经皮肾镜气压弹道联合超声碎石清石的并发症防治

Prevention and treatment of complications of combined pneumatic and ultrasoud lithotripsy during percutaneous nephrolithotomy

目的探讨经皮肾镜气压弹道联合超声碎石清石的并发症防治措施。方法本组634例,男325例,女309例。年龄6～81岁,平均44岁。KUB测量结石最大径1.5～7.2 cm,平均3.3 cm。超声波示344例545侧无肾积水,290例402侧合并肾积水,集合系统分离1.0～4.2 cm。在超声波引导下穿刺并扩张建立F14～F24经皮肾通道,在F20.8肾镜或F8/9.8输尿管肾镜下采用气压弹道联合超声组合式碎石清石系统,Ⅰ期或Ⅱ期粉碎结石并主动吸出体外。结果Ⅰ期手术单侧结石清除时间5～260 min,平均41 min。术中失血约20～400 ml,平均60 ml。单发输尿管上段结石及肾单发结石Ⅰ期手术单侧结石取净率98.2%;肾铸形或多发结石及肾结石合并输尿管上段结石Ⅰ期手术单侧结石取净率70.4%,总的Ⅰ期手术单侧结石取净率77.0%。无严重感染。6例(9.4‰)术后出现严重出血,1例行肾动脉超选栓塞止血后好转,4例经保守止血治疗好转,1例(1.5‰)行患肾切除。218侧肾盂、肾盏内残留结石,残留结石最大径0.2～2 cm。20侧多发的或位于肾盂的最大径>1 cm的残留结石,于Ⅰ期手术后7～10 d行Ⅱ期手术清石;78侧术后1个月行体外冲击波碎石1～4次,28例残余结石排净,其余50例部分排石或未排石,残余结石未引起上尿路梗阻,未行进一步处理;另114侧残留结石均位于肾盏,最大径均<1 cm,未行进一步处理。术后肾功能及肾积水情况较术前改善。302例出院后获随访2～36个月,平均8.8个月,均无严重出血及感染,12例结石复发或残留结石明显增大并引起肾积水,再次行径皮肾镜取石术。结论经皮肾镜气压弹道联合超声碎石清石术治疗肾及输尿管上段结石具有微创、高效、安全和技术难度低的特点,应重视其并发症的防治。

Objective To report the prevention and treatment of complications of combined pneumatic and uhrasoud lithotripsy for renal and upper ureteral calculi during percutaneous nephrolithotomy. Methods The study included 634 patients （325 males, 309 females, aged 6-81 years） treated with PCNL in our department between June 2004 and September 2007. The mean stone diameter was 3.2 （range 1.5-7.2） cm. The kidney was punctured under uhrasonography guidance. An F16-F24 working channel was dilated. Under a F20.8 nephroscopy or F8/9.8 ureteronephroscopy, ultrasonic, pneumatic probes or combined were used for lithotripsy. Results The average operative time for one renal unit was 41 min （ ranged from 5-260 min ）. The average blood loss is 60 ml （ ranged from 20-400 ml ）. All stones were crumbled. The stone-free rate for unilateral kidney was 77.0%. 6 cases had severe hemorrhage postoperatively. 1 was cured with selective angiographic embolization, 4 with conservative therapy and 1 with nephrectomy. No severe infection was observed. 218 kidneys had one or more residual stones smaller than 2cm. 23 kidneys with multiple residual stones or stones bigger than 1 cm underwent the second operation of PCNL. 78 kidneys with residual stones underwent ESWL one month postoperatively. 28 ones had totally calculus clearance and others presented approved clearence. No further treatment for the rest kidneys with residual stones conducted. Follow-up of 2 to 36 months＇ duration for 302 cases showed good results. 12 with recurrent stones or residual stones enlarged. Conclusions The combined pneumatic and uhrasoud lithotripsy during percutaneous nephrolithotomy is an efficacious and safe method for renal and/or upper ureteral calculi. But the prevention and treatment of complications should be emphasized.