The staghorn calculus: anatrophic nephrolithotomy versus percutaneous litholapxy and extracorporeal shockwave therapy versus extracorporeal shockwave lithotripsy monotherapy. A report of over 6 years' experience

From 1982 to December 1987, 71 with incomplete (C4 by Rocco) and 37 with complete (C5 by Rocco) staghorn calculi underwent anatrophic nephrolithotomy (AN; n = 29), or combined percutaneous nephrostolithotomy and ESWL (PCNL + ESWL; n = 21), or ESWL monotherapy without or with preoperative JJ stenting (n = 37/21). The patients with incomplete staghorn calculi (C4) and preoperative ureteral stenting were free of stones after 6 months in 15 of 17 cases (88%), which is comparable to our results with AN (90%) and combined PCNL + ESWL (85%). ESWL without JJ stenting were free of stones in only 52%. The treatment of infected C4 calculi with JJ stenting was especially successful (92%). Complete staghorn calculi (C5) represented the best results after AN (78%) and combined PCNL + ESWL (75%), in contrast to ESWL without JJ stenting (44%). Four patients with C5 calculi were treated with ESWL and preoperative stenting, three of them were free of stones after 6 months. For incomplete staghorn calculi (C4), ESWL monotherapy with JJ stenting seems to be a justifiable noninvasive method which offers excellent results in stone elimination (88%), with lower costs than AN or PCNL + ESWL. More invasive procedures should be reserved for complete staghorn calculi.     

经皮肾镜取石术联合套石网篮治疗 ESWL 排空障碍的输尿管上段结石合并肾盏结石

目的：探讨经皮肾镜取石术（ percutaneous nephrolithotomy , PCNL ）联合套石网篮治疗体外震波碎石（ extracorporeal shock wave lithotripsy ,ESWL）排空障碍的肾盏及输尿管上段结石的临床疗效。方法2009年4月～2012年8月采用PCNL联合套石网篮治疗ESWL排空障碍的输尿管上段结石合并肾盏结石78例。 B超定位,58例肾盏结石长径＜1 cm或分布于单组肾盏,采用微通道经皮肾镜下气压弹道碎石;20例肾盏结石长径＞1 cm或分布于多组肾盏采用新型经皮肾镜标准通道下气压弹道或超声联合气压弹道碎石。结果78例手术均获成功,手术时间52～98 min,平均61 min。71例一期取净结石,结石取净率91．0％（71/78）;2例二期碎石后取净;3例辅助行ESWL治疗;2例因残留结石较小药物排石排出。住院5～12 d,平均7．2 d。无胸膜及其他重要脏器损伤,无大出血等严重并发症。78例随访3个月,未见结石残留。结论PCNL术中联合套石网篮可减少皮肾穿刺通道数,避免大出血及集合系统狭窄风险,是处理ESWL排空障碍的肾盏及输尿管上段结石恰当的选择。     

Minimal-invasive PCNL (Mini-Perc)

Extracorporeal shock wave lithotripsy (SWL) is the current treatment modality of choice for upper urinary tract calculi. For stones with a diameter >2 cm and in lower calyceal stones and diverticular stones, the stone-free rate of SWL is rather poor. In these cases, conventional percutaneous nephrolithotomy (PCNL) leads to an increased stone-free rate, but morbidity with conventional PCNL is significant higher than in SWL. With the invention of miniaturized nephroscopes (mini-perc), new treatment options are available. The experience based on hundreds of treatments using mini-perc show comparable results of mini-perc to conventional PCNL and a complication rate comparable to that for SWL. These favorable results are independent of stone size, stone location, and patient age. In summary, mini-perc can be recommended as a primary approach to stones of the upper urinary tract exceeding 1 cm, larger lower-pole stones, and calyceal diverticular stones. Mini-perc can be regarded as an alternative treatment modality to conventional PCNL.     

Combination of percutaneous surgery and extracorporeal shockwave lithotripsy for the treatment of large renal calculi

Open surgery for large or complex renal calculi may be difficult, particularly in patients with recurrent stones, and may require special operative techniques to preserve renal function. With the advent of percutaneous nephrolithotripsy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) new approaches are now available for the treatment of these difficult cases. A review of 67 patients who presented between November 1984 and May 1986 has shown that it was possible to clear large stones in 71% of patients using a combination of PCNL and ESWL. There was no mortality; the morbidity for both procedures was low and was less than when either procedure was used alone for the treatment of complex stones.     

