经皮肾通道顺行输尿管软/硬镜联合输尿管镜治疗恶性输尿管梗阻

目的探讨斜仰卧截石位经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤致输尿管梗阻的安全性及临床效果。 方法回顾性收集并分析2016年10月至2019年1月我院收治的25例恶性肿瘤引起的输尿管梗阻患者的资料,上述患者均因常规逆行膀胱镜或输尿管镜置双J管失败,进而以斜仰卧截石位利用经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管。 结果25例患者（32侧输尿管梗阻）中,1例因肿瘤侵犯输尿管造成双侧输尿管管腔完全闭塞,双J管置入失败。其余24例均成功放置双J管（成功率93.7%）。手术时间平均（57.4±22.4）min,平均住院时间（5.5±1.9）d,术中无严重肾出血,无输尿管穿孔及撕脱。术后6~14 d拔除肾造瘘管,拔除肾造瘘管后随访12个月,肾积水缓解。 结论斜仰卧截石位皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤引起的输尿管梗阻安全、有效,值得临床推广。     

One-stage versus staged ureteroscopy and percutaneous nephrolithotomy for simultaneous ureteral and renal stones

Objectives:This study is aimed to investigate the outcome of one-stage ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) for simultaneous ureteral and renal stones over 10years at a tertiary urology institute.Materials and methods:We retrospectively analyzed the data of patients who were operated on for simultaneous ureteral and renal stones from January 2011 to December 2020. Patients were divided into 2 groups: group A, who underwent one-stage URS and prone PCNL, and group B, who underwent staged procedures. The overall success, complications, operative time, and hospital stays were compared between the 2 groups.Results:Data for 190 patients were reviewed; mean age was 50 ± 13years old, and 146 (77%) were male. The one-stage (A) and staged (B) groups included 102 and 88 patients, respectively. Group A included older patients, with a high The American Society of Anesthesiologists score, while group B included more patients with multiple or staghorn stones. The one-stage group recorded shorter operative time (120 ± 12min vs. 140 ± 16min, p = 0.02) and shorter hospital stays (3days [2-6] vs. 4days [3-9], p = 0.06). Otherwise, both groups had equal outcomes in terms of success rates and complications.Conclusions:PCNL and URS can be performed in one-session for simultaneous ureteral and renal stones, except for multiple renal and staghorn stones. The results are comparable to those of the staged procedure in terms of success rate and complications, with the advantage of a shorter operative time and hospital stay.     

Endourologic management of upper and mid ureteral calculi: percutaneous antegrade extraction vs transurethral ureteroscopy

Fifty patients requiring intervention for upper or mid ureteral calculi were managed initially with a percutaneous antegrade approach (25 patients) or a transurethral ureteroscopic approach (25 patients). In both groups, a crossover to the other modality was at times utilized to accomplish stone removal. Success for either group was defined as complete stone removal without the need for open intervention.     

Is antegrade ureteroscopy better than retrograde ureteroscopy for impacted large upper ureteral calculi?

OBJECTIVE: This study was planned to compare the risks and advantages of antegrade and retrograde ureteroscopy for impacted large upper ureteral calculi. PATIENTS AND METHODS: From September 1996 to February 1998, ureteroscopy was offered to 43 patients. Of these, retrograde ureteroscopy was done in 20 patients, while antegrade ureteroscopy was performed in 23 patients. All these patients were followed up to evaluate the immediate and long-term success of the procedure. The incidence and nature of complications were also noted. RESULTS: During retrograde ureteroscopy, complete stone clearance was achieved in 11 patients (55%), while pushback of the whole or fragmented calculus was seen in the rest. These patients with residual calculi were later treated by extracorporeal shockwave lithotripsy (SWL). The stone-free rate at the end of 3 months was 85%. Three patients developed minor ureteroscopy-related complications. Complete stone clearance was achieved in all patients with antegrade ureteroscopy. No intraoperative or postoperative complications were encountered. CONCLUSION: In this series, antegrade ureteroscopy was found to be a safe and effective option for impacted upper ureteral calculi and assured better results than retrograde ureteroscopy.     

