The management of paediatric urolithiasis

OBJECTIVE: To evaluate the efficacy and safety of the management of paediatric urolithiasis by extracorporeal shock wave lithotripsy (ESWL), endoscopic ureterolithotomy, percutaneous nephrolithotomy (PCNL) and open nephrolithotomy. PATIENTS AND METHODS: In a 3-year period (1997-1999), 59 children were treated for urolithiasis and underwent a total of 79 procedures. Thirty-two ESWL sessions were performed in 23 children (mean age 7.4 years, median 6.0). PCNL was undertaken in 30 renal units in 25 children (mean age 6.4 years, median 4.0). Eight patients (mean age 7.8 years, median 5) underwent 17 ureteroscopic procedures, six of which involved the use of a holmium laser. Three children with staghorn calculi underwent open nephrolithotomy under conditions of renal ischaemia and hypothermia. RESULTS: Of the 23 children treated using ESWL, 21 (91%) became stone-free; 17 underwent one ESWL session (74%), three had two sessions and three (13%) had three sessions. All eight patients who underwent ureteroscopy became stone-free. Four patients in whom the stone could not be reached by ureteroscopy initially had a JJ stent inserted, and the stone and stent subsequently removed. Stones were cleared using PCNL in 27 of 30 renal units (90%); three patients who had residual stone fragments were rendered stone-free by ESWL. Two of three children undergoing open nephrolithotomy were stone-free after surgery and the remaining one rendered stone-free with ESWL. Metabolic evaluation showed that 25 of 45 children (55%) had a urinary infection, eight (18%) had hyperoxaluria, three (7%) had hypercalciuria, two (4%) had cystinuria, and no identifiable cause was found in seven (16%). Treatment by a single modality rendered 52 of the 59 children (88%) stone-free; when the different modalities were combined, 57 of 59 patients (97%) were cleared of their stones. CONCLUSIONS: Technological advances in ESWL, ureteroscopy and PCNL have had a significant effect on the management of urolithiasis in children, allowing a safe and successful outcome. The comprehensive care of children with urolithiasis should include a full metabolic evaluation. Anatomical anomalies contribute to the complexity of many cases, necessitating a close liaison between adult and paediatric urologists, nephrologists and radiologists to optimize stone management in children.     

Minimally invasive treatment of urinary tract calculi in children.

OBJECTIVE: To report experience of a broad multimodality approach to the treatment of calculi in children using extracorporeal shock wave lithotripsy (ESWL), ureteroscopy/laser lithotripsy, lithoclast and percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: The treatment and outcome were reviewed in 43 children managed by a range of minimally invasive modalities, either singly or in combination, between 1990 and 1997. These patients represent a selected group deemed suitable for minimally invasive management during a period of developing experience with these techniques. Of this cohort, six children had previously undergone open stone surgery and contributory metabolic abnormalities were identified in seven. ESWL was the sole treatment modality in 24 children (56%). In five children (12%) ureteroscopy/laser lithotripsy was combined with ESWL, eight (18%) underwent ureteroscopy/laser lithotripsy alone, whilst three with bladder stones were treated with the lithoclast. Combined therapy including PCNL was required in three patients. RESULTS: Of the 43 children treated, 38 (88%) were rendered stone-free. Metabolic disorders accounted for three of the five cases of residual calculi. Complications requiring intervention occurred in two children (7%) and three subsequently underwent open pyelolithotomy or ureterolithotomy after unsuccessful minimally invasive treatment. CONCLUSIONS: Used selectively, the range of minimally invasive procedures available for adults, including ureteroscopy and PCNL, can be safely and effectively extended to the treatment of urinary tract calculi in children. The role of open surgery will diminish further with the availability of specialized instruments for paediatric PCNL.     

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.     

Urolithiasis in the horseshoe kidney: a single-centre experience

OBJECTIVE

To report the operative management and subsequent stone‐free rates of patients with urolithiasis in a horseshoe kidney and treated at one centre.

PATIENTS AND METHODS

We retrospectively reviewed all patients presenting to our centre with a horseshoe kidney and urolithiasis over a 15‐year period. The stone burden, surgical management, complications and stone clearance rates were recorded.

