复杂肾结石CT三维成像与PCNL通道选择的临床意义

目的：探讨复杂肾结石CT三维成像与经皮肾镜碎石术（PCNL）操作通道选择的临床意义。方法：收集41例复杂肾结石和29例单纯肾结石患者,PCNL术前行双肾CT扫描,采用多平面重建后处理方法。观察复杂结石的位置及其与肾脏周围结构的关系,规划PCNL最佳操作通道。三维成像复杂肾结石,观察结石的分布情况。术前、术后测量结石面积、残留碎石,计算肾结石清除率和残留碎石率,运用SPSS软件进行统计学分析。结果：（1）两组肾结石在肾盂肾盏中的分布、经PCNL钬激光碎石效果均有统计学差异。（2）经第11肋间与第12肋下建立操作通道,PCNL钬激光碎石效果：单纯肾结石组两位置间无统计学差异;复杂肾结石组两位置间有明显统计学差异。（3）经上盏或中盏穿刺建立操作通道,PCNL钬激光碎石效果：单纯肾结石组两盏间无统计学差异;复杂肾结石组两盏间有明显统计学差异。结论：（1）对于复杂肾结石,根据CT三维成像和体表标志选择在第11肋间或第12肋下,及影像学定位选择后组上盏或中盏穿刺,建立PCNL操作通道具有临床应用价值;（2）PCNL的结石清除率满意,残留碎石率明显减少,提高选择及建立PCNL操作通道的成功率,可明显降低PCNL并发症的发生。     

输尿管软镜碎石术与经皮肾镜碎石术治疗 直径≤2 cm肾结石的临床疗效对比

目的 比较输尿管软镜碎石术（FURS）与经皮肾镜碎石术（PCNL）治疗直径≤2 cm肾结石患者的临床疗效,为≤2 cm肾结石患者选择合适的治疗方法提供依据。方法 选取2017年7月~2018年7月来我院就诊的160例直径≤2 cm的肾结石患者为研究对象,按手术方式分为FURS组和PCNL组,每组80例。对比两组的手术时间、术中出血量、手术成功率、住院时间、住院费用、碎石成功率以及并发症发生率。结果 FURS组平均手术时间少于PCNL组[（45.05±12.89）min vs （65.95±14.63）min],术中出血量、住院时间及费用均低于PCNL组,差异具有统计学意义（P＜0.05）。FURS组和PCNL组的手术成功率分别为95.00%和92.50%,结石清除率分别为90.79%和87.84%,差异均无统计学意义（P＞0.05）。FURS组术后并发症发生率低于PCNL组（5.26% vs 17.57%）,差异具有统计学意义（P＜0.05）。结论 治疗直径≤2 cm的肾结石,FURS和PCNL两种手术方式均具有较高的结石清除率,但PCNL的术后并发症发生率更高,相比PCNL,FURS具有术中出血量少、住院时间短以及住院费用低等优势,因此FURS是治疗直径≤2 cm肾结石更好的手术选择。     

Guy's结石评分和改良Clavien分级方法预测PCNL术后结石清除率和并发症的研究

目的 探讨Guy's结石评分（GS）预测经皮肾镜碎石取石术（PCNL）术后结石清除率及利用改良Clavien分级方法（MCC）预测PCNL术后并发症发生的可靠性。方法 选取2015年1月~2016年12月我院收治的155例行PCNL的肾结石患者（160个肾单位）,所有患者根据术前泌尿系CT结果应用GS进行肾结石分组,利用术后KUB结果评估患者术后结石清除率,并且通过MCC预测患者术后并发症的发生。结果 160个行PCNL的肾单位中,GS1、GS2、GS3及GS4分别为15、63、73和9个。每个组的结石最大直径:GS1=25 mm,GS2=28 mm,GS3=48 mm,GS4=69 mm,差异具有统计学意义（P＜0.05）。根据GS进行数据分析,四组手术时间［GS1=（32.50±14.10）min,GS2=（55.80±29.70）min,GS3=（80.80±35.10）min,GS4=（116.30±54.80）min］,通道数［GS1=1个,GS2=（1.10±0.30）个,GS3=（1.20±0.50）个,GS4=（2.00±1.30）个］,结石立即清除率（GS1=100.00%,GS2=87.30%,GS3=67.10%,GS4=66.70%）,患者术后并发症（GS1=6.70%,GS2=28.60%,GS3=31.50%,GS4=44.40%）比较,组间差异有统计学意义（P＜0.05）。首次PCNL失败的患者,无论最终再次PCNL成功与否,患者的结石最终清除率比较,差异无统计学意义（P＞0.05）。结论 GS和MCC可精确评估患者经皮肾镜术后结石清除率及有效预测患者术后并发症的发生。     

