軟式輸尿管雷射碎石的成果：單一醫學中心的經驗

劉展榮、黃鶴翔、林永明¹

成大醫院 泌尿部¹

outcomes of Flexible ureteroscopic laser lithotripsy for ureteral stones and renal stones: a single center experience

Chan-Jung Liu, Ho-Shyan Huang, Yorng-Ming, Lin¹

Department of Urology, Cheng-Kung University Hospital, Tainan, Taiwan¹

Purpose: Significant improvements in the field of flexible ureterorenoscopes (FURSs) have been made in the past 2 decades. Advances in distal-tip deflection, improved scope durability, decreases in scope diameter, improved image quality, and extended field of vision and the advent of the holmium:yttrium-aluminium-garnet (YAG) laser have all strengthened the role of flexible ureteroscopy from a diagnostic tool to a therapeutic procedure. In Western tertiary medical centers, flexible ureterorenoscopes have already routinely used for the management of calculus disease. However, the clinical applications of flexible ureterorenoscopes in Taiwan were relatively late. To review literature, no related flexible ureteroscopy experience was reported. In current study, we shared the outcomes of flexible ureterorenoscopic laser lithotripsy toward ureteral stones and renal stones.

Materials and Methods: We retrospectively reviewed patients who received flexible ureterorenoscopic laser lithotripsy from 2014/08 to 2016/03 due to renal stones or upper third ureter stones. Based on the last image before fURS, we recorded the stone sizes and stone location. Most of these patients (70.6%) received abdominal computed tomography before fURS. According to abdominal CT results, hounsfield unit of urinary calculi was documented as above 900 and below 900. Besides, after fURS, residual stone size was recorded based on the first image. Stone free was defined as no visible stone or size below 5mm. Whether patients received ESWL or repeated lithotripsy management or not after fURS was also recorded. All surgeries were performed by one Urologist using an 8.5-Fr (Olympus America Inc., Center Valley, PA, USA) flexible ureterorenoscope type V. Patients were placed in the lithotomy position under general or spinal anesthesia. Cystoscopy was performed routinely before flexible ureteroscopy in all patients to place a hydrophilic guidewire into the renal pelvis. After the passage of a safety guidewire into the renal pelvis, a ureteral access sheath was placed to facilitate fURS to pass upto renal pelvis. Ureteral stones were fragmented with a holmium:YAG laser with a 365-µm fiber. Laser energy and pulse frequency were varied on the basis of stone volume. 

Results: A total of 34 patients was enrolled (25 males and 9 females). Mean age was 53.59 year old. Median size of urinary calculi was 2.04mm. Most of these patients were within renal stones (30/34), but 4 in these were within ureteral stones. 17 renal stones located in lower calyx and 7 renal stones in renal pelvis. Mean fURS surgery time was 62.56 minutes. 5 of these patients received further ESWL for residual stones. 7 patients received further surgery for residual stones. Median operation time was 65.6 minutes. 23 patients received abdominal CT before surgery, and 12 of them had less than 900 in housfield unit. No correlation was found between housfield unit and residual stone size. However, residual stone size was significantly related to operation time (p<0.05).

Conclusions: Flexible ureteroscope remains a highly promising diagnostic and therapeutic means to deal with renal stones or upper ureter stones, especially in those not suitable for PCNL. More clinical experience should be achieved after more practices. Housfield unit did not correlate with residual stones, but operation time will have signigicant related with residual stones.