肾移植术后上尿路结石个体化治疗策略
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摘要
目的:探讨肾移植术后移植肾上尿路结石的个体化治疗策略。方法:回顾性分析2003年12月～2017年9月于我院泌尿与碎石中心治疗肾移植后移植肾上尿路结石10例患者的临床资料。其中男6例,女4例,平均年龄(42.1±8.6)岁。6例移植肾及输尿管上段结石,4例移植肾输尿管中下段结石。单发结石4例,多发结石6例,平均结石负荷(1.0±0.6)cm。所有患者均有不同程度肾积水,8例肾功能异常,4例尿路感染。结果:6例移植肾及输尿管上段结石患者中,1例行体外冲击波碎石(ESWL)成功;5例行经皮肾镜取石术(PCNL)成功。4例移植肾输尿管中下段结石患者,1例输尿管支架更换术中膀胱镜下活检钳取石成功;1例输尿管镜取石术(URS)成功;1例URS失败改PCNL成功;1例URS和PCNL处理结石均失败,留置造瘘、透析治疗。所有患者术后肾积水得到缓解,肾功能恢复,感染得到纠正。无患者出现术后发热。3例患者接受输血治疗。结论:肾移植结石患者情况特殊且病情相对复杂,术者应根据患者具体情况决定个体化的治疗策略,从处理结石的多种方法中选择最适合患者的手术方式和治疗方案。虽然清除结石是重要治疗目标,但应充分考虑患者身体耐受程度,不可盲目追求结石的清除效果。
Objective:To discuss the individual treatment strategy for upper urinary tract calculi in transplanted kidneys.Method:From December 2003 to September 2017,10 patients with upper urinary tract calculi in transplanted kidneys who received treatment at Urological and Lithotriptic Center in Peking University People's Hospital were retrospectively analyzed.There were 6 males and 4 females with the mean age of(42.1±8.6)years old.Six cases had renal or upper ureteral calculi and 4 cases had middle-lower ureteral calculi.Four cases had solitary stone and 6 cases had multiple stones,and the mean stone burden was(1.0±0.6)cm.All the cases suffered from varying degrees of hydronephrosis.Eight cases had abnormal renal function and 4 cases had urinary tract infection.Result:Of the 6 cases with renal or upper ureteral calculi,1 case was successfully treated by extracorporeal shockwave lithotripsy(ESWL),and other 5 cases were successfully treated by percutaneous nephrolithotomy(PCNL).Of the 4 cases with middle-lower ureteral calculi,1 case's calculus was successfully removed by biopsy forcep under cystoscope during ureteral stent replacement,1 case was successfully treated by ureteroscopic(URS)lithotomy,1 case was successfully treated by PCNL after the failure of URS during surgery and 1 case was treated by dialysis with nephrostomy tube after the failure of URS and PCNL.The hydronephrosis was alleviated,renal function recovered and infection was corrected after treatments.No patient developed postoperative fever and 3 patients received blood transfusion.Conclusion:Renal transplant patients with upper urinary tract calculi have special and complex conditions,therefore,urologists should implement individual treatment strategy on the basis of different physical situations and calculi conditions of patients and choose the optimal surgical methods and treatment schemes from multiple methods treating calculi.Though the clearance of calculi is a critical therapeutic goal,the patients' surgical tolerance level should be given considerable thought,not blindly pursuing the removal effect of stones.
Objective:To discuss the individual treatment strategy for upper urinary tract calculi in transplanted kidneys.Method:From December 2003 to September 2017,10 patients with upper urinary tract calculi in transplanted kidneys who received treatment at Urological and Lithotriptic Center in Peking University People's Hospital were retrospectively analyzed.There were 6 males and 4 females with the mean age of(42.1±8.6)years old.Six cases had renal or upper ureteral calculi and 4 cases had middle-lower ureteral calculi.Four cases had solitary stone and 6 cases had multiple stones,and the mean stone burden was(1.0±0.6)cm.All the cases suffered from varying degrees of hydronephrosis.Eight cases had abnormal renal function and 4 cases had urinary tract infection.Result:Of the 6 cases with renal or upper ureteral calculi,1 case was successfully treated by extracorporeal shockwave lithotripsy(ESWL),and other 5 cases were successfully treated by percutaneous nephrolithotomy(PCNL).Of the 4 cases with middle-lower ureteral calculi,1 case's calculus was successfully removed by biopsy forcep under cystoscope during ureteral stent replacement,1 case was successfully treated by ureteroscopic(URS)lithotomy,1 case was successfully treated by PCNL after the failure of URS during surgery and 1 case was treated by dialysis with nephrostomy tube after the failure of URS and PCNL.The hydronephrosis was alleviated,renal function recovered and infection was corrected after treatments.No patient developed postoperative fever and 3 patients received blood transfusion.Conclusion:Renal transplant patients with upper urinary tract calculi have special and complex conditions,therefore,urologists should implement individual treatment strategy on the basis of different physical situations and calculi conditions of patients and choose the optimal surgical methods and treatment schemes from multiple methods treating calculi.Though the clearance of calculi is a critical therapeutic goal,the patients' surgical tolerance level should be given considerable thought,not blindly pursuing the removal effect of stones.
