320排肾脏CTA在“腰肋悬空”仰卧位PCNL中的应用价值

320 row computed tomographic angiography for planning of "Flank suspended" supine percutaneous nephrolithotomy

目的:评价320排肾脏CTA(CT血管造影)"在腰肋悬空"仰卧位经皮肾镜碎石术中的应用价值及腰肋悬空仰卧位的影像解剖学特点。方法:2010年9月～2011年7月对23例肾结石患者术前行320排肾脏CTA及三维重建,明确肾脏分支血管分布情况及肾脏与周围脏器毗邻关系,进而设计最佳穿刺路径建立经皮肾穿刺通道。患者平均年龄(49.5±11.5)岁;最大径2～6cm,平均为(2.97±1.29)cm。均采用椎管麻醉;手术体位采用腰肋悬空仰卧位。在B超引导下穿刺肾盂或目标肾盏成功后,依次扩张通道至F16或F20,用钬激光或三代超声将结石完全击碎。术后复查320CTA验证穿刺路径及了解结石残留情况。结果:肾脏320排CTA可清晰显示肾内分支血管分布情况。本组23例患者全部穿刺成功,建立通道满意,一期清石率82.6%(19/23)。所有患者均未输血,无胸膜及内脏器官损伤。术后320排CTA检查显示肾造瘘管位于肾脏无血管区。结论:320排CTA可以明确结石、肾盂肾盏、肾分支血管分布及三者关系,真实反映肾脏与周围器官毗邻关系,以利于设计最佳通道,从而降低大出血及损伤邻近脏器风险。腰肋悬空仰卧位时经腋后线于水平方向进针,可通过肾脏无血管区建立通道。

Objective： Retrospective evaluation computed tomographic angiography（CTA） of kidney before ＂ flank suspended＂ supine （FSS） percutaneous nephrolithotomy（PCNL） and anatomic image information of FSS. Method：Twenty-seven consecutive patients with renal calculi underwent 320 row CTA in FSS or complete supine position to predict calculus positon, intrarenal vessels and adjacent visceral organ for planning of PCNL. Their av- erage age was （49.5±11.5） years, and the average bulk of the stone was （2.97±1.29） cm. All patients were placed in FSS. Under ultrasound guidance, the desired calix or pelvis was punctured near the posterior axillary linel then dilate the tract and establish the F16 or F20 tract for PCNL. Result：CTA images of intrarenal artery were obtained before operation in all cases. Pelvicaliceal system could be successfully approached in all patients. All pa- tients were well tolerated. Mean operation time was （87.54±33.07） minutes. 82.6%of the patients were ren- dered free of stones by the initial PCNL. None of patients required blood transfusion. None of the patients suf- fered visceral injury. 320 row CTA demostrate that nephrostomy tube pass through avascular plane after opera- tion. Conclusion：Three hunder and twenty row CTA can accurately demonstrate calculus positon, intrarenal ves- sels, spatial relationships of the collecting system and adjacent visceral organ before PCNL. It is effective for se- lecting optimal sites for FSS-PCNL tracks to give maximum stone clearance and minimal risk of bleeding and vis- ceral organ injury. Puncture near the posterior axillary line in horizontal direction pass through avascular plane in FSS.