可视化超微通道经皮肾镜碎石术治疗儿童无积水肾结石的疗效分析

目的探讨可视化超微通道经皮肾镜碎石术治疗儿童无积水肾结石的安全性及有效性。方法回顾性分析上海交通大学医学院附属新华医院小儿泌尿外科2018年8月至2019年11月采用可视化超微通道经皮肾镜碎石术治疗的14例无积水肾结石患儿的临床资料。其中男童8例,女童6例;手术时中位年龄60.77个月,年龄范围7～190个月;左侧6例,右侧7例,双侧1例;单发肾结石3例,多发性肾结石11例,结石平均直径(14.47±6.52) mm,范围8～30 mm,术前结石的平均CT值为(1 031.80±341.35) HU,范围498～1951 HU。所有患儿膀胱截石位留置输尿管导管制造人工肾积水,俯卧位B超引导下应用可视化穿刺系统穿刺目标肾盏,根据结石大小和盏颈情况选择扩张至F12超微通道。结果 14例患儿共进行15侧次碎石手术,共建立15个工作通道,1侧次辅助F4.8极微通道辅助碎石,一次穿刺成功率100%,平均手术时间(107.00±18.25) min,范围80～145 min,术后血红蛋白下降(13.60±10.93) g/L,无输血及栓塞止血病例。术后发热2例,无集合系统穿孔、腹腔脏器损伤及胸膜损伤。其中2例鹿角形结石患儿因结石负荷大,需要分期手术,另有1例术后残留一个8 mm大小的结石,辅助体外冲击波碎石术(extracorporeal shock wave lithotripsy,ESWL)治疗,一期结石清除率80.0%(12/15),二期结石清除率93.3%(14/15)。术后平均随访时间(12.58±4.87)个月,范围6～22个月,仅有1例胱氨酸结石复发。结论可视化穿刺系统可安全、快速地建立皮肾工作通道,配合超微通道经皮肾镜碎石术治疗儿童无积水肾结石具有较高的结石清除率和安全性。     

微造瘘经皮肾镜碎石术治疗学龄前儿童上尿路结石

目的 评价微造瘘经皮肾镜碎石术在治疗学龄前儿童上尿路结石的安全性和有效性.方法 应用B超引导穿刺的微造瘘(16F)经皮肾镜碎石术治疗平均年龄46个月的学龄前患儿35例共42侧上尿路结石,其中肾结石34侧,上段输尿管结石8侧,结石平均长径(16.9±9.2)mm.结果 所有病例均I期成功建立通道并处理结石,手术时间平均为(35.4±14.9)min.手术清除率分别为92.9%,术后血红蛋白含量下降了12.7%,术后感染率5.0%,没有需要输血.毗邻脏器损伤或循环超负荷的病例.结论 微创经皮肾镜碎石术治疗学龄前儿童上尿路结石是安全、有效的.     

学龄儿童肾结石经皮肾取石术疗效评估

目的 评价经皮肾取石术(PCNL)治疗学龄儿童肾结石的疗效与安全性.方法 2006年8月至2011年8月对25例7～12岁学龄儿童肾结石患者接受经皮肾取石术治疗.X线定位穿刺,建立16F经皮肾通道,8/9.8F输尿管镜下碎石取石.结果 平均手术时间74 min.20例肾结石患儿I期PCNL取出结石,2例患儿接受Ⅱ期pCNL治疗并取净结石,结石清除率88％(22/25).无严重并发症发生.结论 对有手术指征的学龄儿童肾结石,采用经皮肾取石术治疗是安全有效的.     

