微创经皮肾镜取石术治疗马蹄肾结石的效果

Treatment of calculi in horseshoe kidney with minimally invasive percutaneous nephrolithotomy

目的探讨微创经皮肾镜取石术（MPCNL）治疗马蹄肾结石的手术技巧及临床应用价值。方法MPCNL治疗马蹄肾结石患者17例。其中男13例，女4例。年龄17-53岁，平均34岁。17例均由KUB加IVU及CT确诊。单发肾盂结石5例，下盏结石3例，多发、复杂结石9例（其中鹿角形结石4例）。结石大小0．9cm×l．4cm-3．8cm×4．3cm。肾盂、输尿管无明显狭窄。B超引导下穿刺选定肾盏，置入安全导丝，顺穿刺方向用微穿刺扩张器依次扩张至18F，推入Peel-away鞘建立肾穿刺通道。输尿管硬镜下用气压弹道碎石机碎石。结果17例经一次穿刺成功建立通道，手术时间40-180min，平均90min。术中出血20-100ml，平均40ml，均未输血。13例一期取净结石，3例经二次取石，2例取净。2例有残石者术后配合体外冲击波碎石治疗，1例排净，1例有少许残石。术后4例一过性出血、2例发热，经内科治疗后痊愈。随访3-24个月，17例肾积水均有不同程度好转，16例结石取净者未见结石复发，1例有少许残石患者结石体积无明显变化。结论MPCNL治疗马蹄肾结石效果明显、操作安全、创伤较小，术后并发症少。

Objective To discuss the procedure technique and efficacy of minimally invasive percutaneous nephrolithotomy （MPCNL） for calculi in a horseshoe kidney. Methods The clinical data of 17 cases （13 males and 4 females） treated by MPCNL were retrospectively analyzed. The age ranged from 17 to 53 years （mean 34）. All the 17 cases were diagnosed by KUB＋ IUV and CT. Five cases had single stone in pelvis and 3 cases in lower calices while complex calculi were in 9 cases （4 had staghorn calculi）. The size of stone ranged from 0.9 cm×1.4 cm to 3.8 cm×4.3 cm. UPJ stricture was not found in this series. Lumbar anesthesia combining epidural block anesthesia was applied. Renal transfixion pin was punctured to select renal calices by monitoring with B-ultrasonography. Calculi were shredded by lithotripsy with pneumatic lithotripter. Results All PCN procedures were performed in a standard one-session technique with B-ultrasonography whole range guidance. The operative time ranged from 40 to 180 min （mean 90 min）. Bleeding amount ranged from 20 to 100 ml （mean 40 ml） and no case needed blood transfusion. Calculus was completely removed one-session in 13 cases. The calculi of 3 cases were treated with second-look MPCNL by quondam sinus tract or secondary puncturation,and 2 cases were completely removed. Fragment residual caliceal stones in 2 cases were treated with ESWL and 1 case was completely removed. Transient bleeding in 4 cases and trivial fever in 2 cases were found and cured with medical treatment. All the 17 cases were followed up for 3 to 24 months. Nephrohydrops had improved in them. None of them had calculus recurrence in 16 cases whose calculi were completely removed. Fragment residual caliceal stone in 1 case was not found in- creasing. Conclusions MPCNL is effective and has minimal trauma for renal calculi in horseshoe kidney. Postope-rative complications are rare.