经皮肾镜联合腔内切开手术治疗肾结石合并肾盂输尿管连接部梗阻

Percutaneous Nephrolithotomy and Endopyelotomy in the Treatment of Renal Calculus and Ureteropelvic Junction Obstruction

目的探讨经皮肾镜联合腔内切开手术治疗肾结石合并肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)的有效性和安全性。方法回顾性分析2009年1月~2016年6月26例肾结石合并肾盂输尿管连接部梗阻的资料,采用B超引导建立标准通道,负压清石系统清除结石,自制电刀切开肾盂输尿管狭窄段,顺行留置海马管(加强型输尿管成形管)3个月,观察治疗前后肾积水严重程度及肾动态显像检测肾功能变化。结果 26例手术均顺利完成,平均手术时间50(45~90)min,术中出血量60(50~115)ml,住院时间6(5~9)d,结石清石率96%(25/26),狭窄段内切开率92.3%(24/26)。26例随访6~24个月,平均9个月。24例IVP或CTU显示内切开段造影剂可顺利通过,肾积水程度较术前减轻,分肾功能改善;2例效果不佳。1例残留肾结石5 mm,行体外冲击波碎石排出。结论经皮肾镜联合腔内切开手术治疗肾结石合并肾盂输尿管连接部梗阻安全、有效,可一期治疗结石和狭窄,术后中短期随访效果良好,长期随访结果有待进一步研究。

Objective To explore the efficacy and safety of percutaneous nephrolithotomy and endopyelotomy in the treatment of renal calculi with ureteropelvic junction obstruction（ UPJO）. Methods A retrospective review of 26 cases of renal calculus complicated with UPJO from January 2009 to June 2016 was performed. A standard access was established guided under ultrasound.The renal calculus was fragmented and extracted by pneumatic and ultrasound lithotripter. The obstruction was cut open with a selfmade electrical scalpel. A hippocampal tube（ enhanced ureteral tube） was placed and retained for 3 months after the procedure. The changes of hydroneprhosis and renal scintigraphy were evaluated before and after operation. Results All the procedures were completed successfully. The mean operation time was 50 min（ range,45-90 min）,the mean blood loss was 60 ml（ range,50-115 ml）,the mean postoperative hospital stay was 6 d（ range,5-9 d）,and the stone removal rate was 96%（ 25/26）. The endopyelotomy was required in 92. 3%（ 24/26） of patients. The mean time of follow-up was 9 months（ range,6-24 months） in all the26 cases. The CTU or IVP revealed contrasts passing the obstruction site smoothly,the extent of hydronephrosis reduced,and renal scintigraphy showing better function as compared with former results in 24 cases. Two cases did not recover well. One patient with residual stones（ 5 mm in dimer） was given extracorporeal shock wave lithotripsy（ ESWL）. Conclusion Percutaneous nephrolithotomy and stimultaneous endopyelotomy is a safe and feasible therapy for patients with renal calculus combined with UPJO.