心脏机械瓣膜置换术后输尿管中下段结石的手术及围术期处理

探讨心脏机械瓣膜置换术后输尿管中下段结石的手术方法选择及围手术期抗凝药物的使用及其安全性。【方法】8例心脏机械瓣膜置换术后罹患输尿管中下段结石患者,长期口服华法林抗凝治疗,入院后停用华法林,改用普通肝素0．5 mg／kg ,q4 h 静脉注射,调整凝血酶原时间（PT ）至正常范围之内,于手术前24 h 停用抗凝药物。手术方式采用全麻下输尿管硬镜气压弹道碎石加 D‐J 管内置术,手术时间控制在30 min 之内,术后24～48 h 口服华法林并与肝素重叠使用,3 d 后停用肝素,单服华法林并维持国际标准化比率（INR）于治疗范围之内。【结果】8例患者均顺利渡过围术期,一次性碎石排石率100％。【结论】针对心脏机械瓣膜置换术后输尿管中下段结石患者,在合理调整抗凝药物种类、剂量及用法,掌握合适的抗凝强度,并注意术中操作及术后处理的前提条件下,输尿管镜碎石＋ D‐J 管内置术,其疗效确,安全可靠。     

腹腔镜联合输尿管镜治疗肝胆管结石52例临床研究

目的 探讨腹腔镜联合输尿管镜治疗肝胆管结石的临床疗效.方法 选择肝胆管结石患者98例,随机分为观察组（腹腔镜联合输尿管镜治疗组）52例和对照组（开腹手术组）46例.比较两组手术时间、术中出血量、住院时间、结石清除率、术后胃肠功能恢复时间、并发症等各项指标差异.结果 观察组手术出血量、住院时间及术后胃肠功能恢复时间、并发症方面优于对照组,差异均有统计学意义（均P＜0.05）;观察组手术时间和T管拔除时间较对照组长,差异均有统计学意义（均P＜0.05）;两组术中副损伤率、胆石清除率、胆石残留率差异均无统计学意义（均P＞0.05）.结论 腹腔镜联合输尿管镜治疗肝胆管结石具有创伤小、并发症少、术后恢复快等优点,是治疗肝胆管结石的一种安全、有效的微创手术方法.     

mPCNL治疗鹿角形肾结石的疗效分析

目的探讨微创经皮肾镜取石术（mPCNL）治疗鹿角形肾结石的疗效和安全性。方法应用经皮肾输尿管镜联合气压弹道碎石治疗61例鹿角形肾结石患者,采用实时彩色多普勒超声引导穿刺、扩张建立F20微通道,使用气压弹道粉碎结石。统计碎石时间、结石取净率以及手术并发症等。结果 61例均一期建立通道。平均手术碎石时间为80min,一次治疗结石取净率为70.5%,总取净率为88.5%,术后8例出现发热,2例行超选择性肾动脉介入栓塞控制出血,未发生脏器损伤和感染性休克病例。结论微创经皮肾镜取石术（mPCNL）联合气压弹道碎石治疗鹿角形肾结石效率高、出血量少,是治疗鹿角形肾结石的安全、有效方法     

多层螺旋CT非增强扫描对输尿管结石的诊断价值

目的评价多层螺旋CT非增强扫描对输尿管结石的诊断价值。方法30例患者,行腹盆部多层螺旋CT非增强扫描。输尿管成像方法为选取冠状面进行曲面重建。结果30例输尿管成像均清楚地显示输尿管,同时显示结石大小、形状、位置和输尿管梗阻扩张程度及范围。结论多层螺旋CT可全面、立体、直观地显示输尿管结石及梗阻扩张的程度,在诊断和鉴别诊断方面具有重要的临床价值。     

B超引导下经皮肾镜超声联合气压弹道碎石清石术的临床观察

目的探讨复杂上尿路结石碎石治疗中B型超声引导下经皮肾镜超声碎石联合气压弹道碎石的临床效果。方法选取笔者所在医院2008年1月～2010年12月泌尿外科收治的复杂上尿路结石患者106例,行B型超声引导下经皮肾镜超声碎石联合气压弹道碎石术进行治疗,另选取体外震波碎石治疗的患者100例作为对照组(109侧)。结果本组患者单侧平均手术时间(61.2±10.7)min;术中平均出血量为(70.3±9.2)mL;术后平均住院时间(6.5±2.3)d。一期手术清石率为90.27%(102/113),总清除率为96.46%(109/113)。研究组单侧手术时间与对照组相比明显缩短(P<0.05),两组住院时间与术中出血量无显著差异(P>0.05),研究组结石清除率显著高于对照组(P<0.05)。结论 B型超声引导下经皮肾镜超声碎石联合气压弹道碎石治疗复杂上尿路结石具有清石率高、并发症少的优势,适合临床推广使用。     