基于彩色3D打印技术的肾结石个性化手术治疗

目的　探究彩色3D打印技术在泌尿外科经皮肾镜碎石取石术（PCNL）中的应用及临床意义。 方法　随机选择16例彩色3D打印肾结石患者作为A组,利用逆向工程与彩色3D打印技术进行重建并备1:1大小完整的肾脏、肾血管及肾彩色结石3D模型。选取23例传统PCNL患者作为B组,观察比较A、B两组的手术时间、术中出血量、住院时间、并发症以及结石清除率。手术医师填写模型评估调查问卷,患方填写调查问卷并进行评分。 结果　成功打印出患者的彩色3D结石模型。纳入研究的两组患者年龄、结石大小、铸型结石量无统计学差异。两组的预估穿刺深度与实际穿刺深度分别为A组：（6.5±0.8）cm vs（6.8±1.1）cm （P>0.05）; B组：（6.5±1.5）cm vs （7.6±1.8）cm（P<0.05）。两组医师评分分别为（8.4±0.4）,（6.5±0.5）（P<0.05）;患者评分分别为（9. 0±0.7）,（7.2±0.6）（P<0.05）。两组的结石清除率,手术时间,术中出血量,住院时间,并发症例数分别为： 81.25% vs 73.91%（P<0.05）,（52.27±9.64）min vs（67.39±10.81）min（P<0.05）,（55.49±18.16）mL vs（92.92±22.17）ml（P<0.05）,（6.48±1.51）d vs（7.32±1.43）d（P >0.05）,1例vs 3例（P<0.05）。这些结果提示使用彩色3D打印结石模型预估的穿刺点和穿刺深度与实际手术基本相符,出血量更少,手术时间更短、并发症更少。手术医师评价彩色3D打印结石模型满意,患方术前谈话满意度更高。 结论　彩色3D打印技术能够使泌尿外科医生在术前精确、直观地了解肾结石情况,较传统手术获得更高的精确性和安全性。使用彩色3D打印结石模型对患者进行病情讲解和术前谈话可以提高其对肾结石及手术并发症的理解,有利于构建良好的医患关系。     

超声引导微创经皮肾镜碎石取石术治疗复杂性肾结石的疗效及安全性分析

目的:分析经超声引导微创经皮肾镜碎石取石术(Percutaneous nephrolithotomy,PCNL)治疗复杂性肾结石(Renal calculi,RC)患者的疗效及安全性.方法:选取我院88例复杂性RC患者(2018年2月至2020年4月),随机分为两组,各44例.对照组接受开放性肾切开取石术治疗,观察组接受超声引导微创PCNL治疗,比较两组结石清除率、手术相关指标(手术时长、术中失血量)、术后恢复情况(下床活动及住院时间)、术前及术后1周肾功能[血清尿素氮(Blood urea nitrogen,BUN)、脂质运载蛋白(Neutrophil gelatinase-associated lipocalin,NGAL)、肌酐(Serum creatinine,Scr)]、术前及术后1d炎性应激反应[白细胞计数(White blood cell,WBC计数)、C反应蛋白(C-reactive protein,CRP)、白细胞介素-10(Interleukin-10,IL-10)]、并发症.结果:与对照组对比,观察组结石清除率较高(P<0.05);观察组手术、下床活动及住院时间均较对照组短,术中失血量较对照组少(P<0.05);术后1周,观察组血清BUN、NGAL、Scr水平均低于对照组(P<0.05);术后1 d,与对照组对比,观察组WBC计数、CRP、IL-10水平均较低(P<0.05);观察组并发症发生率较对照组低(P<0.05).结论:超声引导微创PCNL治疗复杂性RC,能优化手术相关指标,提高结石清除率且对患者肾功能、炎性应激反应影响较小.     

