孤立肾并发复杂性结石32例的治疗探讨

The treatment choice of 32 patients solitary kidney complicated with complex calculi

目的探讨孤立肾并发复杂性结石的处理方式，提高其治疗的有效性和安全性。方法回顾性分析32例孤立肾并发复杂性结石的临床资料。其中先天性孤立肾6例（18．8％）、后天原因26例（81．2％）；左侧12例（37．5％）、右侧20例（62．5％）。均为铸形或鹿角状、多发性结石，9例合并输尿管结石，8例因梗阻性无尿急诊入院；铸形或鹿角状结石首选体外冲击波碎石术（ESWL）后经皮‘肾镜取石术（PGNL）治疗，多发性结石先行PCNL后行ESWL处理，部分病例配合腔内碎石。结果29例（90．6％）经ESWL及PCNL联合治疗痊愈，12例PCNL术中辅以腔内碎石，8例梗阻性无尿者急诊ESWL或腔内碎石后12h内恢复排尿；3例（9．4％）因肾盂输尿管畸形、梗阻改行开放手术，1例继发反复感染需长期肾造瘘。随访4～36个月，29例（90．6％）肾功能良好，3例（9．4％）存在肾功能不全，2例（6．2％）结石复发。结论联合应用ESWL及PCNL可安全有效地清除多数孤立肾的复杂性结石；梗阻性无尿者行急诊ESWL是必要的，对输尿管下段梗阻性结石可首选腔内碎石；伴肾盂明显畸形或输尿管连接部严重狭窄者以选择开放手术为宜。

Objective To investigate the therapeutics of solitary kidney complicated with complex calculi, and improve the effect and safety of treatment. Methods Experiences in the treatment of 32 patients with solitary kidney complicated with complex calculi were summarized. Congenital solitary kidney was 6 cases （ 18.8% ）, postnatal reason was 26 cases （81.2%）, left was 12 cases （37.5%）, right was 20 cases （62.5%）. All patients were with mould or multiple calculi, 9 cases were complicated with ureter calculi, and 8 cases were hospitalized because of obstructive anuria. The patients with mould calculi received extracorporeal shock-wave lithotripsy （ESWL） prior to percutaneous nephrolithotomy （PCNL）. While the patients with multiple calculi received PCNL prior to ESWL. Some cases were treated by lithodialysis. Results Twenty-nine cases （90.6%） were cured by ESWL combined with PCNL, 12 cases received lithodialysis during PCNL. Eight cases with obstructive anuria recovered in 12 hours after emergent ESWL or lithodialysis, 3 cases（9.4%） underwent open operation because of deformity or obstruction in renal pelvis and ureter, 1 case had to keep nephrostomy because of repeated infection. Followed up 4-36 months, 29 cases （90.6%） kept good kidney function, 3 cases （9.4%） had renal insufficiency, 2 cases （6.2%） reoccurred calculi. Conclusions The therapeutics of ESWL combined with PCNL may clear complex calculi of solitary kidney effectively and safely. It is necessary to take emergent ESWL in renal obstruclive calculi cases. And the patients with lower ureter obstructive calculi may take lithodialysis first. It is proper to choose open operation on the patients with deformity of renal pelvis or obstruction of ureter.