电子输尿管软镜钬激光碎石治疗复杂肾结石45例分析

Clinical evaluation of digital flexible ureteroscopy with holmium laser lithotripsy for complicated renal callculi

目的探讨电子输尿管软镜钬激光碎石术在治疗复杂肾结石中的临床应用价值。方法回顾分析我科使用奥林巴斯电子输尿管软镜钬激光碎石处理的45例复杂肾结石患者,其中肾盂肾盏多发性结石23例(含10例孤立肾结石),孤立肾感染性结石4例,肾盏憩室内结石11例,肾盏嵌顿结石4例,多发性肾乳头黏膜下钙化3例。术中先行输尿管硬镜镜检,留置斑马导丝并放置F12～14输尿管扩张鞘后经鞘或直接沿斑马导丝入镜。软镜进入肾盂后首先镜下观察肾盂及上、中、下各盏并定位结石,根据结石位置选用365μm或200μm光纤,功率选择在0.5～1J、15～30Hz范围,以表面蚕蚀、周缘穿孔、中央穿孔等方法将结石完全粉碎至2mm以内,若患者留置输尿管鞘,则以冲水引流、套石蓝取石等方法将结石取出或部分取出。所有患者常规留置double-J管2周,术后第1天拔除导尿管,术后2周拔除double-J管,术后4周常规复查泌尿系平片(KUB)或双肾CT平扫,评估结石排净率。残留结石≥4mm为有临床意义的结石残留。结果本组45例患者39例成功置放输尿管鞘,输尿管镜鞘放置成功率86.7%,进镜成功率100%,术中寻找结石成功率100%。一期手术成功碎石38例,结石均排尽或残余结石<4mm,无需进一步处理。另2例下盏憩室内结石,2例下盏结石,3例肾乳头黏膜下钙化结石/残石均≥4mm,辅助体外冲击波碎石或2期输尿管软镜手术。结论输尿管软镜特别是最新一代的电子输尿管软镜,视野清晰、微创安全,几乎可以达到所有肾内集合系统所有位置,结合钬激光适合治疗各类复杂肾结石。

Objective treatment of complex renal To explore the clinical value of digital flexible ureteroscope with holmium laser lithotripsy in the calculi. Methods Data of 45 cases of complicated renal calculi treated with Olympus e-flexible ureteroscope with holmium laser lithotripsy in our department were retrospectively analyzed. 23 of the cases were multiple stones in the renal pelvis and calyx （including 10 cases of solitary kidney stones）, 4 were solitary kidney infection calculi, 11 were calyx diverticulum stones, 4 were impacted calycolithiasis, and 3 were multiple submucosal calcification. Ureteroscopy was conducted. Guide wires were indwelt and F12-14 ureteral dilatation sheath was placed. After the flexible ureteroscope en- tered the pelvis, renal pelvis and upper, middle and lower calyx were observed to locate the calculi. 365μm or 200μm fiber was chosen according to stone location, and the power ranged between 0.5～1 J and 15～30 Hz. Stones were completely smashed to 2 mm. If ureteral sheath was placed, stones could be removed or partially removed with flush drainage or stone-bag. Double-J tube was indwelt in all patients for two weeks. The first day after the operation catheter was removed. 4 weeks after the surgery, KUB or CT was performed to assess the stone excretion rate. Results 39 of the 45 cases （86.7%） had successful place- ment of ureteral sheaths, and all cases had ureteroscope entered successfully and located the calculi. 38 cases had no stone residual or stone residuals 〈4 mm after the first operation. Conclusions Providing clear vision, digital flexible ureteroscope is safe and minimal invasive. Combined with holmium laser, it can be used in the treatment of all types of complex renal calculi.