体外震波碎石治疗小儿上尿道结石：（附14例报告）

应用国产ＪＴ－ＥＳＷＬ－Ⅲ型碎石机治疗小儿上尿道结石１４例，其中双肾结石２例，输尿管结石４例；结石大小５ｍｍ×４ｍｍ～５０ｍｍ×３５ｍｍ；７８％患者在肌注安定镇痛药下行碎石治疗，避免了全麻的副作用。所有结石均完全粉碎，无严重并发症，１个月结石排空率为９２％。认为体外震波碎石不仅可用于门诊小儿上尿道结石的碎石治疗，而且可用于治疗小儿复杂性、多发性肾结石。     

Extrahepatic biliary schwannomas: a case report

Benign schwannomas arise in neural crest-derived Schwann cells. They can occur almost anywhere in the body, but their most common locations are the central nervous system, extremities, neck, mediastinum, and retroperitoneum. Schwannomas occurring in the biliary tract are extremely rare and mostly present with obstructive jaundice. We recently experienced a case of extrahepatic biliary schwannomas in a 64-yr-old female patient who presented with intra- and extrahepatic bile duct and gallbladder stones during a screening program. To the best of our knowledge, extrahepatic biliary schwannomas associated with bile duct stones have not been reported previously in the literature.     

术前三维CT模拟穿刺对经皮肾镜取石手术的价值

[目的]探讨术前三维CT重建模拟穿刺对经皮肾镜取石手术的价值.[方法]本院行经皮肾镜手术治疗的上尿路结石患者100例,根据患者术前是否行三维CT重建模拟穿刺分为对照组与观察组,比较两组患者手术相关情况.[结果]两组患者肾积水程度与结石位置相比较差异无显著性(P＞0.05);观察组穿刺时间、经皮通道数目、术后血红蛋白下降值及结肠损伤发生率显著低于对照组(P＜0.05),而一次性穿刺成功率与结石清除率显著高于对照组且差异有显著性(P＜0.05).[结论]经皮肾镜手术治疗前行三维CT重建模拟穿刺能有效了解结石的形态与肾脏集合系统,提高术前评估的准确性,提供最有效的穿刺方法,提高穿刺成功率与结石清除率,减少对周围组织的不必要损伤.     

How accurate is unenhanced multidetector-row CT (MDCT) for localization of renal calculi?

Purpose

To investigate the correlation between unenhanced MDCT and intraoperative findings with regard to the exact anatomical location of renal calculi.

Design, setting, and participants

Fifty-nine patients who underwent unenhanced MDCT for suspected urinary stone disease, and who underwent subsequent flexible ureterorenoscopy (URS) as treatment of nephrolithiasis were included in this retrospective study. All MDCT data sets were independently reviewed by three observers with different degrees of experience in reading CT. Each observer was asked to indicate presence and exact anatomical location of any calcification within pyelocaliceal system, renal papilla or renal cortex. Results were compared to intraoperative findings which have been defined as standard of reference. Calculi not described at surgery, but present on MDCT data were counted as renal cortex calcifications.

Results

Overall 166 calculi in 59 kidneys have been detected on MDCT, 100 (60.2%) were located in the pyelocaliceal system and 66 (39.8%) in the renal parenchyma. Of the 100 pyelocaliceal calculi, 84 (84%) were correctly located on CT data sets by observer 1, 62 (62%) by observer 2, and 71 (71%) by observer 3. Sensitivity/specificity was 90–94% and 50–100% if only pyelocaliceal calculi measuring >4 mm in size were considered. For pyelocaliceal calculi ≤4 mm in size diagnostic performance of MDCT was inferior.

Conclusion

Compared to flexible URS, unenhanced MDCT is accurate for distinction between pyelocaliceal calculi and renal parenchyma calcifications if renal calculi are >4 mm in size. For smaller renal calculi, unenhanced MDCT is less accurate and distinction between a pyelocaliceal calculus and renal parenchyma calcification is difficult.