引文
1 Susal C,Opelz G.Transplantation:Desensitization and survival in kidney transplant recipients[J].Nat Rev Nephrol,2017,13(4):196-198.
2 Manook M,Koeser L,Ahmed Z,et al.Post-listing survival for highly sensitised patients on the UK kidney transplant waiting list:a matched cohort analysis[J].Lancet,2017,389(10070):727-734.
3 Turk C,Petrik A,Sarica K,et al.EAU Guidelines on Interventional Treatment for Urolithiasis[J].Eur Urol,2016,69(3):475-482.
4叶海云,许清泉,黄晓波,等.经皮肾镜取石术围手术期抗生素应用情况调查[J].北京大学学报(医学版),2015,47(4):718-719.
5许清泉.体外冲击波碎石术与半硬输尿管肾镜钬激光碎石术治疗输尿管上段大结石的比较[J].中华泌尿外科杂志,2005,26(3):72-72.
6陈益民,杨庆亚,许清泉,等.输尿管镜取石与经皮肾镜取石治疗输尿管上段结石[J].中国微创外科杂志,2015,15(3):235-237.
7李建兴,田溪泉,牛亦农,等.B超引导经皮肾镜气压弹道联合超声碎石术治疗无积水肾结石[J].中华外科杂志,2006,44(6):386-388.
8许清泉,黄晓波,熊六林,等.B超引导下经皮肾镜手术建立皮肾通道的学习曲线[J].中国微创外科杂志,2009,9(1):38-40.
9 Krambeck A E,Leroy A J,Patterson D E,et al.Percutaneous nephrolithotomy success in the transplant kidney[J].J Urol,2008,180(6):2545-2549.
10 Lu H F,Shekarriz B,Stoller M L.Donor-gifted allograft urolithiasis:early percutaneous management[J].Urology,2002,59(1):25-27.
11 Klingler HC,Kramer G,Lodde M,et al.Urolithiasis in allograft kidneys[J].Urology,2002,59(3):344-348.
12 Challacombe B,Dasgupta P,Tiptaft R,et al.Multimodal management of urolithiasis in renal transplantation[J].BJU Int,2005,96(3):385-389.
13 Streeter E H,Little D M,Cranston D W,et al.The urological complications of renal transplantation:a series of1535patients[J].BJU Int,2002,90(7):627-634.
14 Green H,Rahamimov R,Goldberg E,et al.Consequences of treated versus untreated asymptomatic bacteriuria in the first year following kidney transplantation:retrospective observational study[J].Eur J Clin Microbiol Infect Dis,2013,32(1):127-131.
15 Origuen J,Lopez-Medrano F,Fernandez-Ruiz M,et al.Should Asymptomatic Bacteriuria Be Systematically Treated in Kidney Transplant Recipients?Results From a Randomized Controlled Trial[J].Am J Transplant,2016,16(10):2943-2953.
16 Rifaioglu M M,Berger A D,Pengune W,et al.Percutaneous management of stones in transplanted kidneys[J].Urology,2008,72(3):508-512.
17 Gupta M,Lee M W.Treatment of stones associated with complex or anomalous renal anatomy[J].Urol Clin North Am,2007,34(3):431-441.
18许清泉.泌尿系结石的药物治疗和预防[J].中国临床医生,2011,39(9):3-5.
19 Turk C,Knoll T,Seitz C,et al.Medical Expulsive Therapy for Ureterolithiasis:The EAU Recommendations in2016[J].Eur Urol,2017,71(4):504-507.
20 He Z,Li X,Chen L,et al.Minimally invasive percutaneous nephrolithotomy for upper urinary tract calculi in transplanted kidneys[J].BJU Int,2007,99(6):1467-1471.
