经皮肾镜超声联合气压弹道碎石治疗复杂性肾结石

Percutaneous nephrolithotomy in treatment of complex renal calculi with a combination of ultrasonic and pneumatic lithotripsy

目的:探讨由X线实时监视的经皮肾镜超声联合气压弹道碎石取石术治疗复杂性肾结石的疗效和安全性.方法:回顾性分析2006～2011年采用B超或X线C形臂定位穿刺,由X线实时监视经皮肾镜碎石取石(PNL)治疗复杂性肾结石458例,男285例,女173例,年龄1～80(48±26)岁.其中鹿角形结石156例(34.1%);马蹄肾结石5例(1.1%);肾盏憩室内结石18例(3.9%);小儿肾结石38例(8.3%);孤立肾或对侧肾无功能者45例(9.8%);其余196例(42.8%)为大于30mm的肾盂结石或多发肾结石.所有患者均在全麻下截石位经膀胱镜先向患侧逆行插入输尿管导管,改俯卧位后,采用超声或X线C形臂定位,向目标肾盏穿刺,由X线实时监视建立皮肾通道,经肾镜用EMS超声联合气压弹道进行一期或多期碎石、取石.结果:单通道取石439例,双通道取石17例,三通道2例;Ⅰ期完成碎石取石317例,Ⅱ期124例,Ⅲ期16例,Ⅳ期1例.手术时间30～150(75±28)min.7例术后继发性出血,经输血及超选择性肾动脉栓塞治疗后痊愈,3例术后当晚发生感染性休克,经抗休克治疗后缓解.术后平均住院5.6(3～26)d,术后3个月随访尿路平片(KUB),结石取净率为85.8%(393/458).术后28例再行ESWL治疗,术后6个月随访结石排净率达90.2%(413/458).结论:由X线实时监视的经皮肾镜超声联合气压弹道碎石取石治疗复杂性肾结石效率高,安全有效,损伤小,可重复取石,是治疗复杂性肾结石的可靠方法.

Objective:To evaluate the clinical efficacy and safety of percutaneous nephrolithotomy(PNL)under the guidance of X-ray in the treatment of complex renal calculi with a combination of ultrasonic and pneumatic lithotripsy.Methods:Between 2006 and 2011,458patients(285males and 173females)with complex renal calculi underwent PNL.Of these cases,staghorn calculi were found in 156 cases,horseshoe kidney calculi in 5cases,calyceal diverticulum stones in 18 cases,pediatric kidney calculi in 38 cases,solitary kidney calculi in 45 cases,and the remaining 196 cases were multiple or diameter more than 30 mm calculi.Under general anesthesia,an ureteral stent was placed to the ureter by cystoscopy.With the prone position,percutaneous access was established by placement of an access needle into the intended calix under ultrasonographic or fluoroscopic guidance.Ultrasonic and pneumatic probes were combined through nephroscopy for lithotripsy.Results:A single tract was used in 439 patients,and two or three tracts in the remaining 19 patients.One step procedure to remove the stones was in 317 patients,the need for secondary intervention was in 124 patients,16for third procedure,and 1for fourth procedure.The mean time of operations were 30-150(75±28)min.Major complications were rare,haemorrhage occurred in7 patients after operation,which were successfully treated with blood transfusion and super-selective arterial embolization.Sepsis occurred in 3cases after PNL,these 3patients were recovered after conservative treatment.The mean postoperative hospitalization stay were 5.6(3-26)days.The stone cleared rate was 85.8%(393/458)at one month follow-up.28 cases needed ESWL after PNL.The stone-free rate in all was 90.2%(413/458)at 6month follow-up.Conclusions:The combination of ultrasonic and pneumatic intracorporeal lithotripsy under the guidance of X-rayappears is to be efficacious and safety for removing complex renal calculi.