“一站式”诊疗方案在复杂性肾结石经皮肾镜碎石术中的应用

Application of one-stop diagnosis and treatment plan in percutaneous nephrolithotomy for patients with complex renal calculi

目的评价术前CT尿路成像（CTU）三维重建结合术中X线和B超实时引导穿刺建立通道，采用EMS系统行经皮肾镜碎石术（PCNL）的“一站式”诊疗方案在复杂性肾结石中的应用价值。方法回顾性分析华中科技大学同济医学院附属协和医院泌尿外科2008年12月至2011年12月收治的210例复杂肾结石患者临床资料，其中119例纳入“一站式”方案诊疗组，术前行CTU及三维重建规划设计穿刺路径，采用B超和X线实时引导穿刺建立通道，应用EMS系统行经皮肾镜碎石术。余91例术中无X线监测行经皮肾镜碎石术病例纳为对照组，统计分析两组间1次穿刺成功率、平均通道建立时间、平均手术时间、术中平均出血量及I期结石清除率等指标。术后随访至2012年6月。结果“一站式”方案诊疗组1次穿刺成功率98．3％（117／119），高于对照组92．3％（84／91），差异有统计学意义（P=0．037），手术时间（97．8±13．2）rain较对照组（110．0±14．7）min缩短（P=0．043），且I期结石清除率92．4％（110／119）较对照组83．5％（76／91）高（P=0．037）。两组平均通道建立时间分别为（15．3±3．7）min和（13．9±3．9）min、术中平均出血量分别为（195．8±84．2）ml和（263．3±82．1）ml，差异均无统计学意义（均P〉0．05）。两组均无严晕并发症发生，随访期间未见结石复发。结论CTU三维罩建结合X线、B超引导建立通道行PCNL的“一站式”诊疗方案，有助于规划最佳手术路径，提高穿刺成功率和I期结石清除率，减少穿刺和手术并发症。

Objective To evaluate the safety and efficacy of preoperative computed tomography urography （CTU） three-dimensional reconstruction, intraoperative radiology and ultrasound guidance followed by percutaneous nephrolithotomy （PCNL） in the treatment of complex renal calculi. Methods We summarized the clinical data of 210 patients with complex renal calculi treated at our hospital from December 2008 to December 2011 in this retrospective study. In the one-stop diagnosis and treatment group （n = 119）, the optimal puncture approach was designed according to CTU imaging and three-dimensional reconstruction. Percutaneous track was established by ultrasound and radiology guided puncture. PCNL was performed with EMS system. The control group （ n = 91 ） underwent PCNL without radiological guidance. The success rate of puncture, mean accessing tittle, mean operative duration, intraoperative volunle of blood loss and stone-free rate after one operative session were observed. Post-operative follow-ups were conducted until June 2012. Results Compared to the control group, the one-stop diagnosis and treatment group showed a higher success rate of puncture [ 98.3% （117/119） vs 92.3% （84/91）, P = 0. 037 1, a shorter operative duration [97.8 ± 13.20 vs 110.0± 14. 73 rain, P =0. 043] and a higher stone-free rate after one operative session [92. 4% （110/119） vs 83.5% （76/91）, P = 0. 037 1- No significant difference was detected in the mean accessing time[ 15.3 ±3.7 vs 13.9 -±3.9 min, P = 0. 398 J or intraoperative volume of blood loss [ 195.8 ± 84. 15 vs 263.3 ± 82. 06 ml, P = 0. 059 1 , No severe complications occurred. No recurrence of calculi was noted during the follow-up period. Conclusion One-stop diagnosis and treatment plan （CTU 3-D reconstruction plus radiology, ultrasound guidance followed by PCNL） may identify the puncture path, improve the successful rate of puncture and stone-free rates and reduce the complications of PCNL.