超微经皮肾镜与输尿管软镜碎石取石术在肾结石(≥2.0cm)治疗中的效果对比

目的:对比超微经皮肾镜与输尿管软镜碎石取石术在肾结石(≥2.0 cm)患者疗效.方法:将我院88例肾结石(≥2.0 cm)患者按照取石术分为超微经皮肾镜组(45例)和输尿管软镜组(43例).分别于术后2 d或4周评估两组结石清除率、炎症因子水平、并发症发生情况.结果:术后2 d,超微经皮肾镜组的结石清除率明显高于输尿管软镜组(P<0.05);而术后4周两组结石清除率、并发症总发生率和术后2 d炎症因子无明显差异;超微经皮肾镜组术后膀胱刺激征发生率明显低于输尿管软镜组(P<0.05).结论:超微经皮肾镜碎石取石术能有效预防结石≥2.0 cm的肾结石患者术后并发症并减轻机体炎症损伤,有效且安全.     

经皮肾镜碎石取石术的疗效及术后复发的危险因素分析

目的 观察经皮肾镜碎石取石术（PCNL）治疗泌尿系结石的临床疗效及术后复发的危险因素。方法 选择我院2012年7月~2019年4月160例行PCNL患者的临床资料,收集患者年龄、性别、病例分型、诊断、麻醉方式、切口类型、愈合情况、住院时长和术后愈合情况。采用Logistic回归分析术后结石复发的危险因素。结果 160例患者中肾积水伴肾结石60例（37.50%）、肾积水伴输尿管结石35例（21.87%）、单纯肾结石41例（25.67%）、其他类型泌尿系结石24例（15.00%）;男女比例为1∶0.8, 2017年及以后,女性手术患者增加的幅度大于男性,均为二类切口,甲级愈合。不同疾病类型的患者住院时间比较,差异有统计学意义（P＜0.05）;年龄是结石复发的危险因素（OR=1.058,95% CI:1.017~1.099）。结论 经皮肾镜取石术治疗泌尿系结石疗效确切,患者预后良好,肾积水伴肾结石/输尿管结石的患者住院时间较单纯肾结石患者长,高龄患者应作为结石复发的重点预防群体。     

经皮肾镜钬激光治疗257例肾结石患者回顾性探讨

目的：就我科室在既往3年内接诊的经皮肾镜钬激光治疗的肾结石患者的治疗效果进行回顾性分析。方法择取我科室在2010年8月~2013年8月间收治的257例肾结石患者,并对全部患者实施经皮肾镜钬激光进行治疗。结果257例中213例一期结石清除,一期结石清除率为82.88%,36例患者行二期结石清除,二期结石清除率为14.01%,合计结石清除率96.89%(249/257)；剩余8例患者经体外冲击碎石术进行治疗,均将残余结石清除。257例患者在手术过程及术后均未出现明显大出血及其他的不良反应。结论临床在面对肾结石患者时,对其实施经皮肾镜钬激光进行治疗的效果是非常理想的,值得在各医院进行推广应用。     

16F微通道输尿管镜经皮肾钬激光治疗肾结石与输尿管软镜治疗肾结石的比较

【摘要】目的:分析16F微通道输尿管镜经皮肾钬激光治疗肾结石与输尿管软镜治疗肾结石的临床效果。方法:选择90例肾结石（<2 cm）患者作为研究对象,根据随机数表法将所选患者分为观察组和对照组,每组45例。对照组患者采用16 F微通道输尿管镜经皮肾钬激光治疗,观察组患者采用输尿管软镜治疗。观察两组患者术中出血量、手术时间、血红蛋白下降、住院时间、住院费用、结石清除率、血尿素氮（BUN）、血清肌酐（Cr）水平以及并发症发生情况。结果:观察组患者术中出血量、血红蛋白下降、住院时间及住院费用［（6.19±1.37） mL、（2.37±1.92） g/L、（4.26±1.04） d、（3 325.48±413.51）元］均明显少于对照组［（24.38±6.52） mL、（7.76±5.83） g/L、（7.15±2.17） d、（4 226.15±546.82）元）］,差异有统计学意义（P<0.05）;两组患者在手术时间上的比较差异无统计学意义（P>0.05）;观察组患者术后即刻清石率（95.56%）比对照组（82.22%）更高,对比的差异有统计学意义（P<0.05）;两组患者术后1月清石率比较差异不明显,无统计学意义（P>0.05）;术后,观察组患者BUN和Cr水平［（19.86±0.19） mmol/L、（315.08±10.84） μmol/L］高于对照组［（15.44±0.32） mmol/L、（267.29±19.25） μmol/L］,对比的差异有统计学意义（P<0.05）;观察组患者术后并发症的发病率（8.89%）显著高于对照组（28.89%）,比较的差异有统计学意义（P<0.05）。结论:与16F微通道输尿管镜经皮肾钬激光治疗相比,输尿管软镜治疗结石直径<2 cm的肾结石患者具有术中出血量少、创伤小、恢复快、并发症少的优点,建议在临床进一步推广应用。     

