导丝及穿刺针在经皮肾镜碎石术中的新应用

Application of guide wire and puncture needle in percutaneous nephrolithotomy

目的探讨导丝及穿刺针在经皮肾镜手术中提高一次结石清除率的临床疗效。方法 2008年10月至2009年10月本科收治的鹿角型结石患者中,有19例患者使用导丝及穿刺针来提高结石清除率,其中男性11例,女性8例,平均年龄42.8岁。左侧10例,右侧9例,术前行CT、肾盂分泌造影等检查明确诊断。患者均给予全身麻醉,穿刺点选择在第12肋缘下、腋后线与肩胛下线之间区域,超声引导下用18G穿刺针进行穿刺,穿刺成功后经穿刺针留置导丝,扩张穿刺通道至F18后,留置Peel-away鞘,置入肾镜,用钬激光将视野所能见结石击碎,并将结石碎块冲出体外。如X线或超声检查证实有肾盏结石残留,保留原穿刺通道,超声引导下经有残余结石的肾盏进行穿刺,穿刺成功后将导丝置入肾盂,X线片证实导丝位于肾盂内,经第1个穿刺通道进境寻找导丝,沿导丝寻找肾盏内结石,必要时行肾盏颈口劈开。如因角度问题,沿导丝无法探及结石,撤出导丝,超声引导下用穿刺针直接穿到结石表面,并稍用力将肾盏内结石推入肾盂内进行碎石。结果 2例肾盏颈口较窄,行两通道碎石,其余17例均碎石成功,结石一次性完全清除,平均手术时间83.2min,术中估计出血量100ml,术后下床活动时间14.6d,术后住院5.8d。3例患者术后出现发热,无尿瘘、胸膜损伤、大出血等并发症出现。结论经皮肾镜手术中导丝及穿刺针的新应用,可显著提高一次结石清除率,尤其对于复杂性鹿角形结石患者,可减少多通道手术过程中引起的出血、术后感染等并发症。

Objective To study the application of guide wire and puncture needle in percutaneous nephrolithotomy for improving the stone free rate.Methods Nineteen patients（11 males and 8 females） with staghorn stones admitted to our department from October 2008 to December 2009 were enrolled in this study.Their average age was 42.8 years.CT and pyelography showed staghorn stones in the left kidney of 11 patients and in the right kidney of 9 patients.General anesthesia was performed in all patients.Puncture was performed in the area under the costal margin 12 between the posterior axillary line and subscapular line using a 18F needle under the guidance of ultrasound.The puncture channel was dilated to the F18,where the peel-away sheath of the needle was left.A ureteroscope was inserted and the visible stones were fragmented using Holmium laser and then removed out of the body.If there were residual stones in any calyx inaccessible with the ureteroscope,another puncture was made under the guidance of ultrasound to the calyx with residual stones.The guide wire was inserted through the needle to the pelvic,and the ureteroscope was inserted through the first puncture channel to find the guide wire,along which the calyx calculi were observed.The renal calyx neck was split if necessary.The guide wire was withdrawn if the stones could not be touched by the guide wire because of a bad angle,and the surface of calyx calculi was directly punctured with a puncture needle under the guidance of ultrasound.The stones were slightly pushed away from the calyx to renal pelvic and fragmented.Results Two-channel fragmentation of stones was performed in 2 patients due to a large pelvic and a small calyx with a narrow calyx neck.Lithotripsy was successful in the other 17 patients with a stone free rate of 100%.The average operation time was 83.2 min and the mean estimated intraoperative blood loss was 100 ml.The mean postoperative hospital stay time of the patients was 5.6 d.Fever occurred in 3 patients after operation and was alleviated after treatment with antibiotics.No urinary leakage,pleural injury,hemorrhage and other complica-tions occurred.Conclusion Guide wire and puncture needle can significantly improve the stone free rate of percutaneous nephrolithotomy,decrease the blood loss in patients with staghorn stones and post-operative complications such as infection.