Percutaneous chemolitholysis of cystine stone

Although cystine stone accounts for only 1-3% of renal calculi, many of the pure cystine stones usually can not be fragmented by ESWL and the residuals after PCNL is quite common. Percutaneous dissolution alone or combined with ESWL and PCNL could successfully dissolve these stones including all the residuals. This paper reported seven patients (8 pieces of renal and 2 pieces of ureteral stones) with cystine calculi in whom percutaneous renal irrigation or per-ureteral catheter irrigation with tromethamine-E (THAM-E) were performed for a relatively short period of time. All the stones disappeared completely or near completely. The authors recommend that percutaneous irrigation alone (including irrigation with ureteral catheter) or combined with PCNL and ESWL are the method of choice in the treatment of pure cystine stone of the kidney.     

肾下盏结石的治疗方法选择

目的探讨肾下盏结石较佳的治疗方法。方法对53例肾下盏结石患者中的42例,结石大小在0.6~1.5cm,行ESWL治疗,1周后复查KUB或IVP;11例结石大小在1.5cm以上,采用PCNL,在X线或B超引导下进行,术后2~3天复查。结果行ESWL者最多碎石3次,3个月结石排净率为71%;PCNL者均为一期,术后1例发热,无大出血、尿外渗等并发症;2例结石残留,行二期取石。结论根据肾下盏结石大小,对1.5cm以内的结石行ESWL治疗,结石大小在1.5cm以上采用PCNL治疗,能获得较好的效果。     

Extracorporeal shockwave lithotripsy, endourology and open surgery: the management and follow-up of 200 patients with urinary calculi

The management and follow up of 200 consecutive patients with renal and ureteric calculi are presented. The primary treatment of 185 (92.5%) was by extracorporeal shockwave lithotripsy (ESWL), of whom three (1.6)%) with large calculi underwent percutaneous nephrolithotripsy (PCNL) prior to ESWL as a planned combined procedure. Twelve (6%) were treated by PCNL or ureterorenoscopy (URS) as their definitive treatment and three (1.5%) by conventional open renal and ureteric surgery. The average in-patient stay was 3.8 days and most returned to normal activity within one day of discharge. Of the 185 patients 102 (55%) required no analgesia after treatment by ESWL, 29 (15.6%) required parenteral analgesia and the rest were comfortable with oral non-narcotic medication. Thirty (16%) required auxillary treatment by percutaneous nephrostomy (PCN), PCNL and URS following ESWL for obstructive complications from stone particles. Two required further ESWL and one PCNL at three months for large fragments. Overall, open surgery was required for only 1% of renal calculi and 13% of ureteric stones. These results are consistant with the extensive West German experience confirming that most urinary calculi are now best managed by ESWL and endoscopic techniques. Where these facilities are available open surgery should only be necessary for less than 5% of upper urinary tract stones.     

ESWL与输尿管镜碎石联合处理上尿路结石

目的：探讨对部分上尿路结石采用ESWI．与输尿管镜碎石联合处理的方法。方法：对70例上尿路结石患者采用ESWI。与输尿管镜下钬激光碎石（URS）联合交替治疗。其中输尿管结石48例,。肾结石22例。结果：结石总排净率为91．4％00（64／70）,其中输尿管结石排净率为95．8％（46／48）,肾结石排净率为81．8％（18／22）。3例治疗失败,其中1例输尿管结石因输尿管狭窄无法入镜;另2例肾结石,1例因交替治疗次数过多中途停止治疗,1例因结石硬度过大ESWI,不佳,均改为PCNL术。结论：ESW[。与URS联合交替进行的疗法处理上尿路结石,避免了创伤性治疗,扩大了ESWI,治疗范围,降低了URS手术难度,缩短了URS操作时间,提高了结石排净率,患者创伤微小、恢复快、并发症少,是治疗上尿路结石,特别是部分复杂性上尿路结石较理想的方法之一。     

Extracorporeal shock wave lithotripsy for large renal stones. To what size is extracorporeal shock wave lithotripsy alone feasible?