输尿管镜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 观察输尿管镜钬激光碎石术与体外冲击波碎石术治疗输尿管结石的临床疗效。方法 选取2015年1月~2018年10月在余江县人民医院治疗的输尿管结石患者72例,采用随机数字表法分为对照组和观察组,各36例。对照组采用体外冲击波碎石术治疗,观察组采用输尿管镜钬激光碎石术治疗,比较两组清石率、手术时间、住院时间以及并发症（血尿、输尿管水肿、结石移位）发生情况。结果 观察组结石直径≥1 cm清石率为92.30%,高于对照组的85.71%,差异有统计学意义（P＜0.05）;观察组结石直径＜1 cm清石率为91.30%,与对照组的90.90%比较,差异无统计学意义（P＞0.05）;观察组结石直径≥1 cm、＜1 cm手术时间均短于对照组,差异有统计学意义（P＜0.05）;观察组并发症发生率为5.56%,低于对照组的23.08%,差异有统计学意义（P＜0.05）。结论 输尿管镜钬激光碎石术治疗输尿管结石手术时间短,并发症少,且对于结石直径＞1 cm者效果更优。     

Novel insights into renal mineralization and stone formation through advanced imaging modalities

ABSTRACT

Purpose/Aim: The most common kidney stone composed of calcium oxalate forms on interstitial calcium phosphate mineral known as a Randall’s plaque (RP). Due to limited information about events leading to the initial deposition of nanometer size interstitial calcium phosphate pre-clusters, there continues to be a debate on the initial site of calcium phosphate deposition and factors leading to stone formation. Materials and Methods: High-resolution X-ray micro-computed tomography (CT), and light and electron microscopy techniques were used to characterize human renal pyramids and five representative kidney stones with identifiable stems. Mineral densities of mineralized aggregates within these specimens were correlated with micro- and ultra-structures as seen using light and electron microscopy techniques. Results: The earliest detectable biominerals in the human renal papilla were proximal intratubular plate-like calcium phosphate deposits. Unoccluded tubules in stems connected to calcium phosphate stones were observed by electron microscope and X-ray micro-CT. These tubules were similar in diameter (30–100 μm) and shape to those observed in the distal regions of the renal papilla. Conclusions: Observations were patterned through a novel and unified theory of stepwise-architecture guided biomineralization (a combination of smaller structures leading to a larger but similar structural framework). A plausible stepwise progression in renal biomineralization is proposed; proximal intratubular calcium phosphate deposits can lead to interstitial yet calcium phosphate rich RP and mature into a stem on which a calcium oxalate stone grows within the collecting system of a kidney.     

