微造瘘经皮肾镜吸引取石术治疗上尿路结石858例报告

MPCNL with irrigation and clearance system treatment urinary tract stones:Report of 858 cases

目的:探讨微造瘘经皮肾镜吸引取石术的安全性及有效性。方法:2008年8月～2011年4月应用专利微造瘘经皮肾镜吸引清石系统对上尿路结石行微造瘘经皮肾镜吸引取石术858例,其中肾结石626例(双肾结石32例,鹿角形肾结石302例),结石平均负荷为(8.57±2.25)cm2;输尿管上段结石并肾积水232例(双侧输尿管上段结石65例),结石平均负荷为(1.16±0.25)cm2。所有患者均平俯卧位,肾脏不固定,B超引导穿刺,根据KUB及CT图像建立合理通道,利用硬质鞘活动灵活的特点,连续大流量灌注,采用大功率钬激光碎石,同步吸引取石。结果:858例共955侧均成功建立通道,行818例915侧一期手术,40例40侧二期取石,其中单通道883侧,双通道54侧,三通道18侧。平均每个通道建立时间为3.2min。肾结石平均取石时间为45.4min,输尿管结石为9.3min。肾结石一期结石清除率为91%(599/658侧),输尿管结石为100%(297/297侧)。辅助治疗后,肾结石清除率为96.8%(637/658),平均出血量为(55±23.1)ml,输血率为1.75%(15/858)。术后介入治疗率为0.69%(6/858例),术后发热发生率为3.8%(33/858例),灌流液外渗发生率为2.1%(18/858例),无周围脏器损伤,无死亡病例。结论:微造瘘经皮肾镜吸引取石术在微创的基础上负压吸引、主动、快速清石,术中肾盂正、负压低,明显降低了术后发热、菌血症、脓毒血症等并发症,提高了安全性,可应用于小儿肾结石的治疗,是一种新型、安全、高效、单通道一期清石率高的术式。

Objective,. To investigate the safety and efficacy of MPCNL with irrigation clearance system. Meth- od：A retrospective analysis 858 patients underwent MPCNL with patent sheath and irrigation clearance system. From August 2008 to April 2011. There were 626 cases of renal stones （including 32 cases with bilateral renal calculi, 302 cases of staghorn calculi） with an average stone burden of （8.57±2.25） cm2 there were 232 cases of upper ureteral stones complicated by hydronephrosis （including 65 cases of bilateral upper ureteral stones）, with an average stone burden of （1.16±0.25） cm2. There were 86 cases complicated by pyonephrosis and 65 cases had a history of open surgery to remove the stones. The patient was placed in a flat prone position without boosting the abdomen to prevent the fixation of the kidneys. The MPCNL was performed after establishing a percutaneous tract under the guidance of B ultrasound combined with KUB and CT images, with the aid of the patented system. The lithotripsy was performed using a high-powered holmium laser. Result： Percutaneous tracts were established successfully in all 858 cases, in which stones were located in 955 sides. There were 915 sides that had lithotripsy on the first surgery and 40 sides that underwent a second-stage lithotripsy due to complicated pyonephrosis. There were 843 sides in which a single percutaneous tract was used, 54 sides in which double percutaneous tracts were used, and 18 sides in which 3 percutaneous tracts were used. The average time in establishing a pereutaneous tract was 3.2 rain. The average stone clearance time was 45.4 rain for kidney stones and 9.3 minutes for ureteral stones. Stone clearance by one surgery was 91% for kidney stones （599/658 sides） and 100% for ureteral stones （297/297 sides）. Stone clearance rate after supplemental therapies was 96.8 % （599/658 sides） for kidney stones. The average amount of bleeding was （55±23. 1） ml. The percentage of cases needing blood transfusion was 1. 75%（15/858）. The percentage of cases needing interventional embolization to stop bleeding was 0.69% （6/858）. The percentage of cases that had postoperative fever was 3.8% （33/858）. The percentage of cases that had irrigation fluid extravasations was 2.1% （18/858）. There was no case that had injury to surrounding organs during the surgery. Conclusion： MPCNL with irrgation clearance system is a minimally invasive, quick, safe surgical procedures, and significantly reduced bacteremia, sepsis and other complications.