经肾造瘘管顺行低压冲洗在输尿管上段结石输尿管硬镜碎石术中的临床应用:附58例报告

Treatment of upper ureteral calculi with ureteroscope after anterograde low-pressure irrigation by percutaneous nephrostomy fistulation: a report of 58 cases

目的总结经肾穿刺造瘘管顺行低压冲洗在逆行输尿管硬镜下处理输尿管上段结石的临床资料,寻找简单、适合基层医院的输尿管上段结石微创手术方法。方法选择2013年6月-2014年12月在解放军第309医院行输尿管上段结石逆行输尿管硬镜碎石术的患者58例,其中男33例,女25例,年龄平均43.5（22~67）岁,结石长径平均1.25（0.7~1.8）cm。患者先行超声引导下经皮肾穿刺造瘘,术中经肾造瘘管顺行低压冲洗,同时逆行输尿管硬镜下行气压弹道碎石术。因输尿管狭窄无法完成输尿管镜检查者不纳入临床观察。结果 58例患者中54例（93.1%）一期碎石成功。2例（3.4%）伴有明显肉芽组织形成包裹结石,更改为腹腔镜手术。2例（3.4%）部分结石返回肾盂,其中1例留置D-J管后行体外冲击波碎石治疗,另1例结石再次嵌顿二次输尿管硬镜碎石。手术时间平均47（24~70）min。无感染发生,术后2d拔除肾造瘘管,无继发出血。平均住院时间4.5（2~7）d。无发热,无脓肾,无菌血症和败血症的发生,肾造瘘处无继发出血,无漏尿。结论超声引导下经皮肾穿刺造瘘通过顺行冲洗,使输尿管硬镜下输尿管上段结石气压弹道碎石术安全、有效,结石返回肾盂发生率明显降低,清石率高。该方法顺行、低压冲洗可避免逆行感染,且简单易行,费用低,适合基层医院开展。

Objective To summarize the method and ex periences of the treatment of upper ureteral calculi w ith ureteroscope after anterograde low-pressure irrigation by percutaneous nephrostomy fistulation, and to establish a minimal invasive operation mode with high clearance of stone and low urinary infection rate. Methods Fifty-eight patients were enrolled with upper ureteral calculi having undergone ureteroscopic pneumatic lithotripsy from Jun. 2013 to Dec. 2014 in 309 Hospital of PLA. Before surgery, all patients had undergone percutaneous nephrostomy under ultrasound scanning. Low-pressure flushing was done during operation, and ureteroscopic pneumatic lithotripsy was done during surgery. Patients in whom complete ureteroscopy could not be done were excluded. Among 58 patients, 33 were male and 25 female, the mean age was 43.5 years（22-67 years）, and the average length of the ureter stones was 1.25cm（0.7-1.8cm）. Results The ureter stones in 54 cases（93.1%） were successfully crushed during the operation; the ureter stones in 2 cases（3.4%） were wrapped by granulation tissue, and the operation was changed to laparoscopic surgery. Fragments of stones were returned to the renal pelvis during the operation in 2 patients（3.4%）, and in 1 patient a D-J indwelling tube was inserted and extracorporeal shock wave for lithotripsy was done. One another patient underwent a secondary ureteroscopic lithotripsy. The mean operative time was about 47min（24-70min）. No infection or secondary bleeding occurred 2 days after the removal of nephrostomy tube. The mean time of hospitalization was 4.5d（2-7d）. No infection or leakage of urine occurred in all the patients. Conclusions Treatment of upper urinary calculi with ureteroscope after anterograde lowpressure irrigation through percutaneous nephrostomy fistula is a safe and effective operation method which is easy to perform, with low cost, minimal invasion, fewer complications, lower rate of ureter stone returning to pelvis and higher stone clearance rate. It is the preferred treatment of upper urinary calculi.