输尿管上段结石不同治疗方法疗效的比较分析

Comparative analysis of different treatments of proximal ureteral calculi

目的：通过对输尿管上段结石不同治疗方法疗效的比较分析，探讨不同情况下治疗输尿管上段结石最有效的手术方法。方法：比较研究体外冲击波碎石术（ESWL）、经尿道输尿管镜碎石术（URSL）、输尿管软镜（RIRS）、经皮肾镜取石术（PCNL）、后腹腔镜输尿管切开取石术（RLU）及肾盂输尿管切开取石术的不同适应证，根据患者自身情况选择合理并有效的术式。结果：直径〈8mm的输尿管上段结石，采取保守治疗，排石率达70．6％；直径8-10min，采用ESWL，排石率达77．6％；直径〉10mm，采用URSL术，排石率达74．2％，应用封堵器及拦截网篮，排石率可达85．1％；对于URSL治疗失败的肾盂肾盏结石伴／不伴盏颈狭窄的肾盏憩室内结石，可采取RIRS，排石率达58．6％；URSL失败或较大结石，采取PCNL术，排石率达84．8％；以上治疗失败及解剖结构异常的复杂结石患者可行RLu或开放手术，虽然排石率可达100％，但创伤大出血多。结论：对于直径≤10mm的输尿管上段结石，可采用保守、ESWL治疗；直径〉10mm，可采用URSL RIRS、PCNL；以上治疗失败及解剖结构异常的复杂结石患者可采用RLu或开放手术。URSL可应用封堵器及拦截网篮，提高手术成功率。

Objective： To discuss the most effective treatment of proximal ureteral calculi in various cases through the comparative analysis of outcomes of different treatments. Method： Extracorporeal shockwave litho tripsy （ESWL）, transurethral ureteroscopic lithotripsy （URSI.）, percutaneous nephrolithotomy （PCNL）, retro grade intrarenal surgery （RIRS）, retroperitoneal laparoscopic ureterolithotomy （RLU） and pyelolithotomy/uret- erolithotomy were involved in this study, and their indications were comparatively analyzed. The reasonable and effective procedures were given to patients according to their individual situations. Result： If the calculi diameter （ψ） was less than 8 mm, the response to a conservative therapy was 70.6%. When ψwas from 8 mm to 10 mm, the response to ESWL was 77.6%. The resPonse to URSL in case of ψ〉10 mm was 74.2%, while with the as- sistance Of an occluder and an N-trap it increased to 85.1 %. RIRS may be applied in patients with pelvocalyceal stones or stones in calyceal diverticula w/or w/o calyceal neck stenosis if URSL fails and 58.6% will be received. The response to PCNL after failure of URSL or in the case of large stones was 84.8%. RLU and an open surgery achieved a complete elimination of stones, although it might also result in trauma and haemorrhage. Conclusion： A conservative therapy or ESWL was appropriate for stones ψ≤10 ram. When ψ was longer than 10 mm URSL, RIRS or PCNL should be considered. RLU or open surgery may be considered for anatomically complicated stones or when all the above treatments fail. Occluders or N-traps might enhance therapeutic success of URSL.