经尿道输尿管镜下气压弹道碎石术治疗输尿管结石

目的探讨输尿管镜下气压弹道碎石术治疗输尿管结石的疗效。方法输尿管镜下气压弹道碎石术治疗输尿管结石56例，尿管上段结石3例，中段结石32例，下段结石21例中结石位于左侧30例，右侧25例，双侧1例。结果56例输尿管结石粉碎53例（94．6％），1例结石移动至肾盂未完成手术，1例置镜失败而改行开放手术，1例发生输尿管下段穿孔，经放置双J管内引流后改行ESWL治疗。30例（53．6％）术后有肉眼或镜下血尿，所有病例无尿路感染、输尿管黏膜剥脱、撕裂及狭窄等严重并发症。结论输尿管镜直视下气压弹道碎石术治疗输尿管结石，疗效确切、安全、组织损伤小，并发症少，可作为输尿管中段和下段结石的首选治疗方法。     

Extracorporeal shock-wave versus pneumatic ureteroscopic lithotripsy in treatment of lower ureteral calculi

Aim: To compare the efficacy and complications of extracorporeal shock-wave lithotripsy (SWL) and pneumatic ureteroscopic lithotripsy (URS) in the treatment of lower ureteral calculi. Methods: From August 1997 to June 1999, 210 patients with calculi in the distal third of the ureter were treated with SWL and the other 180 with URS. The stones were fragmented with either HB-ESWL-V lithotripter or JML-93 pneumatic lithotripter through Wolf 7.5～9.0 Fr ureteroscope. The outcome was assessed in terms of stone clearance rate, re-treatment rate and complication incidence. Results: The stone clearance rate was 78.1% with SWL and 93.3 % with URS (P<0.05). SWL had a re-treatment rate of 11.9 %, vs 2.2 % in the URS group (P<.05). URS caused ureteral perforation in 3.3% of patients, while it was 0 with SWL (P<0.05). The differences in the incidence of other complications such as infection and stricture between the two groups were insignificant. Conclusion: Though the selection of these two options depends on equip     

A prospective randomized controlled trial on ureteral stenting after ureteroscopic holmium laser lithotripsy

PURPOSE: A prospective randomized controlled trial was conducted to evaluate whether postoperative ureteral stenting is necessary after ureteroscopic laser lithotripsy. MATERIALS AND METHODS: A total of 58 patients with unilateral ureteral stones were randomized into either stented or unstented groups. Ureteroscopic laser lithotripsy was performed using a semirigid ureteroscope (6.5/7Fr) and holmium laser without ureteral orifice dilation. There were no selection criteria regarding stone size, location, preoperative ureteral obstruction and hydronephrosis. Endoscopic evidence of stone impaction or mucosal edema/damage did not exclude a patient from the study. Ureteral perforation on completion retrograde pyelogram was the only intraoperative criterion for study exclusion. Postoperative pain scores and symptoms were recorded. Excretory urography was performed to document stone-free status and stricture formation. Radionuclide scan was performed selectively to exclude functional obstruction when ureteral narrowing was found on excretory urogram. RESULTS: Mean stone size +/- SD was 9.7 +/- 4.0 mm. (range 4 to 27). Proximal ureteral stones accounted for 43% of all stones. Stented and unstented groups were comparable with respect to demographic data, stone parameters, preoperative obstruction and hydronephrosis. There was no significant difference in operating time, laser energy used, stone impaction and mucosal edema/damage between the 2 groups. Postoperative pain and symptoms were more severe and frequent (p <0.05) in the stented group. However, there was no difference in the incidence of postoperative sepsis and unplanned medical visits. The stone-free and stricture formation rates showed no statistical difference between the 2 groups. CONCLUSIONS: Ureteral stenting is not necessary after uncomplicated ureteroscopic laser lithotripsy for ureteral stones. Ureteral stent increases the incidence of pain and urinary symptoms but does not prevent postoperative urinary sepsis and unplanned medical visits. Severity of preoperative obstruction and intraoperative ureteral trauma were not shown to be determining factors for stenting.     

Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr

PURPOSE: Flexible ureteroscopes smaller than 9Fr are widely used in endourology. We systematically evaluated the functional durability of these instruments in the clinical setting. MATERIALS AND METHODS: We performed ureteronephroscopy 92 consecutive times in 84 patients at our hospital using a flexible Storz model 11274AA,double dagger Circon-ACMI model AUR-7, section sign Wolf model 7325.172 parallel and Olympus model URF/P3 ureteroscope paragraph sign. Preoperatively and postoperatively we evaluated all flexible ureteroscopes for luminosity, irrigant flow at 100 mm. Hg, number of broken image fibers and active deflection range. During the procedure a record was kept of the duration that the endoscope remained in the urinary tract, average irrigation pressure, method of insertion, various devices used within the working channel, need for lower pole access, and surgeon overall impression of visibility and maneuverability. RESULTS: The luminosity and irrigant flow of all endoscopes remained relatively unchanged during consecutive applications, while active deflection deteriorated 2% to 28%. Endoscopes were used for an average of 3 to 13 hours before they needed repair. The most fragile part of these instruments was the deflection unit. CONCLUSIONS: Small diameter flexible ureteroscopes are effective for diagnosing and treating upper urinary tract pathology but improved durability is required. Currently they represent a highly effective but high maintenance means of achieving retrograde access to the ureter and kidney with a need for repair after only 6 to 15 uses.     