尿结石患者体重指数对血尿生化及结石成分的影响

目的 分析尿路结石患者体重指数（BMI）对24h尿液、血液生化指标及结石成分的影响。方法 对2017年1月~2018年7月我院收治的尿路结石患者150例进行血尿生化分析,按照BMI分为体重正常组45例、超重组65例,肥胖组40例,检测24h尿钙、磷、尿酸、血钙、血磷、血尿酸及尿pH等指标,同时收集患者结石标本进行红外光谱结石成分分析。比较组间各指标及结石成分的差异性;根据结石成分不同分为四组（草酸钙组、磷酸钙组、尿酸组和磷酸镁铵组）,比较组间各指标的差异性。结果 超重组和肥胖组尿液pH均低于正常组（P＜0.05）;体重正常组患者24h尿钙、尿磷、尿酸和血磷、尿酸明显低于超重或肥胖组（P＜0.05）。磷酸镁铵组患者尿液pH高于其它组（P＜0.05）。尿酸组和磷酸钙组24h尿磷高于草酸钙组和磷酸镁铵组（P＜0.05）。尿酸组24h尿酸高于其它组,磷酸镁铵组24h尿酸低于其它组（P＜0.05）。尿酸组血尿酸高于其它组,磷酸镁铵组血尿酸低于磷酸钙组和尿酸组（P＜0.05）。磷酸镁铵组BMI低于其它组（P＜0.05）。肥胖组、超重组草酸钙、尿酸结石比例均高于正常组（P＜0.05）,而磷酸镁铵比例则低于正常组（P＜0.05）。BMI与尿液pH的相关性分析表明两者高度相关（r=-0.725,P＜0.05）。结论 肥胖及超重对血尿生化、血生化、尿pH及结石成分比例有一定影响,且存在性别差异,建议肥胖或超重的尿结石患者行血尿生化、结石成分等评估,注意饮食控制、减重等措施。     

Microhardness measurements of renal calculi: regional differences and effects of microstructure.

Microhardnesses of five types of renal calculi: calcium apatite (82.5%)/magnesium ammonium phosphate hydrogen (10%)/calcium oxalate monohydrate (7.5%); calcium apatite (95%)/calcium oxalate monohydrate (5%); magnesium ammonium phosphate hydrogen (90%)/calcium apatite (10%); calcium oxalate monohydrate (85%)/calcium apatite (15%); and cystine (100%) were measured. Using Knoop and Vickers indenters the effects of chemical composition and microstructure on the microhardness measurement were assessed. Calcium oxalate monohydrate, magnesium ammonium phosphate hydrogen, and cystine stones, without apparent structure pattern, showed neither regional nor directional differences in their microhardness. In contrast, calcium apatite stones, with distinctly concentric laminae structure, showed regional variations which were correlated with the chemical composition of stone constituents. Scanning electron microscopy of the indenter impressions were taken to help in interpreting the directional dependence in Knoop hardness measurements with respect to the microstructure of the calculi. Vickers measurements showed the crystalline stones were isotropic within a layer. Combined results of Knoop and Vickers measurements indicate that the anisotropic Knoop hardness readings seen in the laminated regions were structural but not material-based. Implications of the results for the fragmentation of renal calculi in extracorporeal shock wave lithotripsy are discussed.     

草酸钙肾结石大鼠模型肾组织中Klotho的表达及其意义

目的:初步探究Klotho在草酸钙肾结石大鼠模型肾组织中的表达及其意义.方法:将30只6～8周龄雄性SD大鼠随机分为结石组和对照组,每组15只,结石组采用乙二醇和氯化铵诱导法构建草酸钙肾结石模型.28 d造模完成后采集大鼠24 h尿液、血清标本,比较两组血肌酐(Cr)、尿素氮(BUN)、血Ca2+、24 h尿Ca2+及草酸(Ox)指标;采集肾组织标本,HE染色比较各组肾脏病理改变及草酸钙结晶的沉积情况,荧光定量PCR、Western印迹及免疫组织化学染色检测两组肾组织中Klotho mRNA及蛋白表达,并对肾脏氧化应激相关指标总抗氧化能力(total antioxidant capacity,T-AOC)、丙二醛(malondialdehyde,MDA)、过氧化氢酶(catalase,CAT)进行测定.结果:结石组在光学显微镜观察下可见草酸钙结石晶体沉积并有伴肾小管病理性改变,血清Cr,BUN,24 h尿Ca2+及Ox较对照组升高,差异有统计学意义(P＜0.01),血Ca2+差异无统计学意义(P＞0.05);结石组Klotho mRNA及蛋白表达较对照组下降,差异有统计学意义(P＜0.01);肾脏氧化应激相关指标中,结石组T-AOC,CAT较对照组降低,MDA较对照组升高,差异均有统计学意义(P＜0.01).结论:草酸钙肾结石的形成与Klotho表达异常及氧化应激反应有关;Klotho可能通过调控Ca2+代谢和氧化应激反应参与草酸钙肾结石的发病过程.     

