旋转透视并经皮肾盂造影设计肾造瘘经皮入路

Rotational fluoroscopy and fine needle antegrade pyelography for determining kidney access in percutaneous nephrostomy

目的探讨经皮肾造瘘术中细针经皮肾盂穿刺造影结合旋转透视选择经皮入路的应用价值。方法肾、输尿管上段结石患者543例,大C臂血管造影X线机导向下实施经皮肾造瘘,术中先行正位至侧位旋转透视,结合经皮细针肾盂穿刺顺行造影,显示肾盂和结石的立体结构及其相互关系,根据肾镜最佳取石路径选择合适的皮肤穿刺点和肾小盏,用19G带鞘针穿刺靶小盏后引入超滑导丝,必要时配合使用导管通过梗阻,扩张穿刺道后置入造瘘管。结果 542例上尿路结石肾造瘘成功,539例造瘘管置入输尿管或肾盂,3例置入肾盏。并发症有肾盂撕裂5例,胸膜损伤3例,术后少量出血3例和迟发大出血1例,1例经皮肾镜术后心功能衰竭死亡。随后的经皮肾镜一次结石取净率为88%。结论旋转透视结合细针顺行造影定位,提高了经皮肾造瘘的成功率并有效降低了并发症的发生率。

Objective To investigate the clinical value of fine needle antegrade pyelography combined with rotational fluoroscopy in determining the puncture track of percutaneous nephrostomy. Methods A total of 543 patients with upper ureter calculus had percutaneous nephrostomy guided by C-arm fluoroscopy. After rotating fluoroscopy from anterior to lateral positions, fine needle percutaneous antegrade pyelography was performed under fluoroscopic guidance, which allowed three--dimensional mapping of the calculi, renal pelvis and their relationship. Using the nephroscope to select the optimal skin and calyceal puncture site by a 19G EV needle, the hydrophilic guide wire with or without a catheter was introduced and passed though the ureteric obstruction into the bladder. The punctured track was dilated and a nephrostomy tube was inserted. Results Successful nephrostomy was performed on 542 patients. The nephrostomy tube was insetted into the ureter or renal pelvis in 539 cases and insetted into renal calices in 3 cases, with complications of renal pelvic tear in 5, pleura injury in 3, mild post-operative hemorrhage in 3 and delayed massive hemorrhage in 1. One patient died of heart failure after nephrolithotomy. The total stone-free rate was 88% after the fast nephrolithotomy. Conclusion The use of fine needle antegrade pyelography combined with rotational fluoroscopy to determine the kidney access improves the success rate and reduces the incidence of complication.