| BackgroundWith the improvement of people’s living standard and changes of living method and eating habits, there is an upward trend in the prevalence of urolithiasis in China at about 2%～5% incidence. Ureteric calculi accounted for the proportion of urinary calculi at 33%～54%, and up to 65% of upper urinary tract lithiasis. More than 90% of the ureter stone is formed in the kidney and then fell to the ureter. It is rare stones primary formed within the ureter, unless patient has the ureteral obstruction.For impacted upper ureteric calculus is located above the inferior margin of the fourth lumbar vertebra which stays in the same place for at least 8 weeks that results in ureteral obstruction. The main reasons for calculus incarcerated include:(1) volume of calculi are large, the largest diameter could greater than 0.6cm; (2) the parts that calculi located or lower the position of calculi appear ureteral polyps; (3) lower the position of calculi appear ureteral stricture or distorted; (4) the parts that calculi located have chronic inflammation in ureteral and surrounding tissue. The purpose of surgical treatment for ureteral calculi is to remove calculi completely and eliminate obstruction regardless of the size and location of the calculi, on the other hand, as little as possible complication is better.Treatments for impacted upper ureteric calculi are always the thorny problems in urology department. Incarcerated calculi are always wrapped by polyp or adhered with ureteral mucosa. For this reason, there will be no satisfactory effect when using traditional extracorporeal shock wave lithotripsy (ESWL). In recent years, transurethral ureteroscopy lithotripsy (URL), minimally invasive percutaneous nephrolithotomy (MPCNL) and retroperitoneal laparoscopic ureteral incision nephrolithotomy (RLU) are three main types of minimally invasive surgeries. With the popularity of cavity mirror technology and the progress of medical apparatus and instruments, open surgery has been largely abandoned, minimally invasive surgery has become a main method for the treatment of impacted upper ureteric calculis. But the efficacy and safety of these three kinds of minimally invasive surgeries still need more studies to confirm.ObjectiveThe aim of this research is to summarize the surgical methods, techniques, intraoperative considerations and the prevention and control of related complications ect. of URL, MPCNL and RLU. Then investigate the efficacy and safety of these three kinds of minimally invasive surgeries when using it as the treatment of impacted upper ureteric calculis, in order to provide the theoretical basis for clinical selection and application.Methods:We chose 256 cases of patients who were diagnosed as impacted upper ureteric calculis in urology department of Zhongshan City, Tanbei Hospital and Zhongshan Port Hospital from January,2012 to February,2014. Excluded the following contraindication such as hypertension, diabetes mellitus, important organ dysfunction,severe hydronephrosis secondary infection or renal abscess, spinal deformity of lower limb dysfunction, pelvic trauma, etc.. According to the different surgical methods would be used, patients were divided into three groups. There are 108 cases in URL group,117 cases in MPCNL group and 31 cases in RLU group. Before operation, all cases would finish B ultrasonography, computed tomography (CT), kidney ureter bladder(KUB) and (or) intravenous urography (IVP) in order to make a definite diagnosis. Calculi position is above the inferior margin of the fourth lumbar vertebra, stays in the same place for at least 8 weeks which lead to utrteral obstruction. All the patients underwent urine culture and drug sensitivity test, when there exist infection, used anti-infection treatment for 3 to 7 days before operation.Observe and compare the diversities of operation time, postoperative hospitalization days, postoperative extracorporeal shock wave breaking lithotomy (ESWL) rate, complications and postoperative calculi clearance rate in 3 days and 1 month, etc. among three groups. Using SPSS 17 statistical software for data analysis. Compared with the measurement data of the single factor analysis of variance and Q test, count data using chi square test or calibration of 2 x 2 test, with P<0.05 as the difference had statistical significance.URL:German Wolf 6/7.5F ureter mirror and Lumenis 60w holmium laser lithotripter were employed in our study. In order to clear and definite the position of the calculi, all the patients would take the preoperative radiography again. According to the result of KUB, some patients could adjust operative plan if necessary, some calculi negative patients would use CT or B ultrasonography to make sure the localization. Patients who adopted URL would use dorsal lithotomy position or recumbency lithotomy position in addition with a combined spinal epidural anesthesia or general anesthesia. Then inserted F6 or F8 no balloon catheter into the bladder under the monitor of ureter mirror. Plug in the guide wire into ureterostoma and open it through hydraumatic, then insert the ureteroscope slowly. After ureteroscope enter the nephric ducts, it need to adjust down the hydraumatic in order to prevent the drifting of calculi, or connect suction apparatus to ensure clear vision if necessary. All the action should as soft as possible. When find the calculi, using holmium laser lithotripter to pliers out the calculi, when find the polyps, also using holmium laser ablation. Indwelling double J tube and catheter after finish all procedure.MPCNL:Patients also used a combined spinal epidural anesthesia or general anesthesia. First, took the dorsal lithotomy position, after insert 6F ureteral catheter then changed prone position or incline lithotomy position. Puncture the renal calyx under the guidance of B ultrasonography, then expanded the channel to 18F in order to imbedding German Wolf 8/9.8F or 6/7.5F ureter mirror. When find the calculi, insert holmium laser optical