Contrasting Histopathology and Crystal Deposits in Kidneys of Idiopathic Stone Formers Who Produce Hydroxy Apatite,Brushite, or Calcium Oxalate Stones

Our previous work has shown that stone formers who form calcium phosphate (CaP) stones that contain any brushite (BRSF) have a distinctive renal histopathology and surgical anatomy when compared with idiopathic calcium oxalate stone formers (ICSF). Here we report on another group of idiopathic CaP stone formers, those forming stone containing primarily hydroxyapatite, in order to clarify in what ways their pathology differs from BRSF and ICSF. Eleven hydroxyapatite stone formers (HASF) (2 males, 9 females) were studied using intra‐operative digital photography and biopsy of papillary and cortical regions to measure tissue changes associated with stone formation. Our main finding is that HASF and BRSF differ significantly from each other and that both differ greatly from ICSF. Both BRSF and ICSF patients have significant levels of Randall's plaque compared with HASF. Intra‐tubular deposit number is greater in HASF than BRSF and nonexistent in ICSF while deposit size is smaller in HASF than BRSF. Cortical pathology is distinctly greater in BRSF than HASF. Four attached stones were observed in HASF, three in 25 BRSF and 5–10 per ICSF patient. HASF and BRSF differ clinically in that both have higher average urine pH, supersaturation of CaP, and calcium excretion than ICSF. Our work suggests that HASF and BRSF are two distinct and separate diseases and both differ greatly from ICSF. Anat Rec, 297:731–748, 2014. © 2014 Wiley Periodicals, Inc.     

Why oral calcium supplements may reduce renal stone disease: report of a clinical pilot study

AIMS: To investigate whether increasing the daily baseline of gut calcium can cause a gradual downregulation of the active intestinal transport of calcium via reduced parathyroid hormone (PTH) mediated activation of vitamin D, and to discuss why such a mechanism might prevent calcium oxalate rich stones. To demonstrate the importance of seasonal effects upon the evaluation of such data. METHODS: Within an intensive 24 hour urine collection regimen, daily calcium supplementation (500 mg) was given to five stone formers for a 10 week period during a six month crossover study. In a further population of patients on follow up for previous renal stone disease, observations were made on 1066 24 hour urine samples collected over five years in respect of seasonal effects relevant to the interpretation of the study. RESULTS: In the group of patients on calcium supplements the following results were found. During calcium supplementation, the proportion of urine calcium to oxalate was higher (increased calcium to oxalate molar ratio), the 24 hour urine product of calcium and oxalate did not rise, and urine oxalate was lower during the first six weeks of supplementation. Twenty four hour urine calcium was 10.2% higher than baseline in the final four weeks of the 10 weeks of supplementation. Twenty four hour urine phosphate was 11.4% lower during the first six weeks of supplementation, but then rose while the patients were still on supplementation; renal tubular reabsorption of phosphate (TmP/GFR) mirrored the urine phosphate changes inversely. PTH was higher after stopping supplementation, but 1,25-(OH)2-cholecalciferol changes were not detected. In the 1066 urine samples collected over five years the following results were found. Calcium and oxalate excretion correlated positively and not inversely. Urine calcium and phosphate excretion were 5.5% and 2.5% higher, respectively, in "light" months of the year compared with "dark" months. A post summer decline in both urine calcium and urine phosphate was relevant to the interpretation of the study. CONCLUSIONS: Regular calcium supplementation does not raise the product of calcium and oxalate in urine and the proportion of oxalate to calcium is reduced. The underlying mechanisms of the changes seen in phosphate, calcium, and PTH and the observations on 1,25-(OH)2-cholecalciferol are not clear. Observed changes in phosphate could possibly be part of a calcium regulating feedback loop operating over a period of weeks. In evaluating these mechanisms background seasonal effects are important. It is possible that "programming" of the gut mucosa in terms of calcium transport is a major determinant of the relation between calcium and oxalate concentrations in urine and their relative abundance. Increased oral calcium, in association with a reduction of the relative proportion absorbed, may be pertinent to the prevention of calcium oxalate rich stones.