逆行经硬性与软性输尿管镜下钬激光治疗60岁以上老年患者完全性鹿角形肾结石11例分析

Alternating use of retrograde rigid and flexible ureteroscopy combined with Holmium laser lithotripsy in the treatment of complete staghorn calculus of a unilateral kidney in elderly patients over the age of 60 years （Analysis of cases）

目的 报道逆行经硬性与软性输尿管镜下钬激光治疗60岁以上老年患者完全性鹿角形肾结石的经验并评价其效果.方法 本院2012年1月～2013年5月治疗11例老年单侧完全性鹿角形肾结石患者,年龄60～77岁,平均67±7.2岁.患者主诉为严重肉眼血尿.术前留置7Fr Bard输尿管支架1周.术中首先应用Olympus 8/9Fr硬性输尿管镜和科医人100W钬激光机粉碎视野内结石部分,然后换成7.9Fr软性输尿管镜粉碎剩余结石,手术时间控制在120 min内.术后常规留置7Fr D-J管3个月.术后3个月末查KUB评估结石排净率,仍残留较大结石的,行第二次手术碎石.结果 本组11例均安全经受手术,手术成功率100％.硬性软性输尿管镜一期碎石取石成功1例,10例需两次手术碎石,两次手术总净石率为10/11（90.9％）.未发生手术并发症.结论 逆行交替应用硬性软性输尿管镜联合钬激光治疗完全性鹿角形肾结石对60岁以上患者心血管循环系统影响小、净石率高、并发症少、也易于被患者接受,可作为治疗老年患者完全性鹿角形肾结石的首选术式之一.

Objectives To report the treatment procedure of alternating use of retrograde rigid and flexible ureteroscopy combined with Holmium laser lithotripsy in the treatment of complete staghorn calculus of a unilateral kidney in elderly patients over the age of 60 years and to evaluate its efficiency.Methods 11 patients of such kind underwent this treatment procedure from January 2012 to May 2013.They were 60 ～ 77 years old（mean 67 ± 7.2 yrs）.Severe hematuria was their main complaints.7Fr Bard double J stent was placed in ureter one week before operation routinely.Firstly,retrograde rigid ureteroscopic Holmium laser broke up the part of pyelocalyceal calculi in direct vision.Then flexible ureteroscopy was used to treat the remainder of staghorn calculi.The procedure of lithotripsy might be divided into stages but the operative time of one stage was controlled within 120 minutes.Second-look lithotripsy was performed in patients with significant residual fragments.Stone clearance was defined as no fragments or a single fragment less than or equal to 4 mm in diameter on standard radiograph at 3-month follow-up.Results All 11 patients underwent the operations safely and no complications happened.In all,one case（9.1％） were stone-free after the first procedure and another 10 needed an second-look procedure to become stone-free,resulting in a 90.9％ stone-free rate.Conclusions In these select patients,complete staghorn renal calculi can be treated safely and efficiently with retrograde rigid and flexible ureteroscopic techniques.Especially,blood circulation systems of these patients were not interfered with this kind of procedure perioperatively.Staged,retrograde,alternating rigid and flexible ureteroscopy combined with Holmium laser may be one of first-class therapy with acceptable efficacy and low morbidity for complete staghorn calculus of a unilateral kidney in elderly patients over the age of 60 years.