超声引导经皮肾镜气压弹道联合超声碎石清石术治疗复杂上尿路结石

Pneumatic combined with ultrasound lithotripsy in percutaneous nephrolithotomy under ultrasound guidance for treatment of complex upper urinary tract stone

目的探讨超声定位引导经皮肾镜气压弹道联合超声碎石清石术治疗复杂上尿路结石的安全性及其疗效。方法2005年6月-2009年10月,采用在新型微创经皮肾镜(F20.8)下超声联合气压弹道碎石清石术治疗1088例复杂上尿路结石患者,其中肾多发结石583例,部分或完全鹿角状结石387例,感染性结石35例,孤立肾结石13例,合并肾功能不全(氮质血症)43例,肾盏憩室结石27例,均在B超引导下穿刺并扩张建立F24皮肾通道,在肾镜下应用瑞士EMS三代气压弹道联合超声碎石清石系统进行碎石并吸出体外,术中B超检查示有残留结石的患者,则在B超引导下进入结石位置肾盏进行碎石。结果866例患者一期经皮肾镜碎石(PCNL)取净所有结石,一期净石率为79.6%。一期手术的时间为20～180min,平均手术时间为(45.2±4.7)min;术中失血量为10～450mL,平均失血量为(40.3±3.5)mL。术后泌尿系X线平片检查显示115例(10.6%)有残留的直径>5mm的结石,行二期PCNL取石;76例(7.0%)患者接受三期PCNL取石。29例(2.7%)术后行辅助体外冲击波碎石治疗。9例术后出现严重出血,8例行超选择性肾动脉栓塞止血后好转,1例因术后严重迟发性出血止血效果不理想行肾切除;1例术后出现肾周巨大血肿,行保守治疗后好转。结论采用经皮肾镜下超声联合气压弹道碎石清石术治疗复杂上尿路结石安全、高效,术中应用B超检查残留结石简便、易行,并能帮助引导肾镜清除残留结石,可显著提高复杂上尿路结石的治疗效果。

Objective To evaluate the efficacy and safety of pneumatic combined with ultrasound lithotripsy in percutaneous nephrolithotripsy （PCNL） for treatment of complex upper urinary tract stone. Methods From June 2005 to October 2009, a total of 1,088 patients with complex upper urinary tract stone underwent primary PCNL by pneumatic and ultrasonic lithotripsy under ultrasound guidance. Of the 1,088 patients, 387 had staghorn calculi, 583 had multiple calculi, 35 had infective calculi, and 13 had solitary renal calculi. Ultrasonography was performed after the extraction of all the endoscopically detected stone fragments. The residual fragments were removed under the assistance of B type ultrasonography through pneumatic or ultrasoud lithotripsy. Results Kidney ureter and bladder X-Ray （KUB） demonstrated that 879 cases （79.6%） were stone-free after the primary procedure. Residual calculi （greater than 5 mm） were found in 115 cases （10.6%） by postoperative KUB, and they received a second PCNL; 76 cases （7.0%） received a third PCNL; 29 patients （2.7%） received an ancillary extracorporeal shock wave lithotripsy. The average operative time was （45.2±4.7） min （ranging 20-180 min）; the average blood loss was （40.3±3.5） mL （ranging 20-450 mL）. Eight cases had severe hemorrhage postoperatively and were cured withsuperselective angiographic embolization; only one case who had severe hemorrhage was transferred to open operation. One case had giant perirenal hematoma postoperatively was cured with conservative therapy. Conclusion Pneumatic combined with ultrasound lithotripsy during percutaneous nephrolithotomy is effective and safe for complex upper urinary tract stone. Intraoperative ultrasonic inspection is simple and easy to perform, which allows sensitive intraoperative detection of residual fragments and can effectively reduce residual stones, enabling immediate removal during the primary procedure or the planning of necessary second look nehroscopy.