微通道经皮肾镜碎石术治疗感染性结石合并尿液CRPA感染两例

目的:总结一期行微通道经皮肾镜碎石术(microchannel percutaneous nephrolithotripsy,m PCNL)治疗上尿路感染性结石合并尿培养为耐碳青霉烯铜绿假单胞菌(carbapenem resistant pseudomonas aeruginosa,CRPA)的经验。方法:选择我院收治两例左肾结石合并尿培养为CRPA的患者,经积极抗感染治疗后,病例一行左侧经皮肾镜碎石术,病例二先行右肾穿刺造瘘术成功后行左侧经皮肾镜碎石术,观察分析两例患者术后结石清除情况,术中术后出现发热、腰痛、大出血、尿路损伤及肾功能衰竭等并发症情况。结果:两例患者术后复查双J管位置良好,结石基本清除;术中、术后均未出现发热、腰痛、大出血、尿路损伤及肾功能衰竭等并发症。结论:经过合适的围手术期处理,一期微通道经皮肾镜碎石术治疗感染性结石合并尿培养为耐药菌的患者是安全可行的。     

微创经皮肾镜碎石术治疗输尿管上段嵌顿结石

目的:分析微创经皮肾镜碎石术(minimal invasive percutaneous nephrolithotomy,mPCNL)治疗输尿管上段嵌顿性结石的临床疗效.方法:采用B超或X线定位,mPCNL治疗102例嵌顿性输尿管上段结石,其中2例经皮穿刺抽吸脓性尿液,留置造瘘管,抗炎治疗后二期手术.术后生命体征、B超和尿路平片(kindey ureter bladder,KUB)等检查并随访.结果:100例Ⅰ期穿刺成功并气压弹道或钬激光mPCNL,手术时间55-75 min.碎石、取石时间15-35 min.术后住院4-7 d.无穿刺损伤腹腔脏器、术中未有肾孟穿孔和输尿管损伤、无大出血等术中和术后并发症.mPCNL术后2 dKUB检查结石清除率为91.1%(93/102),9例残留结石,术后辅以体外冲击波碎石治疗.术后1个月结石清除率为100%(102/102).结论:微创经皮肾穿刺取石治疗嵌顿性输尿管上段结石创伤小、恢复快且有很高的清除率,值得临床推广应用.     

侧卧位经皮肾微造瘘输尿管镜下取石治疗上尿路结石56例报道

目的:探讨侧卧位施行经皮肾微造瘘输尿管镜下取石(MPCNL)治疗上尿路结石方法及疗效。方法:回顾分析56例上尿路结石侧卧位施行PCNL治疗的临床资料,其中肾铸形结石33例,输尿管上段结石23例。结果:56例均手术成功,无穿刺失败或中转开放手术。一次结石取净率80%,两次手术合计达96%。术中均无输血,无肠道损伤等并发症。结论:侧卧位施行MPCNL手术患者易耐受,手术更安全,术中碎石易排出。效果良好。     

斜仰截石位输尿管镜联合经皮肾镜治疗复杂性输尿管上段结石

目的:研究斜仰截石位输尿管镜联合经皮肾镜治疗复杂性输尿管上段结石的安全性和有效性.方法:2011年2月-2012年2月采用斜仰截石位输尿管镜联合经皮肾镜治疗复杂性输尿管上段结石患者36例,平均年龄(47±15)岁,结石位于左侧20例,右侧16例.结石最大径1.5-3.0 cm,平均(2.0± 1.0) cm.该体位摆放完成后患者整体成一斜向截石位.采用连续硬膜外麻醉或气管插管全麻,先行URSL,将结石击碎成若干较大碎石块,结石或碎石块上移达接近肾盂水平后,在B超引导下穿刺肾盂或目标肾盏成功后,依次扩张通道至16F或24 F,用EMS第四代碎石清石系统碎石.结果:36例均穿刺成功并能良好耐受手术,患者无因体位不适终止手术者.平均手术时间(75± 25) min.一次性结石清除率为91.6 ％(33/36),残留结石3例,其中行二期手术取尽结石1例.术后高热2例.无胸膜、腹腔脏器损伤等并发症发生.结论:斜仰截石位URSL联合PCNL治疗复杂性输尿管上段结石安全有效,患者耐受性好.     

