组合式输尿管软镜钬激光治疗上尿路结石57例报道

李 明 何 华 万恩明 张佳义 李洪才 时 俊 李 顺 许 超

(湖北省江汉油田总医院泌尿外科，潜江 433124)

·临床论著·

组合式输尿管软镜钬激光治疗上尿路结石57例报道

李 明 何 华 万恩明 张佳义 李洪才 时 俊 李 顺 许 超

(湖北省江汉油田总医院泌尿外科，潜江 433124)

目的探讨组合式输尿管软镜联合钬激光碎石处理上尿路结石的临床价值。方法2011年10月～2013年5月，治疗上尿路结石57例。中上组肾盏结石24例，下组肾盏结石14例，肾盂结石12例，输尿管上段结石硬镜碎石术中结石或碎片上移至肾盂7例。其中3例肾上盏结石及2例中盏结石为经皮肾镜术后残余结石。合并脊柱侧弯畸形2例。结石直径9～24 mm，平均16 mm。全麻或硬膜外麻醉，截石位。在斑马导丝引导下置入输尿管导引鞘，组合式输尿管软镜沿鞘上行至肾盂、肾盏寻找结石，使用钬激光碎石。术后常规留置F5双J管4～5周，留置导尿管2～7天。术后2～3天常规复查KUB或B超，了解结石粉碎情况及双J管位置。结果本组57例中，50例(87.7%)顺利寻及结石并一次碎石成功。碎石成功率，中上组肾盏95.8%(23/24)，下组肾盏64.3%(9/14)，肾盂结石91.7%(11/12)，输尿管上段结石上移100%(7/7)。5例经皮肾镜术后残余结石全部碎石成功。手术时间40～120 min，平均75 min。无输尿管穿孔、撕脱、大出血等并发症。术后高热7例，体温38.5～39.6 ℃，经抗感染治疗3～5天体温恢复正常。术后住院时间3～7 d，平均5 d。术后4周复查KUB或B超并拔除双J管，7例残石碎片3～4 mm，均位于肾下盏，予随诊观察。结论组合式输尿管软镜治疗上尿路结石，具有微创、疗效确实、并发症少的优点，对于输尿管上段结石上移及经皮肾镜取石术后残余结石的处理可作为很好的补充。

组合式输尿管软镜； 钬激光； 上尿路结石

具有可弯曲功能的输尿管软镜可以经尿道逆行至输尿管、肾脏进行碎石。输尿管软镜的使用极大地扩展了治疗上尿路结石的适应证，且并发症更少[1]。我院2011年10月～2013年5月采用组合式输尿管软镜联合钬激光治疗上尿路结石57例，取得满意疗效，现报道如下。

1 临床资料与方法

1.1 一般资料

本组57例，男32例，女25例。年龄21～72岁，平均46岁。腰痛46例，肉眼血尿29例。病程2天～5年。B超、IVU、CTU等检查确诊为上尿路结石。中上组肾盏结石24例，下组肾盏结石14例，肾盂结石12例，输尿管上段结石硬镜碎石术中结石或碎片上移至肾盂7例。合并脊柱侧弯畸形2例。结石直径9～24 mm，平均16 mm。5例肾盂结石及3例输尿管结石行ESWL治疗无效。3例肾上盏结石及2例中盏结石为经皮肾镜术后残余结石经肾造瘘二期取石未取净者。肾结石患者术前1周留置F5双J管扩张输尿管。

1.2 方法

1.2.1 特殊器械 德国POLYSCOPE组合式输尿管软镜的特点是最大限度地保存了软镜的核心价值部件，易损件可以随时拆卸更换。外径仅2.65 mm(8F)，工作长度70 cm。包含光源、成像光线插入通道及操作通道。光学系统具有10 000像素，成像清晰。目镜、成像光纤和摄像头借助三节臂固定在电视摄像系统的推车上，操作简便。

1.2.2 手术方法 全麻51例，硬膜外麻醉6例，截石位。将WOLF F8/9.8输尿管硬镜置入输尿管内直视下观察及扩张输尿管，拔除患侧预留双J管。在斑马导丝引导下插入F12/F14输尿管软镜导引鞘(Cook公司)至输尿管上段或近肾盂处。连接组合式输尿管软镜，经软镜导引鞘上行至肾盂、肾盏寻找结石。使用钬激光(科医人公司)200 μm激光光纤，功率设置0.6～1.0 J/ 10～15 Hz(6～15 W)，将结石击碎至3 mm以下，部分患者用套石篮尽量取净结石。7例输尿管上段结石行输尿管硬镜碎石结石或碎片上移至肾盂，改用组合式输尿管软镜碎石。5例经皮肾镜术后残余结石经肾造瘘二期取石未取净者，术中即改用组合式输尿管软镜钬激光碎石。术后留置患侧F5双J管4～5周，留置导尿管2～7天。术后2～3天常规复查KUB或B超了解结石粉碎情况及双J管位置。

