微通道与标准通道经皮肾镜取石术治疗肾结石的疗效

Comparison of clinical effects between mini-percutaneous nephrolithotomy and percutaneous nephrolithotomy for renal calculi

目的探讨微通道经皮肾镜碎石取石术(mPCNL)与标准通道经皮肾镜碎石取石术(PCNL)治疗肾结石的疗效和优缺点,以期提高肾结石的治疗水平。方法 2009年1月—2012年7月,在B超引导下采用mPCNL治疗178例肾结石患者,采用标准通道PCNL治疗194例肾结石患者。比较两组患者的手术时间(开始穿刺至肾造瘘管留置结束)、肾造瘘管留置时间、术中出血量、Ⅰ期结石清除率、术中输血率,测定血清肌酐(sCr)水平和肾小球滤过率(GFR),观察患者术后有无并发症(迟发型出血、感染等)发生。结果 mPCNL组各种类型结石患者的手术时间均显著长于标准通道PCNL组(P值均<0.05),术中出血量显著少于标准通道PCNL组(P<0.05)。mPCNL组肾盏多发结石的Ⅰ期结石清除率为90.1%(64/71),显著高于标准通道PCNL组的76.5%(65/85,P<0.05);单纯性肾盂结石的Ⅰ期清除率为78.5%(51/65),显著低于标准通道PCNL组的95.1%(58/61,P<0.05)。mPCNL组术后第1、3天的sCr水平均显著高于同组术前(P值均<0.05),标准通道PCNL组术后第3天和术后1个月的sCr水平均显著高于同组术前(P值均<0.05);mPCNL组术后第1、3天的sCr水平均显著高于标准通道PCNL组同时间点(P值均<0.05),而术后1个月的sCr水平显著低于标准通道PCNL组同时间点(P<0.05)。两组术后第1天的GFR均显著低于同组术前(P值均<0.05),标准通道PCNL组术后第3天的GFR显著高于同组术前(P<0.05);mPCNL组术后第1天的GFR显著低于标准通道PCNL组同时间点(P<0.05)。结论较大的肾盂结石优选标准通道PCNL,肾盏多发结石首选mPCNL处理。标准通道PCNL对患者肾功能的影响小于mPCNL。建立通道扩张所引起的肾功能损伤小于灌注压力的危害。

Objective To compare the clinical outcomes between standard percutaneous nephrolithotomy（PCNL）and mini-PCNL（mPCNL）for the treatment of renal calculi in order to improve the treatment of kidney stones.Methods From January 2009to July 2012,B-ultrasound guided PCNL was performed in 194patients with renal calculi and mPCNL in 178patients.Operation time,blood loss,one-stage stone-free rate,blood transfusion,serum creatinine（sCr）,and glomerular filtration rate（GFR）were recorded.Postoperative complications,such as hemorrhage and infection were observed.Results The mPCNL group had a longer operation time than the PCNL group in various types of stones（P0.05）.The blood loss in mPCNL was significantly less than that in PCNL（P0.05）.The one-stage stone-free rate for multiple stones in renal calices in the mPCNL group was significantly higher than that in the PCNL group（90.1%vs.76.5%,P0.05）.But the clearance rate for simple renal pelvis stone in the mPCNL group was significantly lower than that in the PCNL group（78.5% vs.95.1%,P0.05）.Compared with preoperative values,sCr was significantly increased on day 1and 3postoperatively in the mPCNL group,and on day 3and month 1postoperatively in the PCNL group（P0.05）.The level of sCr was significantly higher in the mPCNL group than that in the PCNL group on day 1and 3postoperatively（P0.05）,while one month later,the level of sCr was significantly lower in mPCNL group than that in PCNL group（P0.05）.The GFR was significantly decreased as compared with preoperative one in all patients（P 0.05）.The GFR was significantly higher in PCNL group than that in mPCNL group on day 1and 3postoperatively（P 0.05）.Conclusion The PCNL may be suitable for large renal pelvis stone,while mPCNL has advantages in the treatment of renal calyx stone.Renal function is less affected by PCNL as compared with mPCNL.Renal function impairment caused by expansion in the establishment of channel process is far lower than caused by the perfusion pressure.