21 Yuan H J,Yang D D,Cui Y S,et al.Minimally invasive treatment of renal transplant nephrolithiasis[J].World JUrol,2015,33(12):2079-2085.
22 Skuginna V,Nguyen D P,Seiler R,et al.Does Stepwise Voltage Ramping Protect the Kidney from Injury During Extracorporeal Shockwave Lithotripsy?Results of a Prospective Randomized Trial[J].Eur Urol,2016,69(2):267-273.
23 Swearingen R,Roberts W W,Wolf J S Jr.Ureteroscopy for nephrolithiasis in transplanted kidneys[J].Can JUrol,2015,22(2):7727-7731.
24许清泉,黄晓波,马凯,等.超声引导下肋间通路经皮肾镜取石术的疗效和安全性[J].中国微创外科杂志,2009,9(8):728-730.
25许清泉,黄晓波,马凯,等.计算机断层扫描三维重建在B超引导下经皮肾镜取石术中的应用[J].北京大学学报(医学版),2010,42(4):485-486.
26王田,黄晓波,许清泉,等.合并代谢综合征的上尿路结石患者行经皮肾镜取石术的疗效和安全性[J].北京大学学报(医学版),2011,43(4):556-558.
27谢天朋,黄晓波,许清泉,等.不同成分上尿路结石行经皮肾镜取石术的疗效和安全性[J].临床泌尿外科杂志,2012,27(12):904-906.
28 Ghani K R,Andonian S,Bultitude M,et al.Percutaneous Nephrolithotomy:Update,Trends,and Future Directions[J].Eur Urol,2016,70(2):382-396.
29洪扬,许清泉,黄晓波,等.经皮肾镜取石术治疗14岁以下小儿上尿路结石的疗效分析[J].临床泌尿外科杂志,2018,33(7):542-544,550.
30安立哲,黄晓波,许清泉,等.经皮肾镜碎石取石术后发生全身炎症反应综合征的多因素分析[J].中国微创外科杂志,2017,17(11):965-969.
31朱振杰,许清泉,黄晓波,等.糖尿病患者经皮肾镜取石术后发生全身炎症反应综合征的危险因素分析[J].北京大学学报(医学版),2016,48(4):643-649.
32 de la Motte L,Kehlet H,Vogt K,et al.Preoperative methylprednisolone enhances recovery after endovascular aortic repair:a randomized,double-blind,placebocontrolled clinical trial[J].Ann Surg,2014,260(3):540-548;discussion 548-549.
33 Cassis P,Gallon L,Benigni A,et al.Erythropoietin,but not the correction of anemia alone,protects from chronic kidney allograft injury[J].Kidney Int,2012,81(9):903-918.
2 Manook M,Koeser L,Ahmed Z,et al.Post-listing survival for highly sensitised patients on the UK kidney transplant waiting list:a matched cohort analysis[J].Lancet,2017,389(10070):727-734.
3 Turk C,Petrik A,Sarica K,et al.EAU Guidelines on Interventional Treatment for Urolithiasis[J].Eur Urol,2016,69(3):475-482.
4叶海云,许清泉,黄晓波,等.经皮肾镜取石术围手术期抗生素应用情况调查[J].北京大学学报(医学版),2015,47(4):718-719.
5许清泉.体外冲击波碎石术与半硬输尿管肾镜钬激光碎石术治疗输尿管上段大结石的比较[J].中华泌尿外科杂志,2005,26(3):72-72.
6陈益民,杨庆亚,许清泉,等.输尿管镜取石与经皮肾镜取石治疗输尿管上段结石[J].中国微创外科杂志,2015,15(3):235-237.
7李建兴,田溪泉,牛亦农,等.B超引导经皮肾镜气压弹道联合超声碎石术治疗无积水肾结石[J].中华外科杂志,2006,44(6):386-388.
8许清泉,黄晓波,熊六林,等.B超引导下经皮肾镜手术建立皮肾通道的学习曲线[J].中国微创外科杂志,2009,9(1):38-40.
9 Krambeck A E,Leroy A J,Patterson D E,et al.Percutaneous nephrolithotomy success in the transplant kidney[J].J Urol,2008,180(6):2545-2549.
10 Lu H F,Shekarriz B,Stoller M L.Donor-gifted allograft urolithiasis:early percutaneous management[J].Urology,2002,59(1):25-27.
