复杂性肾结石治疗方法的选择

复杂性肾结石是指鹿角形结石或伴有肾脏解剖结构及功能异常的多发性结石.一般而言,肾结石的复杂性与以下因素有关:(1)结石的成分、大小、形状及其在肾内的分布情况;(2)肾功能是否正常;(3)是否同时存在泌尿系感染[1].     

复杂性肾结石化学成分分析(附84例报告)

目的 :分析复杂性肾结石化学成分特点 ,为预防其复发提供依据。方法 :对 84例在我院行微经皮肾镜取石术的复杂性肾结石患者 (纳入标准为鹿角形结石、单肾或双肾多发性结石且最大结石直径 >2 .5cm)进行结石化学成分分析 ,同时收集相关临床资料。结果 :80例 (95 .2 % )为含钙混合性结石和感染结石 ,其中草酸钙加磷酸钙 30例 (35 .7% ) ;草酸钙加尿酸 14例 (16 .7% ) ;草酸钙加磷酸钙加尿酸 10例 (11.9% ) ,草酸钙加磷酸钙加胱氮酸 1例 ;含钙结石并发感染结石 14例 (16 .7% ) ;感染结石 11例 (13.1% )。 4例 (4 .8% )为单一成分。结论 :体积较大的复杂性肾结石成分复杂 ,生长过程中常多种病因参与 ,应加强其病因诊断和针对多种病因采用积极的预防性治疗     

不同体位多镜联合治疗复杂性肾结石

目的探讨针对不同患者选择合适体位联合多种内腔镜治疗复杂性肾结石的安全性及疗效。方法对在2011年7月至2013年1月选择适合体位联合多种内腔镜进行治疗的78例复杂性肾结石患者资料进行回顾性分析。男51例,女27例,平均年龄49(26~73)岁,肾鹿角形结石47例,多发肾盂、肾盏结石31例。其中孤立肾结石3例(左侧2例,右侧1例),合并肾盂输尿管连接部(UPJ)狭窄3例,合并同侧输尿管结石13例,合并对侧输尿管结石6例,合并双侧输尿管结石4例,同侧肾切开取石术后复发6例,合并肾功能不全3例。选择俯卧位57例,向健侧倾斜45°的仰卧位8例,斜仰卧截石位13例。所有患者均联合应用多种内腔镜进行碎石、取石治疗。结果该组78例患者肾穿刺通道均一次成功建立,未出现大出血、气胸、严重感染等并发症。肾结石一期清除率86.7%,输尿管结石清除率100%。5例残留肾结石经原经皮肾通道二次取石,3例术后配合体外冲击波碎石治疗,2例行二期经皮肾镜取石术(PCNL)。手术时间70~120min,平均85min;住院时间平均7.6d。结论针对不同患者选择适合体位联合多种内腔镜治疗复杂性肾结石,安全、高效,能明显减少二次麻醉及手术的几率,值得推广应用。     

一种手术体位的固定支架在“双镜联合”治疗肾结石中的应用

目的 探讨通过一种手术体位的固定支架行经皮肾镜联合输尿管软镜钬激光碎石术,治疗复杂性肾结石有效性及安全性。方法 回顾性分析2014年5月至2018年12月我院31例采用半侧卧截石位行经皮肾镜联合输尿管软镜钬激光碎石术治疗肾结石患者的临床资料。结果 31例患者手术时间(82.5±12.4)min,术后住院(6.8±2.3)d,一次碎石清石成功率达93.54%(29/31)。2例结石残留患者术后3周行体外冲击波碎石后结石排出;术后出血1例、高热2例,6例术前肾功能不全患者肾功能均好转。结论 “双镜联合”治疗复杂性肾结石,是安全有效的。     

肾窦内肾盂加肾实质切开治疗复杂性肾结石

目的探讨复杂性肾结石手术取石方法。方法对58例复杂性肾结石患者，采用肾窦内肾盂加肾实质切开取石术。结果全部病例均取出结石，术后肾功能恢复好，小结石残留9例，并发漏尿4例，继发出血1例而行肾切除。结论本术式操作简单、出血少、对肾功能影响小，适合于复杂性肾结石的治疗。     