经皮肾镜取石术治疗小儿复杂肾结石合并上尿路梗阻

目的探讨微创经皮肾镜取石术(MPCNL)治疗小儿复杂肾结石合并上尿道梗阻的疗效和临床应用价值。方法回顾性分析我们于2006年6月至2009年6月采用微创经皮肾镜取石术(MPCNL)治疗的20例小儿复杂肾结石合并上尿路梗阻患儿临床资料,其中男14例,女6例,年龄8个月至11岁,平均年龄4.5岁。结果全部患儿平均住院时间6 d,20例中,16例一期全部取净,4例行二期取净,一期结石清除率为80.0%(16/20),术中未见肾盂大穿孔或肾皮质撕裂的并发症,无一例需术中输血,所有患儿术后随访6~12个月,未见输尿管狭窄或闭锁等并发症。结论微创经皮肾镜取石术(MPCNL)治疗小儿复杂肾结石合并上尿路梗阻安全有效,值得在临床上推广。     

微创经皮肾镜取石术治疗婴幼儿肾结石

目的 探讨微创经皮肾镜取石术(MPCNL)治疗婴幼儿肾结石的临床效果和安全性.方法 2008年12月至2009年10月行MPCNL治疗婴幼儿肾结石24例.男18例,女6例.年龄10～42个月,平均23个月.左侧10例,右侧8例,双侧6例,共30侧.结石最长径11～22 mm,平均14.2mm.通过B超、螺旋CT薄层平扫予以诊断.结果 24例患儿,共30侧肾行MPCNL治疗.手术时间25～90min,平均40min.术中出血5～40ml,平均15ml.建立经皮通道成功率为1(00%.术后全部留置肾造瘘管,3～5d后拔除.60%(18/30)的病例留置双J管,1个月后膀胱镜下拔除.所有病例未输血,未发生严重并发症.静脉应用抗生素3～7 d,术后住院4～10 d,出院时尿检阴性.患儿随访6～18个月,生长发育良好,经B超和尿检,22例肾结石消失,并无复发,肾盂积水消失或减轻,尿检阴性.2例患儿有肾结石残留.结石清除率91.7%(22/24).结论 采用MPCNL术治疗婴幼儿肾结石安全有效,术后恢复快、住院时间短,具有微创的优势.     

微创经皮肾取石治疗小儿复杂肾结石

目的总结小儿复杂肾结石微创治疗经验，探讨小儿肾结石微创经皮肾取石（mini—PCNL）的治疗效果。方法回顾了10年间（1995-2005年）行mini—PCNL的35例患儿的临床资料，男20例，女15例，平均年龄8岁（3．5～14岁），其中伴尿路畸形8例（22．9%），3例伴UPJ梗阻同时行顺行肾盂输尿管狭窄内切开术，1例UPJ梗阻输尿管镜扩张，4例联合ESWL。结果Ⅰ期mini-PCNL为26例（74．3％），Ⅱ期mini—PCNL为9例（25．7％）；Ⅰ期结石完全清除25例（71．4%），Ⅱ期结石完全清除6例（17．1％），联合ESWL4例（11．4％），总的结石清除率为97．1％。手术时间平均40min（30-120min）；平均住院时间7d（4～15d）。4例UPJ梗阻治疗效果良好。结论微创经皮肾取石治疗小儿复杂肾结石是安全有效的方法，但要根据结石和设备技术情况，联合ESWL成功率更高。     