Urgent ureteroscopy as first-line treatment for ureteral stones: a meta-analysis of 681 patients

There are various recent studies on the use of ureteroscopy and debate on whether this should be the first-line treatment for patients with ureteral stones. The aim of this meta-analysis was to understand the role of this surgical procedure in the emergency setting as first-line treatment and to compare the immediate procedure with a delayed one in terms of stone-free rate and complications. A bibliographic search covering the period from January 1980 to March 2010 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the six studies found that fulfilled the predefined inclusion criteria. A total of 681 participants were included. The number of participants in each of the studies considered ranged from 27 to 244 (mean 113). Stone-free rates were 81.9% (72.0–91.8) for the proximal ureter, 87.3% (82.6–92.0) for the mid-ureter, 94.9% (92.1–97.6) for the distal ureter and 89.5% (86.5–92.5) overall according to the logistic regression applied. These values are not statistically significantly different from those reported in the AUA and EAU guidelines. The stone diameter seems to affect the stone-free rate. An increase of the stone diameter of 1 mm beyond 8 mm corresponded to a reduction of stone-free rate of 5% (2.4–8.0) and 8.1% (3.8–12.1) for the distal and proximal ureters, respectively. There is a complete lack of information in international guidelines on the ureteroscopic management of ureteral stones in an emergency setting and the currently available results are dispersed in a few studies in the literature. The rationale for using emergency ureteroscopy is more rapid stone clearance and relief from colic pain. According to our meta-analysis, immediate ureteroscopy for ureteral stone colic seems to be a safe treatment with a high success rate. This evidence will be validated by further randomized studies, with larger series of patients.     

Removal of asymptomatic ipsilateral renal stones following rigid ureteroscopy for ureteral stones

PURPOSE: To evaluate the feasibility and outcome of flexible ureteroscopic removal of small (<1-cm) asymptomatic renal stone(s) following rigid ureteroscopy for ureteral stones. PATIENTS AND METHODS: Ten female and nineteen male patients underwent rigid ureteroscopy and holmium lasertripsy for removal of ureteral stone(s). All had asymptomatic renal stone(s) on the same side, which were then removed using flexible ureteroscopy. The renal stones were either removed intact with a tipless Nitinol basket or fragmented with the laser to small pieces (<2 mm), with basket removal of larger fragments. The number and size of stones, total operative time, added time needed for flexible ureteroscopy, and intraoperative and postoperative complications were recorded. Follow-up at 1 month included a plain abdominal film and renal ultrasonography or noncontrast CT scan. RESULTS: Fifty-six renal stones with a mean size of 5.7 mm were treated. Fourteen patients had stones on the right side, and 15 had stones on the left. The mean total operative time was 56.5 minutes, with a mean added time of 16.7 minutes for flexible ureteroscopy. Stones were removed intact in 18 patients and fragmented in 8 patients, resulting in an immediate success rate of 90%. There were three failures. One-month follow-up confirmed all patients were either stone-free or had residual fragments <2 mm in diameter, with no new-onset hydronephrosis. CONCLUSIONS: Removal of small asymptomatic renal stones at the time of ureteroscopy for ureteral stones appears safe and effective and requires little additional operative time.     

The impact of preoperative percutaneous nephrostomy as a treatment strategy before flexible ureteroscopy for impacted upper ureteral stones with hydronephrosis

BackgroundThe treatment of impacted upper ureteral stones with hydronephrosis remains a challenge for urologists. The current study aimed to evaluate the impact of preoperative percutaneous nephrostomy (PNS) as a treatment strategy before flexible ureteroscopy (f-URS) of asymptomatic impacted upper ureteral stones with hydronephrosis.MethodsThis multicenter retrospective study included patients who underwent PNS (group A, n=61) and those who did not (group B, n=75) before f-URS for asymptomatic impacted upper ureteral stones with hydronephrosis. Impacted ureteral stones are defined as those that remain in one position for >2 months. Operative outcomes, including stone-free rate, operation time, postoperative hospital days, and complication rate, were evaluated.ResultsThere were no significant differences in age, sex, and stone size between the two groups except in the grade of hydronephrosis, with group A having more cases of advanced hydronephrosis than group B. The stone-free rate was significantly higher in group A than in group B [95% vs. 77% (P=0.004)]. However, there were no significant differences between the groups in operation time [55 vs. 55 min (P=0.84)], postoperative fever [5% vs. 5% (P=1.00)], and postoperative hospital days [2 vs. 2 days (P=0.44)]. In group A, preoperative PNS placement was performed 4 days before f-URS, and the PNS was removed postoperatively on the same day of the f-URS. Additionally, subgroup analysis was performed in cases of grade 2 and 3 hydronephrosis. A total of 110 patients, 60 who underwent f-URS with PNS and 50 who underwent f-URS without PNS, were included. The stone-free rate was significantly higher in f-URS with PNS than in f-URS without PNS [95% vs. 76% (P=0.005)]. However, no significant differences were found between the groups in operation time, ureteral injury, postoperative fever, and postoperative hospital days.ConclusionsAt grade 2 or 3 hydronephrosis, preoperative PNS as a treatment strategy for a few days prior to f-URS for impacted upper ureteral stones improved the stone-free rate without increasing the operation time and postoperative length of hospital stay.     