RESULTS

In all, 55 patients with urolithiasis in horseshoe kidney were treated. Percutaneous nephrolithotomy (PCNL) was used in 60 renal units in 47 patients. Five patients had extracorporeal shock wave lithotripsy (ESWL), two had flexible ureteroscopy and one had a laparoscopic pyelolithotomy for a stone extending into the isthmus. PCNL was used for large stones (mean digitized surface area = 614.32 mm²) and required one to four stages to achieve an overall stone clearance rate of 88%. Stones were cleared at one sitting in 77% of PCNL procedures, completely cleared in two‐thirds of patients treated by ESWL, and in both who had flexible ureteroscopy and the one treated with laparoscopic pyelolithotomy. Complications were minimal, with 15% minor and 3% major complications in the PCNL group only.

CONCLUSION

Appropriate management of urolithiasis within the horseshoe kidney depends not only on stone burden, but also on stone location, calyceal configuration and malrotation. Stones can be cleared successfully in almost all patients providing that all techniques are available to the operating surgeon.     

孤立肾并复杂性结石的治疗选择

目的探讨孤立肾并复杂性结石的处理方式,提高其治疗的有效性和安全性。方法总结42例孤立肾并复杂性结石的治疗经验。其中先天性4例(10％)、后天原因38例(90％);左侧16例(38％)、右侧26例(62％)。均为铸形或鹿角状、多发性结石,8例合并输尿管结石,6例因急性梗阻性无尿入院;铸形或鹿角状结石首选体外震波碎石(ESWL)后经皮肾镜取石(PCNL)治疗,多发性结石先行PCNL后ESWL处理,部分病例配合腔内碎石。结果36例(86％)经ESWL及PCNL联合治疗获愈,11例PCNL术中辅以腔内碎石,6例梗阻性无尿者急诊ESWL或腔内碎石后12h内恢复排尿;6例(14％)因肾盂输尿管畸形、梗阻改行开放手术,2例继发反复感染需长期肾造瘘。37例获随访6～18个月,32例(86％)肾功能良好、5例(14％)存在肾功能不全,4例(11％)结石复发。结论联合应用ESWL及PCNL可安全有效地清除多数孤立肾的复杂性结石;肾性梗阻性无尿者行急诊ESWL是必要的,对输尿管下段梗阻性结石可首选腔内碎石;伴肾盂明显畸形或输尿管连接部严重狭窄者以选择开放手术为宜。     

软镜钬激光治疗上尿路结石的技巧及疗效分析

目的研究输尿管软镜钬激光治疗上尿路结石的操作技巧及疗效分析。 方法选择2014年7月至2015年9月收治的46例输尿管软镜钬激光碎石病例。结石直径10～25 mm。术前常规放置输尿管支架1周,术中输尿管硬镜探查患侧输尿管,导入软镜输送鞘,Olympus F7.5输尿管软镜碎石。若推送鞘无法插入,可直接插入输尿管软镜。术后1 d泌尿系统X线平片(KUB) 检查,了解碎石及输尿管支架情况;术后28 d复查KUB或双肾CT平扫,评估碎石效果。 结果术前常规放置双J管1周后输尿管硬镜探查,可降低输尿管严重损伤的风险,有利于放置较大的软镜输送鞘。低能量、高频率的激光碎石,可将结石粉末化,增加排石率。软镜总进镜成功率95.6% (44/46 ),钬激光碎石成功率95.4%(42/44 ),2例患者无法进镜改经皮肾镜碎石。4周后结石清除率为90.5% (38/42)。3例残余结石经体外碎石后治愈。总的结石清除率为93.2%(41/44)。手术时间60～155 min,平均76 min。无一例发生严重并发症。 结论输尿管软镜钬激光碎石是治疗直径10～25 mm肾和输尿管上段结石的安全有效的方法,也可以作为体外冲击波碎石失败和经皮肾镜碎石术后残留结石的治疗选择。     