经皮肾微造瘘输尿管镜下钬激光碎石术治疗儿童上尿路结石

目的 探讨经皮肾微造瘘输尿管镜下钬激光碎石术治疗儿童上尿路结石的疗效与安全性.方法 上尿路结石患儿51例,平均年龄5.6岁,均为14岁以下.其中肾结石41例,结石平均大小16.8 mm（11～28 mm）,输尿管结石10例,结石平均大小11.5 mm（10～16 mm）.全部病例使用全身麻醉下经皮肾微造瘘输尿管镜下钬激光碎石术治疗.术后行超声或X线摄片观察疗效,术后随访2～20个月.结果 51例患儿中,单通道取石49例（96%）,双通道取石2例（3%）.一期取石46例（90%）,二期取石5例（9%）.结石排尽率96%（49/51）.平均手术时间85.5 min.一期取净结石者住院时间7～10 d,平均8 d.术中操作鞘脱出腹膜后渗液1例,置腹膜后引流管后渗液消失.术后发热4例（7%）;1例（2%）术后大出血予输血及超选择性肾动脉栓塞后治愈.4例残石患儿,2例二期行原窦道或再次穿刺取石取净;1例一期取石术后ESWL治疗仍有残石,1例一期取石术后出血放弃再次取石.全部病例术后半年复查彩超,49例肾积水消失,2例重度肾积水转为轻度肾积水,手术肾脏未见缩小.结论 经皮肾微造瘘输尿管镜下钬激光碎石术并发症少,净石率高,可重复取石,是治疗儿童上尿路结石安全有效的手段.     

经皮肾穿刺微造瘘取石术治疗儿童肾结石

目的探讨经皮肾穿刺微造瘘取石术（mini—PCNL）治疗儿童肾结石的手术技巧及临床应用价值。方法回顾性分析总结35例儿童肾结石患儿采用mini—PCNL术治疗的临床资料。结果22例I期取净结石，12例经二次取石，9例取净，另有1例经三次取石仍未取净。4例有残石者术后配合ESWL治疗，2例排净。随访2～32个月，患儿肾积水明显好转，结石无复发，7例肾盏颈部扩张者狭窄消失。1例有少许残石患儿结石体积有增大。结论mini—PCNL治疗儿童肾结石创伤小，安全、有效。结合术后ESWL治疗可以代替开放手术而成为儿童肾复杂结石、鹿角形结石以及合并肾内狭窄的首选治疗方法。     

经皮肾穿刺碎石取石术治疗婴幼儿肾结石

目的探讨微创经皮肾穿刺碎石取石术（MPCNL）治疗婴幼儿肾结石的疗效与安全性。方法回顾性分析湖南省儿童医院2008年10月至2011年2月,应用经皮肾穿刺术钬激光治疗婴幼儿肾结石47例的临床资料。结果47例患儿50个肾脏行50次mini—PCNL治疗,其中一期碎石取石成功46个肾脏,二期碎石取石成功3个。肾脏,结石残留1例。单通道取石49个肾脏,双通道取石1个。肾脏。3例肾盂输尿管交界处狭窄（UPJO）患儿经钬激光内切开,8例息肉切除。术中通道迷失1例,经再穿刺成功。术后血红蛋白浓度平均下降2．5g／dL。2例肾功能异常者术后1—3d恢复正常。术后拔出DJ管后4周复查B超或X线平片,结石排尽率94％（47／50）,术后3个月复查,除1例结石残余外,其余均排尽。手术肾脏未见缩小,IVU检查提示8例双肾显影正常。38例肾积水患儿中,30例肾积水消失,8例由中重度肾积水转为轻度肾积水。47例术后随访2个月至1年6个月,无其他并发症。结论在明确掌握适应证和操作熟练的情况下,经皮肾穿刺碎石取石术治疗婴幼儿肾结石安全、有效,是一种较为理想的方法。     

小儿尿路结石的腔内微创治疗

目的探讨小儿尿路结石施行腔内微创治疗的临床价值。方法对79例小儿尿路结石患儿施行腔内微创治疗。男47例，女32例。年龄0．5～14岁，平均7．9岁。肾结石18例；输尿管上段结石14例（阴性结石和多发性结石各1例），输尿管中段结石2例，输尿管下段结石10例，膀胱内型输尿管囊肿内结石1例，肾结石合并输尿管上段结石4例；膀胱结石18例；尿道结石12例（后尿道6例，前尿道6例）。结石横径0．5～2．8cm，长径0．5～1．5cm。上尿路结石中左侧24例，右侧22例，双侧3例。结果30例下尿路结石、13例输尿管中下段结石行经输尿管镜碎石术（URL），1例肾盂结石、4例输尿管上段结石行后腹腔镜肾盂输尿管切开取石术（RPPL／RPUL），31例肾、输尿管上段结石行微创经皮肾镜取石术（MPCNL），手术均获成功。术中、术后无严重不良反应发生。结论综合应用各种腔内治疗技术，小儿尿路结石可以实现现代微创治疗，并可作为一线治疗的选择。     

