输尿管镜下同期治疗双侧上尿路结石的有效性和安全性

Bilateral same-session ureteroscopic lithotripsy-safety and efficacy

目的探讨输尿管镜下同期治疗双侧上尿路结石的有效性和安全性。方法选取2013年1月至2014年12月收治的双侧上尿路结石患者32例，男19例，女13例。年龄19～79岁，平均（53．2±14．2）岁。术前行B超、CT、IVU等检查评估结石负荷（最大径）、数量、位置。结石总负荷14—40mm，平均（23．7±7．6）mm，其中肾结石0—37mm，平均（15．4±9．7）mm，下盏结石负荷占肾结石总负荷的47．4％；输尿管结石0～34mm，平均（8．2±7．2）mm。结石共109枚，其中肾结石78枚，输尿管结石31枚。根据影像学检查提示的输尿管条件及结石负荷决定术前是否留置输尿管支架，术前置管23例（71．9％）。全麻下行半硬性输尿管镜联合输尿管软镜下钬激光碎石取石术，对于输尿管上段结石上移者，则按肾结石行输尿管软镜下钬激光碎石取石术。术中采用c臂监测导丝、镜鞘位置及残石情况。术后留置输尿管支架（2—4周）或输尿管导管（24～48h）。术后第1天及拔除输尿管支架或导管1个月后复查KUB或CT平扫以评估清石情况。记录手术次数、手术时间、术后住院天数、即刻及拔管后1个月的结石清除率、并发症及结石成分。设定结石总负荷≤20mm为低负荷组，〉20mm者为高负荷组。比较两组的清石率及并发症。结果本组32例中，一期手术30例，二期手术2例。手术时间平均（99．2±32．5）min。术后SCr较术前无显著差异[（78．3±15．0）μmoL／LVS．（77．9±15．3）μmol／L，P=0．711]。一期手术清石率84．0％（27／32），二期手术清除率91．0％（29／32）。低负荷组的结石即刻清除率显著高于高负荷组（100％V8．50％，P=O．002）。血尿1例，发热4例，均治愈。随访7～30个月，平均（20．3±6．6）个月，未见输尿管狭窄等远期并发症。结论对于经选择的双侧上尿路结石病例，输尿管镜下同期碎石取石术是可行、安全、有效的，该术式对肾功能无明显影响，无严重并发症，对于结石负荷420mm的患者即刻清石率较高。

Objective To investigate the safety and efficacy of same session ureteroscopical lithotripsy as a valuable treatment for the bilateral upper urinary stones. Methods 32 cases with bilateral upper urinary stones were enrolled into this study from Jan 2013 to Dec, including 19 male and 13 female. The age ranged from 19 to 79 years old [ mean （53.2 ± 14.2） years old]. Ultrasound, CT and IVU were used to evaluate the details about the stone burden, number and location. The total stone burden was （23.7 ± 7.6）mm, ranged from 14 to 40mm. The kidney stone burden ranged from 0 to 37mm [ mean （15.4± 9. 7）mm]. and ureter stone burden ranged from 0 to 34 mm [mean （8.2 ±7. 2）mm]. Total stone number was 109 , including 78 stones in kidney and 31 stones in ureter. 23 （71.9%） patients had stents placed before the surgery. All the patients were treated with FURL and（or） URL by the same surgeon under general anesthesia, and C arm was used routinely to monitor the position of the guide wire, sheath and residual stones. The stents were placed for 2 to 4 weeks post-operatively. The ureteral catheters were placed for 24 to 48 hours. Stone-free rates（SFRs） were judged by KUB and（or）NCCT on the first day after the surgery and one month after withdraw the stent. The number of procedures, operative duration, hospital stay, SFRs in different time phase, serum creatinine, stone composition and complications were evaluated. All patientswere divided into low burden group and high burden group, based on the borderline of stone burden （20mm）. The SFR and complication was compared among those group. Results Among 32 cases, 30 cases underwent the one stage procedure and 2 cases underwent two stage procedure. Operative time was （99.2 ± 32. 5） mins. There was no significant difference of serum creatinines before and after the surgery. [ （78.3 ± 15.0） μmol/L vs. （77.9± 15.3 ） μmol/L, P = 0.711 ]. The overall SFRs after 1,2 procedures were 84. 0% （27/32） and 91.0% （29/32）, respectively. The immediate SFRs for patients with a preoperative stone burden ≤20 and 〉20 mm showed significant difference（ 100% vs. 50%, P =0. 002）. Only 5 minor postoperative complications, including fever in 4 patients, hematuria in 1 were recorded. Long- term complication, such as ureteral stricture, was not noticed. Conclusions For selected cases with bilateral upper urinary stones, bilateral same-session ureteroscopy is effective and safe with little influence on the kidney function. For those whose stone burden less than 20mm, the immediate SFRs are much higher.