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     

输尿管软镜联合钬激光碎石术治疗肾和输尿管上段结石:附86例报告

目的 评价输尿管软镜联合钬激光治疗上尿路结石的效果及影响碎石成功的因素和技巧.方法 2008年7月至2011年6月86例输尿管软镜钬激光碎石病例.共104枚结石,结石最大直径10~25 mm.术中使用输尿管硬镜探查患侧输尿管,放置输尿管软镜鞘并换用Storz Flex-X2 F7.5输尿管软镜.若输尿管鞘无法插入,可直接在导丝引导下插入输尿管软镜至肾盂.如果软镜仍不能直接插入,则在放置导丝后留置6 F双J管,1~2周后第二次试行输尿管软镜碎石.术后4周复查KUB或双肾CT平扫,评估碎石效果.结果 软镜一次进镜成功率87.2%(75/86),余11例第二次手术9例成功进镜,总的进镜成功率为97.6%(84/86),钬激光碎石成功率95.3%(82/86).4周后结石清除率为83.7%02/80.12例再次行输尿管软镜碎石,其中9例排净结石.总的结石清除率为94.1%(81/86).平均手术时间为45 min(18-75 min).无严重并发症.结论 输尿管软镜钬激光碎石是治疗10~25mm肾和输尿管上段结石的安全有效的方法.其结石排净率高、并发症低,可以作为体外冲击波碎石失败和经皮肾镜碎石术后残留结石的治疗选择.     

Lithotripsy in the treatment of urinary lithiasis

Based on an extensive review of the literature and on our own clinical experience, this article attempts to present clear guidelines for the management of various kidney stones, particularly regarding the extracorporeal shock waves lithotripsy (ESWL) treatment nowadays. Few technical developments have changed medicine more within a short period of time than ESWL. Fifteen years after the first clinical application, ESWL has gained world-wide acceptance as first choice therapy for most forms of urolithiasis. Ninety-eight per cent of stones can be successfully fragmented by the application of shock-waves, but the ability of the kidney and ureter to clear the resulting fragments is far more important in terms of successful treatment outcome. Increasing experience with new ultrasound-guided lithotriptors has shown that there are some advantages: cost reduction, permanent monitoring and lack of exposure to ionising radiations. ESWL is a safe procedure for the treatment of urolithiasis; nevertheless some problems remain. In ureteric stones, ureteroscopy (rigid or flexible device) allows a rate of stone-free patients better than ESWL. For treatment of large staghorn calculi combined approach of PCNL and ESWL is preferred. For stones located at lower calyx, the stone-free rate in patients treated by ESWL fell to 50%, when unfavourable anatomy is present. The potential long-term renal damage, associated with ESWL in children, have delayed the acceptance of shock-waves into paediatric practice. Recent reports suggest that the renal damage, including the potential risk of hypertension induced by ESWL, is mild and transient. A subgroup of patients (e.g. solitary kidney, impaired renal function, children) required further attention. The fate of residual fragments is unclear. In some cases residual lithiasis tend to result in regrowth and further progression, although ESWL itself does not increase the recurrence rate of urolithiasis. Nevertheless follow-up of stone patients after ESWL is mandatory and the ultimate goal of treating stones by whatever means is to get the patient stone-free and prevent recurrence.     

腹腔镜肾盂切开取石术联合切取法活检术在肾铸型结石合并肾盂癌诊治中的作用

本研究回顾性分析了2015年3月至2019年6月浙江大学医学院附属第二医院收治的3例肾铸型结石合并肾盂癌患者的病例资料,男2例,女1例。年龄52~81岁。既往均有腔镜碎石术史。3例术前检查发现肾盂或肾盂输尿管连接处可疑占位。3例均行腹腔镜肾盂切开取石术,术中切取占位组织活检,分别确诊为肾盂中-低分化鳞癌、浸润性尿路上皮...     

