经皮肾镜标准通道下气压弹道-超声碎石清石系统治疗复杂性肾结石(附26例报告)

Standard Tract Percutaneous Nephrolithotomy Combined with Pneumatic and Ultrasound Lithotripsy for Complicated Renal Calculi:Report of 26 Cases

目的探讨经皮肾镜标准通道下气压弹道-超声碎石清石系统治疗复杂性肾结石的疗效及安全性。方法2008年1月～2009年3月采用B超引导,经皮肾镜标准通道下气压弹道-超声碎石清石系统治疗26例复杂肾结石。结果一期PCNL20例,12例结石完全清除;3例残石直径≤0.5cm,5例残石直径≥1.2cm,分别行二期PCNL3例,ESWL治疗残石5例。手术时间15～240min,(117±68)min。一期PCNL无术中、术后大出血需要输血者,无胸膜、腹腔器官损伤等严重并发症。2例因肾实质撕裂、穿刺通道迷失而中转开放手术。1例孤立肾合并肾结石、重度肾积水因服用农药中毒致急性肾功能衰竭,PCNL通道建立后镜下寻找结石困难,患者病情危重,行肾造瘘转ICU治疗。二期PCNL3例,均为术中肾穿刺孔道撕裂,灌注液外渗,不能耐受而结束一期手术;1例二期PCNL见肾盂输尿管交界处炎性闭塞,2周后行开放输尿管肾下盏吻合术。3例术中导丝脱出。3例PCNL结束时双J管不能置入膀胱。一期PCNL术后留置肾造瘘管(6.9±1.6)d。1例术后造瘘管周围持续漏尿10d。2例二期PCNL在一期PCNL术后发生肾盂肾炎及肾周围炎。结论标准通道下经皮肾镜联合EMS第3代超声气压弹道-超声碎石清石系统具有高效、安全的特点,但对于复杂肾结石应加强并发症的防治。

Objective To investigate the effect of standard tract percutaneous nephrolithotomy（PCNL） combined pneumatic and ultrasound lithotripsy on patients with complicated renal stones. Methods From January 2008 to March 2009, 26 patients with renal calculi underwent standard tract PCNL combined with pneumatic and ultrasound lithotripsy in our hospital.Their clinical data were reviewed retrospectively. Results Phase Ⅰ lithotripsy was performed on 20 cases with a mean operation time of （117±68） min （range： 15-240 min）. In 12 of them, the stones were removed completely, while in the other 8 patients,residual stones were detected after the surgery （≤0.5 cm in diameter in 3 cases,and ≥1.2 cm in 5 cases）. No patient had massive hemorrhage or injuries to the pleura or abdominal organs after the Phase Ⅰ surgery. In the 20 patients, two were converted to open surgery because of renal parenchymal injury and failure in establishing renal channel;nephrostomy was performed on one case, who had calculi in solitary kidney complicated with hydronephrosis, because of acute renal failure after drinking pesticide and difficulty in localizing the stones. After the procedure, the renal catheter was withdrawn in（6.9±1.6）d; one of the cases developed urine leakage after the operation and was not cured until 10 days later. Delayed phase Ⅱ lithotripsy was carried out in 3 cases who couldn’t tolerate PCNL for 2.5-4 h due to renal perforating injury and multiple or staghorn calculi. In one of the three cases, open surgery for anastomosis between the ureter and lower renal calices was carried out because of inflammatory obstruction. During the operation, the wire moved from the renal channel in 3 cases. After the surgery, we failed in placing double-J tube into the bladder in 3 cases. Pyelonephritis and perinephritis were detected in two cases after the phase Ⅱ surgery. Conclusions Standard tract PCNL combined with pneumatic and ultrasound lithotripsy is effective and safe. Attention should be paid to the prevention and management of complications for complicated kidney stones.