曾国华-软镜联合钬激光PPT

1、病例讨论：憩室结石的临床处理Management of Caliceal Diverticular Stones：A case report 广州医学院第一附属医院微创中心Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical College曾国华Zeng Guohua临床资料clinical data1.40岁男性，因“左侧腰痛，伴肉眼血尿1周”入院。2.查体：左肾区叩痛（+），余无特殊。3.手术史：曾行ESWL失败。4.结合影像资料诊断为：左侧上极憩室结石1.A 40 yrs

2、 old man，with left flank pain and macroscopic haematuria for one week, was admitted to hospital .2. Physical examination: Pain to percussion in left renal area. 3. Operation history ： failed in ESWL 4. Diagnosis combined the Radiology date: caliceal diverticular stone in left upper pole kidney术前影像放射

3、科资料一：IVPRadiology findings（1）： IVP 术前影像资料二：CT Radiology findings（2）： CT讨论1：憩室结石最佳术式?Discussion 1： The best option for caliceal diverticular stones ？ESWL?URS?PCNL?Open Surgery ?本次处理：输尿管软镜钬激光碎石术Management： F-URS with Holmium Laser术后6天复查：KUBStone completely clear confirmedby KUB post-operate 6 days1.憩室

4、的发病率1% ；憩室患者结石发生率为1050%1. Incidence of diverticula 1% ; calculi within calyceal diverticula:1050%2.有症状的憩室结石是手术指证。清除结石和扩大憩室颈是治疗目的。2. Indication for treatment: A symptomatic stone-bearing diverticulum is an. Aim : remove the stone and enlarge the diverticular neck to avoid recurrence 3.文献报告的治疗憩室结石的结果：

5、Results of the treatment of diverticula stone in previous literatures: 88届AUA大会Dretler提出治疗憩室结石的手术选择：Dretler had described an endoscopic classification as:(1) large neck (treatable by SWL);(2) narrow and short neck (treatable by F-URS);(3) narrow and long neck (treatable by PCNL); (4) closed neck其他文献

6、综述对憩室结石治疗的观点*：Some other viewpoint on the issue：ESWL:结石直径小于1cm，憩室颈显影，缺点:引流不理想PCNL:结石直径大于1cm，多发性结石，憩室颈狭窄，缺点：通道较多的穿过实质时，出血风险大URS:经ESWL或PCNL治疗失败，或上盏中盏的小结石，缺点:不适合 大结石ESWL: stone is 1 cm ，multiple stones，narrow diverticular neck Drawback: tract goes through more renal parenchyma increased risk of hemorrh

7、age.URS: failed in ESWL or PCNL，small stones in the middle or upper pole.BJU Int. Turna B, 2007 Jul;100(1):151-6.最近一篇关于软镜联合钬激光治疗憩室结石的研究结果如下*：ESWL failure history: 78%Mean stone size：12.4mmSF Rate :55.3%CIRFs Rate: 26.3%Operative time :80 210 min (mean 91min)Complications:7.9%J Endourol. Sejiny M, 20

8、10 Jun;24(6):961-7.Conclusion: F-URS could be the best option in managing stone-bearing caliceal diverticula, especially for those patients in whom there was SWL failure讨论2： F-URS联合YAG 激光治疗憩室结石手术要点 Keys to the F-URS with YAG1，确认憩室颈2，钬激光环切与碎石1，Confirm the diverticular neck2，YAG lasers incise the dive

9、rticular neck and disintegrated stones1.确认憩室颈1. Confirm the diverticular neck1.确认憩室颈1. Confirm the diverticular neck第七步：进入肾盂肾盏系统，有靛蓝淡褐色的液体漏出的部位即为憩室颈 2.钬激光环切与碎石YAG lasers incise the diverticular neck and disintegrated stones Generally ，200-um or 365-um holmium laser fiber was used to incise the diver

10、ticular neck.A pressure of 100 cm of H2O associated with a manual irrigation pump was used to improve visualization. If the infundibulum was longer than 0.5 cm, the laser incision was carried out gradually and carefully with high frequency and low energy (10Hz, 0.8J).一般200-um 或 365-um用来逐步环切憩室颈用灌注泵10

11、0cm的水压冲洗清晰视野。 如果漏斗管长度超过5mm,一般使用高频率，低能量进行环切(10Hz, 0.8J)小心逐步的环切。结论(Conclusion)输尿管软镜可以直视憩室颈，导丝可以放入憩室腔，相对PCNL减少出血风险，且没有ESWL排石引流困难的缺点，联合钬激光治疗是一种成功率高地微创治疗方法，尤其对上极、中极憩室结石可以作为首选治疗Flexible ureteroscope could visualize the diverticular neck directly, and a guide wire may be passed through the infundibulum and into the diverticular cavity. It reduce bleeding risk compared PCNL, and not have the drainage dilemma compared ESWL. F-URS can produce a high