Grasso M, Bagley D
Department of Urology, New York University, New York, USA.
J Urol. 1998 Nov;160(5):1648-53; discussion 1653-4.
We studied and developed ureteroscopic technique and instrumentation beyond our initial experience with small diameter, actively deflectable, flexible ureteropyeloscopy.
Flexible ureteropyeloscopy was performed at 2 university centers in 492 consecutive patients. Endoscope designs and development were based on strict specifications, including 8F or less tip diameter, 3.6F or greater working channel, 2-way active tip deflection and secondary deflection for lower pole intrarenal access. Flexible ureteroscopes manufactured by 5 companies were studied through various prototypic steps and surgical technique. Complementary accessories were developed for specific treatments, including endoscopic lithotripsy, management of urothelial lesions, treatment of upper urinary tract obstruction (that is strictures) and percutaneous access with ureteroscopic assistance in select complex cases.
A total of 584 procedures were performed with the small diameter, actively deflectable, flexible ureteroscopes. Flexible ureteropyeloscopic access was always preformed over a working guide wire without an operative sheath. In addition, the 10F dual lumen catheter was the primary device used to obtain 2 guide wires (working and safety), and gently and minimally dilate the intramural segment. Larger dilators were required in only 12% of procedures. The entire intrarenal collecting system was accessed in 94% of cases with lower pole access requiring secondary or passive deflection in 60% of procedures. Endoscopic lithotripsy was the most common procedure performed in this series (303, 52%). Small diameter, flexible ureteroscopy and holmium laser lithotripsy were successful in 97% of patients with ureteral and 79% with intrarenal calculi. When a 2-stage ureteropyeloscopy procedure was used for large upper urinary tract calculi, the success rate for intrarenal calculi increased to 91%. Endoscopic biopsy and treatment of upper urinary tract transitional cell carcinoma were performed in 101 procedures (17%), while retrograde ureteroscopic incision for stricture disease was performed in 36 (6%). The overall major complication rate was less than 1% and there were no ureteral perforations, avulsions, sepsis or deaths. These new endoscopes were more fragile than larger predecessors but a maximum of 30 procedures were performed between interval repair.
Small diameter, actively deflectable, flexible ureteropyeloscopy facilitates various minimally invasive endoscopic therapies. Although this class of endoscope has greater fragility, it is easy to use and has broadened the therapeutic range of ureteroscopic treatment to include intrarenal lesions.
我们在最初使用小直径、可主动弯曲的软性输尿管肾盂镜的经验基础上，对输尿管镜技术及器械进行了研究与改进。
在2所大学医学中心对492例连续患者实施了软性输尿管肾盂镜检查。内镜的设计与研发基于严格的规格要求，包括尖端直径8F及以下、工作通道3.6F及以上、尖端双向主动弯曲以及用于肾下盏进入的二级弯曲。对5家公司生产的软性输尿管镜进行了不同原型阶段及手术技术的研究。针对特定治疗开发了辅助配件，包括内镜碎石术、尿路上皮病变的处理、上尿路梗阻（即狭窄）的治疗以及在某些复杂病例中输尿管镜辅助下的经皮穿刺进入。
使用小直径、可主动弯曲的软性输尿管镜共实施了584例手术。软性输尿管肾盂镜检查总是在工作导丝引导下进行，无需手术鞘。此外，10F双腔导管是获取2根导丝（工作导丝和安全导丝）并轻柔、适度扩张壁内段的主要器械。仅12%的手术需要更大的扩张器。94%的病例能够进入整个肾内集合系统，其中60%的手术进入肾下盏需要二级或被动弯曲。内镜碎石术是本系列中最常见的手术（共303例，占52%）。小直径软性输尿管镜联合钬激光碎石术治疗输尿管结石的成功率为97%，治疗肾内结石的成功率为79%。对于较大的上尿路结石采用两阶段输尿管肾盂镜手术时，肾内结石的成功率增至91%。101例手术（占17%）进行了内镜活检及上尿路移行细胞癌的治疗，36例手术（占6%）进行了逆行输尿管镜下狭窄切开术。总体严重并发症发生率低于1%，未发生输尿管穿孔、撕脱、脓毒症或死亡。这些新型内镜比之前较大的内镜更易损坏，但两次维修间隔期间最多可进行30例手术。
小直径、可主动弯曲的软性输尿管肾盂镜有助于开展各种微创内镜治疗。尽管这类内镜更易损坏，但使用方便，拓宽了输尿管镜治疗的范围，可涵盖肾内病变。
