Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis

We report the results in 118 patients with infection staghorn stones treated with an anaesthesia-free minimally invasive method that combined repeated shock-wave lithotripsy (SWL) sessions (unmodified Dornier HM3 lithotripter) and percutaneous chemolysis with Renacidin. The stone-free rate was 60%. In 27 consecutive patients with infection staghorn stones representative of patients with this stone type in the population, a stone-free rate of 77% was recorded. The latter figure is comparable with results reported for open surgery, percutaneous surgery and sandwich therapy, and superior to that recorded with SWL alone. During the study period, no patient referred to us with an infection staghorn stone was treated with percutaneous, ureteroscopic or open surgery, and all treatments were carried out without regional or general anaesthesia. The described treatment concept had a very low complication rate, but required a fairly long hospital stay, with a mean of 32 days (range: 5-82). The long period necessary for completing the treatment in the most complicated cases might render the procedure less attractive as a standard method, but it is nevertheless an excellent option in high-risk patients and in all those patients in whom other procedures are impossible.     

Management of staghorn renal stones

Staghorn stones are large branching stones that fill part of all of the renal pelvis and renal calyces and they can be complete or partial depending on the level of occupancy of the collecting system. Although kidney stones are commoner in men, staghorn stones are less often reported in men compared to women and they are usually unilateral. Due to the significant morbidity and potential mortality attributed to staghorn stones, prompt assessment and treatment is mandatory. Conversely, conservative treatment has been shown to carry a mortality rate of 28% in 10-year period and 36% risk of developing significant renal impairment. Staghorn stones are, therefore, significant disease entity that should be managed aggressively and effectively. Generally, the gold standard treatment for staghorn stones is surgical with a view to achieve stone-free collecting system and preserve renal function. Percutaneous nephrolithotomy should be the recommended first-line treatment for staghorn stones. Other non-surgical options are usually considered in combination with surgery or as monotherapy only if patients are surgically unfit. The decision for optimal treatment of staghorn stones should be individualized according to the circumstances of the patient involved and in order to do so, a closer look at the advantages and disadvantages of each option is necessary.     

鹿角形肾结石的微创治疗进展

鹿角形肾结石的治疗一直是泌尿外科较为棘手的问题.随着微创泌尿外科的发展,鹿角形肾结石的治疗发生很大的改变.目前认为凡是新诊断的鹿角形肾结石,都需积极的外科处理方法清除结石,经皮肾镜取石术(PCNL)已成为临床治疗鹿角形肾结石的主要方法.本文对鹿角形肾结石的几种微创治疗方法进展作一综述.     

微创治疗胆总管结石的术式选择

目的探讨不同条件下胆总管结石(CBDS)的微创手术方案。方法分析近9年间我科治疗的203例CBDS患者的临床资料。据手术方式不同分组:十二指肠镜下乳头气囊扩张取石术(EPBD)组(22例)、十二指肠镜下乳头括约肌切开取石术(EST)组(105例)、腹腔镜胆总管切开取石术(LCBDE)组(76例)。结果 3组的手术成功率、近期并发症发生率、残石率比较差异无统计学意义(P0.05)。手术时间3组比较差异有统计学意义(P=0.000),LCBDE组最短;住院时间3组间差异有统计学意义(P=0.000),EPBD组最短。随访期间结石复发率、反流性胆管炎及乳头狭窄发生率3组间差异有统计学意义(P0.05),LCBDE组与EPBD组相当,EST组最差。结论有适应证的CBDS患者首选EPBD,失败或无适应证者选择LCBDE,EST仅适用于有严格适应证者。     

微通道经皮肾镜取石术治疗肾铸型结石的应用体会

目的总结经皮肾镜取石术（PCNL）治疗铸型结石的治疗经验。方法回顾性分析PCNL治疗95例铸型结石的病例资料。男性60例,女性35例,平均48．6岁。结石直径3～8．4cm。结果本组95例PCNL治疗105次,其中一期PCNL85例（89．5％）,二期PCNL治疗10例（10．5％）;1个工作通道75例,2个工作通道20例。一期结石完全清除率72．7％（70／95）,二期完全清除率91．6％（87／95）。结合ESWL,完全清除率98．0％（93／95）。结论在操作熟练的前提下,PCNL是治疗铸型肾结石安全、有效的方法;根据手术和结石和情况,联合ESWL成功率更高。     