The complications after extracorporeal shock wave lithotripsy (ESWL) for large renal calculi could be reduced by insertion of ureteral stents. In a prospective study, the critical stone size for ESWL combined with ureteral stenting was looked for. Sixty consecutive patients entered the study, 17 patients suffered from renal calculi with a length of greater than 4 cm and a width of greater than 3 cm (group 1), and in 43 patients the calculi measured between 4 x 3 and 2.5 x 1.5 cm2 (group 2). ESWL was performed with the Dornier apparatus HM-3. A ureteral stent was placed immediately before ESWL. In group 1 with very large stones, significantly more obstructive problems were encountered. Three months after ESWL, only 6 of 14 (43%) were free of stones or with stone material likely to discharge spontaneously. In group 2, a success rate of 25 of 29 (86%) was noticed, which was considered satisfactory. For most stones greater than 4 x 3 cm2 the combination of percutaneous nephrolithotomy and ESWL seems to be the preferred treatment.     

超声联合气压弹道碎石术治疗复杂性肾结石(附78例报道)

目的:探讨经皮肾镜下超声联合气压弹道碎石术治疗复杂性肾结石的方法及疗效。方法:B超引导下穿刺并扩张建立F22经皮肾镜操作通道,在F20.8肾镜下采用瑞士第三代EMS超声气压弹道碎石机,争取一期粉碎结石并主动吸出体外。结果:78例83侧肾结石,单侧结石清除时间43~156min,平均89min。结石粉碎率100%,结石取净率85.6%(71/83)。术后随访1~9个月,平均5.6个月,均无严重并发症如出血及感染,亦无结石复发。结论:经皮肾镜超声联合气压弹道碎石术可以明显地提高复杂性肾结石取石的效率,降低结石的残余率,具有高效、安全、微创的特点,有较好的推广应用价值。     

Clinical experience and results of ESWL treatment for 3,093 urinary calculi with the Storz Modulith SL 20 lithotripter at the Singapore general hospital

We study the outcome of 2,700 patients treated for 3,093 urinary calculi over a period of 60 months. All patients underwent Extracorporeal Shock Wave Lithotripsy (ESWL) treatment using the Storz Modulith SL20, predominantly on an outpatient basis (99.9% using intravenous pethidine for analgesia). The treatment outcome of 1,666 renal calculi and 1,427 ureteric calculi were analysed and stratified according to size and site. Follow-up status at 3 months was available for 91.8% of patients. For renal calculi, the overall success rate was 81% (re-treatment rate 29.7%). The majority of failures were stones larger than 2 cm and those situated in the lower pole of the renal calyces. The overall success rate for ureteric calculi is 85% with similar clearance rates throughout the ureter (re-treatment rate 22.8%). Failures were predominantly with stones larger than 2 cm. For the entire series, the morbidity rate requiring hospital admission was 2.9%, there was no mortality. The commonest cause for admission was for pain control (1.8%). To our knowledge, our experience with this lithotriptor is the largest to date. We have demonstrated that ESWL with Storz Modulith SL20 is safe, well tolerated and highly effective for the treatment of urolithiasis.     

复杂性肾结石治疗方法的比较

目的：探讨复杂性肾结石的首选治疗方法。方法：分别应用ESWL、开放手术、经皮肾镜取石术（PCNL）及微创经皮肾镜取石术（MPCNL）治疗复杂性肾结石患者132例,并随访观察其疗效及并发症发生率。结果：采用ESWL治疗56例,3个月后结石排净率53．6％;采用开放手术治疗37冽,手术均获成功,结石排净率达96％;采用PCNI。治疗39例,3个月后结石排净率为92％。结论：PcNL＋MPCNL＋ESWL为复杂性。肾结石的首选治疗方法,可适合于绝大部分复杂性肾结石患者,其中ESWI。适用于无肾盂肾盏扩张的复杂性且硬度较低的肾结石。开放手术可作为其他治疗方法的适当补充术式。     

斜仰截石位下经皮肾镜取石术的临床研究

目的 研究斜仰截石位经皮肾镜取石术( percutaneous nephrolithotomy,PCNL)治疗肾和输尿管上段结石的临床价值. 方法 采用斜仰截石位行PCNL治疗肾输尿管结石患者68例,其中肾结石28例,输尿管上段结石40例.结石最大径平均(2.1 ±1.6) cm. 结果 本组68例患者均手术成功,无一例中转开放手术.采用单通道64例,双通道4例.平均手术时间(88.0 ±36.5) min,术中平均出血量(150.0±70.5) ml.一次性结石清除率为89.7％(61/68),残留结石7例,其中4例二期手术取尽结石,3例行ESWL治疗.术后严重出血3例,行输血治疗;高热2例,予敏感抗生素治疗后痊愈.无胸膜、结肠等腹腔脏器损伤等并发症发生. 结论 斜仰截石位行PCNL术治疗肾输尿管结石安全有效,患者耐受性好.     