2 结果

1例肾上盏憩室内结石找不到憩室开口，2例下盏结石未寻及，均放弃手术；3例下盏结石软镜插入钬激光光纤后因弯曲角度不足，光纤前端不能触及结石，改微创经皮肾镜碎石成功；1例肾盂结石入镜后未取头低位，冲水及碎石过程中结石落入肾下盏，择期ESWL治疗。3例残余结石直径5～11 mm，术后2周行ESWL，其中1例ESWL无效再次用组合式输尿管软镜碎石成功。50例(87.7%)顺利寻及结石并一次碎石成功。碎石成功率，中上组肾盏95.8%(23/24)，下组肾盏64.3%(9/14)，肾盂结石91.7%(11/12)，输尿管上段结石上移100%(7/7)。5例经皮肾镜术后残余结石全部碎石成功。手术时间40～120 min，平均75 min。无输尿管穿孔、撕脱、大出血等并发症。术后高热7例，体温38.5～39.6 ℃，血白细胞 (10.6～16.2)×109/L，中性粒细胞0.75～0.94，经抗感染治疗3～5天体温恢复正常。术后住院时间3～7 d，平均5 d。术后4周复查KUB或B超并拔除双J管，7例残石碎片3～4 mm，均位于肾下盏，予随诊观察。

3 讨论

输尿管软镜联合钬激光治疗上尿路结石是一个趋势，改变了传统开放手术及经皮肾镜手术大出血等并发症的缺点。然而电子输尿管软镜及一体式输尿管软镜的使用及维护成本较高，每使用5～18次就需要维修[2，3]，大大限制了其推广应用。组合式输尿管软镜是一种可拆卸式输尿管软镜，可随时更换易损部件，能在一定程度上降低使用和维修成本[4，5]。

本组57例上尿路结石患者碎石成功率87.7%(50/57)，其中中上组肾盏95.8%(23/24)，肾盂结石91.7%(11/12)，肾下盏结石64.3%(9/14)，>4 mm残余结石3例。从结果中看出中上组肾盏结石、肾盂结石效果好于下组肾盏结石。由于组合式输尿管软镜只能单向弯曲，不能像一体式软镜末端自由转向；需要操作者手腕转动使镜头达到各肾盏寻找结石。虽然理论最大弯曲角度为225°，插入激光光纤时可以弯曲180°[6]。而实际插入激光光纤后软镜的弯曲角度变小，加之部分患者因解剖因素肾盂与肾下盏夹角过小，导致部分患者尤其是肾下盏结石虽然镜下可以看见，而钬激光光纤却不能触及结石，导致手术失败或术后残余结石，显示出组合式输尿管软镜对于肾下盏结石的处理有一定局限性。在降低残石率方面，我们体会，术中病人头低臀高位，同时将手术床向健侧倾斜10°～15°，使肾盂呈喇叭状、出口斜向下方，结石及碎块容易移动至上、中组肾盏或肾盂，从而更有利于碎石。激光碎石功率宜选择较低能量，0.6～1.0 J/ 10～15 Hz(6～15 W)。尽量从结石边缘开始“蚕食”结石，避免“钻孔法”或将结石碎成较大石块，否则不利于将结石进一步粉末化。如果下盏结石因角度问题光纤难以接触结石，可以将光纤伸入肾盏内，在结石表面连续激发激光，使结石在肾盏壁与光纤顶端来回触碰，结石不断被切削变小。还可以将患侧肾区抬高或顶起以方便碎石。按上述方法，只要结石碎裂，就有机会将其移动至上中盏或肾盂便于处理。

上段输尿管结石术中结石上移是导致输尿管硬镜碎石失败的主要原因。而经皮肾镜碎石术中平行肾盏结石的处理亦很棘手，要么增加皮肾通道，要么加大镜体摆动，撕裂肾盏引起出血。我们应用组合式输尿管软镜处理输尿管上段结石上移7例，经皮肾镜术后残余结石5例，全部获得成功，无手术并发症。

Michel等[7]报道尿源性脓毒症休克的病死率达20.0%～40.0%。本组57例中术后高热7例，体温38.5～39.6 ℃，血白细胞(10.6～16.2)×109/L，中性粒细胞0.75～0.94，经抗感染治疗3～5天体温恢复正常，无严重并发症发生。我们认为，术中常规留置输尿管导引鞘和控制手术时间，降低术中灌注压力以减少冲洗液、细菌、毒素的吸收，术前、术中有效使用抗生素，能够减少或预防术中、术后感染并降低尿源性脓毒症休克的发生率。术中避免使用灌注泵，用注射器根据视野的清晰程度给予低压、间断冲洗为好。

