输尿管软镜下钬激光憩室颈部切开及碎石治疗微小出口肾盏憩室结石

目的：评价输尿管软镜下定位肾盏憩室微小出口的可行性，报道应用输尿管软镜下钬激光行微小出口憩室颈部切开及憩室内结石碎石术。方法：回顾分析2012年11月至2014年11月在北京大学第三医院泌尿外科行输尿管软镜治疗微小出口肾盏憩室结石的病例，共收集10例，其中女性3例，男性7例，平均年龄36.9岁（20~62岁），6例憩室位于右肾，4例憩室位于左肾。CT测平均结石负荷（1.33±0.43） cm。5例患者术前于外院行体外冲击波碎石（extracorporeal shock wave lithotripsy，ESWL）治疗，均无结石排出。术前完善静脉肾盂造影（intravenous urography，IVU）及CTU（CT-urography）检查。患侧预留置输尿管支架双J（double-J）管扩张输尿管管腔2周后，于全身麻醉下行电子纤维软输尿管镜下钬激光肾盏憩室颈部切开+碎石取石术，术中探查各组肾盏，并于镜下逆行注入美蓝协助定位憩室颈部微小出口。术后留置患侧双J管并口服排石药物1~3个月。术后1个月、3个月复查泌尿系X线平片（kidney ureter bladder，KUB）。结果：患者术中见7例憩室颈部位于上盏，3例位于中盏。平均手术时间（123.7±59.6）min,平均术中出血量（29.3±32.1） mL。10例术中均于软镜下切开憩室颈部，定位成功率100%。术后复查KUB，1个月及3个月结石清除率分别为50.0%及80.0%。2例患者术后体温超过38.0 ℃并伴有畏寒，发生尿源性感染，未见其他严重并发症。结论：对于严格筛选的病例，输尿管软镜下钬激光憩室颈部切开及碎石取石治疗微小出口肾盏憩室结石安全、有效；术前应完善CTU及IVU检查以利于憩室定位，术中逆行推注美蓝可准确定位肾盏憩室颈部微小出口，术后排石时间延长。

Management of calyceal diverticular calculi with stenotic infundibulum by flexible ureteroscopic holmium laser infundibulectomy and lithotripsy

Objective：To evaluate the efficacy and safety of flexible ureteroscopic holmium laser lithotripsy in treating calyceal diverticular calculi with stenotic infundibulum and to present our initial experience.Methods: From Nov. 2012 to Nov. 2014, 10 patients with stone bearing calyceal diverticulum and stenotic infundibulum underwent flexible ureteroscopic holmium laser lithotripsy in our hospital, including 3 female patients and 7 male patients with an average age of 36.9 years (range: 20 to 62 years). There were 6 patients with right side while 4 patients with left side calyceal diverticular calculi. The average cumulative stone size was (1.33±0.43) cm. Five patients underwent extracorporeal shock wave lithotripsy (ESWL) before hospital admission but no stone was discharged. All the patients received intravenous urography (IVU) and CT-urography (CTU) preoperatively and underwent double-J stents placement 2 weeks before operations. A digital-fiber flexible ureteroscopy and 200 μm holmium laser fiber were used for treatment. Surgeries began with routine flexible ureteroscopy and methylene blue injection was used to identify the small ostium of infundibulum. Then infundibulectomy followed by lithotripsy was performed. All the patients receive double-J stents placement and traditional Chinese medicine for 1 to 3 months after operations. The stone clearance was estimated by kidney ureter bladder (KUB) within 3 months’ follow up.Results:The locations of calyceal diverticulum were upper pole in 7 patients, and interpolar regions in 4 patients. The average operation time was (123.7±59.6) min, and the average estimated blood loss was (29.3±32.1) mL. Successful flexible ureteroscopic holmium laser infundibulectomies were performed in all the 10 patients. Success rate was 100%. The stone clearance rates for 1 and 3 months after surgery were 50.0% and 80.0%, respectively, which were observed by KUB follow-up. Two patients had serious post operative fever (>38.0 ℃) in coexistence with chills. The mobidity of urosepsis was 20.0%. No major complications were identified.Conclusion:In selected patients, calyceal diverticular calculi with stenotic infundibulum can be treated safely and efficiently with flexible ureteroscopic homium laser lithotripsy. CTU and IVU should be completed preoperatively for calyceal diverticulum location and technique difficulty prediction. Retrograde methylene blue injection can be used to identify the ostium during surgery. And prolonged post-operation stone clearance was observed.