absorptive and renal subtypes were found in patients with hematuria and urolithiasis. Treatment used to prevent the recurrence of calculi also was highly effective in resolving hematuria. Despite differences in age and clinical presentation, these children appeared metabolically similar and responded favorably to therapeutic regimens that reduce urinary calcium excretion.     

Bladder lithiasis: from open surgery to lithotripsy

Bladder calculi account for 5% of urinary calculi and usually occur because of bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Children remain at high risk for developing bladder lithiasis in endemic areas. Males with prostate disease or relevant surgery and women who undergo anti-incontinence surgery are at a higher risk for developing vesical lithiasis. Open surgery remains the main treatment of bladder calculus in children. In adults, the classical treatment for bladder calculi is endoscopic transurethral disintegration with mechanical cystolithotripsy, ultrasound, electrohydraulic lithotripsy, Swiss Lithoclast, and holmium:YAG laser. Novel modifications of these treatment modalities have been used for large calculi. Open and endoscopic surgery requires anesthesia and hospitalization. Alternatively, extracorporeal shock wave lithotripsy has been demonstrated to be simple, effective, and well tolerated in high-risk patients. Recently, simultaneous percutaeous suprapubic and transurethral cystolithotripsy has been tested as well as percutaneous cystolithotomy by using a laparoscopic entrapment sac.     

Epidemiology and risk factors in urolithiasis

Stone formation in the urinary tract affects about 5-10% of the population in industrialized countries, although it is very rare in other countries such as Greenland or Japan. The high incidence and recurrence rate contribute to making the urolithiasis a serious social problem. Nowadays, urolithiasis must be considered a 'disease in evolution' for several reasons, such as epidemiological changes, evolution of the methods used for diagnosis, and the treatment and prophylaxis of the population considered 'at risk' of stone disease. Some features of stone disease have changed over the last few years due to many social, economical and cultural factors that are described here. The increased prevalence of small urinary calculi has brought about a change in clinical symptoms, with frequent episodes of renal-ureteral colic, persistent pain and hydronephrosis. Similarly, the presence of residual fragments after extracorporeal shock wave lithotripsy has induced a radical change in the management of small calculi through the use of mini-invasive surgical techniques.     

Lithotripsy in the treatment of urinary lithiasis

Based on an extensive review of the literature and on our own clinical experience, this article attempts to present clear guidelines for the management of various kidney stones, particularly regarding the extracorporeal shock waves lithotripsy (ESWL) treatment nowadays. Few technical developments have changed medicine more within a short period of time than ESWL. Fifteen years after the first clinical application, ESWL has gained world-wide acceptance as first choice therapy for most forms of urolithiasis. Ninety-eight per cent of stones can be successfully fragmented by the application of shock-waves, but the ability of the kidney and ureter to clear the resulting fragments is far more important in terms of successful treatment outcome. Increasing experience with new ultrasound-guided lithotriptors has shown that there are some advantages: cost reduction, permanent monitoring and lack of exposure to ionising radiations. ESWL is a safe procedure for the treatment of urolithiasis; nevertheless some problems remain. In ureteric stones, ureteroscopy (rigid or flexible device) allows a rate of stone-free patients better than ESWL. For treatment of large staghorn calculi combined approach of PCNL and ESWL is preferred. For stones located at lower calyx, the stone-free rate in patients treated by ESWL fell to 50%, when unfavourable anatomy is present. The potential long-term renal damage, associated with ESWL in children, have delayed the acceptance of shock-waves into paediatric practice. Recent reports suggest that the renal damage, including the potential risk of hypertension induced by ESWL, is mild and transient. A subgroup of patients (e.g. solitary kidney, impaired renal function, children) required further attention. The fate of residual fragments is unclear. In some cases residual lithiasis tend to result in regrowth and further progression, although ESWL itself does not increase the recurrence rate of urolithiasis. Nevertheless follow-up of stone patients after ESWL is mandatory and the ultimate goal of treating stones by whatever means is to get the patient stone-free and prevent recurrence.