输尿管软镜对于肾盂、肾盏和输尿管上段疾病的诊断和治疗具有不可替代的优势，尤其是联合钬激光应用于上尿路2 cm以下结石的治疗，微创高效[8]。对于新开展技术不成熟的单位，组合式输尿管软镜能降低器械的使用成本，是不错的选择。患者易于接受，尤其对于肾盂和肾上、中盏结石成功率高。对于输尿管上段结石上移及经皮肾镜取石术后残余结石的处理可作为很好的补充，但对肾盏憩室内结石及下盏结石的处理有一定的局限性。

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4 程 跃，严泽均，马建伟，等.组合式输尿管软镜联合钬激光治疗肾结石46例报告.中华泌尿外科杂志，2012,33(1):29-31.

5 Bansal H,Swain S,Sharma GK，et al.Polyscope:a new era in flexible ureterorenoscopy.J Endourol，2011,25(2):317-321.

6 Bader MJ,Gratzke C,Walther S,et al.The PolyScope:a modular design,semidisposable flexible ureterorenoscope system.J Endourol，2010,24(7):1061-1066.

7 Michel MS,Trojan L,Rassweiler JJ,et al.Complications in percutaneous nephrolithotomy.Eur Urol,2007,51(4):899-906.

8 卢 剑，肖春雷，张树栋，等.新型组合式输尿管软镜治疗上尿路结石的初步体会.中国微创外科杂志，2010，10(6):517-519.

(修回日期：2013-11-24)

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ModularFlexibleUreteroscopeCombinedwithHolmiumLaserfortheTreatmentofUpperUrinaryCalculi:aReportof57Cases

LiMing,HeHua,WanEnming,etal.

DepartmentofUrology,JianghanOilFieldGeneralHospital,Qianjiang433124,China

ObjectiveTo evaluate the efficacy and clinical value of modular flexible ureteroscope combined with holmium laser for the treatment of upper urinary calculi.MethodsA total of 57 patients with upper urinary calculi were treated, including 24 cases of calculi in upper and middle calyx, 14 cases of lower calyx calculi, 12 cases of renal pelvis calculi and 7 cases of upper ureteral calculi. The upper ureteral calculi of the 7 cases have all moved up to renal pelvis in rigid ureteroscope operations. Three cases of calculi in upper calyx and two cases of middle calyx calculi were residual calculi after PCNL. Two cases were combined with scoliosis. The diameter of the calculi ranged 9-24 mm (average, 16 mm). The patients were under general or spinal anesthesia and were at lithotomy position. After dilating the ureter, a F14flexible ureteral access sheath was inserted along the guide wire. Finally, Ho:YAG lithotripsy was performed by modular flexible ureteroscope. The cases with upper ureteral calculi were firstly performed by rigid ureteroscope, and modular flexible ureteroscope was used when the calculi moved up to renal pelvis. F5double J tube was indwelt regularly for 4-5 weeks postoperatively, and Foley-urethral tube was retained for 2-7 days. KUB was performed 2-3 days after the surgery to detect the results of lithotripsy and the position of double J tube.ResultsLithotripsy was performed successfully in 50 patients (87.7%, 50/57). In the cases with upper and middle calyx calculi, the stone-free rate was 95.8% (23/24); it was 64.3% (9/14) in the cases with lower calyx calculi, 91.7% (11/12) in the cases with renal pelvis calculi, and 100% (7/7) in the upper ureteral calculi which moved up to renal pelvis. The five cases with residual stones after percutaneous nephrolithotomy (PCNL) went through operation successfully. The operation time was 40-120 min (average, 75 min). There were no severe complications such as ureteral perforation, septicemia or hemorrhage. Seven patients had postoperative high fever with temperature ranging 38.5-39.6 ℃, and were cured by anti-infective therapy after 3-5 days. The patients were discharged from hospital in 3-7 d (average, 5 d) postoperatively. All cases were reviewed with X-ray or B ultrasonography 4 weeks after operation, and double J tubes were removed simultaneously. The residual stones (diameter, 3-4 mm) were observed in 7 cases, which were all located in lower calyx and did not need further treatment.ConclusionsModular flexible ureteroscope is safe, effective and convenient for lithotripsy of the upper urinary calculi. It is a good supplement for the treatment of upper ureteral calculi and residual stones after PCNL.

Modular flexible ureteroscope; Holmium laser; Upper urinary calculi

R692.4

：A

：1009-6604(2014)02-0140-03

10.3969/j.issn.1009-6604.2014.02.015

2013-08-21)