经皮肾镜下气压弹道联合超声碎石术学习曲线的探讨

Learning curve of percutaneous nephrolithotripsy with pneumatic and ultrasonic lithoclast

目的探讨缩短经皮肾镜下气压弹道联合超声碎石术学习曲线的方法。方法对20只猪肾结石模型进行穿刺、扩张及置镜技术训练。对76例（79例次）肾及输尿管结石患者行经皮肾镜取石术（PCNL）,其中单发结石26个肾,多发结石32个肾,鹿角型结石11个肾,上段输尿管结石10侧。结果20只成龄猪肾结石模型,穿刺目标肾盂、肾盏60次,一次性成功19次。肾镜及剖肾观察见对侧集合系统戳穿伤14次,工作通道撕裂伤18次。成功置肾镜11次中均成功寻找到模型肾结石,并击碎清除。79例次患者成功建立20.8~24F皮肾通道并Ⅰ期碎石,其中2例患者行Ⅱ期碎石。平均手术时间80 min,平均结石处理时间56 min。肾脏、输尿管结石清除干净63侧,净石率79.7%。结石残留16侧,行二次肾镜取石,或辅助体外冲击波碎石治疗。临床培训79例次,其中示教10例次,带教完成20例次,独立完成手术操作49例次,手术频度平均每月4.4例次。结论猪肾结石模型进行PCNL训练,有助于顺利开展人体经皮肾镜气压弹道联合超声碎石术,有助于缩短学习曲线。

Objective To explore and shorten the learning curve of percutaneous nephrolithotripsy （PCNL） by using pneumatic and ultrasonic lithoclast. Methods Exercises were performed in 20 pig models to get familiar with the skills of percutaneous puncture, dilatation and nephroscopy. Clinical performance of PCNL were conducted in 76 patients or 79 cases （26 kidneys with sole pelvic calculus, 32 multiple calculi, 11 staghorn calculi and 10 impacted proximal ureteral calculi）. Results The 20.8 -24F percutaneous renal access was successfully established. Immediate phase Ⅰ lithotripsy was performed in all of the 76 patients, while phase Ⅱ lithotripsy was performed in 2 patients. Average time required was 80 min for entire procedure, and was 56 min for calculus management. No residual calculus fragments were found in 63 kidneys and ureter, with the calculi clearance rate being 79.7%. Residual calculi fragments in the 16 kidneys were treated by second PCNL or adjuvant ESWL. The learning curve of PCNL with pneumatic and ultrasonic power in the present study involved 79 cases, including demonstration in 10 cases, supervised operation in 20 cases, and independent operation in 30 cases, with an average of 4.4 cases performed each month. Conclusion Appropriate training program based on pig model of renal calculus helps urologists master the pneumatic and ultrasonic means in PCNL quickly, shortens the learning curve, and safeguards the practice of efficient and safe PCNL.