fiber, adjust the power to (0.5～1.5J/8～15hz) to rubble. Merger 6F double J tube in ureter after finished the operation process.RLU:Patients underwent preoperative conventional KUB, IVP and kidney figure to make sure the position of the calculi. RLU patients would take 90 degree lateral position and a tracheal intubation general anesthesia. Then make a crosswise skin incision on axillary midline skeletons crest, separate to lumbodorsal fascia step by step. Afterward enter retroperitoneum and inflate, then take out the hydrocele after the expansion of retroperitoneal space. After that, insert laparoscope and operating apparatus under the guidance of performer’s fingers through different Trocar. Inflate CO2 into retroperitoneal space until the air press reach 12-15mmHg. Expose pararenal fat, dissociate ureter and find the ureter which the calculi located. Use clamp to confirm calculi softly. Make a longitudinal incision of ureter and take out the calculi, then indwelling double J tube. It is necessary to.make sure that one end of J tube is insert into bladder, the other end of J tube is merged in renal pelvis. At last, suture the ureter, irrigate by saline solution, down regulate the air press, then put in the drainage tube.Results1. Except the diameters of calculi in RLU group were much longer than URL group and MPCNL group (P<0.01), there were no diversities of sex, age, lesion distribution, and the treatment failure rate of ESWL among three groups (P>0.05).2. URL group, MPCNL group and RLU group, operation time were (45.9±5.7) min, (61.8±13.3) min and (82.7±20.9) min, respectively, The difference of operation time among three groups has highly significant (RLU group>MPCNL group >URL group, P<0.01).3. Postoperative hospitalization days of URL group, MPCNL group and RLU group were (3.2 ±0.7) days, (6.9±2.1) days, and (5.1 ±0.8) days, respectively. The diversity among three groups also has significant (MPCNL group>RLU Group>URL, P<0.01).4. Postoperative calculi clearance rate in 3 days of URL group, MPCNL group and RLU group was 82.4%,93.2% and 96.7%, respectively. And the postoperative calculi clearance rate in 1 month of URL group, MPCNL group and RLU group was 87.0%,97.4% and 100%, respectively. Postoperative calculi clearance rate in 3 days and 1 month of MPCNL group and RLU group were both higher than URL group(P<0.05 and P<0.01), but there was no difference between MPCNL group and RLU group (P>0.05).5. Postoperative extracorporeal shock wave breaking lithotomy (ESWL) rate of URL group, MPCNL group and RLU group were 12.0%,6.0% and 3.2%, respectively, and there was no significant difference among three groups (P>0.05).6. Five cases failed procedure, three cases had postoperative fever, three cases appeared secondary ureteral stenosis in URL group and the complication rate was 10.2%. One case failure of operation, one case had postoperative fever, four cases appeared secondary urteral stenosis, two cases combined with massive haemorrhage and one case have perforated renal collecting system, and the complication rate was 8.5%. And RLU group have one case which the surgery was unsuccessful, two cases had postoperative fever, one case erupt leakage of urine, and the complication rate was 12.9%. The difference of complication rate among three groups has no significant (P>0.05).Conclusion1. URL, MPCNL and RLU are effective treatment for impacted upper ureteric calculi, and these three kinds of minimally invasive surgeries are safety and less complication.2. URL is a technique using the body’s natural orifices, which has so many advantages such as simple operation, small surgical injury, short operation time and postoperative hospitalization time, quick recovery after operation, and can handle both ureter polyp, stenosis and other diseases. But it also has its disadvantages for example, intraoperative calculi might drift upward, and the effect might slightly worse than MPCNL and RLU. With the popularization of ureteroscopy and the improvement of holmium laser lithotripsy technology, such as the use of 6/7.5F even more small caliber of ureteroscopic treatment of upper ureteral calculi, the successful rate of URL is increasing and the complication occurrence rate is decreasing too.3. The damage of MPCNL might slightly obvious. Technology of performer demands higher in MPCNL than the other two kinds of operations. But MPCNL has much higher calculi clearance rate, furthermore it can handle ipsilateral kidney stones and ureteropelvic junction stricture at the same time, nevertheless, it has a long postoperative hospitalization time. Although, the puncture channel was obviously decreased, but MPCNLA still has the risk of bleeding and surrounding organs damaging.4. RLU also has many virtues such as less intraoperative blood loss volume, less pain, higher calculi clearance rate, rapid recovery and shorter hospitalization time, however, difficulty of RLU is relatively higher than URL and MPCNL, and the trauma of RLU is also more severe than the other two kinds of surgeries. Calculi drifting during intraoperative may also appear in RLU and patients also have the risks that combining with ureteral stricture postoperatively. In the end, RLU requires performers are familiar with laparoscopy.5. Urologists should choose the appropriate treatment for impacted upper ureteric calculi patients according to not only the size and location of the calculi, but also in view of whether there has inflammatory polyp package and obstruction, degree of hydronephrosis, equipments and the technical proficiency, even including the patient’s wish. We consider that if patient has lightly hydronephrosis and lower location of the calculi, URL is the prime choice. And we suggest that MPCNL is preferred for the patient whose calculi is larger and has severe hydronephrosis, or choose MPCNL after unsuccessful URL. If URL or MPCNL operation failure, urologists could consider to use RLU as the remedial treatment. |
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