【作者】 王海涛；

【导师】 李青；

【作者基本信息】 山东大学 ， 泌尿外科学， 2011， 硕士

【摘要】 背景随着医疗设备的更新换代、推陈出新,在许多领域,微创技术正逐步取代传统的开放手术。输尿管软镜作为泌尿微创腔镜技术的重要部分,在泌尿外科疾病的诊断和治疗中发挥着越来越重要的作用。目的探讨输尿管软镜在上尿路疾病中的临床应用。方法回顾分析了我科自2009年2月至2011年2月应用输尿管软镜完成上尿路疾病的诊断和治疗64例：其中逆行输尿管软镜联合钬激光治疗上尿路结石37例(结石体积<20mm),其中输尿管上段结石8例、肾结石29例,术前均行KUB平片+IVP检查,部分平片及造影诊断不明确者行CT及增强CT检查,术后2周及1月复查泌尿系统B超、KUB平片及CT检查以明确疗效；诊断性质不明的输尿管、肾盂、肾盏内占位病变及血尿16例,术前行泌尿系B超、KUB平片、IVP等检查,部分肾盂、输尿管内占位性病变系术前行B超查体时发现,术中取活检送病理以明确诊断,根据病理结果决定下一步治疗方案；输尿管软镜联合单通道经皮肾镜(PCNL)治疗多发性肾结石(结石体积>25mm) 11例,术前均行KUB平片、IVP检查及CT检查,术后3天复查泌尿系统B超、KUB平片及CT检查以明确结石排出情况及是否残留结石。结果逆行输尿管软镜治疗上尿路结石37例,一次进镜成功36例,一次进镜成功率97.3% (36/37),1例因输尿管狭窄无法到达结石所在部位而失败,34例成功寻及结石并将结石击碎,碎石手术时间32-72min,平均41min,碎石成功率为91.9%(34/37)。2例因肾盂、肾盏内渗血,视野不清,输尿管软镜无法进入结石所在肾盏导致碎石失败。术后2周复查泌尿系B超、KUB、CT以明确结石排出情况及是否残留,影像学检查显示30例未见明显结石残留,4例存在小结石残留,残留结石最大者约5mm,结石排净率为81.1%(30/37)。术后1月复查显示33例未见明显结石残留,1例存在肾下盏小结石残留,结石大小约5mm,结石排净率为89.2%(33/37)。统计我科同类结石病例(结石体积<20mmm)35例行ESWL治疗,行ESWL1次治疗示结石排净率60.0%(21/35),行χ2检验,α=0.05,χ2=8.173,P=0.004<0.05表示差异有统计学意义。行ESWL2次治疗示结石排净率65.7% (23/35),行χ2检验,α=0.05,χ2=5.735,P=0.017<0.05两组间的差异存在统计学意义.行ESWL3次治疗示结石排净率68.6%(24/35),行χ2检验,α=0.05,χ2=4.636,P=0.031<0.05两组间的差异存在统计学意义；逆行输尿管上段及肾盂肾盏内检查及活检16例,其中15例成功进镜完成检查,1例因输尿管狭窄导致进镜失败,检查成功率93.8%(15/16),术后病理活检结果显示：肾盂及肾盏肿瘤7例,输尿管息肉5例,血凝块1例。另有上尿路静脉曲张出血1例,未发现明显异常1例；输尿管软镜联合单通道PCNL治疗多发性肾结石11例,碎石成功率81.8% (9/11),2例术后复查CT可见6mm及4mm大小结石残留。结论应用输尿管软镜诊断和治疗上尿路疾病是一种安全的、有效的、微创的方法,在输尿管硬镜不能到达部位的上尿路结石的治疗、性质不明的上段输尿管、肾盂、肾盏内占位病变及血尿等的诊断、多发性肾结石的联合治疗中具有重要的意义和价值。更多还原

【Abstract】 [Background] With development of the medical equipments, in many medical fields, minimally invasive technology is gradually replacing traditional open surgery. Flexible ureteroscopy as an important part of the urinary micro-traumatic techniques is playing more and more important role in diagnosis and treatment of urinary diseases.[Methods] We reviewed all the records of the 64 patients undergoing the flexible ureteroscopy for diseases in urinary system from February 2009 to February 2011 in our hospital retrospectively.37 cases of calculi (<20mm) in upper urinary tract were selected to be treated by retrograde flexible ureteroscopy with Holmium laser.8 cases of calculi were in upper ureter, and 29 were in renal pelvis and renal calyx. All the 37 cases received KUB, IVP and CT before the surgeries. Further examinations such as KUB, IVP, CT, were received 2 weeks and 1 month later to evaluate the treatment. Flexible ureteroscopy was performed for diagnosis of 16 cases of space-occupying lesion or hematuria. All the 16 cases received BUS, KUB, IVP or CT before the surgeries. We got biopsy during surgery for the occupying lesions, then chose a best therapeutic regimen according to the pathology result.11 cases of multiple renal calculi (>25mm) were selected to be treated by single channel percutaneous nephrostolithotomy (PCNL) combined with flexible ureteroscopy lithotripsy using holmium laser. All the 11 cases received KUB, IVP and CT routinely before the surgeries. The evaluation of calculi evacuation was performed 3 days later by KUB or CT scan after operation.[Results] We succeeded in inserting the ureteroscopy in 36 calculi cases (<20mm) which were treated by retrograde flexible ureteroscopy with Holmium laser 97.3%(36/37).1 was failed in inserting because of ureteral stricture.34 cases of calculi were successfully found and treated. Mean time for the lithotripsy was 41 min (32-72 min). The rate of lithotripsy was 91.9%(34/37).2 cases were failed to find the calculi because of bloody vision.30 cases had no residual calculus 2 weeks later according to KUB or CT. The rate of evacuation is 81.1%(30/37).33 cases had no residual calculus 1 month later according to KUB or CT. The rate of evacuation is 89.2%(33/37). In 35 similar cases, evacuation rate of ESWL once was 60.0%(21/35),α=0.05,χ2=8.173, P=0.004<0.05. There are differences with a statistical significance. Evacuation rate of ESWL twice was 65.7%(23/35),α=0.05,χ2=5.735, P=0.017<0.05. There is difference with a statistical significance. Evacuation rate of ESWL three times was 68.6%(24/35),α=0.05,χ2 =4.636, P=0.031<0.05. There is difference with a statistical significance. Successfully diagnostic flexible ureteroscopy identified occupying lesions and hematuria in 15 cases:tumors (7 cases), polyp of ureter (5 cases) blood clot (1 cases), varicose vein in renal pelvis (1 cases), no obvious abnormity(1 cases).1 case failed to insert the flexible ureteroscopy because of ureteral stricture. The achievement ratio was 93.75%(15/16). 11 cases of multiple renal calculi were treated by single channel percutaneous nephrostolithotomy (PCNL) combined with flexible ureteroscopy lithotripsy and Holmium laser. The stone-free rate was 81.8%(9/11).2 cases (13.3%) had a residual 6 mm and 4 mm calculi.[Conclusions] Flexible ureteroscopy is an effective and minimally traumatic diagnostic and therapeutic technique for upper urinary tract diseases. Flexible ureteroscopy is especially valuable and potential in the treatment of calculi in upper urinary tract and the diagnosis of occupying lesions in upper urinary tract and hematuria.更多还原