Preminger Glenn M
The Comprehensive Kidney Stone Center, The Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Urol Res. 2006 Apr;34(2):108-11. doi: 10.1007/s00240-005-0020-6. Epub 2006 Feb 7.
Current ureteroscopic intracorporeal lithotripsy devices and stone retrieval technology allow for the treatment of calculi located throughout the intra-renal collecting system. Difficulty accessing lower pole calculi, especially when the holmium laser fiber is utilized, is often encountered. Herein we review our experience where 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. Lower pole stones less than 20 mm can be primarily treated by ureteroscopic means in patients: that are obese; have a bleeding diathesis; with stones resistant to shockwave lithotripsy (SWL); with complicated intra-renal anatomy; or as a salvage procedure after failed SWL. Lower pole calculi are fragmented with a 200 microm holmium laser fiber via a 7.5 F flexible ureteroscope. For those patients where the laser fiber reduced ureteroscopic deflection, precluding re-entry into the lower pole calyx, a 1.9 F nitinol basket is used to displace the lower pole calculus into a more favorable position, thus allowing for easier fragmentation. A nitinol device passed into the lower pole, through the ureteroscope, for stone displacement cause only a minimal loss of deflection and no significant impact on irrigation. Eighty-five percent of patients were stone free by IVP or CT scan performed at 3 months. Ureteroscopic management of lower pole calculi is a reasonable alternative to SWL or percutaneous nephrolithotomy (PNL) 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 for repositioning of the stone into a less dependant 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位于整个肾内集合系统的结石。在使用钬激光光纤时，常常会遇到进入下极结石困难的情况。在此，我们回顾了我们的经验，即通过钬激光碎石术对下极肾结石进行输尿管镜处理，结石可原位处理，也可借助镍钛诺结石取出装置先将结石移位至依赖性较小的位置。对于以下患者，直径小于20mm的下极结石可首选输尿管镜治疗：肥胖患者；有出血倾向者；对冲击波碎石术（SWL）耐药的结石患者；肾内解剖结构复杂者；或SWL失败后的挽救性手术患者。通过7.5F可弯曲输尿管镜，使用200微米的钬激光光纤对下极结石进行碎石。对于那些激光光纤降低了输尿管镜偏转度、无法再次进入下极肾盏的患者，可使用1.9F镍钛诺网篮将下极结石移位至更有利的位置，从而便于更轻松地进行碎石。通过输尿管镜将镍钛诺装置插入下极以移位结石，只会导致极小的偏转度损失，且对冲洗无显著影响。85%的患者在3个月时通过静脉肾盂造影（IVP）或CT扫描显示结石清除。对于结石量少的患者，输尿管镜处理下极结石是SWL或经皮肾镜取石术（PNL）的合理替代方案。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取器取出结石，可将结石重新定位至依赖性较小的位置，从而便于结石碎石。
