無放射線暴露的軟式輸尿管鏡碎石手術
1戴逸昇、1戴槐青、2黃士維、3李苑如
1輔仁大學醫附設醫院泌尿科
2國立臺灣大學醫學院附設醫院雲林分院泌尿部
3國立臺灣大學醫學院附設醫院泌尿部
A Fluoroscopy-Free Retrograde Intrarenal Surgery for Renal Stones: A Feasibility and Efficacy Study Compared with Conventional Flexible Ureteroscopy
1Yi-Sheng Tai, 1Huai-Chin Tai, 2Shi-Wei Huang and 3Yuan-Ru Lee
1Department of Urology, National Taiwan University Hospital, Yun-Lin Branch
2Department of Urology, National Taiwan University Hospital, Yun-Lin Branch
3Department of Urology, National Taiwan University Hospital
Purpose:
The aim of this study is to investigate the safety of ureteral sheath insertion and efficacy of renal stone manipulation in retrograde intrarenal surgery (RIRS) without fluoroscopic guidance
Materials and Methods:
Between December 2015 to July 2016 and Between December 2015 to March 2017, 89 patients with renal stones were treated with flexible ureteroscopic laser lithotripsy. Thirty-two conventional, fluoroscopy-guided and 57 fluoroless procedures were performed by a single urologist.
These fluoroless procedures included the following steps: (a) evaluation of the ureters by semi-rigid ureteroscopy, (b) introducing guide-wire followed by ureteral sheath using tactile feedback and direct visualization, (C) flexible ureteroscopy and stone manipulation using holmium laser technique and (D) real-time ultrasound was used to facilitate stone location and residual stone check intraoperatively.
The primary outcomes are successful rates of intraoperative ureteral sheath stenting as well as post-operative stone clearance rate and reduced stone burden at first month. The post-operative complications were also evaluated. Stone size was calculated as cumulative stone burden defined as the two-dimensional area. Stone clearance which was defined as residual stone fragments < 3mm in the post-op kidney, ureter, and bladder X-ray or renal ultrasonography.
Result:
The median age of the patients was 54.8 years (IQR: 47.2-65.8). The mean stone burden was 112.4± 114.8 (33- 384) mm2 in fluoroless vs 120.5± 96 (20- 694.2) mm2 in conventional group (p=0.726). Five (8.7%) and one (3.1%) patients in fluoroless and conventional group had failed access sheath insertion, respectively (p=0.38). The fluoroless group had significant shorter mean operative time 57.4± 20.6 vs 68.5± 24.4 minutes than in conventional group (p=0.025).
There was no difference of stone clearance rate (fluoroless vs conventional group, 64.9% vs 71.8%, p=0.638) nor percentage of reduced stone burden (fluoroless vs conventional group, 85.8% vs 86.0%, p=0.998) between two groups. In the multivariate regression analysis, only cumulative stone burden≧ 150mm and location at lower calyx were predictor factors of reduced stone clearance rate (p=0.039 and 0.006, respectively). Stone location at lower calyx and failed access sheath insertion increased percentage of residual stone burden significantly (p= 0.006 and 0.1, respectively).
The post-operative complication is not common; sepsis rate was no difference between 2 groups (fluoroless vs conventional group; 10.5% vs 6.3%, p=0.499). There was no patient needed intensive care or had mortality. No patient had ureteral injury needed surgical repair.
Conclusion:
This study demonstrates the feasibility and safety of the completely fluoroless RIRS to reduce both radiation exposure to the patients and staff as well as operative time. RIRS without fluoroscopic guidance can be safely and effectively performed in selected patients with renal stones.