输尿管镜钬激光碎石术和后腹腔镜输尿管切开取石术治疗输尿管上段结石的临床疗效比较

目的:比较输尿管镜钬激光碎石术(USL)和后腹腔镜输尿管切开取石术(RLU)治疗输尿管上段结石的疗效,探讨治疗输尿管上段结石的最佳方法.方法:回顾性分析115例输尿管上段结石患者临床资料,其中71例采用输尿管镜术治疗,44例采用后腹腔镜术治疗,比较两种手术方法的临床治疗效果.结果:后腹腔镜组的手术成功率(97.7％)明显高于输尿管镜组(83.1％)(P＜0.05).输尿管镜组和后腹腔镜组手术时间分别为(43.2± 14.7)min和(79.6± 24.1)min,术中出血量分别为(3.1±0.8)ml和(36.4± 3.7)ml,术后住院天数分别为(3.3±2.1)d和(6.7±1.3)d,差异均具有显著统计学意义(P＜0.01),输尿管镜组均优于后腹腔镜组.输尿管镜组手术后并发症6例,后腹腔镜组5例,两组并发症的发生率比较差异无统计学意义(P＞0.05).术后1个月复查腹部X线平片(KUB),输尿管镜组17例有结石残留,后腹腔镜组均无结石残留,输尿管镜组的结石残留率明显高于腹腔镜组(P＜0.01).结论:输尿管上段结石采用输尿管镜钬激光碎石术和后腹腔镜输尿管切开取石术治疗各有其优缺点.RLU具有安全、高效、创伤小、并发症少、结石清除率高的优点;而USL相对具有出血少、手术时间及住院时间短等优点,但手术成功率和结石清石率低,需其他辅助方式治疗结石.因此,泌尿外科医师应根据结石大小、位置、有无炎性息肉包裹、梗阻程度、肾积水量等术前检查结果及所拥有的设备与技术熟练程度选择最合适的治疗方法.     

微创经皮肾镜取石术治疗输尿管上段结石合并轻度肾积水疗效观察

目的探讨微创经皮肾镜取石术治疗输尿管上段结石合并轻度肾积水的临床疗效。方法选取我院收治的140例输尿管上段结石合并轻度肾积水患者为研究对象,将患者随机分为对照组和观察组各70例,对照组70例行经后腹腔镜输尿管、肾盂切开取石术治疗,观察组行微创经皮肾镜取石术治疗,比较两组患者的治疗效果。结果两组患者在手术时间、术中出血量、胃肠道功能恢复时间及住院时间、血清炎性因子水平方面比较,观察组均明显优于对照组(P0.05);观察组患者的结石清除率与对照组比较,差异无统计学意义(P0.05)。结论输尿管上段结石合并轻度肾积水患者实施微创经皮肾镜取石术治疗的效果显著,有利改善患者血清炎性因子水平,值得推广应用。     

输尿管软镜治疗上尿路结石的疗效观察

目的探讨输尿管软镜治疗上尿路结石的临床效果。方法选择2018年1月～2019年6月在我院行输尿管上段结石及肾结石治疗的70例患者为研究对象,按随机数字表法进行分组,每组35例。A组采用经皮肾镜碎石术,B组行输尿管软镜钬激光碎石术,观察比较两组患者结石清除率及手术情况(包括手术时间、住院时间、术中出血量)。结果两组患者的结石清除率比较,A组为91.43%、B组为94.29%,两组比较差异无统计学意义(P0.05)。B组患者的手术时间、住院时间均短于A组,手术出血量少于A组,两组比较差异均有统计学意义(P0.05)。结论经皮肾镜碎石术与输尿管软镜钬激光碎石术的疗效相近,但输尿管软镜钬激光碎石术的手术时间短,患者恢复快。     