Safety of ungated shockwave lithotripsy in pediatric patients

ObjectiveUngated extracorporeal shockwave lithotripsy (ESWL) in adults is associated with cardiac arrhythmias. We report on the safety and efficacy of this method for treatment of renal calculi in children.Patients and methodsChildren under 14 years with radio-opaque renal stones were treated by ungated ESWL. Pre-treatment plain radiographs and intravenous urography and post-treatment ultrasonography and plain films were used to follow up clearance of fragments. All children were monitored for arrhythmias.ResultsThirty-seven children (28 males, nine females) with a median age of 5 years (range 2–14 years) underwent 69 ungated ESWL sessions for renal calculi. Nineteen children had stones located in the left kidney, 17 had stones located in the right kidney and one child had bilateral renal stones. The stone size ranged from 6 to 25 mm (mean 9.9 mm). Shockwave number ranged from 800 to 3650 (mean of 2500 shockwaves per session). All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. No patient had cardiac arrhythmias or other intra-procedural complications. No patient required conversion to gated ESWL. The overall stone-free rate was 86%.ConclusionThe results suggest that ungated ESWL is safe in children under 14 years. The efficacy was comparable to that of gated ESWL from previously published series.     

Minimally invasive percutaneous nephrolithotomy in preschool age children with kidney calculi (including stones induced by melamine-contaminated milk powder)

Purpose

This study was undertaken to assess the safety and efficacy of minimally invasive percutaneous nephrolithotomy (mini-PCNL) using ureteroscope and pneumatic intracorporeal lithotripsy in preschool age children with kidney calculi.

Methods

We studied 27 renal units in 20 patients of preschool age (≤6?years) who underwent mini-PCNL at our institute. The mean age was 42.6?months (range 14–68?months). The average stone burden was 1.85?cm (range 0.9–2.8?cm). Eight patients aged 14 to 58?months had been exposed to melamine-tainted powdered formula. The mini-PCNL was performed with an X-ray-guided peripheral puncture. Minimal tract dilatation was undertaken to fit a 14–16?Fr peel-away sheath. Ureteroscope and pneumatic intracorporeal lithotripsy were used to fragment the stones.

Results

Complete clearance was achieved in 23 renal units (85.2?%) with mini-PCNL monotherapy. This has increased to 92.6?% after adjunctive ESWL. The average fall in hemoglobin was 1.28?g/dL. None of the patients required blood transfusion. The median length of hospital stay was 8.2?days. Patients were followed up every 6?months for 2?years. There has been only one recurrence of stone and no long-term complications.

Conclusion

Mini-PCNL is a effective treatment for pediatric kidney stones refractory to extracorporeal shock wave lithotripsy, including stones induced by melamine-contaminated milk powder. The “mini-PCNL” technique, which uses ureteroscope and pneumatic intracorporeal lithotripsy, is a safe and feasible modality for treating renal calculi in preschool age children.     

