【EAU指南学习】输尿管镜（逆行和顺行，RIRS）
3.4.6.Ureteroscopy (URS)
(retrograde and antegrade, RIRS)
输尿管镜（URS）（逆行和顺行，RIRS）
The current standard for rigid ureteroscopes is a tip diameter of < 8 French (F). Rigid URS can be used for the whole ureter. However, technical improvements, as well as the availability of digital scopes, also favour the use of flexible ureteroscopes in the ureter.
目前标准的输尿管硬镜尖端直径<8 F。输尿管硬镜可用于整个输尿管。但是，随着技术的进步以及数字内镜的应用，在输尿管中也可使用输尿管软镜。
Percutaneous antegrade removal of ureteral stones is a consideration in selected cases, i.e. large (> 15 mm), impacted proximal ureteral calculi in a dilated renal collecting system, or when the ureter is not amenable to retrograde manipulation.
对于某些患者，即大型（> 15 mm）嵌顿性输尿管近端结石伴肾脏集合系统扩张，或输尿管不适合进行逆行操作，应考虑对输尿管结石进行经皮顺行性取石。
Ureteroscopy for renal stones (RIRS)
肾结石的输尿管镜治疗（RIRS）
Technical improvements including endoscope miniaturisation, improved deflection mechanism, enhanced optical quality and tools, and introduction of disposables have led to an increased use of URS for both renal and ureteral stones. Major technological progress has been achieved for RIRS. A recent systematic review addressing renal stones > 2 cm showed a cumulative SFR of 91% with 1.45 procedures/patient; 4.5% of the complications were > Clavien 3. Digital scopes demonstrate shorter operation times due to the improvement in image quality.
随着内镜微型化、偏转性能提高、光学质量和工具有所改进以及一次性产品的应用等技术的进步，URS在肾结石和输尿管结石中的应用越来越多。RIRS已取得重大技术进步。最近一项针对> 2 cm肾结石的系统性回顾显示，每例患者1.45次手术的累积SFR为91％。4.5％的并发症为Clavien3级以上并发症。数字内镜由于图像质量更高，所以操作时间更短。
Stones that cannot be extracted directly must be disintegrated. If it is difficult to access stones within the lower renal pole that need disintegration; it may help to displace them into a more accessible calyx.
对于无法直接取出的结石，必须进行碎石。如果需要碎石的结石位于难以进入的肾下极，可以将结石移至更容易接近的肾盏，这可能有助于碎石。
Best clinical practice in ureteroscopy
输尿管镜治疗的最佳临床实践
Most interventions are performed under general anaesthesia, although local or spinal anaesthesia is possible. Intravenous sedation is suitable for female patients with distal ureteral stones. Antegrade URS is an option for large, impacted, proximal ureteral calculi.
虽然可以进行局部或椎管内麻醉，但大多数干预都是在全身麻醉下进行的。静脉镇静适用于输尿管远端结石的女性患者。顺行性URS是较大的嵌顿性输尿管近端结石的治疗选择之一。
Safety aspects安全方面
Fluoroscopic equipment must be available in the operating room (OR). We recommend placement of a safety wire, even though some groups have demonstrated that URS can be performed without it. Balloon and plastic dilators should be available, if necessary.
手术室（OR）必须配有X光透视设备。即使一些小组证明无需置入安全导丝也可进行URS，但仍建议置入安全导丝。如有必要，应配有气囊扩张器和塑料扩张器。
Prior rigid URS can be helpful for optical dilatation followed by flexible URS, if necessary. If ureteral access is not possible, insertion of a JJ stent followed by URS after seven to fourteen days offers an alternative. Bilateral URS during the same session is feasible resulting in equivalent-to-lower SFRs, but slightly higher overall complication rates (mostly minor, Clavien I and II).
进行可视下扩张及输尿管软镜治疗时，如果有必要，先插入输尿管硬镜也许有帮助。如果无法进入输尿管，可先置入双J支架，7-14天后再行URS。同期手术中进行双侧URS是可行的，其SFR为同等至较低水平，但总体并发症发生率略高（多数为不严重的并发症，Clavien I和II级）。
Ureteral access sheaths输尿管输送鞘
Hydrophilic-coated ureteral access sheaths, which are available in different calibres (inner diameter from 9 F upwards), can be inserted (via a guide wire) with the tip placed in the proximal ureter.
可以（通过导丝）插入输尿管亲水涂层输送鞘，并将尖端插入输尿管近端，目前有各种口径的输送鞘（最小内径9 F）。
Ureteral access sheaths allow easy, multiple, access to the UUT and therefore significantly facilitate URS. The use of ureteral access sheaths improves vision by establishing a continuous outflow, decreases intra-renal pressure, and potentially reduces operating time.
