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ESWL并发症（三）

2021

08/09

医学镜界

A-

A+

体外冲击波碎石术已被证明是一种非常有效的治疗肾结石的术式。冲击波可碎裂大多数类型的结石，且作为泌尿系结石的唯一非侵入式疗法，相当有吸引力。然，凡事皆有利弊两面性，ESWL也有其缺点：可致肾脏及周边器官血管损伤。这种急性肾损伤可能很严重，甚至导致功能肾容积永久损伤的瘢痕形成，并与潜在严重的长期副作用有关。既如此，岂不投鼠忌器？有云：“若是后人不问来由，一律的奉以为法，岂不因噎废食了么？” （清·吴趼人《二十年目睹之怪现状》第二十一回），凡事皆有法，万物皆有度，那么ESWL针对临床并发症“法”为何，“度”何在呢？

减少副作用的机制

肾出血一般发生在三个部位：通常在治疗焦点（F2）所在或附近的肾周、肾包膜下和实质内。血肿部位的组织病理学检查显示小静脉、动脉、肾小球和管周毛细血管破裂 ^【9】。此外，附近的肾元出现冲击波直接损伤和缺血性变化的证据。肾血肿例数随冲击波碎石数量的增涨而增加 ^【9】。此外，ESWL能级升高，随着肾损伤体积增加从而肾血流相应减少 ^【2⁸^】。ESWL似乎不仅影响碎石侧肾，且诱发明显的血管收缩也影响对侧肾 ^【7,⁹⁶^】。在动物模型中，肾损伤程度的加大均与大量冲击波冲击次数、高能级、密集治疗周期、治疗幼小肾及肾功能不全的肾等相关 ^【7】。Evan及其同事也报告，ESWL期间，急性肾盂肾炎可能持续加大肾损伤 ^【9⁷^】。因此，某些患者、肾脏和治疗特征参数可显著改变ESWL相关副作用的风险。

保护性预治疗及治疗方案

虽然有些患者和ESWL治疗特征不能改变，但也有些特征可以修改，以降低ESWL相关并发症的风险。可以改变冲击波传导的某些方面以减少ESWL时肾的持续损伤。如：

1）确保输尿管末段无梗阻

2）应在ESWL术前治疗尿路感染

3）采用冲击波预适应规程，如：先用100个低能量剂量冲击波冲击。

4）预适应冲击后暂停3-4分钟

5）降低冲击波冲击频率（如：每分钟30~60个冲击波）

6）碎石过程，经常及时影像查看、评估碎石情况

7）结石一旦碎裂即刻停止治疗

猪模型试验已证实，所谓的“预适应规程”（也称“启动规程”）：即在启动治疗性冲击波（注：能量达到足以碎石的冲击波）之前，先用低能量冲击波冲击肾脏的一个区域，可减少肾组织损伤^【9⁶^】。

Willis 及其同事用HM3碎石机，以24kV激励电压，每分钟120个冲击波，2000个冲击波的临床剂量治疗雌性农场猪，经测量得出约6%的功能肾容积损伤。而在完整的治疗性冲击波开始碎石前，采用12kV激励电压仅100个冲击波对肾脏预适应冲击所测得功能肾容积损伤降低至0.3%^【9⁶^】。预适应规程可能引起血管收缩，从而降低了血管对冲击波压力的敏感性。但，Connors后来的一项研究表明，起保护作用的不是小剂量的预适应冲击能量，而是冲击波传导的中断^【9⁸^】。该项研究发现分别采用12,18和24kV激励电压作为预适应能量时，所引起的肾损伤大小相同。但，在预适应冲击后，延迟3-4分钟继续治疗性冲击波碎石，才观察到肾保护作用。

在另一项猪模型研究中，降低冲击波频率似乎也能减少肾损伤^【9⁹^】。冲击波频率降至每分钟30个冲击波则肾功能容积损伤低于0.1%^【9⁹^】。慢冲击波频率对肾组织损伤效应与采用预适应规程相似。降低冲击波传导频率的另一好处是提高碎石率。一项对589名患者的荟萃分析表明，慢速ESWL(每分钟60个冲击波)比快速ESWL(每分钟120个冲击波)碎石效率更高^【1⁰⁰^】。其它几项前瞻性临床试验^【1⁰¹^-1⁰³^】和一项独立荟萃分析^【1⁰⁴^】也报告证实了这一点。

犬模型的研究也证明了减少总冲击波数量是有好处的。当冲击波数从 1000 个增加到 2000 个时，肾瘢痕大小由原来的 1.4% 增加到 12.8%。因此，建议在 ESWL 过程中应X光透视多观察碎石情况，当发现达到较满意的碎石效果时，及时停止治疗。

另外，ESWL时冲击波经患者体表皮肤向体内目标结石传导，必需要有声耦合。HM3碎石机的“水浴耦合”是近乎完美的声耦合方式，但所需的水处理-循环-浴缸装置庞大笨重。尽管现代碎石机治疗头的声耦合采用“干式耦合水囊”设计，这样整机更紧凑、易于运输，且便于每位泌尿科医生操作，但耦合效果还是逊于水浴耦合。干式治疗头声耦合比水浴耦合操作难，效率低。因为一开始耦合时，耦合面上就会出现难以排出的气泡，且如果患者稍微挪动或重新定位，则会产生更多的气泡。体外试验研究表明，如果耦合面上出现仅2%的气泡，发现碎石率下降20~40%（下图） ^【¹⁰⁵^】。目前还没有一种评价耦合质量的方法。但体外研究表明，可采取一些简单的措施来改善干式治疗头的声耦合 ^【¹⁰⁶^】。该研究发现，如果耦合剂以大剂量团状直接从存储罐自然流注在治疗头水囊耦合面上，而不是从软管或挤压瓶中挤出，则可以提高声耦合质量。因为挤压软管中耦合剂会产生更多的气泡，或在耦合水囊面上涂抹凝胶也会产生气泡。研究人员发现，若耦合剂直接以大剂量团状流注在耦合水囊面上，且耦合水囊与患者体表皮肤接触时自然扩散，则耦合效果更好。另，利用治疗头耦合水囊充盈摊开耦合剂也可显著改善耦合质量 ^【¹⁰⁶^】。

自19世纪80年代初至今，ESWL已成为广泛应用的输尿管结石和肾结石的一线治疗方法。因其微创和门诊治疗的特点，成为对患者和医生越来越有吸引力的结石治疗方法。 ESWL确实会发生短期和长期并发症，包括肾实质及周边脆弱组织的损伤。但大量临床实践表明，若恰当使用，ESWL对大多数泌尿结石是一种安全、恰当的治疗选择。改进ESWL过程的操作，包括使用低电压（低能量）预适应规程、3~4分钟治疗暂停、降低冲击波冲击频率和限制冲击波总数量（总能量），可提高碎石效果，同时限制肾组织损伤，有助于预防ESWL并发症发生。声耦合的低质量和可变性是另一个亟待解决的挑战。应尽量做到完全耦合，以确保冲击波的有效传导。总而言之，注意选择适应症患者，优化治疗变量，术后密切随访可以确保ESWL的安全性和有效性，并降低复碎率。

ESWL是一种非侵入式治疗，适合老人和儿童。

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