输尿管上段嵌顿性结石两种微创钬激光碎石术临床疗效对比研究

Comparison of Tow Minimally Invasive Methods in the Therapeutic Effect of Upper Ureteral Stone by Holmium Laser Lithotripsy

目的:探讨应用钬激光在输尿管镜碎石术及微创经皮肾穿刺取石术处理输尿管上段嵌顿性结石的疗效和并发症的比较。方法:2009年2月～2011年6月我院182例输尿管上段嵌顿性结石患者,应用钬激光经URL治疗85例,MPCNL治疗97例,对两种方法疗效进行临床评价比较。结果:MPCNL术中一期碎石清除率为(93/97)95.88%,5例残石者残石大小0.2～0.4 mm,术后1月结石清除率为(97/97)100%,平均手术时间75±29 min,平均住院时间为12±5 d,平均住院费用14589±3284 RMB;URL术一期碎石清除率为(39/85)45.88%,46例残石者残石大小0.3～1.5 mm,需术后联合体外冲击波碎石术等治疗排石,术后1月结石清除率为(72/85)84.71%,平均手术时间102±43 min,平均住院时间为6±3 d,平均住院费用9086±1259 RMB。MPCNL术中有1例因穿刺后出血改行二期MPCNL术。URL术中输尿管扭曲、狭窄、息肉出血视野模糊不清,需改行切开取石术6例,结石移位到肾内改行MPCNL术11例。结论:对于嵌顿性输尿管上段结石,采用MPCNL和URL联合钬激光治疗各有其优缺点。MPCNL安全、高效、并发症少、创伤小、结石清除率高;URL相对具有恢复快、住院时间短、费用较低等优点,但结石移位发生率、残石率较高,需其他辅助方式治疗结石。因此输尿管上段嵌顿性结石的手术方式选择应根据结石位置、大小、梗阻程度、肾积水量、患者经济状况,术前检查结果,充分评估手术风险和难度,结合患者个体差异,术者的经验制定出最佳治疗方案。

Objective：To compare therapeutic effect and complications by minimally invasive percutaneous nephrolithotomy（MPCNL） and ureteroscopic lithotripsy（URSL） with Holmium laser.Methods： From February 2009 to June 2011,182 cases of upper ureteric calculi in our hospital.85 cases were treated by URL with holmium laser lithotripsy,97 cases were treated by MPCNL.Then compared the clinical efficacy of the tow methods.Results： The stone-free rate of the MPCNL group was 95.88%（93/97）,5 patients residual stones size from 0.2 to 0.4 mm,and it was 100%（97/97） in a month postoperation,the average operation time was（75±29）min.The median length of hospital stay was 12±5 d,the average hospital cost was 14589±3284 RMB.The stone-free rate of the URL group was（39/85） 45.88%,46 patients residual stones size from 0.3 to 1.5 mm.extracorporeal shock wave lithotripsy（ESWL）was required postoperation and it was（72/85） 84.71% in a month postoperation,the average operation time was 102±43 min,The medi-an length of hospital stay was 6±3 d,the average hospital cost was 9086±1259 RMB.1 case of the MPCNL group due to bleeding after puncture needed the second MPCNL surgery.6 cases of the URL group was intraoperative ureteral distorted,narrow,blurred vision bleeding polyp,who needed to be diverted to the incision.11 cases of the URL group had stone shift to the kidney diverted MPCNL.Conclusion： MPCNL and URL had its own advantages or disadvantages for impacted upper ureterie calculi with holmium laser iithotfipsy.MPCNL was more safe,efficient,and fewer complications.URL was relative to a faster recovery,shorter hospital stay,lower cost,etc.but the incidence of the stones shift and residual stone rate is higher,requiring other aids to increase the stone clearance rate.So upper ureteral stones surgical options should be based on the stone location,size,degree of obstruction,hydronephrosis volume,the economic situation of patients,reoperative test results,a full assessment of surgical risk and difficulty,combined with individual differences in pa-tients,the surgeon experiences,and the techniques to choose the best treatment options.