Rigid ureteroscopy for ureteral stones: factors associated with intraoperative adverse events

PURPOSE: To analyze some of the factors that may be associated with a higher incidence of complications during management of ureteral stones by rigid ureteroscopy. PATIENTS AND METHODS: We reviewed all ureteroscopic interventions aimed at stone extraction and/or fragmentation in our institution from 2001 through 2005. A total of 442 interventions were eligible for inclusion. Our focus was concentrated on (1) patient characteristics (age, gender, duration of symptoms, history of urinary schistosomiasis, and history of surgery involving the affected ureter), (2) stone characteristics (number, length, width, and level of the ureter affected), (3) the affected reno-ureteral unit (which side was affected, the kidney's ability to excrete contrast medium, and the status of the ureter proximal and distal to the stone), and finally (4) experience level of the surgeon in charge (junior v senior). The occurrence of intraoperative adverse events was considered a dependent variable and was statistically related to each of the above factors as independent variables. RESULTS: Intraoperative adverse events were encountered in 121 interventions including stone migration in 54, minor mucosal injuries in 24, ureteral perforation in 12, ureteral avulsion in 2, and aborted procedure due to bleeding or edema in 29. Symptomatology present for more than 3 months, a negative history of schistosomiasis, a positive history of ureteral surgery, stones above the ischial spines, stones >5 mm in width, a dilated proximal ureter, kidneys that failed to excrete contrast medium, and involvement of a more junior urologist were factors that were associated with a statistically significantly higher incidence of intraoperative complications. CONCLUSIONS: Rigid ureteroscopic stone manipulation remains a procedure that should be handled cautiously. Existence of any of the above risk factors should alert urologists, particularly at training centers, to adopt all possible precautionary measures.     

输尿管软镜技术治疗输尿管上段结石手术技巧探讨

目的 探讨输尿管软镜技术治疗输尿管上段结石的手术技巧.方法 96例输尿管上段结石患者接受一期输尿管软镜钬激光碎石治疗,先以Wolf 8.0 ～ 9.8F输尿管镜在镍钛导丝引导下直接扩张输尿管开口进入输尿管,沿导丝放置一次性导引鞘,遇到输尿管节段性狭窄时,在硬镜下直接置入输尿管球囊进行扩张,扩张后再置入输尿管导引鞘,引入输尿管软镜钬激光碎石,并使用套石篮套取出较大的结石碎片.结果 94例患者一期成功置鞘碎石,2例因输尿管狭窄难以置入输尿管软镜鞘.手术时间30～75 min,平均45 min.术后9例患者寒战发热,无其他严重并发症.术后1个月拔除D-J管,复查CT/KUB,结石清除率94.79％ (91/96).结论 输尿管软镜钬激光碎石技术是处理输尿管上段结石的有效手段,熟练掌握手术技巧及灵活采用辅助手段,能够显著提高一期输尿管软镜手术的置管成功率.     

Treatment of large impacted proximal ureteral stones: randomized comparison of percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy

PURPOSE: We compared the safety and efficacy of percutaneous antegrade ureterolithotripsy with retrograde ureterolithotripsy for large impacted proximal ureter stones in a prospective randomized manner. MATERIALS AND METHODS: A total of 91 patients with large impacted proximal ureteral stones, defined as stones >1 cm in size located between the ureteropelvic junction and the lower border of the fourth lumbar vertebra, were prospectively randomized for antegrade (44) or retrograde (47) ureterolithotripsy. Failure of the procedure (conversion to an open procedure), intraoperative and postoperative morbidity, operative time, hospital stay, stone clearance at discharge home, and follow-up were analyzed in each group. RESULTS: The main complications were bleeding (2.3%; 1 of 43) for the antegrade procedure and ureteral injury (2.3%; 1 of 44) for the retrograde procedure. Percutaneous antegrade ureterolithotripsy was associated with longer operative times (75.4+/-11.8 v 30.6+/-7.8 minutes; P<0.001), longer hospital stay (6.3+/-0.5 v 2.1+/-0.4 days; P<0.001), and a longer interval to return to normal activities (7.8+/-0.7 v 2.7+/-0.6 days; P<0.001). Nevertheless, the percutaneous antegrade procedure had a higher stone-free rate both at discharge home (95.3% v 79.5%; P=0.027), and 1 month post-procedure (100% v 86.4%; P=0.026). CONCLUSIONS: Percutaneous antegrade ureterolithotripsy is a valuable treatment modality for impacted proximal ureteral calculi larger than 1 cm, and achieves higher stone-free rates than those of retrograde ureteroscopy with holmium:YAG laser lithotripsy. The drawbacks of the antegrade procedure are longer operative time and hospital stay.     

