输尿管镜钬激光碎石术治疗输尿管结石的技巧探讨(附82例报告)

Treatment of Ureteral Calculi with Transureteroscopic Holium Laser Lithotripsy(Report of 82 Cases)

目的:探讨输尿管镜钬激光碎石术治疗输尿管结石的手术技巧。方法:回顾性分析2009年应用输尿管镜钬激光碎石术治疗输尿管结石82例患者的临床资料,并结合文献复习。结果:一次碎石成功率89.2%(83/93),其中上段、中下段结石一次碎石成功率分别为86.5%(45/52)和92.7%(38/41),差异无统计学意义(P>0.05)。结石被包裹57侧,一次碎石成功率为91.2%(52/57),未被包裹33侧(3例进镜失败除外),一次碎石成功率为93.9%(31/33),差异无统计学意义(P>0.05)。有ESWL史者43例47侧,一次碎石成功率为87.2%(40/47),无ESWL史者39例46侧.一次碎石成功率为91.3%(42/46),差异无统计学意义(P>0.05)。手术失败共00例10侧,包括结石上移入肾盏7例,进镜失败3例。手术时间10～100 min,平均(38.4±20.9)min;术后住院时间1～20天,平均(4.9±3.0)天。术后泌尿系感染、发热13例,一侧输尿管穿孔1例,无输尿管撕裂、远期输尿管狭窄等并发症。结论:输尿管镜钬激光碎石术是一种治疗输尿管结石安全、高效的方法,尤其适用于ES-WL失败或结石被包裹的患者。持续硬膜外麻醉联合蛛网膜下腔麻醉或全身麻醉有利于输尿管镜成功进镜。采用头高脚低位、缓慢注水、小功率碎石、"蚕食"等方法可以有效防止结石移位。处理合并息肉或被包裹的结石应先处理息肉或包裹组织,暴露结石后再处理结石;对于息肉或包裹组织不必一味追求剔除干净,而残余结石则需仔细清除。正确、熟练掌握输尿管镜钬激光操作技巧可以减少并发症。

Objective：To study the clinical effects and experiences of using ureteroscopie holmium laser lithotripsy to treat patients with ureteral stones. Methods：We analysis the clinical materials of 82 cases patients in our hospital using ureteroscopie holmium laser lithotripsy to treat patients with ureteral stones in 2009. Results：The overall successful rate of fragmentation for all ureteral stones in a single procedure achieved 89.2 %（83/93）. Suc cessful rate of fragmentation in single procedure for the upper,middle-lower ureteral stones were 86.5% （45/52） and 92.7% （38/41）, respectively, without any significant difference cgmpared with each other （P〉0.05）. 57 sides with stones were wrapped by hyperplasia tissues,and the successful rate of fragmentation in a single procedure was 91.2%（52/57）. There were 33 sides did not wrapped by hyperplasia tissues （except the 3 sides failed for inserting the rigid ureteroscope）,with the successful rate of fragmentation in a single procedure was 93.9%（31/33）,without any significant difference compared to each other（P〉0.05）. In 9 sides with ureteral polyps,8 of them were succeed. In 4 sides with ureteral strictures,2 sides were succeed. 1 side with bending ureter also succeed. There were 43 cases（47 sides）with ESWL history,and the successful rate of fragmentation in a single procedure was 87. 25（41/47）. 39 cases （46 sides） without ESWL history got the successful rate of fragmentation in a single procedure at 91. 3% （42/46） , without any significant difference compared with each other（P〉0.05）. Operation time ranged 10-100 rain（mean 38.4±20.9 min）,and duration of hospitalization after operation was 1-20 d,with an average（4.9±3.0）d. 10 sides was abandoned,including 7 sides migrated to the renal pelvis and 3 sides failed to insert the ureteroscope. For those migrated to the renal pelvis,there were 6 sides with the stones in the upper ureter and 1 side with the stone in the middle ureter,all of them accepted ESWL For those failed to insert the ureteroscope,there were 2 sides with longer ureteral strictures not suitable for using holmium laser incision,and 1 side with history of abdominal surgery. There were 58 sides with varying degrees gross hematuria, sustained 1-5 d （mean 2.0±1.0 d）. Hemostasis treatment was given, if necessary. There were 13 sides with urinary tract infection and suffered fever with the highest temperature at 40.0℃. There was 1 side with ureteral perforation,and no one with ureteral avulsion or longterm complications such as ureteral stricture. Conclusions：The transureteroscopic holmium laser lithotripsy is an effective and safe therapy for patients with ureteral calculi, especially for patients failed from ESWL or with stone wrapped by hyperplasia tissues. Continuous epidural anesthesia combined with subarachnoid anesthesia or general anesthesia are conducive to insert the ureteroscope successfully. Breaking the stones gradually,and using small power and slow lavage can prevent stones from translocating efficiently. Stones which combined with polyps or wrapped by hyperplasia tissues should be dealt with the polyps or hyperplasia tissues firstly,then break the stones after stone exposure. It is not necessary to clear the polyps or hyperplasia tissues absolutely,but the stones must be removed absolutely. Correct and skilled ureteroscopic holmium laser manage ment mav decrease the comDlication