输尿管软镜结合负压吸引工作鞘治疗铸型肾结石的疗效分析（附125例报告）*

RIRS with negative pressure ureteral access sheath for renal mid-to-large stone (125 cases)*

摘要:

探讨输尿管软镜（RIRS）结合负压吸引工作鞘（NPUAS）处理肾铸型结石的有效性和安全性。方法?回顾性分析该中心2014年1月-2016年12月使用RIRS治疗125例肾铸型结石患者的临床资料。评价手术效果（结石清除率，住院时间），总结术后并发症率（出现发热、输尿管石街等）。结果?50例患者因泌尿道感染或输尿管狭窄一期术前1周在局麻下行患侧逆行置管，75例术前未置管。一期均能使用钬激光击碎结石，一期RIRS 86例，28例需行二期，11例需三期RIRS。32例术中需要球囊扩张狭窄段，扩张后均成功置入软镜NPUAS。手术时间45～158?min，平均（72.0±23.0）min。术后住院时间2～22?d，平均（7.0± 2.0）d。术后1个月一期结石清除率60.8%（76/125），总结石清除率88.0%（110/125）。7例联合术后体外冲击波碎石（ESWL）成功清除结石。总并发症发生率24.8%（31/125）。21例术后出现输尿管石街，术后发热16例（7例合并输尿管石街），体温均>38.5℃。5例患者（合并输尿管石街）出现感染性休克严重感染症状，经行肾造瘘术解除梗阻、改善引流和抗感染治疗等均治愈。2例孤立肾患者出现输尿管石街，导致梗阻性无尿，需要透析，逆行置管后处理石街，1例肾周血性脓肿，行肾周脓肿穿刺引流、抗感染营养支持处理后治愈。未出现输尿管撕脱、穿孔等严重并发症。结论?RIRS结合NPUAS治疗肾铸型结石是有效的，但为提高手术安全性，单通道经皮肾镜取石术（PCNL）联合RIRS治疗应被推荐。

Abstract:

To evaluate the safety and efficacy of retrograde intrarenal surgery (RIRS) with negative pressure ureteral access sheath in treatment of mid-to-large kidney stones.?Methods?From January 2014 to December 2016, 125 cases of mid-to-large kidney stone were treated by RIRS. Negative pressure ureteral access sheath (NPUAS) was used in all surgery. Stones were fragmented by holmium laser. During one-month follow-up after surgery stone removal and stone free rate were recorded. Residual stones were retreated with a secondary RIRS or ESWL.?Results?Retrograde catheterization was performed in 50 cases 1 week before operation. Among the 125 patients, 86 underwent one-stage, 28 underwent two-stage RIRS and 11 patient underwent three-stage RIRS. The average operation time was (72.0?±?23.0) m (range 45?~?158 m) and the median postoperative stay was (7.0?±?2.0) d (range 2?~?22 d). The six-month stone free rate was 60.8% (76/125). The total stone free rate was 88.0% (110/125) after staged RIRS. 7 patients received ESWL after FURS with stones free. Two cases with solitary kidney experienced infectious shock and acute renal failure due to ureteral stone street and treated by hemodialysis and minimally invasive percutaneous nephrolithotomy (mPCNL). One case developed perirenal urinous abscess and treated by puncture and drainage and cured by mPCNL finally. Postoperative fever occurred in 16 cases after FURS. No ureteral perforation or avulsion occurred. The total complication rate was 24.8% (31/125).?Conclusion?Retrograde intrarenal surgery with NPUAS is safe feasible and effective for most of kidney casting mold-stone. However single-tract mPCNL combined with RIRS should he recommended for larger renal stone.