妊娠合并上尿路结石致肾绞痛的临床诊治策略

目的:探讨妊娠期上尿路结石致肾绞痛的诊断和治疗方法.方法:对103例妊娠期上尿路结石致肾绞痛患者的临床资料及诊治过程进行分析,结合文献讨论本病的临床特点及诊治方法.结果:92例B型超声检查发现结石,11例仅发现患侧肾脏积水.所有患者均先行保守治疗;期间14例行输尿管置管术,7例行输尿管镜下气压弹道碎石术,2例行经皮肾穿刺造瘘术;101例患者顺利足月分娩;2例终止妊娠,孕妇平安.结论:妊娠期上尿路结石的诊断首选超声检查.对于有症状发作者保守治疗是主要治疗方法.治疗用药物应注意保护胎儿.对于顽固性肾绞痛患者,外科治疗首选逆行插管引流尿液,必要时可选择输尿管镜检查或经皮肾穿刺.开放手术为最后的治疗手段.     

应用管路封堵器处理输尿管上段结石的随机对照研究

目的:研究辅助使用管路封堵器后,采用输尿管镜下碎石术处理输尿管上段结石的效果及安全性。方法:选取自2012年6月至2013年2月需输尿管镜处理输尿管上段结石的病例198例,随机分为应用管路封堵器组98例和对照组100例。封堵器组术中输尿管镜发现结石后,封堵器组患者使用英诺伟IVX-SC10型管路封堵器超越结石远端封堵结石,再予钬激光碎石,对照组术中输尿管镜发现结石后,直接予钬激光碎石,术后留置双J管2至4周。记录并随访患者输尿管镜术后结石清除率及肾脏出血相关并发症。结果:管路封堵器组碎石成功率95.9%(94/98),对照组碎石成功率81.0%(81/100),两组有统计学差异(P=0.0011)。碎石成功后管路封堵器组出现3例(3.2%)肾脏破裂出血,而对照组无肾脏破裂出血,两组无统计学差异(P=0.1048)。结论:辅助应用管路封堵器能提高输尿管镜对于输尿管上段结石的碎石成功率;其使用并没有增加术后肾脏出血并发症的发生。     

后腹腔镜治疗输尿管上段结石42例临床分析

目的 探讨后腹腔镜输尿管上段切开取石术的技术要点和临床疗效.方法 回顾性分析后腹腔镜治疗输尿管上段结石42例临床资料.结果 41例患者手术取石成功,1例单侧2个结石,近端结石因患者体位改变上移至肾盂,后经ESWL治疗排出.术后随访6～12月,经B超复查患侧肾输尿管积水均明显好转.结论 后腹腔镜输尿管上段切开取石术是一种安全有效的微创技术,可作为开放手术或其他微创方法的替代或补充.     

孤立肾多发结石患者超声引导微创经皮肾穿刺取石术治疗的效果分析

目的:分析孤立肾多发结石患者超声引导微创经皮肾穿刺取石术治疗的效果。方法:64例孤立肾多发结石患者随机均分为试验组和对照组。其中对照组患者均采用常规开放式取石术治疗,试验组患者则在超声引导下实施微创经皮肾穿刺取石术治疗。比较两组患者的手术时间和术中出血量以及术后取净率等临床资料。结果:两组患者的手术时间并无明显差异(t=1.942,P0.05)且试验组患者的术后取净率和术后两个月排净率均显著高于对照组患者(t=4.731,P0.05,t=4.288,P0.05);对照组患者的并发症发生率显著高于试验组患者(t=4.333,P0.05);试验组患者的术中出血量显著低于对照组(t=3.762,P0.01)。两组患者术前术后以及术后2个月的血肌酐水平比较均无明显差异(均P0.05),并且两组患者血肌酐水平组间比较亦无明显差异(均P0.05)。结论:超声引导下对孤立肾多发结石患者实施微创经皮肾穿刺取石术治疗具有较高的安全性和临床疗效。     

Combined Minimally Invasive Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery for Staghorn Calculi in Patients with Solitary Kidney

Background

To present our experience with simultaneous combined minimally invasive percutaneous nephrolithotomy (MPCNL) and retrograde intrarenal surgery (RIRS) to manage patients with staghorn calculi in solitary kidney, and evaluate the safety, efficiency and feasibility of this approach.

