两步法建立标准通道经皮肾镜取石3052例临床报告

Standard-tract percutaneous nephrolithotomy accessed by two-step dilation for 3 052 patients

目的:探讨两步法建立标准皮肾通道的经皮肾镜技术的安全性和有效性。方法:自2006年6月至2008年12月北京大学人民医院泌尿外科应用B超引导下穿刺,两步法建立标准通道的经皮肾镜碎石、清石技术治疗上尿路结石患者3052例,共3366侧上尿路结石,其中包括:孤立肾108例,肾盏憩室合并结石68例,马蹄肾44例,脊柱畸形26例,海绵肾24例,移植肾1例,结石负荷(长径)(47.2±35.6)mm。结果:3052例患者共行两步法建立标准通道的经皮肾镜碎石术(PNL)3740例次。3730例次(99.4%)一期成功建立通道完成手术。单通道手术的3348例次(89.5%),2通道366例次(9.7%),3通道26例次(0.7%)。平均手术时间(68.4±30.9)min,平均首个通道建立时间(17.6±11.1)min,平均结石处理时间为(35.0±55.3)min。一期手术净石率:单发结石为100%,多发结石与鹿角状结石为72.3%,374例(11.1%)再次接受手术清除残余结石,最终手术净石率88.6%。术中和术后的并发症主要是出血,术中和术后接受输血患者52例(1.4%),其中12例(0.3%)行选择性肾动脉栓塞治疗,1例(0.03%)接受肾切除手术控制出血。毗邻脏器损伤罕见:气胸3例(0.08%),无肠道、肝或脾等腹腔脏器损伤,腹膜后尿或灌注液的外渗有19例(0.5%),未出现感染性休克的病例。结论:两步法建立标准通道的经皮肾镜技术对于上尿路结石的治疗是有效而安全的。

Objective：To evaluate the efficacy and morbidity of 24F-tract percutaneous nephrolithotomy（PNL） accessed by two-step dilation.Methods：A total of 3 052 patients with 3 366 kidneys or upper ureter calculi underwent 24F-tract PNL accessed by two-step dilation between Aug.,2003 and Jan.,2008,including 108 patients with solitary kidney,68 with kidney cysts,44 with horseshoe kidney,26 with vertebral column deformity,24 with medullary sponge kidney and 1 transplanted kidney.Stone burdens were（47.2±35.6） mm in length.Results：99.4% of 3 740 operations were successful in one-session access,in which 3 348 PNLs were accessed by single tract（89.5%）,366 by double tracts（9.7%） and 26 by triple tracts（0.7%）.The mean operating time was（68.4±30.9） min,the mean first accessing time were（17.6±11.1） min.and the mean calculi-dealing time were（35.0±55.3） min.The stone-free rate after one session operation was 100% for single calculus and 72.3% for multiple or staghorn calculi.of all the kidneys,374（11.1%） accepted another PNL to remove the residual calculi,and the last stone-free rate of PNL was 88.6%.During and after operation,52 cases（1.4%）needed transfusion,12（0.3%）underwent selective embolization of renal artery and 1（0.03%）accepted nephrectomy for bleeding control.No injury of organs occurred except for 3 cases with pneumatothorax and 19（0.5%）with urinary extravazation.No septic shock occurred.Conclusion：24F-tract PNL accessed by two-step dilation wtih ultrasound-guided puncture is effective and safe.