小儿输尿管结石体外震波碎石:十年经验

目的报告小儿结石ESWL治疗的10年经验，探讨ESWL治疗的效果和策略。方法回顾性研究67例小儿输尿管结石行ESWL治疗的结果，检测及记录患儿的代谢情况、生理解剖、结石的大小、位置以及各种并发症；其中术前置人输尿管导管52例；术后随访3～9个月。结果67例输尿管结石，首次碎石后，43例（64．2％）结石完全排空；7例（10．4％）经2次ESWL结石完全排空；2例（2．9％）经3次碎石结石完全排空；总结石完全排空率为77．6％。小于10mm结石首次碎石后的完全排空率为100％，37例大于10mm的结石患儿中，23例（62．2％）首次碎石后完全排空。上段结石的完全排空率为92．0％，而中下段结石的完全排空率仅为69．0％。其中11例输尿管中、下段结石和1例上段嵌顿结石ESWL失败者进行了输尿管镜治疗，用APL弹道碎石机击碎结石并取出；3例改行开放手术。结论ESWL是小儿输尿管结石的安全有效的治疗方法；对输尿管中、下段结石应用输尿管镜是ESWL的有效补充治疗；部分结石采用输尿管镜联合ESWL可获得较好的效果。     

Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old

ObjectiveWe present our experience with percutaneous nephrolithotomy (PCNL) for management of large renal calculi in children less than 5 years old, and determine its safety and efficacy when using an adult-size device.Patients and methodsTwenty patients younger than 5 years old underwent PCNL between August 2003 and July 2008. After retrograde catheterization, the nephrostomy tract dilated up to 26 Fr. Then a 24-Fr rigid nephroscope was used and stones were fragmented with a pneumatic lithotripter.ResultsTwenty patients with a mean age of 3.1 years underwent 26 PCNL procedures on 24 renal units. Four patients had bilateral renal stones. Five patients (20%) had staghorn stones, as did five of the other cases with multiple stones. Four patients had undergone previous stone surgery on the same side. All of the patients were managed with only one tract. The mean stone size was 33 (20–46) mm and average operative time was 93.25 (78–174) min. Stones were completely cleared in 79.16% of patients, which increased to 91.67% with adjunctive shockwave lithotripsy. The overall complication rate was 15.38% and mean hospital stay was 5.26 (3–8) days.ConclusionPCNL is an effective and safe treatment for renal calculi in children less than 5 years old, even when using instruments designed for adults.     

Percutaneous nephrolithotomy (pcnl) in paediatric stones

PurposeTo evaluate the role and outcome of percutaneous nephrolithotomy (PCNL)in the management of paediatric urolithiasis.Material and methodsWe retrospectively reviewed the records of children who underwent PCNL procedures for renal calculi from 2004 to 2007 A total of 300 children with renal calculi were treated with PCNL. Patient's age at operation ranged from 8 months to 15 years. Patients had pre-operative blood and urine analysis, ultrasonography of kidneys, ureter, bladder and X-ray IVU. A tract was made in the prone position using fluoroscopy and ultrasound. 22 to 26 Fr sheaths with 18.0, 20.5 and 24 Fr nephroscopes were used accordingly. Ultrasound and pneumatic lithoclast alone or in combination were used for stone fragmentation.Results300 PCNL procedures were performed. Stone burden ranged from 3.1 ± 3.7 cm² (simple 2.1 ± 1.5 cm², complex 5.0 ± 8.8 cm²) with stone clearance rates of 92% and 78% in simple and complex stones respectively. During the procedure mean Hb drop was 1.36 ± 0.8 gm% while 26 (14.6%) patients required blood transfusion. Intra and post operative complications included excessive bleeding, and conversion to open surgery in 8, extravasation of fluid in 11 and 5 cases with urinary sepsis.ConclusionsPercutaneous nephrolithotomy is a suitable and safe procedure in children including the pre-school age group for both simple and complex stones.     

Management of urinary calculi using endourology and extracorporeal shock wave lithotripsy (ESWL)