Treatment of proximal ureteral calculi: holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy

PURPOSE: We compared the safety and efficacy of ureteroscopy with intracorporeal holmium:YAG laser lithotripsy and extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for proximal ureteral calculi. MATERIALS AND METHODS: A total of 67 patients underwent 81 primary procedures, including in situ ESWL with a DoLi 50 lithotriptor (Dornier Medical Systems, Inc.) or ureteroscopy combined with holmium:YAG laser lithotripsy for proximal ureteral calculi. RESULTS: Of the primary procedures 81 involved proximal ureteral calculi, including 35 done for calculi 1 cm. or greater. The initial stone-free rate in patients with calculi 1 cm. or greater was 93% for ureteroscopy combined with holmium:YAG laser lithotripsy and 50% for in situ ESWL. The efficiency quotient for treating proximal ureteral calculi 1 cm. or greater was calculated as 0.76 for ureteroscopic lithotripsy and 0.43 for ESWL. For proximal ureteral calculi less than 1 cm. the initial stone-free rate was 100% and 80% for ureteroscopic laser lithotripsy and ESWL, respectively. The efficiency quotient was calculated as 0.81 for ureteroscopic lithotripsy and 0.72 for ESWL for treating proximal ureteral calculi less than 1 cm. There were no major complications in either group and all procedures were performed on an outpatient basis. CONCLUSIONS: Our study demonstrates that ureteroscopy combined with holmium:YAG laser lithotripsy is an acceptable treatment modality for all proximal ureteral calculi and excellent results are achieved for calculi 1 cm. or larger. Although the stone-free rate was better for smaller stones with ureteroscopic laser lithotripsy, efficiency quotients were similar. Therefore, ESWL should remain first line therapy for proximal ureteral calculi less than 1 cm. because of less morbidity, and a lesser anesthesia and analgesic requirement.     

Management of lower-pole caliceal stones

A series of 205 urologists answered questions about their choice of treatment for lower-caliceal stones. The preferred approaches were extracorporeal shockwave lithotripsy (SWL) for stones <1 cm and percutaneous nephrolithotomy (PCNL) for those >2 cm. For stones of 1 to 2 cm, 65% preferred SWL and 30% would advise PCNL. Thus, SWL is recommended for lower-caliceal stones more frequently than is justified by published success rates. Continued efforts need to be made to inform practicing urologists regarding the most appropriate therapy for patients with lower-pole stones >1 cm.     

小儿肾结石的ESWL和PCNL治疗

目的　总结小儿肾结石ESWL和经皮微造瘘输尿管镜取石术 (mini PCNL)治疗经验。　方法　回顾性分析 10 5例小儿肾结石诊治资料 ,男 72例、女 3 3例 ,平均年龄 8.7岁。其中伴尿路畸形 2 1例 (2 0 .0 % )。ESWL治疗 68例 ;mini PCNL治疗 3 3例 ,4例联合ESWL ;改行开放手术 4例。　结果　 68例ESWL治疗 92次 ,结石完全排空 57例 (83 .8% ) ,1次ESWL治疗成功 47例 (69.1% ) ,2次治疗 18例 (2 6.5% ) ,3次治疗 2例 (4.4% ) ;2例石街经输尿管镜治疗成功。 3 3例mini PCNL治疗者 ,一期PCNL成功 2 4例 (72 .7% ) ,二期PCNL治疗 9例 (2 7.3 % ) ;3例伴肾盂输尿管连接部梗阻者同时行顺行肾盂输尿管内切开术 ,一期结石清除率 2 4例 (72 .7% ) ,二期结石清除率 2 9例(87.9% ) ,联合ESWL 4例 ,总结石清除率为 97.0 %。 4例开放手术中 2例同时行肾盂输尿管成形术 ,1例多发结石术后有残余结石。　结论　ESWL是治疗小儿肾结石安全、有效的首选方法 ;选择PCNL治疗应根据结石和设备技术情况 ,联合ESWL成功率更高     

