肾结石合并输尿管结石的微创治疗

Minimally Invasive Therapy for Renal Stone Complicated with Ureteral Calculi

目的探讨肾结石合并输尿管结石的微创治疗方法。方法 2005年10月~2009年10月,应用微创经皮肾镜取石术（minimally invasive percutaneous nephrolithotomy,MPCNL）或MPCNL联合输尿管镜下碎石术（ureteroscopic lithotripsy,URL）治疗82例肾结石合并输尿管结石,对手术方式,结石清除率和手术并发症进行分析。结果 34例行MPCNL清除肾结石和输尿管上段结石,2例经皮肾镜碎石术中出血放置肾盂造瘘管1周后行MPCNL,7例经皮肾造瘘后抗感染治疗1周后行MPCNL,33例行URL后同期MPCNL,6例URL后留置双J管1周后MPCNL。12例结石残留行Ⅱ期MPCNL。单通道取石78例,双通道取石4例。39例URL平均手术时间26 min（20~35 min）,73例Ⅰ期MPCNL平均手术时间108 min（70~125 min）。Ⅰ期取净结石者术后住院时间5~10 d,平均6.4 d。URL时发生输尿管穿孔3例,术后感染、高热16例（其中发生感染性休克3例,1例血培养为粪球菌感染）,无腹腔脏器损伤,无术后迟发性大出血。1个月后拔除双J管,复查KUB、B超,输尿管结石清除率为95.1%（78/82）,肾结石清除率为90.2%（74/82）。结论肾结石合并输尿管结石需制定个体化治疗方案,MPCNL联合URL治疗肾结石合并输尿管结石,手术成功率高,创伤小,结石清除率高,并发症少,是肾结石合并输尿管结石的安全和有效、微创的治疗方法。

Objective To explore an appropriate minimally invasive therapy for patients with renal stone complicated with ureteral calculus. Methods From October 2005 to October 2009,totally 82 cases of kidney stones with ureteral calculi underwent minimally invasive percutaneous nephrolithotomy（MPCNL） or ureteroscopic lithotripsy（URL） combined with MPCNL at our institute.We analyzed the surgical techniques,stone clearance rate and surgical complications of the patients. Results In the 82 patients,34 of them received MPCNL to clear renal and upper ureteral stones;2 patients received nephropyelostomy because of hemorrhage during MPCNL,and thus underwent a second MPCNL in a week;7 patients received MPCNL after nephropyelostomy and one-week anti-inflammation therapy;MPCNL was performed simultaneously with URL in 33 cases,and was carried out one week after URL and double-J tube indwelling in 6 patients.In the 82 cases,single tract was employed in 78 cases,and double tracts in 4;12 patients had to receive a second stage MPCNL because of residual stones.The mean operation time for URL（39 cases） was 26 min（20-35 min）,and for first stage MPCNL（73 cases） was 108 min（70-125 min）.The mean hospital stay of the patients,who achieved stone clearance after first stage MPCNL,was 6.4 d（5-10 d）.In the patients who underwent URL,ureteral perforation occurred in 3 patients,and postoperative infection and high fever in 16（including infectious shock in 3 patients,and enterococcus faecalis infection confirmed by blood test in one patient）.No patient had injury to the abdominal organs or postoperative hemorrhage.The double-J tube was moved in one month after the surgery,and reexamination by KUB and B-ultrasonography showed a ureteral stone clearance rate of 95.1%（78/82） and renal stone clearance rate of 90.2%（74/82）. Conclusions Individualized therapeutic regime is necessary for patients with renal stones complicated with ureteral calculi.MPCNL combined with URL is a an effective,minimally invasive,and safe treatment for such cases.It is regarded as an optimal choice for the disease owing to a high rate of stone clearance and low rate of complications.