Childhood urolithiasis is uncommon, comprising 2% – 3% of urinary calculi. This paper presents our initial experience in the endourological (EU) treatment of 23 children with urinary calculi presenting to the Royal Childrens' Hospital. Twenty-seven renal, ureteric, and vesical calculi were treated. Three strictures were divided endoscopically synchronously with calculus removal. Twenty-three calculi were renal (6 staghorn, 3 cystine), 2 ureteric, and 2 vesical. In 12 patients (mean age 17.5 years, range 5–24), the underlying cause was a neuropathic bladder secondary to spina bifida. Ten of these had ileal conduits, 1 was successfully undiverted, and 1 previously undiagnosed (all infected). The second group of 11 patients (mean age 10.1 years, range 5–16) had normal renal anatomy. Seventeen (63%) were treated by percutaneous nephrolithotomy (PCNL) or endoscopic lithotripsy via their conduit (n = 1) or bladder (n = 2). Three (11%) underwent combined extracorporeal shock wave lithotripsy (ESWL) and PCNL and 7 (26%) were treated by ESWL alone. Twenty-one (77%) were cleared of stone by their primary procedure. Four patients with residual calculi following ESWL have a decreased volume of stone and 2 patients with staghorn calculi treated by PCNL have peripheral fragments only (1 bilateral). There was no mortality or significant morbidity except sepsis in 4 patients, which was treated medically. This series demonstrates that EU and ESWL techniques are safe and effective in children and patients with spina bifida, who often have marked scoliosis, urinary diversion, and difficulties in access. In our experience, paediatric calculi were associated with infection, metabolic disorders, urinary diversion, and patient deformities, and so the majority were more appropriately treated by endourological techniques. ESWL was effective for small stones and in combination with EU for complex stones. By using EU and ESWL alone or in combination, we have avoided open surgery in all patients with urinary calculi treated so far. Offprint requests to: H. L. Tan     

急诊冲击波碎石术治疗小儿绞痛性输尿管结石的临床研究

目的 评价急诊体外冲击波碎石术(ESWL)治疗小儿绞痛性输尿管结石之效果.方法 回顾1997年1月至2007年12月32例小儿输尿管结石伴急性肾绞痛的急诊ESWL的治疗资料.结果 1次ESWL 25例;2次ESWL 5例;1例3次ESWL治疗失败后改其他治疗,总结石排净率为96.8%(30/31).首次ESWL治疗后,28例肾绞痛完全缓解(90.3%).ESWL术中,静脉全麻19例,镇静加止痛剂者12例.术后无严重并发症.结论 急诊ESWL治疗小儿绞痛性输尿管结石安全快捷、疗效肯定.     

小儿肾窦内肾结石的诊治分析

目的 探讨小儿肾窦内肾结石的诊断与处理方法 .方法 同顾性分析2001～2007年间收治小儿肾窦内肾结石25例的临床资料.男18例.女7例.年龄3个月～13岁.平均3.5岁.左肾结石13例.右肾结石9例,双肾结石3例;多发结石左侧3例.右侧4例,双侧1例;规则状结石17例(20侧).鹿角犁结石5例,铸状结石3例;全部病例均合并轻至重度肾积水.结果 复杂肾窦内肾结石中5例鹿角型结石、3例铸状结石和5例6侧偏大(直径>1.0cm)的规则多发结石.均未阻断.肾蒂血管,肾实质最薄处或肾后下段切开取石,1例合并肾盂输尿管交界处梗阻,Ⅱ期手术治愈;单纯肾窦内肾结石中9例11侧规则肾结石和3例3侧直径小于1.0cm的多发结石均采用类似Anderson-hynes术式行肾内肾盂切开取石.术中发现3例合并肾盂输尿管交界处梗阻.同期行肾盂输尿管成形术.结石最大3.0 cm× 2.0 cm×1.0 cm,数目多达6枚.术中C臂检查无结石残留,术后3～6个月复查B超、KUB平片未见结石复发.结论小儿肾窦内肾结石发病率逐年增高.腹部B超、IVU或逆行造影检查是有效的辅助检查手段.治疗应根据结石类型、数目、大小以及合并肾积水的情况而定,如鹿角型、铸状结石以及多发结石采用肾实质切开取石;合并肾积水者尽量采用肾内肾盂切开取石,有助于术巾探查是否合并肾盂输尿管交界处狭窄,以便同期施行肾盂输尿管成形术.