Hydrodilation of the ureteral orifice in children renders ureteroscopic access possible without any further active dilation

PURPOSE: We review our experience with hydrodilation of the ureteral orifice for ureteroscopic access in children. MATERIALS AND METHODS: We retrospectively reviewed the results of 30 ureteroscopic procedures performed in 26 children who were followed for 6 months. Ureteral access was obtained with the assistance of a hand irrigation pump without any further active dilation in all cases. RESULTS: A total of 26 patients (86.7%) were completely stone-free after 1 procedure. There was no major complication such as ureteral perforation or avulsion. Mild flank pain was observed in 8 cases (26.7%). Predominant symptoms of bladder spasm were observed in 6 cases (20%). At 6-month followup no patient had pyelonephritis or demonstrated hydronephrosis related to ureteral stricture. CONCLUSIONS: Our study shows that hydrodilation of the ureteral orifice in children renders ureteroscopic access possible with no additional active dilation and no associated complications.     

Is pre-shock wave lithotripsy stenting necessary for ureteral stones with moderate or severe hydronephrosis?

PURPOSE: We performed a prospective, randomized clinical trial to evaluate the outcome of ureteral stents for solitary ureteral stones 2 cm or less in moderately or severely obstructed systems using shock wave lithotripsy. MATERIALS AND METHODS: Between 2001 and 2004, 186 patients who met study criteria were randomized into 2 groups. Group 1 received a pre-shock wave lithotripsy 6Fr Double-J stent and group 2 had no stent. Patients were treated with a Dornier MFL 5000 lithotripter. Results were compared in terms of clearance rates, number of shock waves and sessions, irritative voiding symptoms, incidence of complications and secondary interventions. Failure was defined as the need for additional procedure(s) for stone extraction. RESULTS: Overall 164 patients (88.2%) became stone-free after shock wave lithotripsy. Complete stone fragmentation was achieved after 1 to 3 and more than 3 session in 108 (58.1%), 30 (16.1%), 13 (7%) and 14 patients (7.5%), respectively. Ureteral stent insertion did not affect the stone-free rate, which was 84.9% and 91.4% in groups 1 and 2, respectively (p = 0.25). There was no statistical difference in the re-treatment rate, flank pain or temperature in the 2 groups. However, all patients in the stented group significantly complained of side effects attributable to the stent, including dysuria, suprapubic pain, hematuria, pyuria and positive urinary culture. CONCLUSIONS: Pretreatment stenting provides no advantage over in situ shock wave lithotripsy for significantly obstructing ureteral calculi. Shock wave lithotripsy is reasonable initial therapy for ureteral stones 2 cm or less that cause moderate or severe hydronephrosis.     

Management of ureteral calculi: a cost comparison and decision making analysis

PURPOSE: We compared the cost of treatment strategies for ureteral calculi using a decision tree model. MATERIALS AND METHODS: A comprehensive literature review was performed to determine the average success rate of each of 3 treatment modalities, namely observation, ureteroscopy and shock wave lithotripsy. Using these success rates decision analysis models were constructed using Data 3.5 software (TreeAge Software, Inc., Williamstown, Massachusetts) to estimate the cost of treatment and followup for each of the 3 treatments. One-way sensitivity analysis was performed to evaluate the effect of varying individual probabilities of success and costs, and 2-way sensitivity analysis was done to evaluate the model for a wide range of potential costs and success rates of ureteroscopy and shock wave lithotripsy. In addition, a table was constructed to enable individual surgeons and institutions to determine the cost impact of ureteroscopy and shock wave lithotripsy in their unique clinical scenarios. RESULTS: Observation was the least costly pathway if no financial cost, such as emergency room visits, was incurred by failed observation. Ureteroscopy was less costly than shock wave lithotripsy for stones at all ureteral locations. A cost difference between the 2 modalities of approximately $1,440, $1,670 and $1,750 was noted for proximal, mid and distal ureteral calculi, respectively. One-way sensitivity analysis showed that the cost of ureteroscopy would have to increase by more than $1,400, $1,700 and $1,850, and the success rate would have to decrease by 28%, 36% and 39% for proximal, mid and distal stones, respectively, before reaching cost equivalence with shock wave lithotripsy. Likewise, the cost of shock wave lithotripsy would have to decrease by more than $1,489 to achieve cost equivalence with ureteroscopy. Overall ureteroscopy was more cost-effective at all stone sites regardless of the success rate of shock wave lithotripsy. CONCLUSIONS: Ureteroscopy is the most cost-effective treatment strategy for ureteral stones at all locations after observation fails. The high cost of purchasing and maintaining a lithotriptor is responsible for the high treatment cost associated with shock wave lithotripsy. However, cost is only one of a number of important factors that are considered when determining an appropriate treatment strategy.     