45例复杂性肾结石开放取石的术式选择

目的探讨复杂性肾结石开放手术取石术的术式选择。方法回顾性分析45例复杂性肾结石开放手术取石的临床资料,根据术前影像学资料,结石形态与肾脏解剖关系选择手术方式。结果 45例患者手术均顺利完成,术中无意外切除肾脏,术后1个月复查,患者2例结石残留,术侧肾功能良好;随访3～5 a,结石复发率20.0%。结论对于复杂性肾结石,根据结石形态及位置。肾盂类型、肾积水程度、肾实质厚度等因素判断,选择合理的术式,是保障取石干净和减少结石复发的关键。     

斜卧截石联合体位经皮肾镜术治疗复杂性肾结石的临床研究

目的探讨斜卧截石联合体位经皮肾镜取石术(PCNL)治疗复杂性肾结石的方法及疗效。方法 2012年6月至2016年5月我院107例复杂性肾结石患者(25例合并输尿管结石),采用斜卧截石联合体位,经超声或X线引导穿刺并建立取石通道行PCNL,术中可同时输尿管镜逆行经膀胱输尿管进行碎石,将剩余结石冲入肾盂,自经皮肾镜通道取出结石。结果所有患者均采用单通道完成手术操作。总体手术时间为95.1±26.9 min(不包括穿刺定位时间)。总体结石一次手术清除率为85.1%。其中25例合并输尿管结石的患者结石均在首次手术中清除。术后5例患者出现迟发性出血,3例患者出现严重感染。结论斜卧截石联合体位PCNL对于治疗复杂性肾结石是一种安全、有效的手术体位。相比俯卧位PCNL,该体位能够在达到相似结石清除率的同时,明显降低手术时间,利于术中麻醉监测。     

超声引导多通道经皮肾镜取石术治疗复杂性肾结石

目的 评估超声引导多通道微创经皮肾镜取石术(PCNL)治疗复杂性肾结石的方法及效果.方法 对46 例接受超声引导微创多通道PCNL 的患者进行回顾性分析.其中鹿角型肾结石8 例,多发性肾结石38 例.部分残留结石行二期或三期手术取石.结果 双通道取石40 例,三通道6 例;一期取净率76.1%,总结石取尽率为95.6%;一期手术平均手术时间1.8 h.手术平均出血量240 ml.结论 超声引导多通道PCNL 治疗复杂性肾结石安全、有效.     

斜仰卧-截石位双镜联合治疗复杂性肾结石的临床研究

目的:研究斜仰卧-截石位双镜联合(肾镜联合顺-逆行输尿管软镜)治疗复杂性肾结石的疗效和安全性。方法:回顾性分析我院使用斜仰卧-截石位双镜联合治疗的76例复杂性肾结石患者资料,观察碎石、取石效果。结果:69例患者一期手术中双镜联合治疗肾结石(69例均使用顺行输尿管软镜碎石,其中23例顺行输尿管软镜碎石后同期逆行输尿管软镜治疗残留结石),7例二期手术中双镜联合治疗结石。一期手术时间65~133min,平均(95.66±15.21)min,结石清除率为90.7%(69/76);二期手术时间55~106min,平均(73.26±11.33)min,结石清除率96.1%(73/76)。3例患者二期手术后仍有残留结石,术后1个月行体外冲击波碎石术(ESWL)治疗,1例结石完全排出,2例残留结石直径大小0.6~0.9cm。结论:斜仰卧-截石位双镜联合治疗复杂性肾结石安全、迅速,一期手术结石清除率高,患者术后恢复快,是一种安全有效的治疗复杂性肾结石的方法。     

原位低温阻断肾血管肾实质切开取石术

目的探讨原位低温阻断肾血管肾实质切开取石术治疗复杂性肾结石的效果。方法2000年3月～2005年1月采用原位低温阻断肾血管肾实质切开取石术治疗肾内型肾盂复杂性肾结石患者22例,术中快速静脉滴注肌苷2.0g,静滴20%甘露醇250ml。根据术前影像检查结果及术中所见选择肾切口径路:13例充填于各盏的鹿角状结石,行肾背侧Brodt线肾实质肾盏切开取石;5例肾下盏肾盂鹿角状结石,行肾盂肾实质联合切开取石;4例结石过多者,于肾皮质最薄处另作放射状切口取石。结果肾血管阻断时间平均45(30～60)min;手术时间平均110(90～180)min;平均失血量150(80～400)ml。结石一次取净21例,1例残余结石,术后2个月带双J管行ESWL碎石排出。术后1～2月复查肾功能,术前有肾功能损害的8例,血清Cr平均110.2μmol/L,血清BUN平均8.0mmol/L,均明显改善,其余患者肾功能无损害,无严重术后并发症。18例随访6个月～3年无一例复发。结论原位低温阻断肾血管肾实质切开取石术治疗复杂性肾结石安全有效、出血少、结石残留率低。     

