局麻下经皮肾微造瘘二期取石术治疗合并高危因素的肾结石

Two-stage percutaneous nephrolithotomy treats renal stone in high-risk aged patients under assisted local anaesthesia:report of 12 cases

目的探讨合并心肺功能障碍和/或上尿路感染的高危老年肾结石患者手术治疗方式的选择及其安全有效性。方法回顾性总结2006年1月至2008年3月我科治疗的12例患者的临床资料。12例患者术前检查均有通气功能障碍或混合性呼吸功能障碍,7例合并高血压,3例合并心功能不全,4例合并糖尿病,6例合并上尿路感染。术前ASA分级均≥3级。手术均分期进行。一期在1%利多卡因局麻下B超引导经皮肾穿刺,皮肾通道扩张至14F,放置12F造瘘管。5～7 d后局麻下经原皮肾通道行经皮肾镜取石术。应用视觉模拟评分法(visual analogue scale,VAS)评估患者耐受程度。结果12例手术两期均顺利完成。一期手术时间15～25 min,平均21 min。二期手术时间20～45 min,平均35 min。一期手术VAS评分2.1～6.2 mm,平均3.9 mm,二期手术VAS评分1.5～6.4 mm,平均3.5 mm,患者均能良好耐受,无需更改麻醉方式。12例术后均无继发性大出血,无继发肺部感染、电解质异常及心脏并发症。1例术前有明显上尿路感染者一期术后发热2 d,经广谱抗生素治疗后缓解。二期术后复查KUB,仅1例下盏残留结石4 mm。随访6～18个月,均无结石复发,无继发上尿路感染。结论对于选择性的合并心肺功能障碍和/或伴有上尿路感染等高危因素的肾结石患者,采用局麻下分期经皮肾取石术(percutaneous nephrolithotomy,PCNL)的方法疗效确切,同时明显降低了手术风险,是一种可选择的方法。

Obiective To investigate the feasibility and safety of pereutaneous nephrolithotomy （PCNL） by 2 stages on selected patients （age ≥60, insufficiency of cardiorespiratory function and/or upper urinary infection） under assisted local anaesthesia. Methocls Between January 2006 and March 2008, 12 patients （7 men and 5 women with a mean age of 70.2） with unilateral large renal stone were enrolled in this retrospective study. The mean stone diameter was 3.4 cm （ranging from 2.0 to 4.5 cm）. Pulmonary function and blood gas analysis were tested in all patients preoperatively. Abnormal pulmonary function tests were observed in all 12 patients. Seven cases were found to have hypertensive heart disease, 3 patients with cardiac insufficiency, 4 cases with diabetes and 6 patients having upper urinary infection. All patients had an anesthesia risk with American Society of Anesthesiologists （ASA） grade 3 or above. First operation of percutaneous nephrostomy was performed under local anaesthesia （lignocaine） guided by ultrasound in lateral position or prone position. A 12-F nephrostomy tube was left in place for 5 to 7 d, and then the secondary operation was carried out in lateral posi- tion. After having infiltrated the tract and the renal parenchyma with lignocaine, dilatation of the nephrostomy tract was performed. PCNL was done using a 8.5-F rigid ureteroscope and holmium laser lithotripter. Pain scores were measured using 10-era linear visual analogue scale （VAS） after the completion of both procedures. Results The mean operative time of first stage was 21 min （ 15 to 25min）, and that of the second stage was 39 min （21 to 62 rain）. No blood transfusion was needed to any patient. The mean VAS score was 39 mm （21 to 62 mm） for the first stage, while 35 mm （ 15 to 64 mm） in the second stage. The whole procedure was well tolerated without any need for general anaesthesia. Fever （ 〉 38.5 ℃ ） was noted in one patient, who was trea- ted with intravenous antibiotics. Only one patients had residual stone fragments （diameter 0.4 era）. No pulmo- nary infection and cardiac complications were noted in these patients. After 6 to 18 months＇ follow-up, no stone was recurred and no upper urinary tract infection was found. Conclusion Our findings suggest that the twostage PCNL is effective and safe for the selected aged patients with insufficiency of eardiorespiratory function and/or upper urinary infection. Local anaesthesia has no effect on the efficacy and safety of PCNL.