逆行输尿管软镜碎石术治疗儿童肾及输尿管上段结石的疗效与安全性探讨

Flexible ureteroscopic lithotripsy for upper urinary tract calculi in children

目的探讨逆行输尿管软镜碎石术(flexible ureteroscopic lithotripsy,FURS)治疗儿童肾及输尿管上段结石的疗效与安全性。方法回顾性分析湖南省儿童医院2015年3月至2021年3月行逆行输尿管软镜碎石术的215例肾及(或)输尿管上段结石患儿临床资料,其中男141例,女74例;平均年龄4.6岁(1.2~14.4岁)。左侧结石104例,右侧结石87例,双侧结石24例。肾结石179例,其中双侧结石19例;输尿管上段结石36例,其中双侧结石5例。结石直径5~28 mm。患儿均经泌尿系B超、静脉尿路造影(intravenous urography,IVU)及腹部平片(abdominal X-ray,KUB)或CT确诊,排除其他泌尿系严重畸形。收集所有患儿手术及住院时间、结石清除以及术后并发症等情况。结果215例患儿的239侧结石中,共228侧成功完成逆行输尿管软镜碎石术,其中19侧一期在超滑导丝引导下置入输尿管软镜至肾盂,209侧经双J管扩张输尿管4周后置入输尿管软镜碎石。余11侧结石因输尿管软镜不能达到结石位置或不能探及结石而改行微创经皮肾镜碎石术(minimally invasive percutaneous nephrolithotomy,MPCNL)。除5例因结石较小,术后未留置双J管外,其余患儿术后均留置双J管2~4周。术后4周复查B超或CT,148侧结石全部排尽,一期清石率64.9%(148/228);75侧进行了2~3次碎石术。术后3个月复查总清石率为89.9%(205/228);如将直径≤4 mm无临床意义的残石计算在内,则清石率为93.4%(213/228)。平均手术时间55 min(25~115 min),术后平均住院时间3.5 d(2~5 d)。术后早期出现肾脏血肿1例,输尿管下口撕裂5例,肾盂输尿管交界处损伤3例(其中肾盂输尿管交界处穿孔1例),均经留置双J管4周后治愈。随访期间,1例出现肾盂输尿管交界处狭窄,术后6个月时经肾盏输尿管吻合术治愈。随访至2022年3月,成功获得清石的患儿中,共10例出现结石复发。结论逆行输尿管软镜碎石术治疗儿童肾及输尿管上段结石清石效果好,并发症少,安全有效。

Objective To evaluate the efficacy and safety of flexible ureteroscopy for upper urinary tract calculi in children.Methods Between March 2015 to March 2021,clinical data were retrospectively reviewed for 215 children with upper urinary tract calculi undergoing flexible ureteroscopy.With a total of 239 involved sides,there were 141 boys and 74 girls with a mean age of 4.6(1.2-14.4)years.There were renal calculi(n=179;bilateral n=19)and upper ureteral calculi(n=36;bilateral n=5).The diameter of calculi ranged from 5 to 28 mm.All of them were diagnosed preoperatively by urinary tract ultrasonography,spiral computed tomography(CT)or intravenous urography imaging(IVP)without severe urinary tract anomalies.Results The initial insertion of ureteric access sheath and flexible ureteroscope was successful for 19 sides.And 209 sides of ureter were successfully dilated by double-J stent for 4 weeks.Mini-invasive percutaneous nephrolithotomy(MPCNL)was performed for another 11 sides.Flexible ureteroscope was successfully inserted for 228 sides.In addition to 5 cases with small stone burdens and minimal intraoperative bleeding,others were managed with double J stenting for about 2-4 weeks post-operation.Stone-free status was routinely determined by urinary tract ultrasonography or spiral CT.And 148/228 sides(64.9%)remained stone-free at 4 weeks after primary operation and overall stone-free rate was 89.9%(205/228)at 3 months.Ureteroscopic procedures were performed twice or thrice for 75 sides.The average operative duration was 55(25-115)min and average postoperative length of stay 3.5(2-5)days.Severe complications included laceration at ureteral orifice(n=5)and injury at ureteropelvic junction(n=3).The latter included perforation at ureteropelvic junction(n=1).All of them were managed with double J stenting.There was one case of renal hematoma.During follow-ups,one child of stricture of ureteropelvic junction was cured by pyeloureteroplasty 6 months later.Up until March 2022,recurrent calculi were detected(n=10).Conclusion Combining flexible ureteroscopy and holmium laser lithotripsy is both safe and effective for upper tract calculi in children.It offers high stone-free rate and fewer complications.