输尿管软镜联合钬激光碎石术治疗孤立肾结石的疗效及安全性

Safety and efficacy of flexible ureteroscopy and holmium laser lithotripsy for the treatment of renal stones in patients with a solitary kid. ney

目的探讨输尿管软镜联合钬激光碎石术治疗孤立肾结石的安全性及有效性。方法回顾性分析北京协和医院泌尿外科2014年5月-2016年6月采用输尿管软镜联合钬激光碎石术治疗的17例孤立肾结石患者的临床资料。其中男性10例，女性7例，年龄32—67岁，平均45．8岁。左侧9例，右侧8例。功能性孤立肾6例，解剖性孤立肾11例。其中肾盂结石8例，上中盏结石5例，下盏结石4例。结石平均直径为（1．2±0．3）cm。临床主要表现为：无症状10例、腰痛5例、发热2例，入院后完善血尿常规、肝肾功能、凝血功能、心电图、胸部X线片等术前相关检查，同时行清洁中段尿培养。结果手术时间为（74．2±23．6）min，术中出血量为5～15ml，平均8ml，住院时间为3～12d，平均4．5d。术后1例出现尿脓毒血症，经积极抗感染治疗后痊愈。其余患者无严重并发症发生。17例患者术前肌酐78～421μmol／L，平均（161±103）μmol／L，术后1个月复查肌酐85～341μmol／L，平均（124±63）μmol／L，与术前比较差异有统计学意义（P〈0．05）。一期结石完全清除率为82．3％（14／17），二期结石清除率达94．1％。结论输尿管软镜联合钬激光碎石术治疗孤立肾结石，具有创伤小、出血少、并发症少、术后恢复快等优点，是一种安全、有效的方法。

Objective To investigate the safety and efficacy of flexible ureteroseopy and holmium laser lithotripsy for the treatment of renal stones in patients with a solitary kidney. Methods Between May 2014 and June 2016, Clinical records of 17 eases of stones in a solitary kidney who underwent flexible ureteroscopy and holmium laser lithotripsy were reviewed. 10 of these cases were male and the others female; mean age of these eases was 45.8 （32-67） years. 9 were on the left side while 8 were on the right. 6 eases were with functional solitary kidney （with the GFR of the eontralateral kidney less than 10ml/min）, while 11 others were with anatomical solitary kidney （6 due to tumor, 2 due to tuberculosis, 3 being congenital）. All eases underwent BUS, KUB as well as CTU to confirm diagnosis before surgery, with 8 diagnosed with renal pelvis calculi, 5 were with upper or middle calyx calculi, and 4 were with subrenal calyx calculi. The mean ＋ SD size of the stones was 1.2 ± 0.3 cm. Clinical manifestations were asymptomatic in 10cases, backache in 5 eases and fever in 2 eases. All patients underwent exams of CBC, urinalysis, liver and kidney function, coagulation function, ECG, chest X-ray as well as cleaning midstream urine cultivation after admission. Results Mean ＋ SD operation time among all eases was （74.2 ±23.6） rain, the amount of bleeding during surgery was 5-15 （ mean ： 8 ） ml, duration of hospitalization was 3-12 （ mean ： 4.5 ） days, ureteral stents are kept for an average time of 4 weeks after surgery. 3 patients developed fever after opera＇tion, 1 developed urosepsis; all these patients recovered after active anti-infection treatment. No post-operative complications such as fever, renal colic, hematuresis, ureteral perforation, active bleeding as well as sepsis were found among the other patients. The preoperative and postoperative serum creatinine had statistical difference （ P 〈 0.05） . 14 patients were proved to be stone-free by KUB or CTU. The stone-free rate after a single operation was 82.3% （ 14/17 ）. Residual stone were found in the 3 patients , who subsequently underwent a second flexible ureteroscopy and holmium laser lithotripsy. The stone-free rate after a second operation was 94.1%. Conclusions Flexible ureteroscopy and holmium laser lithotripsy is a safe and effective method for the treatment of nephrolithiasis in patients with a solitary kidney with a lower procedure-related injury rate, smaller amount of bleeding, a lower complication rate and a shorter time required to recover after surgery.