输尿管镜钬激光碎石治疗嵌顿输尿管结石临床分析

目的：探讨输尿管镜钬激光碎石治疗嵌顿输尿管结石的有效性和安全性。方法：分析2005年10月～2008年5月输尿管镜下钬激光碎石治疗嵌顿输尿管结石268例患者临床资料，对碎石率、排石率和并发症等进行统计分析。结果：共行272例次输尿管镜钬激光碎石，一次碎石成功率为92．6％（252／272），输尿管上段与中、下段结石一次碎石成功率分别为84．6％（66／78）、95．9％（186／194）；平均手术时间35min。平均碎石时间16min；结石移位改行ESWL8例，结石位置较高改行微创经皮肾镜取石9例，改开放手术取石3例；碎石过程中黏膜撕裂4例、黏膜下假道形成6例，输尿管穿孔4例；18例术后发热（体温〉38．5℃，持续2天以上），5例出现体温〉39℃，其中1例发生感染性休克前兆；术后住院2～6天；2周～1个月拔除双J管，复查B超、KUB、IVP，结石排净率97．1％（264／272），肾盂积水由（2．6&#177;0．6）cm降至（1．4&#177;0．4）cm（P〈0．01）；随访3～24个月，3例发现输尿管狭窄。结论：输尿管镜钬激光碎石治疗嵌顿输尿管结石安全、有效，尤其适用于中、下段嵌顿输尿管结石。     

Treatment of large impacted proximal ureteral stones: randomized comparison of minimally invasive percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy

Objective

To provide appropriate evidence for treatment planning of patients with an impacted proximal ureteral stones ≥1.5 cm in size, by analyzing the therapeutic outcomes for those undergoing minimally invasive percutaneous antegrade ureterolithotripsy and retrograde ureterolithotripsy.

Patients and methods

From September 2010 to November 2011, eligible patients with impacted proximal ureteral stones ≥1.5 cm in size referred to our institute were considered for this study. The closed envelope method was used to randomize the enrolled patients to mini-PCNL (30) or retrograde ureterolithotripsy (29). The efficiency quotient (EQ) was calculated to specifically address the efficiency for both the techniques. All preoperative and postoperative data for both groups were recorded.

Results

The initial stone-free rate was 93.3 % in the mini-PCNL group and 41.4 % in the URSL group (p < 0.001). However, the overall stone-free rate at the 1-month follow-up visit after initial treatment was 100 % in the mini-PCNL group and 89.7 % in the URSL group (p = 0.07). The EQs for the mini-PCNL and URSL groups were 0.83 and 0.50, respectively.

Conclusions

Our study shows that mini-PCNL removal of large impacted proximal ureteral calculi can achieve higher stone-free rates and safe.     

Retrograde percutaneous nephrostolithotomy: an acceptable alternative to antegrade techniques

Retrograde percutaneous nephrostolithotomy was attempted by the urology service in 28 patients. Renal access was achieved with the standard Lawson retrograde nephrostomy set. Tract dilation was performed over the 0.017-inch puncture wire. Successful renal access was achieved in 28 of 30 kidneys (93 per cent) and in 1 session the targeted stone was removed in 26 (87 per cent). Two patients failed the retrograde technique and underwent successful antegrade stone removal under the same anesthesia. Two patients required open stone removal. No patient required a second percutaneous procedure for incomplete stone removal, no major bleeding episodes occurred and no complications requiring surgical intervention were encountered. The technique of retrograde percutaneous nephrostolithotomy is a safe and reliable means to achieve precise, atraumatic intrarenal access. It is easy to learn and does not require the expertise of a trained radiologist.