232例湖北地区泌尿系结石红外光谱成分分析

目的：分析湖北地区泌尿系结石化学成分的构成,为本地区结石的防治提供依据。方法：采用结石红外光谱自动分析系统对2011年11月～2012年8月期间收集到的湖北地区泌尿系结石232例进行成分分析。结果：232例结石中,各成分的检出率为：一水草酸钙（COM）85．34％,二水草酸钙（COD）62．93％,碳酸磷灰石（CA）24．14％,无水尿酸（UA）12．93％,二水磷酸氢钙（PH）4．31％,磷酸铵镁（MAP）6．90％,黄嘌呤1．29％,胱氨酸（CYS）1．29％,方解石0．86％,尿酸铵（AU）0．86％。含草酸钙成分结石86．21％,含磷酸钙成分结石28．45％,含磷酸铵镁成分结石6．90％,含尿酸成分结石13．79％,含胱氨酸成分结石1．29％。混合成分结石181例（78．02％）,尿路结石发病男性多于女性,男女比例为3．14：1。结论：湖北地区泌尿系结石以混合性结石为主,COM检出率最高,其次为COD。结石成分分析对于结石的防治有重要意义。     

延安地区泌尿系结石成分分析的研究

目的利用红外光谱法测定延安大学附属医院泌尿外科手术获得的泌尿系结石成分,探讨延安地区泌尿系结石成分与年龄、性别等关系,比较上、下尿路结石成分特点,分析延安地区泌尿系结石发生的流行病学情况,为临床制定有效的个体化治疗及预防措施提供参考依据。方法收集2013年1月至2017年1月在延安大学附属医院泌尿外科治疗1984例尿路结石患者的年龄、性别、结石部位等临床资料,对比分析延安地区泌尿系结石在不同年龄、不同性别、不同解剖部位的分布特点。结果在1984例泌尿系结石的患者中,按每10岁年龄大小分组排序,统计各年龄阶段泌尿系结石发病情况,男性患者有1346例,女性患者有638例,男性年龄(50.23±14.48)岁,女性年龄(47.87±14.51)岁,男、女患者比例约2.11∶1。在66~75岁年龄段,尿路结石发病率性别差异具有统计学意义(P<0.05)。结石成分以混合性结石为主,以混合性结石为主,共1582例,占79.76%。其中1665例(83.92%)为上尿路结石,上、下尿路结石的比例为5.22∶1,其余为肾结石合并膀胱结石。上尿路结石中男性1062例,女性603例,男女比例为1.76∶1;下尿路结石中男性284例,女性35例,男女比例为8.11∶1。青壮年(年龄≤45岁)泌尿系结石患者草酸钙为主结石、感染性结石多见;中老年(年龄>45岁)泌尿系结石者草酸钙为主结石、尿酸类结石多见。感染性结石患者性别差异具有统计学意义(P<0.05)。结论在延安地区男性较女性更容易患泌尿系结石。同时,不同年龄段结石构成成分具有差异。对于年龄≤45岁患者,主要以草酸钙为主结石、感染性结石多见,这与结石整体发病率基本一致;而对于年龄>45岁患者,主要以草酸钙为主结石、尿酸性结石多见。表明对于不同年龄段的结石患者,可以根据上述结果在结石的预防和治疗上综合考量,给予明确而更加合理的治疗。     

The efficacy of potassium citrate based medical prophylaxis for preventing upper urinary tract calculi: a midterm followup study

