基层医院开展输尿管软镜钬激光碎石术的疗效和安全性

Efficacy and safety of flexible ureteroscopy combined with holmium laser lithotripsy in grass-roots hospitals

目的探讨基层医院经尿道输尿管软镜钬激光碎石术治疗肾、输尿管上段结石的疗效和安全性。方法选取2018年5月-2021年11月该院采用经尿道输尿管软镜钬激光碎石术治疗肾、输尿管上段结石的患者485例,结石长径9~40 mm,平均(18.23±3.51)mm。术前均行肾、输尿管及膀胱平片(KUB)、静脉肾盂造影(IVP)和CT平扫检查,评估适应证,术中先行输尿管硬镜探查患侧输尿管,留置导丝并置入输尿管软镜引导鞘,软镜进入输尿管上段及肾盂,对于输尿管上段结石,则推入肾内碎石,连接200μm钬激光光纤,采取粉末化模式碎石,最后将稍大的结石碎片用套石网篮取出,术毕沿导丝留置双J管。术后第2天根据情况复查KUB或CT,以明确双J管位置及结石粉碎情况,2~4周后拔除双J管,术后1和3个月复查B超和KUB,必要时行CT平扫,以评估碎石效果。结果484例患者进镜成功,进镜成功率99.8%(484/485),碎石成功率93.2%(451/484),术后1个月结石清除率为87.4%(423/484),术后3个月结石清除率为90.9%(440/484)。手术时间26~120 min,平均(72.31±28.64)min。术后住院时间2~7 d,平均(2.31±0.76)d。手术并发症:发热15例,尿源性脓毒症6例,输尿管口活动性出血2例,穿孔尿外渗1例,石街1例,并发症总发生率为5.2%,25例患者均治愈出院,无严重后果。结论基层医院开展经尿道输尿管软镜钬激光碎石术治疗肾、输尿管上段结石,疗效好,安全性高,是值得推广的好方法。

Objective To evaluate the efficacy and safety of flexible ureteroscopy combined with holmium laser lithotripsy in treatment of renal and upper ureteral calculi in grass-roots hospitals.Methods From May 2018 to November 2021,a total of 485 patients with renal or upper ureteral calculi underwent flexible ureteroscopy combined with holmium laser lithotripsy.The maximum stone diameter ranged 9~40 mm,the average was(18.23±3.51)mm.Kidney ureter bladder position(KUB),intravenous pyelography(IVP)and CT plain scan were performed before operation to evaluate the indications.During the operation,the affected ureter was explored by rigid ureteroscopy,the guide wire was indwelling and the guide sheath of flexible ureteroscopy was placed.The flexible ureteroscopy entered the upper ureter and renal pelvis.If it was upper ureteral calculi,it was pushed into intrarenal lithotripsy and connected for 200μm holmium laser fiber,adopted the powdered mode of lithotripsy.Finally,the slightly larger stone fragments were took out with a stone extractor,and double J stent along the guide wire was retained after the operation.The next day after operation,KUB or CT should be rechecked according to the situation to determine the position of double J stent and stone crushing.Double J stent should be removed after 2~4 weeks.B-ultrasound and KUB should be rechecked 1 and 3 months after operation.If necessary,CT plain scan should be performed to evaluate the effect of lithotripsy.Results 484 ureteroscopes were successfully placed,with a success rate of 99.8%(484/485).The success rate of lithotripsy was 93.2%(451/484),the stone free rate one month after operation was 87.4%(423/484),and the stone free rate three months after operation was 90.9%(440/484).The operation time was 26~120 min,the average was(72.31±28.64)min.The postoperative hospital stay was 2~7 d,the average was(2.31±0.76)d.The operative complications included 15 cases of fever,6 cases of urogenic sepsis,2 cases of active bleeding at the ureteral orifice,1 case of perforated urinary extravasation and 1 case of steinstrasse.The total complication rate was 5.2%.All patients with complications were cured and discharged without serious consequences.Conclusion Flexible ureteroscopy combined with holmium laser lithotripsy in grass-roots hospitals is effective and safe in the treatment of renal and upper ureteral calculi.