一期输尿管软镜钬激光碎石术治疗输尿管结石合并输尿管迂曲的疗效观察

Flexible ureteroscopic holmium laser lithotripsy without preoperative stent treat ureteral stone in tortuous ureter

目的探讨一期输尿管软镜钬激光碎石术治疗输尿管结石合并输尿管迂曲的可行性、有效性、安全性。方法回顾性分析2017年3月至2018年12月收治的69例输尿管结石合并输尿管迂曲患者的病例资料。男30例,女39例。年龄19~67岁,平均45岁。输尿管结石长径0.6~3.0 cm,平均1.1 cm。24例术前CT平扫三维重建、静脉尿路造影或泌尿系CTU重建检查可见输尿管结石远端输尿管迂曲,余45例术中发现输尿管迂曲。所有患者术前均未预置输尿管支架管。术前尿培养阴性或经抗感染治疗后复查为阴性方可手术。术中输尿管硬镜检查发现输尿管迂曲后,置入输尿管鞘至迂曲下方,输尿管软镜经鞘进入输尿管,在持续灌注状态下,观察输尿管迂曲方向,控制输尿管软镜头端沿迂曲方向弯曲并轻柔进镜,通过迂曲处发现结石后,将结石推回肾脏碎石。对于无法推动的结石,则在输尿管内将结石碎块化后推回肾脏进一步粉末化。术后常规留置输尿管支架管。结果本组69例中64例成功行一期输尿管软镜钬激光碎石术,手术成功率92.8%。5例手术失败者中,1例因迂曲处输尿管壁薄,输尿管穿孔,改行开放式输尿管切开取石术;1例因迂曲上方结石巨大(结石长径3.0 cm),输尿管软镜通过迂曲处后,无法推动结石及原位碎石,改行开放式输尿管切开取石术;1例因输尿管软镜无法通过输尿管上段迂曲处,改行经皮肾镜取石术;1例因输尿管下段狭窄,无法置入输尿管软镜鞘,留置输尿管支架管后行二期输尿管软镜取石术;1例因术中发现结石梗阻上方尿液浑浊,留置输尿管支架管后行二期输尿管软镜碎石术。64例成功手术者术后1、3个月的结石清除率分别为90.6%(58/64)、95.3%(61/64)。并发症发生率为7.8%(5/64),包括发热4例,患侧腰痛1例,均为Clavien分级Ⅰ~Ⅱ级。结论一期输尿管软镜钬激光碎石术治疗输尿管结石合并输尿管迂曲安全、有效、可行。

Objective To investigate the safety,efficacy and feasibility of flexible ureteroscopic holmium laser lithotripsy without preoperative stent treating ureteral stone in tortuous ureter.Methods 69 patients with ureteral stone in tortuous ureter retrospectively analyzed from March 2017 to December 2018 were enrolled and analyzed retrospectively.There were 30 males and 39 females,aged from 19 to 67 years old,with an average age of 45 years.The burden of ureteral stones was 0.6-3.0 cm,with an average of 1.1 cm.24 patients with CT scan or intravenous urography showed tortuous ureter at the distal end of the ureteral calculi.The remaining 45 patients were found to have tortuous ureter during surgery.None of patients had preoperative ureteral stents.All preoperative urine cultures were negative.During the operation,the ureteral sheath was placed in the distal position of tortuous ureter,and the flexible ureteroscope was inserted into the ureter via sheath.Under continuous perfusion,the flexible ureteroscope was curved and pushed along the direction of the ureteral tortuosity.After through the tortuous position,the stone was pushed back to the kidney and crushed.For stones that could not be pushed,the stones were broken into pieces in the ureter and pushed back to the kidney for further pulverization.The ureteral stent was routinely placed at the end of surgery.Results Among a total of 69 patients,64 patients were treated by flexible ureteroscopic holmium laser lithotripsy without preoperative stent,and the success rate was 92.8%.Among the 5 patients who failed the operation,1 patient underwent ureterolithotomy because the tortuous ureteral wall was weak,resulting in ureteral perforation by flexible ureteroscope;in 1 case,after the flexible ureteroscope passed through the tortuosity,the calculi could not be pushed back to kidney and the in situ lithotripsy could not be performed because of the huge size of calculi(3.0 cm),so ureterolithotomy were performed;1 patient underwent PCNL because flexible ureteroscope could not pass through the tortuosity;1 patient failed to insert the ureteral sheath because of ureterostenosis and underwent flexible ureteroscopic lithotripsy after stent implantation;1 patient underwent stent implantation because of infective urine.Among the 64 patients who had successful operations,the stone clearance rate at the first month and the third month after surgery were 90.6%(58/64)and 95.3%(61/64).4 patients had fever after the surgery,and 1 patient had renal area pain.Clavien classification gradeⅠ-Ⅱ.The complication rate was 7.8%.Conclusions Flexible ureteroscopic holmium laser lithotripsy without preoperative stent was a safe,effective and feasible treatment for patients with ureteral stone in tortuous ureter.