PURPOSE: We examined the efficacy of potassium citrate based medical prophylaxis for preventing upper urinary calculous recurrence, and compared it with the stone recurrence rate in patients who only received intermittent or no medical prophylaxis. MATERIALS AND METHODS: We retrospectively reviewed the records of 493 patients with upper urinary calculi, of whom 237 men and 76 women with a mean age of 56.1 and 51.4 years, respectively, were enrolled in the study. Of the 313 participants 64 (group 1, 20.4%) received regular medical prophylaxis for 24 to 42 months (mean 27.8), 80 (group 2, 25.6%) received intermittent medical prophylaxis for 1.5 to 19 months (mean 7.9) and 169 (group 3, 54%) did not receive any medical prophylaxis. RESULTS: At midterm followup of 24 to 60 months 107 patients (34.2%) had stone recurrence. In group 1 the stone recurrence rate was 7.8%, which was significantly less (p <0.001) than in groups 2 (30%) and 3 (46.2%). Similarly new calculous events in patients with a history of multiple stone recurrence were less frequent in group 1 than in groups 2 and 3 (9.7, 47.4 and 52.2%, respectively, p <0.001). Multiple stone recurrence history, hypercalciuria, hyperuricosuria and calcium oxalate dihydrate calculi were independent risk factors for stone recurrence. CONCLUSIONS: Regular medical prophylaxis may effectively prevent stone recurrence regardless of previous treatment modalities, stone composition, metabolic abnormalities and stone-free status. Cost effectiveness, patient compliance and gastrointestinal upset may limit patient acceptability and clinical use of medical prophylaxis. However, patients with a history of multiple stone recurrence, calcium oxalate dihydrate stones, hypercalciuria and hyperuricosuria benefit from regular medical prophylaxis.     

Stones and urinary tract infections

The term infection stones refers to calculi that occur following urinary tract infections (UTIs) caused by urease-producing gram-negative organisms. They consist of magnesium ammonium phosphate, carbonate apatite and monoammonium urate. Alkaline urine is most favorable to their formation. Urinary tract obstruction, neurogenic bladder, voiding dysfunction, temporary or indwelling urinary catheters, distal renal tubular acidosis and medullary sponge kidney are considered the main risk factors for developing infection stones. Urinalysis and urine culture are essential for diagnosis. A typical finding on imaging is a moderately radiopaque, staghorn or branched stone. Curative treatment is possible only by eliminating all of the stone fragments and by eradicating UTI. A variety of operative and pharmaceutical approaches is available. Metaphylactic treatment is mandatory to prevent recurrences. The relationship between urinary stones and UTIs is well known and shows two different clinical pictures: (1) stones that develop following UTIs (infection stones) which play a key role in stone pathogenesis, and (2) stones complicated by UTIs (stones with infection) which are metabolic stones that passively trap bacteria from coexistent UTIs and may consist of calcium or non-calcium. This article presents an overview of infection stones, analyzing the epidemiology, composition, pathogenesis, diagnosis, treatment and prevention of this type of calculi.     

The aetiological and clinical pattern of childhood urolithiasis in Saudi Arabia

The clinical and aetiological pattern in 85 stone-forming children presenting to an integrated nephrourological service in Riyadh is reviewed. All patients were below the age of 15 years, the male to female ratio being 2∶1. Only 2 children presented with bladder calculi. The remaining all had upper tract stone and, in 12 cases, these were bilateral. Of 34 calculi recovered for analysis, one-third was predominantly calcium oxalate and a further third was composed of uric acid or urate. Four patients had cystine stones and the remaining 7 presented mixed calcium stones, 6 (17.6%) being struvite and infection-related. Of the 85 patients 55 were treated successfully with extracorporeal shock wave lithotripsy, 16 underwent surgery and 7 had their stones removed by endourological procedures. In the remaining 7 children, stones dissolved or were passed spontaneously during medical therapy. Nine children (10.6%) showed a primary metabolic defect leading to their stone formation, 10 (11.8%) had a predisposing anatomical anomaly and 15 (17.6%) presented with urinary tract infection. Of the remaining 51 patients (60%) with idiopathic disease, 6 showed hypercalciuria on investigation and 2 children may have formed their stones due to prolonged recumbency.     

开放手术治疗上尿路结石667例回顾分析

目的 总结开放手术治疗上尿路结石的有效性,探讨在微创时代开放手术治疗上尿路结石的手术适应证.方法 回顾分析1995年1月至2004年12月在四川大学华西医院泌尿外科行开放手术治疗的上尿路结石病例.结果 共667例上尿路结石行开放手术治疗,同期约有9000例上尿路结石病例在我科治疗,开放手术比例约7.4%.开放手术原因包括:复杂结石及巨大结石297例,结石致患肾无功能137例,结石合并上尿路解剖畸形134例,微创治疗失败57例,结石合并各种内科疾病30例,结石合并肾肿瘤5例,结石合并黄色肉芽肿性肾盂肾炎3例,结石合并肾外伤2例,结石合并同侧其他手术2例.145例肾切除病例中共16例出现术中并发症,6例出现术后并发症;522例肾输尿管切开取石病例中,7例出现术中并发症,34例出现术后并发症;术后57例结石残留,总结石清除率为89.1%;围手术期无一例死亡.结论 开放手术在上尿路结石的治疗中仍然有重要作用,结石性无功能肾切除、复杂及巨大肾结石、结石合并解剖畸形、微创治疗失败及合并内科疾病的部分选择性病例适合选择开放手术治疗,治疗效果确切,并发症低.     

