Kim H H, Lee J H, Park M S, Lee S E, Kim S W
Department of Urology, Seoul National University College of Medicine, Korea.
J Endourol. 1996 Dec;10(6):501-5. doi: 10.1089/end.1996.10.501.
To determine the factors influencing stone fragmentation and to suggest when to change treatment modality for ureteral calculi refractory to repetitive in situ extracorporeal shockwave lithotripsy (SWL), we analyzed 369 patients treated primarily by the second-generation lithotripter, Siemens Lithostar, from March 1989 to December 1993. Three hundred forty-two (92.7%) of the patients were ultimately free of stones after repetitive in situ SWL. The cumulative stone-free rates of the first, second, and third session were 64%, 81%, and 88%, respectively, and the increment in the cumulative stone-free rate thereafter with further repeated in situ SWL was minimal (p < 0.01). The cumulative stone-free rate at the third session was 89%, 87%, and 86% for proximal, middle, and lower ureteral stones, respectively (p > 0.05). The cumulative stone-free rate at the third session was 100%, 90%, 87%, 70%, 67%, and 50% for stones <5 mm, 6 to 10 mm, 11 to 15 mm, 16 to 20 mm, 21 to 25 mm, and >25 mm, respectively (p < 0.001). According to the radiopacity of the stone, the cumulative stone-free rate at the third session was 96% for stones with minimal opacity, 94% for those with moderate opacity, and 70% for highly opaque stones (p < 0.001). The cumulative stone-free rate at the second session was 100% without ureteral obstruction; 80% with mild, 57% with moderate, and 67% with severe obstruction; and 50% in patients with nonappearance of the kidney (p < 0.05). From these observations, it could be concluded that the factors influencing fragmentation were the size and radiopacity of the calculi and the degree of ureteral obstruction, whereas the location of the calculi did not influence the cumulative stone-free rate of repetitive in situ SWL. It is preferable to restrict in situ SWL to three sessions in patients with ureteral calculi refractory to shockwaves. An early change of treatment modality either to ureteroscopic manipulation or to open surgery would be recommended if there were risk factors as listed above.
为了确定影响结石碎裂的因素，并建议何时对反复原位体外冲击波碎石术（SWL）治疗无效的输尿管结石改变治疗方式，我们分析了1989年3月至1993年12月期间主要采用第二代碎石机西门子Lithostar治疗的369例患者。342例（92.7%）患者经反复原位SWL后最终结石消失。第一次、第二次和第三次治疗的累计结石清除率分别为64%、81%和88%，此后进一步反复原位SWL时，累计结石清除率的增幅极小（p<0.01）。第三次治疗时，输尿管上段、中段和下段结石的累计结石清除率分别为89%、87%和86%（p>0.05）。第三次治疗时，结石直径<5mm、6至10mm、11至15mm、16至20mm、21至25mm和>25mm的累计结石清除率分别为100%、90%、87%、70%、67%和50%（p<0.001）。根据结石的不透X线性，第三次治疗时，不透X线程度最低的结石累计结石清除率为96%，中度不透X线的结石为94%，高度不透X线的结石为70%（p<0.001）。第二次治疗时，无输尿管梗阻患者的累计结石清除率为100%；轻度梗阻患者为80%，中度梗阻患者为57%，重度梗阻患者为67%；肾不显影患者为50%（p<0.05）。从这些观察结果可以得出结论，影响结石碎裂的因素是结石的大小、不透X线性和输尿管梗阻程度，而结石的位置并不影响反复原位SWL的累计结石清除率。对于对冲击波治疗无效的输尿管结石患者，原位SWL最好限制在三次治疗以内。如果存在上述危险因素，建议早期将治疗方式改为输尿管镜操作或开放手术。
