抗凝患者合并输尿管结石采用双频双脉冲激光碎石术的安全性观察

Efficacy and safety of double-frequency and double-pulse u-100 laser lithotripsy for elimination of ureteral calculi in anticoagulated patients (37 cases report)

目的探讨输尿管镜下双频双脉冲U-100掺钕钇铝石榴石(Nd:YAG)激光碎石术治疗服用抗凝剂患者输尿管结石的安全性及有效性。方法回顾分析该院2005年4月～2008年6月532例输尿管结石患者,其中,37例输尿管结石合并其他器官疾病而需长期口服抗凝剂(西洛他唑,氯吡格雷,华法林)治疗。采用双频双脉冲U-100掺钕钇铝石榴石(Nd:YAG)激光碎石器碎石术。术前5d停服华法林,改为低分子肝素,术后5d恢复口服华法林;术前10d停服氯吡格雷或西洛他唑,改为静脉低分子肝素抗凝,术后5d再恢复口服氯吡格雷或西洛他唑。检测手术前后血红蛋白、肌酐、凝血参数的变化,密切检测有无围手术期出血或血栓性并发症出现。结果平均手术时间35min,术中估计失血量平均46mL,无术中输血。术后无石率91.9%(34/37),术后1个月无石率100%。术后患者出现较重出血1例(2.7%),出血量约600mL,出血3d后停止;无血栓性疾病发生。余36例(97.3%)患者术后恢复原来口服抗凝剂治疗,无后遗症出现。结论合理应用抗凝剂情况下,输尿管镜下U-100激光碎石治疗口服抗凝剂患者的输尿管结石安全、有效。

[Objective]To investigate safety and efficacy of anticoagulated （AC） patients undergoing uretero-scopic lithotripsy （URSL） with frequency-doubled double-pulse U-100 neodymium of YAG （U-100） laser for ureter-al stones.[Methods]532 patients undergoing URSL at our institution from April 2005 to June 2008 were reviewed. 37 patients on AC therapy （cilostazol, clopidogrel, or warfarin） underwent URSL following perioperative reversal and re-initiation of anticoagulation. Twenty-three male, 14 female, mean patient age was 67.3 years （53～77）. Mean stone size was 12 mm （10～22 mm） in diameter. Warfarin was used 5 days pre-op with low molecular weight heparin bridging and resume 5 days post-op, clopidogrel and cilostazol were stopped 10 days pre-op and resume 5 days pos-op. We analyzed change in pre-and post-operative hemoglobin （Hb）, creatinine （Cr）, clotting parameters, as well as intraoperative and postoperative bleeding or thromboembolic complications. [Results]Mean operative time was 35 minutes and mean estimated blood loss （EBL） was 46 mL. There were no intraoperative complications or transfusions. Overall post-operative stone-free rate for RUSL was 91.9% （34/37 cases）, and an overall stone-free rate at one month of 100%. Significant bleeding complications （EBL 600 mL） occurred in 1 patient （2.7%） post-op-eration and the bleeding stopped in 3 days. No thromboembolic complications were noted. The remaining patients （36/37, 97.3%） underwent successful correction of bleeding diathesis with proper return of anticoagulation without sequelae. [Conclusions]Ureterorenoscopic frequency-doubled double-pulse U-100 Neodymium of YAG （U-100） laser lithotripsy （URSL） is safe and effective for treatment of ureteral stones in anticoagulated patients with careful perioperative management of anticoagulation.