输尿管上段结石微创手术方法的比较

Comparison of the minimally invasive surgeries of upper ureteral calculus

目的比较输尿管镜碎石取石术(URL)、微创经皮肾镜碎石取石术(MPCNL)、腹膜后腹腔镜碎石取石术(RLU)手术对输尿管上段结石的治疗效果,探讨输尿管上段结石的最佳微创手术治疗方法。方法回顾性分析288例输尿管上段结石行上述三种手术治疗的临床资料。结果 URL组中88例术后KUB未见残石,40例可见泥沙样残石,23例有较大残石(直径>0.7 cm),予体外碎石治疗,6例术中发生输尿管较大穿孔,改行开放手术取石;MPCNL组中80例术后KUB未见残石,23例由于冲洗原因,输尿管中下段有小残石(直径<0.5 cm),4例术后较大残石(直径>0.7 cm),行体外碎石治疗;RLU组中23例取石成功,1例改开放手术取石。结论应综合分析患者具体病情选择手术方式。结石<2 cm且位置在L3椎体以下,没有远端输尿管狭窄患者首选URL;结石>2 cm且位置在L3椎体以上,合并有肾结石是PCNL的良好适应证;结石>2 cm且位置在L4椎体以上,合并明显尿路感染或者肾功能不全的患者可选择RLU。

Objective To compare the efficacy of minimally invasive treatment of upper ureteral calculus by transureteroscope lithotripsy（URL）,minimally invasive percutaneous nephrolithotripsy（MPCNL） and retroperitoneal laparoscopic ureterolithotomy（RLU）.Methods 288 cases of upper ureteral calculus,who underwent one of those three treatments mentioned abov,were analyzed retrospectively.Results In contrast to 80 non-residual calculus cases and 40 powder-like residual calculus cases with URL,the other 23 cases were followed by ESWL for residual calculi（0.7 cm）,and another 6 cases underwent open surgery for major ureteral perforation.80 and 23 cases with MPCNL were calculus free and with distal small residual ureteral calculi（0.5 cm） respectively.4 cases were followed by ESWL for residual calculi（0.7 cm）.Only a single case was converted to open surgery in RLU group of 24 cases.Conclusions For patients with upper ureteral calculi,the surgery should be individualized according to their different cases.Contrary to MPCNL,which is best for those calculus 2 cm and located higher than L3 vertebra,URL is the treatment for those suffered from distally located（lower than L3 vertebra） small calculus without ureteral distortion,and patients with larger（2 cm） and proximally（higher than L4 vertebra） located calculus fall into RLU,especially those complicated with severe renal insufficiency and urinary tract infection.