微创经皮肾镜碎石术治疗巨大肾鹿角形结石的疗效分析

目的:探讨微创经皮肾镜碎石术治疗巨大肾鹿角形结石的手术经验及其并发症的预防。方法:回顾性分析2001年8月～2007年6月采用微创经皮肾镜气压弹道碎石治疗巨大肾鹿角形结石36例(40例次)的临床资料:男25例,女11例,结石最大径42～126mm,平均68mm,结石表面积1246～6231mm2,平均2455mm2,均为全鹿角形肾结石,其中双肾鹿角形结石4例。结果:平均手术时间193min(140～340min),住院天数8～32天,平均17天。采用双通道取石11例侧,三通道取石25例侧,四通道取石4例侧。术前血红蛋白为(117±25)g/L,一期手术后1～3天复查血红蛋白为(105.5±21.5)g/L。术中损伤十二指肠、胸膜、腹膜各1例,术中或术后输血2例,术后高热4例,术后需要配合ESWL碎石23例。结石总排净率为87.3%。结论:微创经皮肾镜配合气压弹道碎石治疗巨大肾鹿角形结石具有创伤小、恢复快、患者容易接受等优点,但术中或术后要注意并发症的预防。     

Minimally invasive PCNL in patients with renal pelvic and calyceal stones.

Stones of the renal pelvis can be treated either by extracorporeal shock wave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). As a low-risk procedure with a longer treatment period, SWL often leads to persistent residual stone fragments, whereas conventional PCNL achieves a higher stone-free rate and allows a shorter treatment period albeit with a somewhat higher surgical risk. To reduce the invasiveness of conventional PCNL, the application of a miniaturised instrument for PCNL (MPCNL) was evaluated. For MPCNL a rigid nephroscope with a calibre of 12 F was developed and used in 19 patients. After puncture of the kidney under ultrasound control and single-step dilatation, a 15 F Amplatz sheath was placed. Data on the stone size and location, stone-free rate, blood transfusions, operating time and complications were recorded. In all patients, the part of the kidney afflicted by the stone was successfully punctured. On average, retreatment rate was 0.7. The mean stone size was 2.4 cm(2). The average operating time was 99.2 min. In every case, the absence of residual stones was confirmed radiologically and nephroscopically. Hemorrhages requiring a blood transfusion did not occur. A febrile pyelonephritis occurred as a postoperative complication in one patient (= 5.3%). MPCNL represents an alternative to SWL for renal calculi with a size from 1 to 2 cm located in the renal pelvis and calices, especially the lower calix. The advantages are the short treatment time, the high stone-free rate and the accessibility of lower pole stones which are less amenable to SWL. MPCNL is not suitable for large concrements since the limited sheath diameter would increase the operating time. Due to this limitation, MPCNL represents an extension of the indication for conventional PCNL that it can in no way replace.     

前列腺增生合并膀胱结石的微创治疗效果分析

目的 观察微创手术对前列腺增生(benign prostate hyperplasia,BPH)合并膀胱结石的治疗效果.方法 以2014年5月至2015年10月在本院接受治疗的BPH合并膀胱结石的患者为观察对象.根据其手术方式,分为微创手术组(50例)和开放手术组(38例).其中微创手术组采用经尿道前列腺电切术(transurethral resection of the prostate,TURP)联合小切口膀胱切开取石术,开放手术组采用耻骨上经膀胱前列腺切除联合取石术.观察两组患者的手术一般情况,比较两组患者术中、术后并发症和手术前后症状改善情况.结果 微创手术组患者的手术时间、术中出血量、膀胱冲洗时间和导尿管留置时间均较开放手术组少(P＜0.05),两组患者前列腺切除质量无明显差别(P＞0.05);微创手术组患者在术后1个月、3个月、6个月和12个月时IPSS、QOL得分较开放手术组降低,而Qmax得分较开放手术组显著升高(P＜O.05);两组患者膀胱穿孔、直肠损伤和暂时性尿失禁等并发症发生率无明显差别(P＞0.05).结论 微创治疗对BPH合并膀胱结石有较好的治疗效果,可明显改善患者不适,且安全性高.     