Methodology/Principal Findings

The study included 20 patients with staghorn calculi in solitary kidney. Demographic characteristics, stone location and surface area were recorded. After informed consent, the patients underwent one stage MPCNL firstly. Combined second stage MPCNL and RIRS simultaneously were performed at postoperative 5–7 days. Operative parameters, stone-free rate (SFR), stone analyses and complications were evaluated. Serum creatinine (Scr), glomerular filtration rate (GFR) and chronic kidney disease (CKD) were measured preoperatively, postoperatively at 1 month, and each follow-up visit. All patients had staghorn stones involving multiple calyces. The mean stone burden was 1099.9±843.95 mm². All patients had only one percutaneous access tract. The mean whole operative duration was 154.37±32.45 min. The mean blood loss was 64 (12–140) ml. The final SFR was 90%. During the 1-month follow-up study period, four patients improved in CKD stage. Two patients who had CKD (stage 5) still needed dialysis postoperatively. Mean Scr of the rest patients preoperatively was 187.16±94.12 compared to 140.99±57.92 umol/L by the end of 1-month follow-up period (p = 0.019). The same findings were observed in GFR in that preoperatively it was 43.80±24.74 ml/min and by the end of the 1-month follow-up it was 49.55±21.18 ml/min (p = 0.05).

Conclusions/Significance

Combined MPCNL and RIRS management effectively decrease the number and size of percutaneous access tracts, which is safe, feasible, and efficient for managing staghorn calculi in solitary kidney with satisfactory SFR and reducing blood loss, potential morbidity associated with multiple tracts. The approach did not adversely affect renal function at both short-term and long-term follow-up.     

微创经皮肾镜碎石取石术治疗特殊肾结石的临床疗效观察

目的：研究微创经皮肾镜碎石取石术治疗特殊鹿角型或多发肾结石中的临床疗效和安全性。方法：回顾性分析2007年1月-2013年3月我院收治的37例采用微创经皮肾镜碎石取石术（PCNL）手术方式治疗的特殊鹿角形或多发肾结石患者的临床资料。结果：37例患者中,孤立肾9例、马蹄肾7例、海绵肾和多囊肾7例、儿童患者14例。成人结石直径（3．2±0．3）cm,儿童结石直径（2．2±0．2）cm。37例患者均一期单通道情况下顺利完成手术,单次手术成功率100％,结石清除率91．2％（34／37）,平均手术时间（94±21．6）min,平均出血量（62±12．3）mL,术后1月复查B超提示肾脏积水减轻,肾脏功能血肌酐较术前降低,术后一月复查KUB提示3例肾脏下盏少量残留结石,4例患者出现术后低热症状。结论：采用PCNL治疗特殊鹿角形或多发肾结石的安全性好、结石清除率高、并发症较少。     

Ultrasonic Destruction of Kidney Stones

Kidney stones may be removed without using a surgical incision by a combination of techniques and skills recently developed in the fields of urology and radiology. Percutaneous access to the kidney is established under fluoroscopic control. A guide wire placed into the renal pelvis allows a nephroscope to be inserted and the collecting system visualized. A long hollow metal probe is advanced through the nephroscope and placed in contact with the stone. This probe conducts the ultrasonic energy. The stone absorbs the energy and breaks into fine granules, which are evacuated by suction.Twenty-three consecutively seen patients presenting with 27 upper urinary tract calculi for which removal was indicated underwent successful percutaneous ultrasonic lithotripsy. Fifteen stones were located in the renal pelvis, eight in a calix, three at the ureteropelvic junction and one in the upper ureter. One infected staghorn calculus was removed. Two complications resulted in extended hospital stays, but in no patients were surgical incisions required. Of the 23 patients, 9 had previously had a surgical lithotomy. The authors believe that most renal and upper ureteral calculi for which removal is indicated may be extracted percutaneously with the aid of the ultrasonic lithotriptor. The patients may expect a rapid convalescence with diminished pain.     

