后腹腔镜联合经肾盂输尿管软镜治疗巨大多发性鹿角形肾结石的临床研究

Clinical study of laparoscopic pyelolithotomy combined with transpyevic flexible ureteroscopy in treatment of multiple large staghorn calculi

目的探讨后腹腔镜肾盂切开取石术联合经肾盂输尿管软镜治疗巨大多发性鹿角形肾结石的临床应用效果。方法回顾性分析2014年9月至2017年9月在陆军军医大学(第三军医大学)第二附属医院接受后腹腔镜联合经肾盂输尿管软镜治疗巨大多发性鹿角形肾结石的47例患者临床资料,其中男性29例,女性18例,年龄28~67岁,平均45岁。左肾结石27例,右肾结石20例;肾外型肾盂20例,肾内型肾盂27例;肾盂结石合并2个肾盏结石23例,肾盂结石合并3个及以上肾盏结石24例;每例病例患者结石数量均≥3枚;每例病例单枚肾盂结石最大直径1.9~4.3 cm,平均2.9 cm。术中所有患者先行后腹腔镜肾盂切开取石术取出鹿角形结石肾盂内部分,残余结石由输尿管软镜经肾盂切口置入集合系统内取出或粉碎。统计手术并发症、手术时间、出血量及一期结石清除率,术后常规随访3个月了解结石复发情况。结果 47例手术均顺利完成,无死亡或严重并发症。手术时间为(123±12)min,其中输尿管软镜操作时间为(34±9)min,手术出血量(76±18)m L。44例(93.62%)患者一期取净结石;2例(4.26%)患者术后残余结石最大直径≤3 mm,保守治疗(大量饮水联合口服盐酸坦索罗辛)2周后排尽结石;1例(2.13%)术后残余结石最大直径5 mm,保守治疗2周无效,体外冲击波碎石联合保守治疗2周后排尽结石。随访3个月结石无复发。结论后腹腔镜肾盂切开取石联合经肾盂输尿管软镜治疗巨大、多发性鹿角形肾结石安全高效,结石一期清除率高。

Objective To explore the clinical efficacy of laparoscopic pyelolithotomy combined with transpyevie flexible ureteroscopy in treatment of multiple large staghorn calculi. Methods Clinical data of 47 patients with multiple large staghorn calculi, who underwent laparoscopic pyelolithotomy combined with flexible ureteroseopy from September 2014 to September 2017 in the Second Affiliated Hospital of Army Medical University （Third Military Medical University） were collected and retrospective analyzed. They were 29 males and 18 females, and at an average age of 45 （28 to 67） years. There were 27 cases of left kidney stones and 20 cases of right kidney stones, 20 cases of intrarenal pelvis kidney and 27 cases of extrarenal pelvis kidney, and 23 cases of pelvic calculi with 2 calyeeal calculi, and 24 eases of pelvic calculi with 3 or more calyceal calculi. In these patients, the average number of stones was more than 3, and the calculi had a maximal diameter of 1.9 to 4.3 cm, averagely 2.9 cm. All patients received retroperitoneal laparoscopic pyelolithotomy to remove pelvic calculi, followed by transpyevic flexible ureteroscopy for removal of residual calculi fragments. Complications, operation time, bleeding volume and stone-free rate after single surgery were counted and analyzed. All these cases were followed up to observe recurrence after 3 months. Results The surgery was completed successfully in all the 47 cases, with no death or serious complications observed. The operation time was 123 ±12 rain while the time of ureteroscopic application was 34± 9 min, and the blood loss was 76± 18 mL. Calculi were removed completely in 44 cases （93.62%）. Two patients （4.26%） had residual stones （ ≤3 mm） and got stone free in 2 weeks later after conventional therapy （large amount of drinking water and oral administration of tanzosoria hydrochloride）, and 1 patient （2.13%） who had residual stones in maximal size of 5 mm had to underwent extracorporeal shock wave lithotripsy after 2 weeks of conventional therapy, and then got stone-free in another 2 weeks later. No recurrence was seen during the 3 months＇ follow-up. Conclusion Laparoscopic pyelolithotomy combined with transpyelvic flexible ureteroscopy is safe and efficient, and with high stone-free rate after single surgery in treatment of multiple large staghorn calculi.