超声引导穿刺辅助输尿管软镜治疗肾盏憩室结石的临床分析

摘要

目的：探讨超声引导肾盏憩室穿刺辅助输尿管软镜（ FURS）治疗肾盏憩室结石的临床价值。方法回顾性分析2012年11月至2015年7月我院24例肾盏憩室结石患者的临床资料。分为FURS组和经皮肾镜（ PCNL）组，每组12例。FURS组：男8例，女4例，年龄27～67岁，中位年龄48岁；PCNL组男6例，女6例，年龄20～66岁，中位年龄35．5岁。 FURS组均为FURS下寻找憩室失败后经超声引导穿刺憩室辅助FURS辨认憩室；PCNL组经皮肾镜取石＋肾盏憩室黏膜烧灼。 FURS组均穿刺憩室成功，6例经针鞘注入亚甲蓝后可见蓝色液体自憩室口流出，6例不能辨认憩室口者经穿刺针鞘置入导丝辅助FURS辨认憩室位置并切开，重建憩室漏斗。结果 FURS组和PCNL组手术时间分别为（91．8±24．2） min 和（86．3±18．7） min，分别有9例和10例无残留结石，分别有10例和11例成功碎石，两组差异均无统计学意义（ P﹥0．05）。 FURS组和PCNL组分别有2例和1例有临床意义残留结石，第2次FURS术后1个月复查均消失。 FURS组2例发热，2例有临床意义的残留结石。 PCNL组2例发热，1例有临床意义残留结石，1例肾周血肿。 FURS组术后VAS疼痛评分（3．1±1．2）低于PCNL组（5．3±0．9），住院时间（3．4±0．8）d短于PCNL组（5．3±1．0）d，差异均有统计学意义（ P＜0．05）。 FURS和PCNL组分别有10例和12例术前有症状者均术后症状消失。 FURS组6例憩室消失，6例憩室变小；PCNL组有10例憩室消失，2例憩室变小。结论超声引导穿刺辅助可能有助于FURS辨认肾盏憩室，提高FURS的手术成功率。%Objective To evaluate the efficacy of ultrasound guided diverticular puncture combined with flexible ureteroscope to treat calyceal diverticulum calculi, which is difficult in finding the diverticular orifice during ureteroscopic surgery.Methods From November 2012 to July 2015, Twenty-four cases suffered caliceal diverticulum calculi were treated with PCNL or flexible ureterorenoscopic methods.Twelve cases were treated with PCNL in Group PCNL, and 12 cases in Group FURS were all not found orifice or wall under flexible ureteroscope. For Group FURS, ultrasound guided nephrostomy needle puncturing into diverticular calvity were performed, saline-diluted methylthioninium chloride was injected through needle sheaths.The diverticular opening could be recognized in six cases.Guidewires were inserted through needle sheaths for identifying the wall of diverticular cavity in another six cases that could not find the orifice.The stenotic infundibulum or diverticular wall was incised with 200 micron holmium laser fiber for fragment or extraction of diverticular calculi.Results The time of operation, stone free and fragment success cases in Group FURS and PCNL were ( 91.8 ±24.2 ) min vs.( 86.3 ±18.7 ) min, 9 cases vs.10 cases, and 10 cases vs.11 cases, respectively ( P all >0.05 ) .Residual calculi with clinical significance in Group FURS and PCNL disappeared after the second FURS surgery.The VAS score in Group FURS was marked lower than that in Group PCNL [ ( 3.1 ±1.2 ) vs.( 5.3 ±0.9 ) , P﹤0.05 ] .There was no significant difference complication rate between two groups ( 2 cases vs.3 cases, P>0.05 ) .Hospital stay in Group FURS was dramaticly shorter than Group PCNL(3.4 ±0.8) d vs.(5.4 ±1.0) d,P﹤0.05).Diverticula disappeared in 6 cases and became smaller in 6 cases in Group FURS, disappeared in 10 cases and became smaller in 2 cases in Group PCNL.Conclusion Flexible ureteroscope combining with the ultrasound guided puncture of diverticular calvity for management of caliceal diverticula maybe a safe and effective option.