经皮肾镜气压弹道联合超声碎石术治疗感染性肾结石

目的探讨经皮肾镜气压弹道联合超声碎石术治疗感染性肾结石的方法和疗效。方法 2007年9月～2010年4月,27例感染性肾结石患者术前抗感染治疗后,在B超定位及引导下穿刺,用筋膜扩张器、金属扩张器扩张,置入F24的肾镜鞘,采用EMS第三代超声气压弹道碎石清石系统,先用超声吸附装置清理脓液、脓栓及附壁脓苔,并在低压或无压力的状况下超声碎石后吸出脓液,再行超声联合弹道碎石和清石。结果 22例一次取净结石;3例术后残留结石〉1 cm,1周后二次取石;2例术后残留结石〈1 cm,行体外冲击波碎石后排净。术中、术后未出现大出血、肾周脓肿、邻近脏器损伤等并发症,3例术后出现全身炎症反应综合征,1例肾动静脉瘘,均治愈。术后1个月8例肾功能不全者血肌酐平均值较术前降低76μmol/L2。7例随访2～24个月,平均10个月,肾功能、肾集合系统分离好转。结论采用经皮肾镜联合EMS第三代超声气压弹道碎石清石系统清理脓液、脓苔后,再行超声联合弹道碎石和清石,是治疗感染性肾结石的一种安全、高效的方法。     

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比较

目的:比较输尿管镜钬激光碎石术(LL)与体外冲击波碎石术(ESWL)治疗输尿管结石的临床疗效和安全性。方法:总结2008年1月~2012年9月于我院泌尿外科住院治疗的465例输尿管结石患者的临床资料,采用LL治疗输尿管结石196例,其中结石直径1.0cm者104例,≤1.0cm者92例;采用ESWL治疗269例,其中结石直径1.0cm者128例,≤1.0cm者141例。比较两者治疗输尿管结石的手术时间、术后3个月结石排净率及手术并发症发生率的差异。结果:LL组治疗结石直径1.0cm和≤1.0cm的平均手术时间均明显少于ESWL组相应的平均手术时间,差异有统计学意义(P0.01);对直径1.0cm的输尿管结石,LL组术后3个月结石排净率为93.3%,明显高于ESWL组的69.5%,差异有统计学意义(P0.01);而对于直径≤1.0cm的输尿管结石,LL组和ESWL组术后3个月结石排净率分别为91.3%和89.4%,差异无统计学意义(P0.05)。ESWL治疗上段结石的有效率为87.2%,明显高于中下段结石74.3%,差异有统计学意义(P0.01);而LL组的有效率分别为92.0%和92.6%,差异无统计学意义(P0.05)。LL组并发症发生率为4.6%,ESWL组无明显并发症发生。结论:综合考虑,对直径≤1.0cm的输尿管结石,尤其是上段结石,推荐ESWL治疗;而对直径1cm的输尿管结石,尤其是中下段结石,建议首选输尿管镜钬激光碎石术。     

肾鹿角形结石的3种治疗方法比较

目的：总结肾鹿角形结石的治疗经验。方法：应用体外冲击波碎石(ESWL)，开放手术，经皮肾镜取石术(PCNL)，治疗鹿角形结石102例．并随访其疗效及并发症的发生率。结果：EWSL57例，3个月后结石排净率86％；开放手术36例．手术均获成功，无石率达92％；PCNL9例，3个月后结石排净率为89％。结论：PCNL加ESWL为首选方法，ESWL适用于无肾盂肾盏扩张的部分鹿角形结石．开放手术可作为适当的补充术式。     

复杂肾结石经皮肾镜取石术后结石残留的原因与处理

目的:探讨复杂肾结石PCNL术后结石残留的原因及处理方法.方法:回顾分析我院行二期PCNL取石的35例复杂肾结石患者的临床资料,既往有开放手术史17例,2例因术中出血影响视野改二期手术,合并肾盏憩室内结石2例.结果:除2例需辅助ESWL治疗外,其余33例在B超和输尿管镜辅助下,行二期PCNL全部成功取净残留结石.其中3例因残留结石所在肾盏位置远离经皮肾通道或在与皮肾通道平行的肾盏内,重新建立另一通道取石;1例行3通道取石.结论:术中出血、肾盏憩室内结石、既往开放手术史和肾内集合系统解剖异常,是PCNL术后结石残留的主要原因;术中B超及软镜的应用,可以清楚显示有无残留结石及其所在肾盏的位置;了解结石与经皮肾通道的位置关系,帮助引导最大限度地清除结石.