Grasso M, Conlin M, Bagley D
New York University, New York, USA.
J Urol. 1998 Aug;160(2):346-51.
Upper urinary tract calculi that are too large to treat with extracorporeal shock wave lithotripsy are most commonly cleared with percutaneous endoscopic techniques. In a select group of patients who were poor candidates for percutaneous nephrostolithotomy we used retrograde endoscopic lithotripsy, and define the safety and efficacy of this modality in treating large, noninfectious stone burdens (2 cm. or greater).
A total of 51 patients with 66 large (2 cm. or greater) upper urinary tract stones were chosen for retrograde ureteroscopic surgery. Many of these patients had co-morbid conditions that precluded or complicated standard percutaneous treatment. Lithotripsy was based on the application of small diameter fiberoptic ureteroscopes and the holmium laser lithotriptor. Specifically, the 200 micro. laser fiber was used when lower pole renal access was required. Successful therapy was defined as total fragmentation of a stone burden with creation of fine sand and 2 mm. or smaller debris. Second look endoscopy was commonly performed in select patients with large branched calculi or stone burdens in excess of 3 cm. to rule out and treat large residual fragments.
Of 51 patients 48 were treated solely in a retrograde ureteroscopic manner and in 3 either failure of lower pole access or infectious material encountered on initial endoscopy led to conversion to more standard percutaneous techniques. In 34 of 45 renal (76%), and 20 of 21 ureteral (95%) complete ureteroscopic fragmentation of the respective stone burden was accomplished after a single session. Second look endoscopy defined significant residual fragments requiring additional endoscopic lithotripsy in 8 of 15 large renal (53%) and 1 of 3 complex ureteral stone burdens. Success, that is complete pulverization of the stone burden to fine dust and small 2 mm. fragments, increased to 41 of 45 renal (91%) and all 21 ureteral calculi after these second look procedures. One patient required a third session to treat completely an exceptionally large (6 cm.) renal stone burden composed of pure cystine, thus increasing the overall success rate for renal calculi to 93%. Six-month followup data were available for 25 patients with large calculi treated ureteroscopically, of whom 15 (60%) had completely clear imaging, 6 (24%) had small lower pole debris that was decreasing on serial imaging and 4 (16%) had new stone growth which was, in part, related either to uncorrectable metabolic disorders or chronic renal scarring and urinary stasis. There were no intraoperative complications. Three postoperative complications included pyelonephritis in 1 patient, prostatic bleeding in 1 on anticoagulant therapy and a cerebral vascular accident 24 hours after the procedure in 1 with severe vascular disease.
Large and complex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques.
对于体积过大而无法采用体外冲击波碎石术治疗的上尿路结石，最常用的清除方法是经皮内镜技术。在一组经皮肾镜取石术治疗效果不佳的特定患者中，我们采用了逆行内镜碎石术，并确定了该方法在治疗大型、非感染性结石负荷（2厘米或更大）方面的安全性和有效性。
共选择51例患有66枚大型（2厘米或更大）上尿路结石的患者进行逆行输尿管镜手术。这些患者中有许多患有合并症，这使得标准的经皮治疗无法进行或变得复杂。碎石术基于使用小直径纤维输尿管镜和钬激光碎石器。具体而言，当需要进入肾下极时使用200微米的激光光纤。成功治疗的定义为结石负荷完全破碎成细沙和2毫米或更小的碎片。对于一些患有大型分支结石或结石负荷超过3厘米的特定患者，通常会进行二次内镜检查以排除和治疗大的残留碎片。
51例患者中，48例仅采用逆行输尿管镜方式治疗，3例因肾下极进入失败或初次内镜检查时遇到感染性物质而转为更标准的经皮技术。在45例肾结石患者中的34例（76%）以及21例输尿管结石患者中的20例（95%），单次手术后分别完成了各自结石负荷的完全输尿管镜下破碎。二次内镜检查发现，15例大型肾结石患者中有8例（53%）以及3例复杂输尿管结石负荷患者中有1例存在需要额外内镜碎石术的明显残留碎片。经过这些二次检查程序后，成功（即结石负荷完全粉碎成细粉和2毫米以下的小碎片）的比例在45例肾结石患者中增至41例（91%），在所有21例输尿管结石患者中均成功。1例患者需要进行第三次手术来完全治疗一枚由纯胱氨酸组成的异常大（6厘米）的肾结石负荷，从而使肾结石的总体成功率提高到93%。有25例接受输尿管镜治疗的大型结石患者有6个月的随访数据，其中15例（60%）影像学检查完全清晰，6例（24%）肾下极有小碎片且在系列影像学检查中逐渐减少，4例（16%）有新结石形成，部分与无法纠正的代谢紊乱或慢性肾瘢痕及尿路淤积有关。术中无并发症。术后有3例并发症，包括1例肾盂肾炎、1例接受抗凝治疗的患者前列腺出血以及1例患有严重血管疾病的患者在术后24小时发生脑血管意外。
大型和复杂的上尿路结石可以通过逆行内镜技术安全有效地治疗。
