肾上盏入路经皮肾镜取石术的安全性及效果分析

Safety and efficacy of upper-pole access percutaneous nephrolithotomy

目的总结肾上盏入路经皮肾镜取石术（PCNL）的安全性和有效性。方法回顾性分析237例应用肾上盏入路PCNL治疗肾或输尿管上段结石的患者资料。男135例，女102例。年龄8—76岁，平均42岁。其中结石长径〉1．5cm或嵌顿性输尿管上段结石94例，长径≥2．0cm或嵌顿性肾盂结石26例，鹿角形结石或多发性结石68例，复杂性肾下盏结石13例，不适合行体外冲击波碎石术（ESWL）或输尿管镜碎石术（URS）的肾上盏结石12例，肾上盏憩室结石3例，肾结石并肾盂输尿管连接部（UPJ）梗阻或输尿管上段狭窄8例，过度肥胖结石患者3例，马蹄肾肾结石6例，移植肾肾输尿管结石4例。其中经第12肋上入路175例（73．8％），第11肋上入路46例，第12肋下入路12例，移植肾患者经下腹部入路4例。结果采用单一通道结石完全清除176例（74．3％），同期或分期建立多通道取石55例，联合ESWL6例。术后3个月复查结石清除209例（88．2％）。出现胸膜损伤16例（6．8％），行胸腔穿刺术8例，行胸腔闭式引流术5例，保守治愈3例。拔除肾造瘘管后出现胸膜刺激征12例（5．1％），予对症处理。无肺及其他内脏损伤。输血5例，其中行选择性肾动脉造影及栓塞术2例。结论肾上盏入路PCNL操作视野开阔、硬镜操作方便、结石清除率高，可选择性地应用于治疗输尿管上段结石和部分复杂性肾结石。

Objective To review the safety and efficacy of upper-pole access percutaneous nephrolithotomy （PCNL）. Methods From May 2008 to May 2010, 237 cases （ 135 males and 102 females with mean age of 42 yrs） of renal or proximal ureteral calculi treated with upper-pole access PCNL were reviewed. The indications included calculus larger than 1.5 cm or impacted proximal ureteral calculi in 94 cases, ealculus≥2 cm or impacted renal pelvic calculi in 26 cases, staghorn or multiple calculi in 68 cases, complex lower calyx calculi in 13 cases, upper calyx calculi not amenable to ESWL or URS in 12 cases, calculi within upper calyx diverticulum in 3 cases, combined UPJ obstruction or upper ureteral stenosis in 8 cases, morbidly obese patients in 3 cases, calculi within horseshoe kidneys in 6 cases, calculi within transplanted kidneys or ureters in 4 cases. Of the 237 cases, 175 tracts （73.8%） were above the 12th rib, 46 were above the llth rib, 12 were below the 12th rib, 4 were in the lower abdomen for renal transplant patients. Results The overall stone clearance rate with upper-pole access PCNL monotherapy was 74.3%. Additional punctures were required in 55 cases and combined ESWL in 6 cases. Total stone clearance rate at 3 months after operation was 88.2%. 16 patients （6.8%） had a pleural injury. Thoracentesis was required in 8 patients, closed thoracic drainage in 5 patients, conservative treatment in 3 patients. After nephrostomy tube removed, pleural irritation symptom appeared in 12 cases （5.1%） who required symptomatic treatment. No patient had injury to the lung or other viscera. Significant bleeding requiring blood transfusion was observed in 5 patients, while selective renal arterial embolization was required in 2 cases. Conclusions Upper-pole access offers optimal visibility, convenience for the movement of rigid nephroscope and high stone-free rate. It should be attempted in selected cases of upper ureteral calculi and complex renal calculi.