曾国华-软镜联合钬激光.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,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 data,1.40,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 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,术前影像放射科资料一：,IVP,Radiology 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,88,届,AUA,大会,Dretler,提出治疗憩室结石的手术选择：,Dretler had described an endoscopic classication 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 hemorrhage.,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,：,12.4mm,SF Rate:55.3%,CIRFs Rate:26.3%,Operative time:80 210 min(mean 91min),Complications:7.9%,J Endourol.,Sejiny M,2010 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 YAG,1,，确认憩室颈,2,，钬激光环切与碎石,1,，,Confirm the diverticular neck,2,，,YAG lasers incise the,diverticular neck,and disintegrated stones,1.,确认憩室颈,1.Confirm the diverticular neck,1.,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 diverticular 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,100cm,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 success rate and,it should be offered as a,fi,rst-line treatment of,symptomatic stone-bearing caliceal diverticula,especially for small stones in the middle or upper pole.,Thank you!,