前列腺增生伴膀胱结石的微创治疗

目的 探讨经尿道前列腺汽化切除术(TVP)结合钬激光碎石术治疗良性前列腺增生(BPH)并膀胱结石的32效。方法 回顾性分析了56例BPH合并膀胱结石患者采用TVP结合钬激光碎石木，并对随访的32例进行疗效分析。结果 所有56例患者均一次处理成功，无电切综合症(TUES)，无膀胱穿孔出现，有3例部分尿失禁，3月后均恢复。术后3月对随访32例复查无残余结石，MFR＞16mL/s。结论 TVP结合钬激光碎石术对治疗BPH并膀胱结石具有效果确切，并发症少，康复快，符合微创外科的优点。     

上尿路结石并发真菌感染的微创经皮肾镜治疗

目的：探讨输尿管镜和微创经皮肾镜探察取石术，以及术后局部灌注抗真菌药治疗上尿路结石并发真菌感染的有效性。方法：对49例上尿路结石并发真菌感染患者，采用输尿管镜探察和微创经皮肾镜取石术后经皮肾微造瘘管或输尿管外支架管灌洗抗真菌药治疗。结果：49例真菌感染均得到较好控制，尿液真菌培养阴性；45例结石取净，术后肾功能有不同程度的恢复，无一例出现大出血和真菌败血症。结论：输尿管镜探察和微创经皮肾镜取石术，以及术后局部灌注抗真菌药治疗上尿路结石并发真菌感染，是一种微创安全并能同时取石和控制感染的可靠方法。     

胆囊结石合并胆总管结石的微创外科治疗进展

胆石症包括胆囊结石、胆总管结石和肝内胆管结石.胆囊结石合并胆总管结石占胆石症的9.2％ ～ 14.3％,当前临床常用的治疗方法包括传统的开腹胆囊切除及胆总管切开取石+T管引流术(Opencholecystectomy choledocholithotomy and T-tube drainage,OC-OCHTD);经内镜逆行胰胆管造影(ERCP)+内镜下括约肌切开取石(EST),二期腹腔镜胆囊切除术(LC)(即ERCP/EST+LC);同期腹腔镜胆囊切除+胆总管切开取石(LCBDE),这三种术式各有特点.与传统的开腹手术比较,后两者为微创手术治疗方法,体现了微创技术的优势,但手术适应证和操作技术需要不断总结和提高.目前,关于后两种微创方法治疗的文献报道较多,在诸如手术适应证、住院费用、手术时间、治疗风险、并发症、住院时间等方面存在一定争议.比较LCBDE和ERCP/EST+ LC,两者各有优缺点.但是在符合适应证的情况下,LCBDE是一期治疗胆囊结石合并胆总管结石患者的首选方法.对患者而言,无论哪种手术方案,创伤小、操作安全、并发症少的方法才是最适合的治疗手段.     

肝外胆管结石的微创治疗(附64例报告)

目的 探讨三镜(腹腔镜、纤维胆道镜、十二指肠镜)联合微创治疗肝外胆管结石各种方法的可行性及适用范围.方法 64例肝外胆管结石患者接受内镜的微创联合治疗.结果 64例全部治愈.无胆漏、腹腔出血、结石残留、胆管狭窄等并发症.结论 熟练掌握内镜及腔镜微创技术,把握好各种方法的适应证,肝外胆管结石的微创治疗是安全、可行的.     

微创外科治疗胆总管结石的策略探讨

目的 探讨微创外科治疗胆总管结石(CBDS)的策略.方法 回顾性分析2001年6月至2007年1月304例CBDS患者的临床资料.按手术方式不同分三组:十二指肠镜下乳头气囊扩张术加LC组(EPBD组)、十二指肠镜下乳头括约肌切开取石术加LC组(EST组)、腹腔镜联合纤维胆道镜胆总管切开探查术加LC组(LCBDE组).结果 304例中EPBD组35例,EST组138例,LCBDE组131例.三组的手术成功率、近期并发症发生率、残石率比较,差异无统计学意义(x2值分别为1.93、0.038和0.427,P>0.05);手术时间比较差异有统计学意义(F=17.941,P=0.000),LCBDE组优于另两组(EPBD-EST:P=0.122,EST-LCBDE:P=0.000,EPBD-LCBDE:P=0.020);住院时间相比差异有统计学意义(F=24.016,P=0.000),其中EPBD组最短(EPBD-EST:P=0.000,EST-LCBDE:P=0.198,EPBD-LCBDE:P=0.000).远期并发症:EPBD组结石复发2例(6.7%),胆管炎1例(3.3%),无乳头狭窄;LCBDE组结石复发7例(6.0%),胆管炎3例(2.6%),无乳头狭窄;EST组结石复发18例(15.8%)、乳头狭窄9例(7.9%)、胆管炎14例(12.3%);比较三组结石复发、胆管炎、乳头狭窄的发生率,差异有统计学意义(x2值分别为6.482、9.160和12.02,P<0.05),EST组高于EPBD组和LCBDE组.结论 有适应证的胆总管结石可首选EPBD治疗,失败或无适应证者则选择LCBDE,EST仅适用于有严格适应证者.     

