微创经皮肾镜取石术治疗上尿路结石的临床应用336例报道

Clinical application of minimally invasive percutaneous nephrolithotomy to treatment of upper urinary calculi:Report of 336 cases

目的:探讨微创经皮肾镜取石术(mPCNL)治疗肾结石和输尿管上段结石的方法及效果。方法:分析我院2009年11月～2012年11月自主开展的mPCNL 336例。结果:男206例,女130例,年龄16～80岁,平均年龄(47.6±12.1)岁。左侧上尿路结石141例,其中左肾结石93例,左输尿管上段结石20例,左肾结石合并左输尿管上段结石28例;右侧183例,其中右肾结石127例,右输尿管上段结石31例,右肾结石合并右输尿管上段结石25例;双侧上尿路结石12例,其中3例肾结石合并对侧输尿管上段结石,5例双肾结石,4例双侧输尿管上段结石。其中肾铸型结石33例,肾脏多发性结石86例,孤立肾结石6例。结石1.5～7.0cm大小不等,平均(3.1±1.4)cm。336例一期均成功建立经皮肾镜微创通道,手术时间30～240 min,平均(117.0±42.1)min。1例中转开放切除患肾。1例中转开放取石。67例患者一次碎石不完全,有结石残留>8 mm。8例患者一次碎石效果不满意,二次经皮肾镜碎石,其中6例结石清除完全。6例患者术后1周内发生急性大出血,均保守治疗成功。1例通道经过胸膜腔,用凡士林纱布填塞瘘道后吸收愈合。其中145例采用"无管化"。本组无腹腔脏器损伤等严重并发症。总结石取尽率为81.8%。结论:MPCNL治疗肾结石及(或)合并输尿管上段结石安全、有效,具有创伤小,恢复快等优势。

Objective： To investigate the outcomes and approaches to treatment of renal and upper urinary calculi with minimally invasive percutaneous nephrolithotomy （ mPCNL ）. Methods ： Retrospective analysis was performed in 336 patients with upper ureteral calculi undergone mPCNL between Nov. 2009 and 2012 in our hospital. Results ： Of the total 336 cases,206 were male and 130 female. The ages ranged from 16 to 80 years with an average of 47.6 ± 12.1. The stone location was involved in the left upper urinary tract in 141 cases,including 93 in left kidney,20 in left upper ureter and 28 in both left kidney and upper ureter. Another 183 cases were in the right urinary tract,in which 127 were found in right kidney,31 in right upper ureter and 25 in both right kidney and upper ureter. Uroliths of upper urethral tract involved both sides were seen in 12 cases, in whom 3 were in kidney associated with contralateral upper ureter,5 in both kidneys and 4 in both upper ureters. Of the 125 cases with complex calculi ,33 were staghom stones, 86 multiple renal calculi and remaining 6 solitary kidney stones. The stone measured from 1.5 cm to 7.0 cm in diameter with a mean size of （ 3. 1 ± 1.4 ） cm. Primary peroutaneous puncture was .successfully performed in the total 336 patients, and the pro- cedure lasted from 30 to 240 min （ mean 117.0 ± 42.1 min）. One case was referred to surgical removal of the diseased kidney and another one to open nephrolithotomy. Residual stone measured greater than 8 mm was found in 67 cases. Unsatisfactory outcome was seen in 8 patients who re- quired secondary percutaneous nephrolithotomy-lithotripsy and whose stones were totally removed in 6. acute hemorrhea occurred One week after the operation in 6, in whom 1 was managed with expectant intervention and another 1 （ passage traversing pleural cavity） by applying petrolatum gauze to the fistula. One hundred and forty five patients received tubeless minimally invasive percutaneous renal puncture and ureteroscopic ]itho- tripsy. No incidence pertaining to the injury of the abdominal organs or serious complications occurred, and the total stone clearance rate was 81.8%. Conclusion ：mPCNL is safe and effective to the treatment of renal calculus and/or upper ureteric stones, with minimal invasion and early recovery.