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。     

Prediction of outcome of extracorporeal shock wave lithotripsy in the management of ureteric calculi

The present study was designed to evaluate the clinical outcome of using extracorporeal shock wave lithotripsy (ESWL) in the treatment of ureteric calculi and to establish a predictive model for the stone-free rate in patients receiving the treatment. A total of 831 patients with ureteric calculi were accepted in this study. Several parameters, including stone site, stone number, stone size, history of urolithiasis, renal colic, hydronephrosis, and double-J ureteric stent, were analyzed using univariate and multivariate analyses. A prediction model was established based on the logistic regression analysis of the significant factors, and the goodness-of-fit of the model was evaluated by employing the Hosmer–Lemeshow test. At a 3-month follow-up after ESWL treatment, the overall stone-free rate was 96.8% (804/831) with no serious complications being found, while the treatment failed in 3.2% (27/831) of the patients. Five factors, including stone number, stone size, history of urolithiasis, renal colic, and double-J ureteric stent contributed significantly to the clinical outcome of the ESWL treatment. The prediction model had a sensitivity and overall accuracy of 99.8 and 96.9%, respectively. The results show that ESWL remains an effective method for treating ureteric calculi. The prediction model established in this study could be used as a method for estimating prognosis in patients following ESWL treatment.     

ESWL与输尿管镜治疗输尿管下段结石的比较

目的：比较体外冲击波碎石术（ＥＳＷＬ）与输尿管治疗输尿管下段结石的结石排净率和并发症。方法：治疗输尿管下段结石患者３９０例,其中用ＥＳＷＬ治疗２１０例,输尿管镜治疗１８０例。结果：两组患者术后１个月的结石排净率分别为７８．１％和９３．３％（Ｐ〈０．０５）;ＥＳＷＬ组的主要并发症为再次治疗率高（１１．９％）,而输尿管镜组的主要并发症为输尿管穿孔（３．３％）。结论：输尿管镜治疗输尿管下段结石的疗效优于     

Ureteroscopic stone manipulation in the upper third of ureter and the pelvicaliceal system

During the period of January 1984 to March 1987, a total of 15 patients with upper third ureteric calculi and 115 patients with renal calculi were treated by percutaneous nephrolithotomy (PCNL), transurethral ureteroscopy (TUU) or open surgery. In all patients, endoscopic techniques were the primary modalities of therapy. In 15 patients with upper third ureteric calculi and in 22 patients with 27 calculi in the pelvicaliceal system (five had bilateral calculi), TUU was carried out. The success rate was 67% for calculi in the upper third of ureter and 44% for calculi in the pelvicaliceal system. No persistent strictures or other serious complications were encountered. We conclude, that TUU, in experienced hands, could be considered for proximal ureteric calculi and for certain renal calculi, especially in poor risk patients and patients with only one kidney.     

Therapeutic options in lithiasis of the lumbar ureter

INTRODUCTION: In the past 25 years, the treatment of lithiasis of the lumbar ureter has evolved from ureterolithotomy to extracorporeal shockwave lithotripsy and/or endoscopic lithotripsy. Our objective has been to analyse the results of extracorporeal lithotripsy and endoscopic surgery in lithiasis of the lumbar ureter. MATERIALS AND METHODS: We have analysed 734 single calculi of the lumbar ureter treated during the decade 1990-2000, excluding patients with lithiasis in other locations in order to avoid bias in the assessment of the results. Extracorporeal shockwave lithotripsy (ESWL) was carried out using a Siemens Lithostar, urinary diversion with a double pigtail ureteric catheter or percutaneous nephrostomy, semi-rigid ureteroscopy and electrokinetic contact lithotripsy.The patient were divided into six groups. We assessed complete and partial success, the fragmentation index, and complications, analysing the results using a test for the comparison of proportions. RESULTS: In group A, non-obstructive lithiasis treated by in situ ESWL, complete success was achieved in 95.5%. In group B, obstructed lithiasis treated by in situ ESWL, 93.15%. In group C, obstructive lithiasis treated with a double pigtail catheter and ESWL, 81.11%. In group D, obstructive lithiasis treated with percutaneous nephrostomy and ESWL, 93.75%. In group E, ureteric lithiasis <1cm, treated by retrograde displacement to the renal cavities and ESWL, 82.3%. In group F, lithiasis of the lumbar ureter treated by ureteroscopy, 91%. CONCLUSIONS: The primary therapeutic option for the treatment lithiasis of the lumbar ureter, in the absence of criteria for urinary diversion, is in situ ESWL. We consider the criteria for urinary diversion prior to ESWL to be severe obstruction, obstruction associated with urinary tract infection, and obstruction caused by a proximal ureteric calculus adjacent to the inferior renal pole.Ureteroscopy and/or contact lithotripsy is the technique of choice in lithiasis of the lumbar ureter resistant to ESWL due to non-fragmentation or to the persistence of impacted fragments. Ureteroscopy may be the first choice of therapy in obstructive lithiasis, substituting urinary diversion plus ESWL.     

