Kourambas J, Delvecchio F C, Munver R, Preminger G M
Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
Urology. 2000 Dec 20;56(6):935-9. doi: 10.1016/s0090-4295(00)00821-9.
Current ureteroscopic intracorporeal lithotripsy devices and stone retrieval technology allow for the treatment of calculi located throughout the intrarenal collecting system. Difficulty accessing lower pole calculi, especially when the holmium laser fiber is used, is often encountered. We retrospectively reviewed our experience with cases in which lower pole renal calculi were ureteroscopically managed by holmium laser fragmentation, either in situ or by first displacing the stone into a less dependent position with the aid of a nitinol stone retrieval device.
Thirty-four patients (36 renal units) underwent ureteroscopic treatment of lower pole renal calculi between April 1998 and November 1999. Lower pole stones less than 20 mm were primarily treated by ureteroscopic means in patients who were obese, in patients who had a bleeding diathesis, in patients with stones resistant to shock wave lithotripsy, and in patients with complicated intrarenal anatomy, or as a salvage procedure after failed shock wave lithotripsy. Lower pole calculi were fragmented with a 200-micrometer holmium laser fiber by way of a 7.5F flexible ureteroscope. For those patients in whom the laser fiber reduced the ureteroscopic deflection, precluding re-entry into the lower pole calix, a 3.2F nitinol basket or a 2.6F nitinol grasper was used to displace the lower pole calculus into a more favorable position, allowing easier fragmentation.
In 26 renal units, routine in situ holmium laser fragmentation was successfully performed. In the remaining 10 renal units, a nitinol device was passed into the lower pole, through the ureteroscope, for stone displacement. Only a minimal loss of deflection was seen. Irrigation was significantly reduced by the 3.2F nitinol basket, but improved with the use of the 2.6F nitinol grasper. This factor did not impede stone retrieval in any of the patients. At 3 months, 85% of patients were stone free by intravenous urography or computed tomography.
Ureteroscopic management of lower pole calculi is a reasonable alternative to shock wave lithotripsy or percutaneous nephrolithotomy in patients with low-volume stone disease. If the stone cannot be fragmented in situ, nitinol basket or grasper retrieval, through a fully deflected ureteroscope, allows one to reposition the stone into a less dependent position, thus facilitating stone fragmentation.
当前的输尿管镜体内碎石设备和结石取出技术可用于治疗肾内集合系统各处的结石。经常会遇到进入下极结石困难的情况，尤其是在使用钬激光光纤时。我们回顾性分析了我们对输尿管镜下钬激光碎石术治疗下极肾结石病例的经验，该方法可原位进行，也可借助镍钛诺结石取出装置先将结石移至较少依赖重力的位置。
1998年4月至1999年11月期间，34例患者（36个肾单位）接受了输尿管镜治疗下极肾结石。对于肥胖患者、有出血倾向的患者、对冲击波碎石有抵抗的结石患者、肾内解剖结构复杂的患者，或作为冲击波碎石失败后的挽救性手术，直径小于20mm的下极结石主要通过输尿管镜方法治疗。使用200微米的钬激光光纤经7.5F软性输尿管镜对下极结石进行碎石。对于那些激光光纤降低了输尿管镜的偏转从而无法再次进入下极肾盏的患者，使用3.2F镍钛诺网篮或2.6F镍钛诺抓钳将下极结石移至更有利的位置，以便更轻松地进行碎石。
26个肾单位成功进行了常规原位钬激光碎石。在其余10个肾单位中，通过输尿管镜将镍钛诺装置插入下极以移位结石。仅观察到极小的偏转损失。3.2F镍钛诺网篮显著减少了冲洗量，但使用2.6F镍钛诺抓钳时冲洗量有所改善。这一因素并未妨碍任何患者取出结石。3个月时，85%的患者经静脉肾盂造影或计算机断层扫描显示无结石。
对于小体积结石病患者，输尿管镜治疗下极结石是冲击波碎石术或经皮肾镜取石术的合理替代方法。如果结石无法原位碎石，通过完全偏转的输尿管镜使用镍钛诺网篮或抓钳取出结石，可将结石重新定位至较少依赖重力的位置，从而便于结石碎石。
