输尿管软镜联合钬激光碎石术治疗肾和输尿管上段结石:附86例报告

Flexible ureteroscopy combined with holmium laser lithotripsy for renal and upper ureter calculi: Report of 86 cases

目的评价输尿管软镜联合钬激光治疗上尿路结石的效果及影响碎石成功的因素和技巧。方法2008年7月至2011年6月86例输尿管软镜钬激光碎石病例。共104枚结石，结石最大直径10—25min。术中使用输尿管硬镜探查患侧输尿管，放置输尿管软镜鞘并换用StorzFlex—x2F7．5输尿管软镜。若输尿管鞘无法插入，可直接在导丝引导下插入输尿管软镜至肾盂。如果软镜仍不能直接插入，则在放置导丝后留置6F双J管，1-2周后第二次试行输尿管软镜碎石。术后4周复查KUB或双肾CT平扫，评估碎石效果。结果软镜一次进镜成功率87．2％（75／86），余11例第二次手术9例成功进镜，总的进镜成功率为97．6％（84／86），钬激光碎石成功率95．3％（82／86）。4周后结石清除率为83．7％（72／86）。12例再次行输尿管软镜碎石，其中9例排净结石。总的结石清除率为94．1％（81／86）。平均手术时间为45min（18～75min）。无严重并发症。结论输尿管软镜钬激光碎石是治疗10—25mm肾和输尿管上段结石的安全有效的方法。其结石排净率高、并发症低，可以作为体外冲击波碎石失败和经皮肾镜碎石术后残留结石的治疗选择。

Objective To evaluate the efficacy of the flexible ureteroscopy with Holmium laser lithotripsy for renal and upper ureter calculi. Methods From July 2008 to June 2011, 86 cases of renal and upper ureter calculi（sized between 10 to 25 mm in diameter, 104 calculi in total） were treated by flexi- ble ureteroscopy with Holmium laser lithotripsy in our hospital. A rigid ureteroscopy was inserted to observe the ureteral lumen, then a ureteric access sheath was placed and a Storz Flex- X2 F7.5 flexible ureteroscopy with Holmium laser lithotripsy was used to perform the procedure, and a F5 double-J stent would be setup at the end of procedure. When the insertion of rigid ureteroscopy and ureteric access sheath was difficult, the flexible ureteroscpy would be inserted directly via a guide-wire. If the flexible ureteroscopy could not be inserted, a F6 double-J stent would be setup, and the second ureteroscopy procedure would be tried in 1-2 weeks. A follow up by KUB or non-contrast CT scan was done 4 weeks after the procedure to evaluate the result. Result The insertion of flexible ureteroscopy was successful in 87.2% （75/86） cases in the first time, and in 81.8%（9/11） cases in the second time 1-2 weeks later, the total success rate was 97.6% （84/ 86）. The calculi were detected in 84 cases , and laser lithotripsy succeeded in 81 cases. Seventy two cases out of 86 （83.7%） had stone clearance at 4 weeks post primary operation, and 12 cases undergone re-look ureteroscopy, the total stone clearance rate was 94.1%（81/86）. The average operation time was 45 minutes （18-75mins）. No serious complication occurred. Conclusion Flexible ureteroscopy combined holmium laser lithotripsy is a safe and effective procedure for upper tract calculi, it has high clearance rate of stones and less complication and morbidity, it is a better option for managing ESWL failed and PCNL residual calculi.