妊娠期输尿管上段结石的微创手术疗效及安全性分析

Analysis of the efficacy and safety of minimally invasive management of proximal ureteral calculi during pregnancy

目的探讨微创手术治疗妊娠期输尿管上段结石的效果和安全性。方法收集127例我院2006年1月至2016年9月接受微创手术治疗的妊娠期输尿管上段结石患者的临床资料。患者年龄24~38岁,平均29岁;初诊时妊娠时间10~36周,平均24周。患者均有典型肾绞痛症状,经常规治疗无效。采用改良的Clavien分级系统对术后并发症进行评估分级并记录,术后复查泌尿系彩超,评估结石清除状态。结果所有患者手术过程顺利,术后肾绞痛症状均得到明显缓解,未出现先兆流产或早产、输尿管穿孔、撕脱、感染性休克及大出血等严重并发症。88例接受输尿管镜钬激光碎石术,一期清石率为85.3%(75/88);11例接受彩超定位下经皮肾穿刺造瘘术,28例接受输尿管镜下双J管置入术。术后并发症以双J管刺激症、肉眼血尿及伤口疼痛三者发生率较高。结论妊娠期输尿管上段结石诊治过程中严格掌握适应证,施行输尿管镜碎石术安全可行,一期清石率较高,并非禁忌。此外也应根据病情及妊娠情况,选择双J管置入或经皮肾造瘘术,以缓解肾绞痛及减轻泌尿系梗阻。

Objective To investigate the efficacy and safety of minimally invasive surgery in the management of upper ureteral stones during pregnancy. Methods The clinical data of 127 female patients with upper ureteral calculi during pregnancy from January 2006 to September 2016 were reviewed. The mean age was 29（range 24-38） years old and the mean pregnancy time was 24（range 10-36） weeks. All patients complained of typical symptom of renal colic and the conventional treatment was invalid. The postoperative complications were evaluated by modified Clavien classification system and urinary ultrasonography was performed after surgery to evaluate the stone-free rate. Results All surgery was successfully performed and the symptom of renal colic was relieved obviously. No serious complication such as threatened abortion or premature delivery, ureteral perforation, avulsion, septic shock or massive hemorrhage was found. Eighty eight patients underwent ureteroscopic holmium laser lithotripsy with a stone-free rate of 85.3%（75/88）, 11 patients underwent percutaneous nephrolithotomy under color Doppler guiding, 28 cases underwent the insertion of ureteroscopic double-J tube. The most common postoperative complications were double-J tube irritation, gross hematuria and pain. Conclusion The ureteroscopy lithotripsy is safe and feasible with a high stone-free rate. It is not contraindicant in the invasive management of proximal ureteral calculi during pregnancy. Double J tube placement or percutaneous nephrostomy is also a appropriate alteration to relieve renal colic and urinary tract obstruction.