现代微创手术治疗输尿管上段结石

Modern minimally invasive surgical treatments of upper ureteral calculi

目的探讨现代微创手术治疗输尿管上段结石的效果。方法回顾性分析128例输尿管上段结石患者的临床资料,其中经输尿管镜钬激光碎石50例,输尿管镜气压弹道碎石35例,微创经皮肾穿刺输尿管镜取石(MPCNL)24例,后腹腔镜输尿管上段切开取石(RLU)19例。结果输尿管镜钬激光单次碎石成功率为90.74%,1例因输尿管镜逆行插管穿孔、1例因输尿管结石下段明显狭窄僵硬、3例因远端输尿管迂曲而改开放手术取石。气压弹道碎石单次成功率为76.32%,1例因远端输尿管迂曲、1例因输尿管结石下段合并较大息肉、2例因术中输尿管穿孔、1例因输尿管黏膜损伤出血视野不清而改开放手术,1例因远端输尿管迂曲改后腹腔镜取石术,1例因输尿管穿孔留置双J管,2例因结石下段合并狭窄僵硬改开放手术切除狭窄段行端端吻合并取石。MPCNL组成功取石23例,1例因结石残留而行体外冲击波碎石术(ESWL)。RLU组19例全部取石成功,仅1例术后漏尿。结论经输尿管镜腔内碎石是治疗输尿管上段结石安全、有效的方法,在碎石效果和治疗合并输尿管息肉、狭窄等方面,钬激光碎石明显优于气压弹道碎石并可减少结石的上移;MPCNL创伤小,结石取净率高,并发症少,对较大、较硬、靠近肾盂、合并同侧肾结石及儿童输尿管上段结石尤为适宜,可作为复杂性输尿管上段结石的首选方法;RLU取石效果确切,损伤小,术后恢复快,尤其适合既往需要行开放手术取石的患者,并有望部分代替传统的开放性输尿管切开取石术。

[Objective] To investigate the modem treatments of upper ureteml calculi with minimally invasive surgery. [Methods] Retrospective analysis of clinical data of 128 cases of ureteral calculi was studied. 50 cases were treated by ureteroscopic Holmium：YAG laser lithothrypsis, 35 cases were treated by ureteroscopic pneumatic lithothrypsis（URSL）, 24 cases were treated by minimally invasive percutaneous nephrolithotomy （mini-PCNL） and 19 cases were treated by retroperitoneal laparoscopic ureterehthotomy （RLU）. [Results] The single lithothrypsis success rate was 90.74% in cases treated by ureteroscopic Holmium： YAG laser lithothrypsis and the operations were converted to open surgery because of ureter perforation in 1 cases and ureteroscope insertion failure in 4 cases. The hthothrypsis success rate was 76.32% in cases treated by ureteroscopic pneumatic lithothrypsis and the operations were converted to open surgery in 1 case because of distal end ureter circuity, 1 case merged with large polyp, 2 cases of ureter perforation andl case because of bleeding. 1 case changed to retroperitoneal laparoscopic ureterohthotomy, 1 case detained D-J tube and 2 cases changed to open and stegnosis section. 23 cases were successfully treated by mini-PCNL and 1 case needed extracorporeal shock wave hthotripsy（ESWL） treatment because of few stone remained. All cases were successfully treated by RLU and only 1 case had leakage of urine. [Conclusion] The ureteroscopic pneumatic lithothrypsis is an effective and safe method for ureteral calculi and Holmium： YAG laser hthothrypsis is more effective than pneumatic lithothrypsis on patients merged with polyp and stenosis and prevents for stone moving up. Mini-PCNL has advantage of less invasive and complication, high stone removal rate which is optimally suited for complicated ureteral calculi. RLU has certain effect, less invasive and rapid recovery which is suitable for ureteral calculi which treated by open surgery before, and it will partially take place of conventional open surgery in future.