11 Klingler HC,Kramer G,Lodde M,et al.Urolithiasis in allograft kidneys[J].Urology,2002,59(3):344-348.
12 Challacombe B,Dasgupta P,Tiptaft R,et al.Multimodal management of urolithiasis in renal transplantation[J].BJU Int,2005,96(3):385-389.
13 Streeter E H,Little D M,Cranston D W,et al.The urological complications of renal transplantation:a series of1535patients[J].BJU Int,2002,90(7):627-634.
14 Green H,Rahamimov R,Goldberg E,et al.Consequences of treated versus untreated asymptomatic bacteriuria in the first year following kidney transplantation:retrospective observational study[J].Eur J Clin Microbiol Infect Dis,2013,32(1):127-131.
15 Origuen J,Lopez-Medrano F,Fernandez-Ruiz M,et al.Should Asymptomatic Bacteriuria Be Systematically Treated in Kidney Transplant Recipients?Results From a Randomized Controlled Trial[J].Am J Transplant,2016,16(10):2943-2953.
16 Rifaioglu M M,Berger A D,Pengune W,et al.Percutaneous management of stones in transplanted kidneys[J].Urology,2008,72(3):508-512.
17 Gupta M,Lee M W.Treatment of stones associated with complex or anomalous renal anatomy[J].Urol Clin North Am,2007,34(3):431-441.
18许清泉.泌尿系结石的药物治疗和预防[J].中国临床医生,2011,39(9):3-5.
19 Turk C,Knoll T,Seitz C,et al.Medical Expulsive Therapy for Ureterolithiasis:The EAU Recommendations in2016[J].Eur Urol,2017,71(4):504-507.
20 He Z,Li X,Chen L,et al.Minimally invasive percutaneous nephrolithotomy for upper urinary tract calculi in transplanted kidneys[J].BJU Int,2007,99(6):1467-1471.
21 Yuan H J,Yang D D,Cui Y S,et al.Minimally invasive treatment of renal transplant nephrolithiasis[J].World JUrol,2015,33(12):2079-2085.
22 Skuginna V,Nguyen D P,Seiler R,et al.Does Stepwise Voltage Ramping Protect the Kidney from Injury During Extracorporeal Shockwave Lithotripsy?Results of a Prospective Randomized Trial[J].Eur Urol,2016,69(2):267-273.
23 Swearingen R,Roberts W W,Wolf J S Jr.Ureteroscopy for nephrolithiasis in transplanted kidneys[J].Can JUrol,2015,22(2):7727-7731.
24许清泉,黄晓波,马凯,等.超声引导下肋间通路经皮肾镜取石术的疗效和安全性[J].中国微创外科杂志,2009,9(8):728-730.
25许清泉,黄晓波,马凯,等.计算机断层扫描三维重建在B超引导下经皮肾镜取石术中的应用[J].北京大学学报(医学版),2010,42(4):485-486.
26王田,黄晓波,许清泉,等.合并代谢综合征的上尿路结石患者行经皮肾镜取石术的疗效和安全性[J].北京大学学报(医学版),2011,43(4):556-558.
27谢天朋,黄晓波,许清泉,等.不同成分上尿路结石行经皮肾镜取石术的疗效和安全性[J].临床泌尿外科杂志,2012,27(12):904-906.
28 Ghani K R,Andonian S,Bultitude M,et al.Percutaneous Nephrolithotomy:Update,Trends,and Future Directions[J].Eur Urol,2016,70(2):382-396.
29洪扬,许清泉,黄晓波,等.经皮肾镜取石术治疗14岁以下小儿上尿路结石的疗效分析[J].临床泌尿外科杂志,2018,33(7):542-544,550.
30安立哲,黄晓波,许清泉,等.经皮肾镜碎石取石术后发生全身炎症反应综合征的多因素分析[J].中国微创外科杂志,2017,17(11):965-969.
31朱振杰,许清泉,黄晓波,等.糖尿病患者经皮肾镜取石术后发生全身炎症反应综合征的危险因素分析[J].北京大学学报(医学版),2016,48(4):643-649.
32 de la Motte L,Kehlet H,Vogt K,et al.Preoperative methylprednisolone enhances recovery after endovascular aortic repair:a randomized,double-blind,placebocontrolled clinical trial[J].Ann Surg,2014,260(3):540-548;discussion 548-549.
33 Cassis P,Gallon L,Benigni A,et al.Erythropoietin,but not the correction of anemia alone,protects from chronic kidney allograft injury[J].Kidney Int,2012,81(9):903-918.