| Objective:To explore and evaluate the advantage and clinical value of percutaneous nephrolithotripsy and flexible ureteroscopy lithotripsy in the treatment of calyces diverticulum stones.Methods:A retrospective study of 13 patients with renal calycetic diverticulum stones by intraluminal minimally invasive treatment admitted from March 2013 to March 2019 in Shandong Provincial Hospital,including 7 male patients and 6 female patients,with an average age of 33.54±7.30 years(20-44 years),The average weight is 70.69 ±11.60Kg(60-100kg).There were 9 patients with stones in the upper calyx,3 patients with stones in the middle calyx,and 1 patients with stones in the lower calyx.Five patients had diverticulum stones in the left kidney and 8 patients had diverticulum stones in the right kidney.The size of the diverticulum and stones were evaluated according to various imaging examinations before surgery.The average size of the diverticulum was 9.51 ±11.40cm2.and the average size of the stones was 4.76 ±9.02cm2.Among them,2 patients had undergone extracorporeal shock wave lithotripsy outside the hospital to treat diverticulum calculi,1 patient had no stone removing after operation,1 patient had stone removing but postoperative review showed that the stone remained,and the other patients had not undergone surgical treatment.Patients underwent urinary B-ultrasound,KUB,CTU,RP and other examinations before surgery to confirm the preoperative diagnosis,improve renal function,urine culture and other examinations,and give anti-inflammatory and symptomatic treatments if necessary.After excluding related surgical contraindications,6 cases Patients underwent percutaneous nephrolithotripsy directly to treat diverticulum calculi,6 patients underwent flexible ureteroscopy lithotripsy,and 1 patient was transferred to percutaneous nephrolithotomy after flexible ureteroscopy.Results:All 13 patients underwent surgery under general anesthesia.Among them,3 cases were directly operated under percutaneous nephroscopy,and the stones were washed out of the body after ultrasonic lithotripsy.Then,2 patients found a diverticulum opening after retrograde injection of methylthionine chloride solution through the ureteral catheter,and 1 patient underwent holmium laser to open the neck,and a nephrostomy tube was placed behind the neck through the diverticulum and continued to expand after the operation.One patient underwent repeated dilation of the nephrostomy tube through the neck of the diverticulum and continued to expand after the operation.Another patient tried to find the diverticulum opening failed after successful lithotripsy,and the patient's diverticulum neck was completely closed.The operation was completed after comprehensive consideration;3 patients underwent ultramicro channel percutaneous ureteroscopy,all patients successfully took stones,and then 2 patients was retrogradely injected methylthionine solution through the ureteral catheter and found an opening of the diverticulum,and another patient directly explored the opening of the diverticulum under the ureteroscopy.Three patients all repeatedly expanded through the ureteroscopy scope and placed a nephrostomy tube through the neck of the diverticulum.Due to the low angle of the diverticulum and the limited bending angle of the flexible ureteroscopy in the kidney,no diverticulum opening was found after flexible ureteral exploration in a patient,and the percutaneous nephrolithotripsy was switched during the operation.After removing the stone under the microscope,the retrograde injection of the methylthionine solution through the ureteral catheter to find the diverticulum opening,and then repeatedly expanded through the nephroscope,and placed the nephrostomy tube balloon through the neck of the diverticulum;6 patients completed the operation directly under the flexible ureteroscope.Five patients underwent careful exploration under flexible microscope and found diverticulum opening.After holmium laser was used to open the neck and dilated,a large stone was removed with the help of a stone basket and holmium laser lithotripsy was performed.All patients were successfully operated.The average operation time of 7 patients in the percutaneous nephroscope group was 105.71 ± 39.10min.The average value of falling hemoglobin before and after operation was 15.86 ± 13.30g/L.For catheters,the average catheter removal time was 5.43±1.81 days after operation,the average renal fistula removal time was 18.71 ± 10.01 days,the average double J tube removal time was 40.67±18.04 days,and the average hospital stay was 18.29±4.61 days.Re-examination of KUB and CT of the kidneys within 1-2 months after operation showed that no stones remained in all patients.The success rate of lithotripsy was 100%.The reexamination 3 months after Double-J extubation showed that 5 patients had a smaller diverticulum than before,and 2 patients had no significant changes compared with the previous one.The shrinking rate of diverticulum reached 71.4%,and the symptom relief rate reached 100%.No stones were found during long-term follow-up.The average operative time of 6 patients in the flexible ureteroscope group was 85.00 ±26.65min,and the average value of falling hemoglobin before and after operation was 10.67± 8.71 g/L.After operation,conventional double-J tubes and catheters were indwelled.the average time to remove the catheter was 3.50 ± 0.84 days,the average time to remove the double J tube was 36.67 ± 7.69 days,and the average hospitalization time was 9.00 ± 2.76 days.All patients had no obvious complications during and after operation.KUB and double kidney CT were rechecked 1-2 months after operation,showed that 4 patients had no residual stones,1 patient had residual small stones<4mm,the success rate of lithotripsy was 83%,and 1 patient had residual stones with a diameter of approximately 5mm,which was associated with bleeding caused by diverticulum opening and neck reconstruction during operation.Reexamination three months after Double-J extubation showed that the symptom remission rate was 100%.All patients had a smaller diverticulum than before,and the diverticulum reduction rate was 100%.No recurrence of stones was seen in the long-term review.Statistical analysis In this study,the FURL group was significantly better than the PCNL group in terms of hospitalization time and postoperative pain,but there was no significant difference in the success rate of lithotripsy,symptom relief rate,and diverticulum reduction rate.Conclusion:In general,percutaneous nephrolithotripsy and flexible ureteroscopy lithotripsy are safe and effective in treating calyceal diverticulum stones,each with its own advantages and limitations.This study shows that percutaneous nephrolithotripsy is more invasive,patients suffer more pain,and hospital stays are significantly longer,while sofe ureteroscopy lithotripsy is less invasive,which hits patients less physically and mentally,and patients are more likely to receive.the author believes that with the development of related technologies and equipment,the efficacy of FURL is becoming more and more clear,it is the development trend to use flexible ureteroscope to treat urinary stones in the future.Special attention should be paid to the location and size of the diverticulum and stones before the operation,and the patient and the patient's family should fully communicate with each other to jointly choose the reasonable surgical method.In this study,there was 1 case of lower calyx diverticulum stones undergoing flexible ureteral exploration and then converted to percutaneous nephrolithotripsy,which showed that for the lower calyx diverticulum stones,especially the preoperative image positioning considering the limited bending angle of the flexible ureteroscope may affect the surgery When performing diverticulum opening and lithotripsy,it is recommended that percutaneous nephrolithotripsy be preferred,with a higher surgical success rate,or that patients and their families before surgery should be told that FURL treatment of inferior calyx diverticulum stones has a greater chance of transferring PCNL during surgery.For upper and middle calves,stones less than 2cm in diameter,especially kidney ventral diverticulum stones,longer percutaneous nephrolithotomy channel may aggravate kidney injury and bleeding,and the operation angle of nephroscope may be smaller,while flexible ureteroscope Lithotripsy can achieve the same surgical effect,but it can reduce the physical and mental trauma of the patient,reduce the length of hospitalization,and reduce the physical and financial burden of the patient.At this time,FURL should be the preferred treatment. |
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