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.     

斜仰卧截石位经皮肾镜联合输尿管镜处理输尿管上段复杂结石

目的：探讨斜仰卧截石位经皮肾镜联合输尿管镜处理输尿管上段复杂结石的安全性及有效性。方法2009年1月～2012年10月,采取斜仰卧截石位经皮肾镜联合输尿管镜治疗输尿管上段复杂结石67例,气管插管全麻,先行经皮肾镜处理结石,向下移位结石再行输尿管镜将移位结石碎石并经工作通道冲出。结果67例手术均一次完成,手术时间46～106 min,平均76 min。一次结石清除率92．5％（62/67）,结石残留5例,配合ESWL 2周后结石完全清除。均无大出血、输尿管撕脱、脏器损伤等并发症。结论斜仰卧截石位经皮肾镜联合输尿管镜处理输尿管上段复杂结石具有体位舒适,避免术中体位变换带来的不便,手术时间短,有利于术中麻醉监护,碎石取石效果好,并发症少的优点,治疗的安全性高,值得临床推广。     

Open stone surgery: Is it still a preferable procedure in the management of staghorn calculi?

We reviewed 43 patients with staghorn calculi to determine the effectiveness of various treatment modalities such as extracorporeal shock wave lithotripsy (ESWL) monotherapy, ESWL and percutaneous nephrolithotomy (PCNL) combined therapy, and open stone surgery. While ESWL monotherapy and ESWL+PCNL were performed in 25 and 8 patients, respectively, 10 patients underwent open stone surgery. Of the 25 patients treated with ESWL, 8 were stone-free, whereas 4 out of 8 patients treated with ESWL+PCNL and 8 out of 10 patients treated with open surgery were stone-free. The complications of ESWL monotherapy consisted of pyelonephritis in one patient, and stone street formations in three. In the group of ESWL+PCNL, one patient developed pyonephrosis, and another perinephritic abscess. No serious complication was noted in patients who underwent open surgery, but an average of 525 ml of blood transfusion was required. We conclude that open stone surgery, although invasive, is still beneficial in the treatment of staghorn calculi. Presented at the 10th Congress of the European Association of Urology, July 1992, Genoa.     

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。     

体外冲击波碎石在治疗结石形成导致双J管滞留中的价值

目的探讨体外冲击波碎石术在在治疗结石形成导致双J管滞留的应用价值。方法 2003年1月～2012年1月对31例经皮肾镜气压弹道碎石术、输尿管镜检查及碎石术后结石形成导致双J管滞留者采用体外冲击波碎石,电压从6kV开始,根据患者耐受力逐渐增加至7 kV,冲击次数3000～3500次,时间约90 min。冲击从膀胱端开始,依次为输尿管、肾盂,重点冲击肾盂输尿管连接部,当透视发现结石与双J管分离且结石直径〈3 mm治疗结束。结果 22例1次ESWL后双J管顺利拔出;5例2次ESWL后拔出;2例2次ESWL后仍不能拔出,改行输尿管镜后顺利拔出;2例由于结石较大且合并肾盂结石改行微通道经皮肾镜取石术后顺利拔出双J管。31例术后随访6个月,26例无结石复发,5例复发肾结石（4例行排石药物治疗,1例行体外冲击波碎石治疗,结石均顺利排出）。结论对于结石形成导致双J管滞留,ESWL是一种简单、安全、有效的治疗方法。