腹腔镜肾盂成形术联合肾盂镜超声碎石取石术治疗肾盂输尿管连接部梗阻合并肾结石

doi:10.19723/j.issn.1671-167X.2022.04.026

摘要/Abstract

摘要：

目的: 探讨应用腹腔镜肾盂成形术联合肾盂镜超声碎石取石术治疗肾盂输尿管连接部梗阻(ureteropelvic junction obstruction，UPJO)合并肾结石的有效性和安全性。方法: 回顾性分析北京大学人民医院2016年6月至2022年1月接受该术式治疗的8例患者的临床资料，男性5例，女性3例，平均年龄40.5岁(23~51岁)，平均体重指数(body mass index，BMI)27.0 kg/m² (18.8~32.4 kg/m²)；病变全部位于左侧，其中2例为孤立肾，1例为马蹄肾；单发结石1例，其余7例为多发结石，铸型结石2例；结石最大径平均为1.5 cm (0.6~2.5 cm)；中度肾积水5例，重度肾积水3例。术中于肾盂前壁剪开约1.5 cm切口，经腹腔镜Trocar和肾盂切口置入19.5F(1F≈0.33 mm)肾镜于肾盂内，经肾镜置入3.3 mm超声碎石探针，利用超声探针将结石击碎并通过负压吸引将结石碎屑吸出，取石完毕后行改良经腹腹腔镜肾盂成形术。结果: 全部患者的手术均顺利完成，无中转开放手术，平均手术时间213 min (160~254 min)，平均肾镜操作时间33 min (25~40 min)。术后第1天血红蛋白平均下降10.3 g/L (3~21 g/L)。术后净石率为75%(6/8例)。经改良Clavien分级系统(modified Clavien classification system，MCCS)评估，ⅢA级并发症1例，为肾盂内出血导致肾积水，予局部麻醉下行肾造瘘术后治愈。平均随访30个月(2~68个月)，肾盂成形手术成功率为100%，1例患者因结石增多行经皮肾镜取石，其余患者未见结石复发或增多。结论: 腹腔镜肾盂成形术联合肾盂镜超声碎石取石术治疗UPJO合并肾结石安全、有效，操作性好，可作为现行取石方式的补充。

关键词: 肾盂输尿管连接部梗阻, 肾结石, 腹腔镜检查, 肾盂成形术

Abstract:

Objective: To investigate the efficacy and safety of laparoscopic pyeloplasty combined with ultrasonic lithotripsy via nephroscope in the treatment of ureteropelvic junction obstruction (UPJO) with renal calculi. Methods: From June 2016 to January 2022, eight patients including five males and three females underwent laparoscopic pyeloplasty combined with ultrasonic lithotripsy via 19.5F(1F≈0.33 mm) nephroscope in Peking University People' s Hospital. The age ranged from 23-51 years (mean: 40.5 years) and the body mass index (BMI) ranged from 18.8-32.4 kg/m² (mean 27.0 kg/m²). The lesion located on the left side in all of the eight patients. Two patients had solitary kidney and one patient had horseshoe kidney. Solitary stone was seen in one patient and the other seven patients suffered multiple stones, with two patients had staghorn stones. The largest diameter of stones ranged from 0.6-2.5 cm (mean: 1.5 cm). CT or ultrasound showed that moderate nephrosis was seen in five patients and severe nephrosis was seen in three patients. During surgery, after exposure of renal pelvis and proximal ureter, a small incision of 1.5 cm was performed in the anterior wall of the renal pelvis, and a 19.5F nephroscope was introduced into renal pelvis through laparoscopic trocar and renal pelvis incision. Stones were fragmented and sucked out by 3.3 mm ultrasonic probe placed through nephroscope. After stones were removed, modified laparoscopic pyeloplasty was performed. Results: Surgery was successfully completed in all of the eight patients without conversion to open surgery. The operation time ranged from 160-254 min (mean 213 min) and the time of nephroscopic management time was 25-40 min (mean: 33 min). The hemoglobin was decreased by 3-21 g/L (mean: 10.3 g/L). The stone-free rate was 75% (6/8 cases), stones were incompletely removed in two patients due to abnormal intrarenal structure. The modified Clavien classification system (MCCS) grade ⅢA complication occurred in one patient postoperatively, which was nephrosis due to intrarenal bleeding, and nephrostomy was performed. With the mean follow-up of 30 months (ranged from 2-68 months), there was no evidence of obstruction in all the patients, and one patient underwent percutaneous nephrolithotomy to treat residual calculi. Conclusion: Laparoscopic pyeloplasty combined with ultrasonic lithotripsy via 19.5F nephroscope is feasible and safe, and could be a complementary method to treat UPJO and renal calculi.

Key words: Ureteropelvic junction obstruction, Kidney calculi, Laparoscopy, Pyeloplasty

中图分类号:

R691.2

安立哲,熊六林,陈亮,王焕瑞,陈伟男,黄晓波. 腹腔镜肾盂成形术联合肾盂镜超声碎石取石术治疗肾盂输尿管连接部梗阻合并肾结石[J]. 北京大学学报（医学版）, 2022, 54(4): 746-750.

Li-zhe AN,Liu-lin XIONG,Liang CHEN,Huan-rui WANG,Wei-nan CHEN,Xiao-bo HUANG. Laparoscopic pyeloplasty combined with ultrasonic lithotripsy via nephroscope for treatment of ureteropelvic junction obstruction with renal calculi[J]. Journal of Peking University (Health Sciences), 2022, 54(4): 746-750.

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No.	Age/years	Gender	BMI/(kg/m²)	Symptom	Side	Solitary kidney	Degree of nephrosis	Staghorn stones	Multiple stones	Diameter of the largest stone/cm
1	31	Male	25.1	Loin pain	Left	No	Severe	No	Yes	0.6
2	49	Female	29.8	Loin pain	Left	No	Moderate	No	No	1.3
3	23	Female	18.8	Loin pain	Left	No	Severe	No	Yes	1.2
4	48	Male	31.1	None	Left	No	Moderate	No	Yes	1.2
5	25	Male	32.4	Flank pain	Left	Yes	Moderate	Yes	Yes	2
6	47	Male	23.7	None	Left	No	Moderate	No	Yes	2.3
7	50	Female	29.4	Hematuria	Left	Yes	Moderate	Yes	Yes	2.5
8	51	Male	26.0	Loin pain	Left	No	Severe	No	Yes	1.1

No.	Operative time/min	Time of nephroscopic management/min	Hb drop/(g/L)	Postoperative complication	Clavien grade	Hospital stay after surgery/d	Stone free	Stone recurrence	Follow-up/ months
1	230	39	14	Yes	ⅢA	10	Yes	No	68
2	175	25	3	None		5	Yes	No	42
3	186	28	8	None		6	Yes	No	40
4	207	27	7	None		4	Yes	No	37
5	248	40	21	None		4	No	Yes	36
6	254	32	9	None		4	Yes	No	13
7	247	38	11	None		5	No	No	3
8	160	33	9	None		5	Yes	No	2