输尿管输送鞘可轻松多次地进入上尿路，极大地促进了URS。输尿管输送鞘允许持续的灌注液流动，可改善视野，还可降低肾内压力，缩短操作时间。
The insertion of ureteral access sheaths may lead to ureteral damage, the risk is lowest in pre-stented systems. No data on long-term side effects are available. Whilst larger cohort series showed no difference in SFRs and ureteral damage, they did show lower post-operative infectious complications. Use of ureteral access sheaths depends on the surgeon's preference.
输尿管输送鞘的插入可能会导致输尿管损伤，预先置入支架可将该风险降到最低。目前没有关于长期副作用的数据。虽然较大的队列研究显示使用和不使用输尿管输送鞘在SFR和输尿管损伤方面没有差异，但使用输尿管输送鞘的术后感染并发症确实更低。输尿管输送鞘的使用取决于外科医生的偏好。
Stone extraction取石
The aim of URS is complete stone removal. 'Dust and go' strategies should be limited to the treatment of large (renal) stones. Stones can be extracted by endoscopic forceps or baskets. Only baskets made of nitinol can be used for flexible URS.
URS的目的是彻底清除结石。粉末化碎石+自行排出的策略应仅限于大型（肾）结石的治疗。结石可以通过内镜下取石钳或套石网篮取出。只有镍钛合金制成的套石网篮可用于输尿管软镜。
Intracorporeal lithotripsy体内碎石
The most effective lithotripsy system is the holmium: yttrium-aluminium-garnet (Ho:YAG) laser, which is currently the optimum standard for URS and flexible nephroscopy (Section 3.4.6), because it is effective in all stone types. Pneumatic and US systems can be used with high disintegration efficacy in rigid URS. However, stone migration into the kidney is a common problem, which can be prevented by placement of special anti-migration tools proximal of the stone. Medical expulsion therapy following Ho:YAG laser lithotripsy increases SFRs and reduces colic episodes.
最有效的碎石术是钬激光（掺钬钇铝石榴石，Ho:YAG）碎石，由于钬激光对所有类型的结石均有效，因此是目前URS和软性肾镜治疗的最佳碎石方法。气压弹道碎石和超声碎石的碎石功效较高，可用于输尿管硬镜治疗。但是，结石向肾脏移位是一个普遍的问题，这可以通过在结石近端放置特殊的防移位工具来防止结石移位。钬激光碎石术后药物排石治疗可提高SFR，减少肾绞痛发作。
Stenting before and after URS
URS前和URS后置入支架
Routine stenting is not necessary before URS. However, pre-stenting facilitates ureteroscopic management of stones, improves the SFR, and reduces intra-operative complications.
URS前不需要常规置入支架。但是，预先置入支架有助于结石的输尿管镜下管理，改善SFR，减少术中并发症。
Randomised prospective trials have found that routine stenting after uncomplicated URS (complete stone removal) is not necessary; stenting might be associated with higher post-operative morbidity and costs. A ureteral catheter with a shorter indwelling time (one day) may also be used, with similar results.
随机前瞻性试验发现，对于不复杂的URS（完全清除结石），术后常规置入支架不是必需的。支架置入可能与更高的术后发病率和费用相关。有时可能会短暂留置（一天）输尿管导管，其结果与术后置入支架相似。
Stents should be inserted in patients who are at increased risk of complications (e.g., ureteral trauma, residual fragments, bleeding, perforation, UTIs, or pregnancy), and in all doubtful cases, to avoid stressful emergencies. The ideal duration of stenting is not known. Most urologists favour 1-2 weeks after URS. Alpha-blockers reduce the morbidity of ureteral stents and increase tolerability.
对于并发症风险较高的患者（例如输尿管外伤、碎石残留、出血、穿孔、尿路感染或怀孕）以及在所有可疑情况下，应置入支架，以避免发生紧急情况。理想的支架留置时间尚不清楚。大多数泌尿科医师倾向于URS后1-2周。阿尔法受体阻滞剂可降低输尿管支架的并发症发生率，提高耐受性。
Medical expulsive therapy after ureteroscopy
输尿管镜治疗后药物排石治疗
Medical expulsion therapy following Ho:YAG laser lithotripsy accelerates the spontaneous passage of fragments and reduces episodes of colic.
钬激光碎石术后的药物排石治疗可加速碎石的自发排出，减少肾绞痛发作。
Complications of ureteroscopy
输尿管镜治疗的并发症
The overall complication rate after URS is 9-25%. Most complications are minor and do not require intervention. Ureteral avulsion and strictures are rare (< 1%). Previous perforations are the most important risk factor for complications.
URS后的并发症总发生率为9-25％。大多数并发症都不严重，不需要干预。输尿管撕脱和狭窄较为罕见（<1％）。穿孔是出现并发症最重要的风险因素。
Summary of evidence and guidelines for retrograde URS, RIRS and antegrade ureteroscopy
逆行URS、RIRS和顺行输尿管镜治疗的证据概述和指南建议
声明：