Recurrence of upper urinary tract calculi

Treatment of upper urinary tract stones has changed greatly. The recurrence of calculi after the discharge was studied in the 634 patients with urolithiasis admitted to our department during the 9 years up to the end of 1984. The recurrence rate in the 325 cases followed for more than 3 months after the disappearance of the original stones, was 15.6% after 2 years, 27.6% after 5 year and 51.4% after 8 years. In recurrent stone formers, the rate of recurrence thereafter was greater than that of primary stone formers. The growth of calculi was rapid in the renal stone former concomitant with urinary tract infection together with a past history of renal surgery. In relation to the composition of the stone, uric acid calculi tended to recur more often than calculi composed of other substances. In view of recurrence, pyelolithotomy is preferred to renal parenchymal incision.     

广东东莞地区416例泌尿系结石成分分析

目的 应用红外光谱法测定东莞地区泌尿系结石化学成分,探讨本地区泌尿系结石患者的尿路结石成分特点,为本地区泌尿系结石的深化治疗、防止结石复发及预防提供科学依据.方法 收集经自行排出、碎石后排出或手术中取出的泌尿系结石标本416例,应用溴化钾压片技术的红外光谱法对其化学成分进行定性分析.结果 416例泌尿系结石患者中男性居多,占66.8%(278/416),女性占33.2%(138/416);上尿路结石占88.2%,下尿路结石(膀胱结石居多)占11.8%;结石成分定性分析共检测出一水草酸钙、二水草酸钙、碳酸磷灰石、无水尿酸、六水磷酸铵镁和尿酸铵6种化学成分.单一成分结石163例(一水草酸钙/无水尿酸/碳酸磷灰石/六水磷酸铵镁:98/56/6/3),占39.2%;混合成分结石253例,占60.8%,其中以草酸钙和碳酸磷灰石的混合结石为主(188/253).所有结石标本中草酸钙检出率最高,占80.5%(335/416),其次为碳酸磷灰石(49.3%)及无水尿酸(17.3%);膀胱结石成分以一水草酸钙或无水尿酸为主.结论 东莞为全国泌尿系结石最高发地区,其结石成分以草酸钙和碳酸磷灰石为主,单一成分结石亦占相当比例.尿路结石成分分析对了解结石成因可提供重要的线索,对临床制定个性化治疗方案、预防结石形成及复发具有重要意义.     

Analysis of spontaneously passed urinary tract stones

Most studies on epidemiology, composition, and recurrence of renal calculi include both spontaneously passed calculi and those retrieved after surgical manipulation or shock wave lithotripsy. The present study exclusively focused on epidemiology, composition, and recurrence of spontaneously expelled stones in patients from North and East Mallorca (Spain) which represents a geographically specific non-urban region of a developed country. The study involved 136 patients who spontaneously passed 205 renal calculi. All calculi were classified and sub-classified according to composition after macroscopic and microscopic examination. We also analyzed prevalence, gender, age, and stone recurrence rate over a period of 3 years. The peak incidence of spontaneously stone passage is within the fourth to sixth decade. Overall male to female ratio was 3/1. Calcium oxalate was the most prevalent composition (64.8%) followed by uric acid (25.3%), mixed stones (5.3%) and calcium phosphate calculi (4.3%). Uric acid stones were the most recurrent (50%) followed by calcium oxalate monohydrate papillary calculi (26.4%), calcium oxalate monohydrate un-attached calculi (19.2%), calcium oxalate dihydrate calculi (18.3%), calcium phosphate calculi (14%), and mixed calculi (12.5%). In conclusion, spontaneously passed stones in Mallorcan population have similar epidemiology, composition, and recurrence rate from that found in other developed countries. Calcium oxalate stones are largely the most spontaneously passed type of calculi and uric acid stones are the most frequently recurred. These findings are also found to be similar to those reported in previous studies examining both spontaneously and non-spontaneously passed stones.