上段输尿管结石的现代微创手术治疗

The mini-invasive therapy of upper ureteral caculi

目的评价各种微创手术方法治疗上段输尿管结石的价值。方法对我院收治的78例上段输尿管结石患者的治疗方法进行回顾性分析。其中经输尿管镜下气压弹道碎石24例,输尿管镜钬激光碎石16例,微创经皮肾输尿管镜取石(mPCNL)27例,后腹腔镜取石3例,开放手术8例。结果输尿管镜气压弹道碎石18例碎石成功,4例因较大残石行ESWL,1例因黏膜出血视野模糊终止手术,1例输尿管部分断裂改开放手术;钬激光组16例均碎石成功;逆行输尿管镜共有2例输尿管穿孔,均成功放置D-J管,2例因输尿管过度迂曲成“盲端”,3例因结石以下输尿管僵硬狭窄无法进镜改开放手术;mPCNL组27例全部取石成功,无严重并发症;后腹腔镜组3例均取石成功,无漏尿发生。结论输尿管镜下碎石是治疗上段输尿管结石的有效手段,钬激光碎石优于气压弹道碎石,可明显提高碎石效率;mPCNL是一种安全、非常有效的治疗方法,对于结石较大、较硬以及靠近肾盂的结石尤为适宜;经腹腔镜取石与上述方法相比,耗时长、创伤大,但对曾行微创取石失败的患者是一个理想的选择。

Objective To investigate the treatment of upper ureteral calculi with mini-invasive surgery. Methods The information of 78 cases of upper ureteral calculi were analyzed, which were treated by ureteroscopic pneumatic lithotripsy and Ho： YAG laser lithotripsy, mini-percutaneous nephrolithotomy （mPCNL）, laparoscopic ureterolithotomy and open surgery. Results 18 of 24 cases of ureteroscopic pneumatic lithotripsy obtained satisfactory results, while 4 cases needed ESWL after surgery, 1 stopped operation because of bleeding, 1. changed to open surgery because of partial rupture of the ureteral. All of 16 cases of Ho： YAG lithotripsy were successful. In all of ureteroscopic lithotripsy, 2 developed ureter perforation, 5 failed to reach the stones. 27 cases of mPCNL were successful and no severe complications occurred. 3 laparoscopic operation took out the stones suceessfully, no leakage of urine occurred. Conclusion Ureteroscopic pneumatic lithotripsy is effective to remove upper ureteral calculi and Ho.. YAG laser lithotripsy is more effective, mPCNL is safe and effective to remove upper ureteral calculi especially the big and tough stones, or those near the pelvic. For those who failed with other mini-invasive surgery, laparoscopic ureterolithotomy is a very good choice.