小肾癌的微创治疗与进展

随着影像学的发展,小肾癌的检出率不断地提高,近年来小肾癌的微刨治疗已经受到医学界的广泛重视,保留肾单位的肿瘤切除术其无瘤生存率与根治性肾切除术无统计学意义,开放性手术已不再是唯一治疗手段,小肾癌保留肾单位的微创治疗手术方法很多,如腹腔镜技术,以及腹腔镜下射频消融术、冷冻术、高强度聚焦超声术(HIFU)等),其中较为成熟的是腹腔镜技术.     

微创经皮肾镜钬激光治疗孤立肾鹿角性结石疗效分析

目的报道14例孤立肾鹿角性肾结石患者行微创经皮肾镜钬激光碎石术的疗效以及安全性。方法回顾性总结、分析我院2009年1月至2012年10月应用经皮肾镜钬激光碎石术治疗孤立肾鹿角性肾结石14例的临床资料,对患者的临床资料、结石清除率、术中出血量、术后并发症、术后。肾功能等进行分析。结果13例患者一期顺利完成手术,1例行二期手术治疗,术后随访时间为（20．8±3．0）个月（12～24个月）,术后一周结石清除率为：85．7％（12／14）,手术时间为：（60．8±15．4）min,平均住院时间（8．2±2．6）d,患者术前、术后3个月以及术后12个月肌酐值分别为：（152．8±61．3）umol／L、（104．9±38．5）umol／L、（100．5±43．9）umol／L,术后与术前比较差异具有统计学意义（P〈0．05）,术中术后并发症为：1例术中出现肾穿透伤,1例术后继发出血,1例术后出现发热。结论微创经皮肾镜钬激光碎石术治疗孤立肾鹿角性肾结石并发症的发生率低,安全、有效、可行。     

鹿角形肾结石的治疗

目的　探讨经肾窦内肾盂切开和 /或气压弹道碎石治疗鹿角形肾结石的疗效。方法　对 6 8例、80个肾鹿角形结石采用在肾窦脂肪包膜与肾盂外膜之间的疏松结缔组织内充分分离达肾乳头 ,切开肾盂 ,并向肾窦内肾盂扩大的手术方法。对完全性鹿角形结石 ,结合气压弹道碎石 ,将结石分解成几块 ,再逐一取出。双侧肾结石采用一次分侧手术取石。结果　 34个部分鹿角形肾结石均完整取出 ,4 6个完全性鹿角形肾结石亦较顺利地取出。结论　①熟悉肾窦肾盂的解剖结构 ,术中充分分离肾窦内肾盂是取出鹿角形结石的关键。②对巨大的完全性鹿角形结石 ,采用气压弹道碎石是较好的方法。③双侧肾结石多有梗阻致肾功能受损 ,应双侧一次取石 ,有利于双肾功能恢复。分次手术应在 2周内进行     

Antibiotics therapy was effective in preventing bilateral staghorn renal matrix stones

Herein we report a case for which antibiotic therapy was effective in preventing bilateral staghorn renal matrix stones. A 34-year-old man was referred to our hospital for right lower abdominal pain and fever. Blood data and urinary analysis indicated a urinary tract infection and renal failure. The diagnosis was bilateral pyelonephritis for staghorn renal matrix stones. He had undergone percutaneous neprolithotripsy (PNL) for bilateral staghorn renal matrix stones. Almost all fragments were removed by the grasper. However, 3 months after the operation, bilateral staghorn renal matrix stones rapidly developed, so he underwent PNL again. After the operation, low-dose antibiotic therapy was continued to prevent pyelonephritis. As a result renal matrix stones did not reoccur. Until now, 1 year after the start of antibiotic therapy, no further sign of relapse has been noted.