输尿管上段嵌顿性结石两种微创钬激光碎石术临床疗效对比研究

目的:探讨应用钬激光在输尿管镜碎石术及微创经皮肾穿刺取石术处理输尿管上段嵌顿性结石的疗效和并发症的比较。方法:2009年2月～2011年6月我院182例输尿管上段嵌顿性结石患者,应用钬激光经URL治疗85例,MPCNL治疗97例,对两种方法疗效进行临床评价比较。结果:MPCNL术中一期碎石清除率为(93/97)95.88%,5例残石者残石大小0.2～0.4 mm,术后1月结石清除率为(97/97)100%,平均手术时间75±29 min,平均住院时间为12±5 d,平均住院费用14589±3284 RMB;URL术一期碎石清除率为(39/85)45.88%,46例残石者残石大小0.3～1.5 mm,需术后联合体外冲击波碎石术等治疗排石,术后1月结石清除率为(72/85)84.71%,平均手术时间102±43 min,平均住院时间为6±3 d,平均住院费用9086±1259 RMB。MPCNL术中有1例因穿刺后出血改行二期MPCNL术。URL术中输尿管扭曲、狭窄、息肉出血视野模糊不清,需改行切开取石术6例,结石移位到肾内改行MPCNL术11例。结论:对于嵌顿性输尿管上段结石,采用MPCNL和URL联合钬激光治疗各有其优缺点。MPCNL安全、高效、并发症少、创伤小、结石清除率高;URL相对具有恢复快、住院时间短、费用较低等优点,但结石移位发生率、残石率较高,需其他辅助方式治疗结石。因此输尿管上段嵌顿性结石的手术方式选择应根据结石位置、大小、梗阻程度、肾积水量、患者经济状况,术前检查结果,充分评估手术风险和难度,结合患者个体差异,术者的经验制定出最佳治疗方案。     

微通道经皮肾镜与输尿管软镜碎石取石术对输尿管上段结石患者血液流变学及男性性功能指标的影响

摘要 目的：以血液流变学及男性性功能指标为主要观察指标分析微通道经皮肾镜取石术（MPCNL）与输尿管软镜碎石取石术（FURL）在输尿管上段结石（UUC）中的应用价值。方法：将80例男性UUC患者按简单随机化法分MPCNL组、FURL组各40例;比较两组清石率、血液流变学、性功能指标及不良反应。结果：两组术后1w（82.50% vs 85.00%）、术后1mo（92.50% vs 97.50%）、术后3mo（100.00% vs 100.00%）的清石率无统计学意义（P＞0.05）。FURL组术后1天、术后7天的血液流变学指标水平均低于MPCNL组（P＜0.05）。两组术后男性性功能指标较术前显著改善,但FURL组术后3mo、6mo的男性性功能指标改善更显著（P＜0.05）。结论：对于UUC患者,MPCNL和FURL均能有效清除结石,都是安全有效的方法,但FURL较MPCNL对患者术后血液流变学的影响更小,且更利于术后性功能的恢复。     

Chinese minimally invasive percutaneous nephrolithotomy for intrarenal stones in patients with solitary kidney: a single-center experience

Objective

To report our experience with Chinese minimally invasive percutaneous nephrolithotomy (Chinese MPCNL) to manage patients with intrarenal stones in solitary kidney, and evaluate the safety, efficiency and feasibility of this technique.

