经皮肾镜取石术治疗肾结石出血风险因素分析

Analysis of risk factors affecting bleeding in percutaneous nephrolithotomy for treatment of kidney stones

目的探讨影响PCNL出血的风险因素。方法回顾性分析2008年1月至2011年1月218例肾结石患者的临床资料。男131例，女87例。年龄19～70岁，平均48岁。其中鹿角形结石146例。7例有开放或PCNL手术史。合并糖尿病41例，高血压病89例。本组手术均由同一术者完成。对患者的性别、年龄、体质量指数、伴随疾病、结石类型、穿刺肾盏、通道数量、通道大小、手术时间及术者经验等相关因素进行单变量及多变量回归分析。结果207例手术获得成功，11例因通道建立失败改开放或终止手术。采用单通道碎石176例，多通道碎石31例。采用18F通道163例，24F通道44例。平均手术时间78．4min。输血16例，输血率为7．7％，1例行选择性肾动脉栓塞，1例行肾脏切除。单变量分析中，鹿角形结石（P=0．034）、合并糖尿病（P=0．030）、通道数量（P=0．019）、通道大小（P=0．008）及手术时间（P=0．001）是影响输血率的主要因素。平均血红蛋白下降11．2g／L。其t中鹿角形结石患者平均血红蛋白下降（12．4±4．6）g／L，非鹿角形结石患者（8．3±3．3）g／L；单通道碎石（10．8±3．2）g／L，多通道碎石（13．2±3．5）g／L；18F通道碎石（10．5±2．5）g／L，24F通道碎石（13．2±4．4）g／L；糖尿病患者（12．7±5．3）g／L，非糖尿病患者（10．8±4．1）g／L。鹿角形结石（P〈0．001）、合并糖尿病（P：0．0t5）、通道数量（P=0．016）、通道大小（P〈0．001）及手术时间（P〈0．001）是影响血红蛋白下降的主要因素。年龄、性别、体质量指数、合并高血压、穿刺位置、既往手术史及术者经验不是影响出血的主要因素。多变量回归分析中，鹿角形结石（OR=1．92）、合并糖尿病（OR=1．75）、多通道（OR=2．45）、大通道（OR=1．32）及手术时间过长（OR=1．66）显著增加出血的风险。结论鹿角形结石、多通道、大通道、合并糖尿病及手术时间过长可显著增加PCNL出血的风险。

Objective The present study was designed to investigate the risk factors affecting bleed- ing during pereutaneous nephrolithotomy. Methods The records of 218 patients with percutaneous nepbrolithotomy procedure by a single surgeon were retrospectively reviewed. The mean age was 48 years （ range, 19 -70）. One hundred and forty six patients had staghore stones, and 7 patients had previous open or percutaneous nephrolithotomy histories. Forty-one patients had concomitant diabetes mellitus, and 89 cases bad hypertension. The following factors including age, sex, BMI, diabetes status, hypertension status, stone type, calix of puncture, previous open or percutaneous nephrolithotomy history, number of accesses, size of accesses, operative time, and surgeon experience were analyzed. Univariate analysis and multivariate step regression analysis were used for statistical assessment. Results 207 procedures were successfully performed, and 11 patients failed because of difficulty to establish the accesses. Single-tract was used in 176 cases and multiple-tract was used in 31 cases. 163 cases were performed via a 18 F access and 44 cases via a 24 F access. The mean operative time was 78.4 min. The overall blood transfusion rate was 7.7% , and stone type （P =0.034） , diabetes （P =0.030）, number of accesses （P =0. 019）, size of accesses （P =0. 008） and operative time （P = O. 001 ） were the risk factors affecting blood transfusion requirement. The average hemoglobin （Hb） drop after percutaneous nephrolithotomy procedures was 11.2 g/L, and stone type （P 〈0. 001 ）, diabetes （P =0. 015）, number of accesses （P =0. 016）, size of accesses （P 〈0. 001 ） and operative time （P 〈 0. 001 ） were the risk factors affecting Hb drop. The following covariates including Hb drop： age, sex, BMI, previous open or percutaneous nephrolithotomy history, hypertension status, calix of puncture and surgeon experience were not risk factors affecting blood transfusion requirement and Hb drop. Multivariate stepwise regression analysis showed that diabetes （ OR = 1.75 ）, stone type （ OR = 1.92）, num- ber of accesses （ OR = 2.45 ） , size of accesses （ OR = 1.32） and operative time （ OR = 1.66 ） significantly increased risk of bleeding. Conclusions Stone type, diabetes, number of accesses, size of accesses and operative time were the risk factors affecting blood loss during percutaneous nephrolithotomy.