输尿管软镜激光碎石术治疗肾结石338例报告

目的评价输尿管软镜结合钬激光和FREDDY激光处理不同部位肾结石的有效性,评价影响输尿管软镜碎石成功率的影响因素和手术技巧。方法回顾性分析2002年5月～2007年5月338例输尿管软镜激光碎石术。结石最大直径均〈20mm。288例结石位于上盏、中盏或肾盂内,37例位于下盏,13例位于多个肾盏内。术前均行泌尿系平片（KUB）＋静脉尿路造影（IVU）。放置Terumo导丝后,首先使用F8/9.8Wolf输尿管硬镜探查患侧输尿管。顺利进镜的患者放置输尿管软镜鞘并改用OlympusP3F6.9输尿管软镜。若输尿管硬镜无法顺利进镜,则在放置导丝后留置双J管,2周后行二期输尿管软镜碎石术。使用WOMU-100FREDDY激光或Lumenis钬激光碎石。术后常规留置F7双J管2周。术后第1天拔除导尿管,术后常规静脉给予广谱抗生素2天。2周后拔除双J管,4周后复查KUB或双肾CT平扫,评估结石排净率。残留结石≥4mm为有意义的结石残留。结果一次进镜成功率91.7%（310/338）,余28例进镜失败者在成功留置导丝的前提下放置双J管,2周后成功进镜。329例软镜成功进镜后寻及结石（329/338,97.3%）,其中306例成功碎石（306/329,93.0%）,下盏结石碎石成功率78.0%（32/41）,低于中上盏肾盂内结石的碎石成功率95.1%（274/288）（χ2=13.601,P=0.000）。4周后总结石排净率为87.6%（296/338）,肾中上盏及肾盂内结石术后排净率为90.1%（264/293）,肾下盏结石术后结石排净率为71.1%（32/45）,两者差异有显著性（χ2=12.929,P=0.000）。无输尿管穿孔和出血。平均手术时间为35min（12～55min）。术后肾绞痛11例。无菌血症及急性肾功能不全。术后肉眼血尿1～2天内消失。结论输尿管软镜结合FREDDY激光或钬激光是处理〈20mm肾结石的安全有效的手段。肾中上盏及肾盂内结石较肾下盏结石寻及率高,碎石成功率高,结石排净率高。一期输尿管镜进镜困难的患者可在成功留置双J管2周后二期行输尿管软镜碎石术。

Flexible Ureteroscopy and Laser Lithotripsy for Renal Calculi: Report of 338 Cases

Objective To evaluate the efficacy of the flexible ureteroscopy and Holmium and FREDDY laser lithotripsy for renal calculi at various locations.Methods From May 2002 to May 2007,338 cases of renal calculi（sized less than 20 mm in diameter）were treated by flexible ureteroscopy and laser lithotripsy in our hospital.The data of the patients were analyzed retrospectively.Among the cases,the calculi were located at the upper or middle calyx or the renal pelvis in 288 patients,at the lower calyx in 37,and in multiple calyxes in 13.All the patients received KUB and IVU before the procedures.With the TerumoTM settled in place,a F8/9.8 Wolf rigid ureteroscope was inserted to observe and dilate the ureteral lumen.Then,an Olympus P3 6.9F flexible ureteroscope was used.When the insertion of the rigid ureteroscope was difficult,a re-ureteroscopy would be tried 2 weeks later with a pig-tail stent in place.The WOM U-100 FREDDY laser and the Lumenis Holmium laser were used to perform the procedure and a pig-tail stent would be set at the end of the procedure.The urethral catheter was removed in the first postoperative day and an intravenous antibiotic prophylaxis was administrated during the first 2 days postoperatively.A follow-up by KUB or non-contrast CT scan was done 4 weeks after the procedure to evaluate the result of the endoscopic nephrolithotripsy.Any residual calculi larger than 4 mm in diameter was taken significant.Results In 28 patients the rigid ureteroscope or the ureteral sheath couldn＇t be inserted in the first time,and the success rate of the ureteroscopic insertion was 91.7%（310/338）.The re-ureteroscopy was successful in the patients after 2 weeks.The calculi were detected in 97.3%（329/338）of the patients,and the procedures succeeded in 306 of them（306/329,93.0%）.The success rate of laser nephrolithotomy was 78.0%（32/41）for the lower calyx calculi,which was significantly lower than that for the middle,upper calyxes or renal pelvic calculi 95.1%（274/288）,χ2=13.601,P=0.000].After 4 weeks,the total evacuation rate of the calculi was 87.6%（296/338）.For the calculi in the upper or middle pole or in the renal pelvis,the complete evacuation rate was 90.1%（264/293）,which was significantly higher than that for the lower pole 71.1%（32/45）,χ2=12.929,P=0.000].No patient had ureteric perforation or active bleeding after the surgery.The mean operation time was 35 min（12-55 min）.After the operation,11 cases developed nephritic colic.None of them had septicemia or acute renal failure.Gross hematuria disappeared in 1-2 days postperation.Conclusions The flexible ureteroscopy and Holmium and FREDDY laser lithotripsy are safe and effective for renal calculi sized less than 20 mm in diameter,especially for those in the upper,middle poles and renal pelvis.A re-ureteroscopy with the pig-tail stent in place is suggested in two weeks after the failure of the first procedure.