腔内钬激光碎石术治疗输尿管上段结石305例

Ureteropyeloscopy and Holmium: YAG Laser Lithotripsy for Upper Ureteral Calculi:Report of 305 Cases

目的探讨提高腔内钬激光碎石术治疗输尿管上段结石成功率的方法。方法 2004年4月~2009年9月对305例输尿管上段结石采用Storz F8硬性输尿管肾镜及美国科以人公司钬激光机碎石治疗,首先置入安全导丝,进境困难者行输尿管球囊扩张或用钬激光切开狭窄部分后再行碎石。对于较小结石,控制灌注液体的压力和流量,必要时以套石蓝固定结石再碎石。结石横径〉1 cm者均粉碎至3 mm以下,合并输尿管息肉者一并切除,术后常规放置双J管1~4周。结果 8例因结石移位肾盂、肾盏内,1例跟踪碎石成功,其余7例手术碎石失败,留置双J管后行ESWL治疗。3例因术中操作不当、视野不清转开放手术;4例因反复取石致输尿管穿孔留置双J管失败后转为开放手术。单次碎石成功率95.4%（291/305）。手术时间20~120 min,（41±20）min;术后住院时间1~4 d,（2.2±1.5）d;结石排净时间4~60 d,（13.5±9.2）d。291例术后随访2~10个月,平均6个月,结石排净率97.9%（285/291）。IVU、B超显示：肾盂积水由术前（3.8±0.7）cm降至（1.5±0.4）cm（t=48.63,P=0.00）,无输尿管狭窄发生。结论利用球囊扩张或钬激光切开狭窄段进镜,设置钬激光较高频率（8~10 Hz）,较低能量（〈1.0 J）范围,控制液体的灌注压力约80 cm H2O,结石粉碎〈3 mm,安全导丝的留置是提高手术成功率的关键因素。

Objective To explore the method which can increase the success rate of ureteropyeloscopy combined with Holmium： YAG laser lithotripsy in treating upper ureteral calculi. Methods Totally 305 cases of upper ureteral calculi were treated with rigid ureteropyeloscope（Storz F8） and Holmium： YAG laser（Lumenis） in our hospital from April 2004 to September 2009.A guide wire was inserted at the beginning of the operation;if resistance occurred,we expanded the ureter or cut the stricture by laser,and then performed lithotripsy.For smaller calculi,perfusion fluid pressure and flow rate control were required.Basket extractor was used when necessary.We fragmented calculi with a diameter 1 cm into 3 mm particles,and then resected complicated ureter polyp if any.Double J tubes were indwelt after the operation for 1-4 weeks. Results Among the patients,eight cases failed because of the stones shifting into the pelvis and calices,and one of them was cured with lithotripsy successfully,while other seven had to be converted to ESWL after placing D-J because lithotripsy was failed.Three cases were converted to open surgery because of improper surgical procedures and poor visibility during the ureteropyeloscopy;four cases were due to the failure in Double-J tube indwelling caused by ureteral perforation.The overall one-session fragmentation rate in our patients was 95.4%（291/305）.The operation was completed in 20 to 120 minutes with a mean of（41±20） minutes.Postoperative hospital stay was 1 to 4 days with a mean of（2.2±1.5） days,and the stone-free time was 4 to 60 d with a mean of（13.5±9.2） days.Follow-up was achieved in 291 patients for 2 to 10 months（mean,6 months）,during which a stone-free rate of 97.9%（285/291） was achieved,and IVU and B-ultrasonography showed that the nephrohydrops decreased from（3.8±0.7）cm to（1.5±0.4）cm（t=48.63,P=0.00）.Conclusions The key factors,which can increase the success rate of ureteropyeloscopy combined with Holmium： YAG laser lithotripsy,include expanding the ureter or cutting the stricture by laser,setting higher frequency（8-10 Hz） and lower energy（1.0 J） of Holmium： YAG laser,controlling perfusion fluid pressure and flow rate,fragmenting calculi diameter less than 3 mm,and detaining the guide wire.