Morgentaler A, Bridge S S, Dretler S P
Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston.
J Urol. 1990 Feb;143(2):263-6. doi: 10.1016/s0022-5347(17)39928-7.
The management of 42 impacted ureteral calculi is reviewed. Impacted stones were defined by the inability to pass a guide wire or catheter on initial attempts. Stones were impacted in the upper ureter in 10 patients, mid ureter in 11 and lower ureter in 21. Upper ureteral stones were treated in 8 patients by extracorporeal shock wave lithotripsy after disimpaction by laser or other techniques. Mid ureteral stones were treated by laser alone in 7 patients and by extracorporeal shock wave lithotripsy after disimpaction in 4. Lower stones were treated by laser in 17 patients and ultrasound in 2. Complications included 3 major and 5 minor perforations, and 4 false passages. Treatment was successful without an open operation in 40 of 42 patients (95%). Our current approach to impacted ureteral calculi involves passing a rigid ureteroscope to the stone, with disimpaction performed by laser fragmentation or other dislodgement maneuvers. Proximal stones or large fragments then are treated by extracorporeal shock wave lithotripsy. Mid ureteral stones are treated similarly, unless they are so fragile that in situ fragmentation may be completed easily. Lower ureteral stones are fragmented in situ, with hard fragments extracted by basket. Alternative treatments for impacted calculi at all levels include unstented in situ extracorporeal shock wave lithotripsy, antegrade ureteroscopy and, finally, an operation.
对42例输尿管结石嵌顿的处理进行了回顾。嵌顿结石的定义为初次尝试时无法通过导丝或导管。结石嵌顿于上段输尿管10例，中段输尿管11例，下段输尿管21例。8例上段输尿管结石患者在通过激光或其他技术解除嵌顿后接受了体外冲击波碎石术。7例中段输尿管结石患者仅接受了激光治疗，4例在解除嵌顿后接受了体外冲击波碎石术。17例下段输尿管结石患者接受了激光治疗，2例接受了超声治疗。并发症包括3例严重穿孔和5例轻微穿孔，以及4例假道形成。42例患者中有40例（95%）未进行开放手术治疗成功。我们目前处理输尿管结石嵌顿的方法是将硬性输尿管镜插入结石部位，通过激光碎石或其他移位操作解除嵌顿。近端结石或大的碎片随后通过体外冲击波碎石术治疗。中段输尿管结石的处理方法类似，除非结石非常易碎，可轻易进行原位碎石。下段输尿管结石进行原位碎石，用网篮取出坚硬碎片。各级嵌顿结石的替代治疗方法包括无支架原位体外冲击波碎石术、顺行输尿管镜检查，最后是手术。