Methods

Forty-one patients with intrarenal stones in solitary kidney underwent Chinese MPCNL in our department from March 2009 to February 2011. Demographic characteristics, operative parameters, number of tracts, stone-free rates (SFRs), stone analyses, hemoglobin levels, nephrostomy tube removal time, hospitalization time, and complications were evaluated. Serum creatinine (Scr) and glomerular filtration rate (GFR) were measured preoperatively, postoperatively at 1 month, and each follow-up visit. The 5-stage classification of chronic kidney disease (CKD) was used according to the National Kidney Foundation guidelines.

Results

The initial stone-free status was achieved in 35 (85.4%) patients after Chinese MPCNL. The mean follow-up time was 16.9±4.7 months (range: 12–24), and the final SFR improved to 97.6% after auxiliary procedures. Among all patients, complex stones were detected in 26 (63.4%) patients, and 9 (22.0%) required multiple tracts. The mean operative time and mean hospitalization time were 71.3±23.5 min (range: 40–139) and 6.1±0.5 days (range: 5–11), respectively. During preoperative period and postoperative period (1 month), Scr were 132.1±41.3 umol/L (range: 78.2–231.4) and 108.9±30.7 umol/L (range: 71.6–136.9), respectively (P<0.05), while GFR were 74.9±24.2 ml/min (range: 35–110) and 83.9±27.4 ml/min (range: 65–110), respectively (P<0.05). According to CKD classification, the renal function was stable, improved, and worse in 29 (70.7%), 11 (26.8%), and 1 (2.5%) patients, compared with the preoperative levels. No patient progressed to end-stage renal disease requiring dialysis.

Conclusions

Our experience with Chinese MPCNL demonstrates that it is safe, feasible and efficient for managing the intrarenal calculi in solitary kidney with a low complication rate. At long-term follow-up, renal function stabilized or even improved in the majority of patients with solitary kidney.     

The congenital and acquired solitary kidney

The embryonic insult that results in unilateral renal agenesis may involve not only the ureteral bud but also other mesonephric duct derivatives, including the seminal vesicles, vas deferens, and epididymis; in the female with a solitary kidney, müllerian duct anomalies frequently occur. Normal renal development depends upon a normal ureteral bud, which undergoes orderly branching and penetrates the metanephric blastema at about the fifth week of gestation. Ureteral and kidney development are thought to be interdependent, and when there is failure of the ureteral bud to form or absence of the nephrogenic ridge, the kidney does not develop normally. Unilateral renal agenesis is compatible with normal longevity and does not predispose the contralateral kidney to greater-than-normal risk; nevertheless, patients should have annual surveillance, including a blood pressure measurement, serum creatinine if not initially normal, and urinalysis to detect proteinuria. Removal of one kidney leads to structural and functional changes by the remaining kidney, including increased filtration of the remaining glomeruli. These functional changes have generally been considered beneficial because they mitigate the reduction in the total glomerular filtration rate that would otherwise occur, but experimental evidence suggests that these changes may have an adverse effect on the remaining kidney. Clinical evidence shows that these changes do not lead to renal deterioration in kidney donors because the renal function of kidney donors is well preserved in over 20 years of follow-up after donor nephrectomy.     

侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的临床应用价值

目的：探讨侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的可行性及临床应用价值。方法：回顾性分析2009年8月至2011年9月我院采用侧卧体住下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石患者52例的临床资料：患者同时存在肾脏铸型结石或多发结石和或输尿管上段结石,单个结石最大径8-30mm。结果：平均手术时间60分钟（50—120分钟）;术前血红蛋白116±30g／L,术后第一天复查105±26g／L,无大出血需要输血病例;一次结石取净率为86．5％（45／52）,总取净率为92．3％（48／52）。结论：侧卧体位下经皮肾穿刺取石术及经尿道输尿管镜取石术两种术式联合应用具有可行性及互补性,在预防及减少术中出血、获得清晰的手术视野、减少灌注液外渗、增加结石清除速度及碎石成功率、缩短手术时间、减少术后发热等方面疗效显著,为治疗复杂上尿路结石提供了一个可行的新方法。