Ureteroscopic treatment of lower pole calculi: comparison of lithotripsy in situ and after displacement

PURPOSE: Ureteroscopic management is a viable option for lower pole calculi less than 2 cm. Recently a technique was described to displace the calculus into a more accessible calix using a nitinol basket or grasper before lithotripsy. We compared the efficacy and safety of this technique with in situ treatment of small and intermediate lower pole calculi. MATERIALS AND METHODS: We retrospectively reviewed the records of 95 ureteroscopy cases performed at our institution from January 1997 through August 2001 for renal calculi located only in the lower pole. Preoperative patient characteristics, stone size, operative details, complications and outcomes were compared for calculi treated in situ and those displaced before treatment. RESULTS: Adequate followup was available on 78 patients. Patients in the displacement group were statistically older, more often had a preoperative indwelling ureteral stent and had a mean operative time that was 16 minutes longer (p = 0.04). Average stone diameter in the in situ and displacement groups was 8 and 10.3 mm., respectively (p = 0.04). In patients with radiographic followup greater than 1 month complete success was obtained for 77% of stones 1 cm. or less treated in situ versus 89% treated with displacement first (p = 0.43). For calculi greater than 1 cm. complete success was obtained for 2 of the 7 (29%) treated in situ versus all 7 (100%) treated with displacement (p = 0.005). CONCLUSIONS: When treating lower pole calculi 1 to 2 cm. via ureteroscopy, a higher success rate can be obtained with displacement into a more accessible calix before treatment.     

Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications

PURPOSE: We compare postoperative pain, stone-free rates and complications after ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. MATERIALS AND METHODS: A total of 113 patients with distal ureteral calculi amenable to ureteroscopic treatment were prospectively randomized into stented (53) and unstented (60) groups. Stones were managed with semirigid ureteroscopes with or without distal ureteral dilation and/or intracorporeal lithotripsy. Preoperative and postoperative pain questionnaires were obtained from each patient. Patients with stents had them removed 3 to 10 days postoperatively. Radiographic followup was performed postoperatively to assess stone-free rates and evidence of obstruction. RESULTS: Six patients randomized to the unstented group were withdrawn from the study after significant intraoperative ureteral trauma was recognized, including 3 ureteral perforations, that required ureteral stent placement, leaving 53 with stents and 54 without for analysis. Patients with stents had statistically significantly more postoperative flank pain (p = 0.005), bladder pain (p <0.001), urinary symptoms (p = 0.002), overall pain (p <0.001) and total narcotic use (p <0.001) compared to the unstented group. Intraoperative ureteral dilation or intracorporeal lithotripsy did not statistically significantly affect postoperative pain or narcotic use in either group (p >0.05 in all cases). Overall mean stone size in our study was 6.6 mm. There were 4 (7.4%) patients without stents who required postoperative readmission to the hospital secondary to flank pain. All patients (85%) who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture on followup imaging (mean followup plus or minus standard deviation 1.8 +/- 1.5 months), and the stone-free rate was 99.1%. CONCLUSIONS: Uncomplicated ureteroscopy for distal ureteral calculi with or without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Patients without stents had significantly less pain, fewer urinary symptoms and decreased narcotic use postoperatively.     

Bare naked baskets: ureteroscope deflection and flow characteristics with intact and disassembled ureteroscopic nitinol stone baskets

PURPOSE: Lower pole renal access during flexible ureterorenoscopy is often limited by the active deflection capabilities of the ureteroscope. Deterioration in the deflection and flow capabilities of ureteroscopes occurs with the passage of instrumentation through the working channel. We performed in vitro evaluation of a novel technique using unsheathed nitinol baskets to minimize the deterioration in deflection and maximize the irrigant flow associated with instrument passage through the working channel during flexible ureterorenoscopy. MATERIALS AND METHODS: Alterations in the irrigant flow and active deflection of 4 ureteroscopes from different manufacturers were evaluated. Each ureteroscope was evaluated with an empty working channel, and then with sheathed and unsheathed 2.2, 3 and 3.2Fr (Cook Urological, Inc., Indianapolis, Indiana), 2.4 and 3Fr (Microvasive Urology, Natick, Massachusetts) nitinol baskets in the working channel. RESULTS: With all baskets tested and in all ureteroscopes the deterioration in active deflection and irrigant flow was improved with the unsheathed baskets. The disassembled basket within the working channel allowed an additional 15 to 20 degrees of active deflection. In addition, the disassembled basket allowed for a 2 to 30-fold increase in irrigant flow compared with an intact basket. CONCLUSIONS: The combination of improved deflection and irrigant flow with this technique may improve ureteroscopic access to lower pole renal calculi.     

输尿管结石的影像学分析(附124例报告)

目的探讨B超、腹平片(KUB) 静脉肾盂造影(IVU)、CT对输尿管结石的诊断价值。方法回顾性分析了本院124例输尿管结石患者的B超、KUB IVU的诊断资料。结果B超诊断率为78.2%,KUB IVU诊断率为90.3%,KUB IVU综合B超诊断率达96.8%。结论B超、KUB IVU综合对输尿管结石有很高的诊断价值。CT是B超及KUB IVU的补充检查方法。