超微经皮肾镜取石术治疗31例肾结石的初步体会

Super-mini percutaneous nephrolithotomy for the treatment of kidney stones： a preliminary report of 31 cases

目的 报道一种命名为超微经皮肾镜取石术（super-mini-PCNL,SMP）的新技术,并探讨其治疗肾结石的临床效果、适应证及安全性. 方法 SMP技术利用外径为7F、工作通道为3.3F超细肾镜,通过10～12 F带吸引功能的peel-away鞘,采用钬激光或气压弹道碎石机击碎结石,并借助负压吸引器将碎石屑经带吸引功能的peel-away鞘吸到碎石收集瓶.2013年4-7月采用SMP技术治疗肾结石31例,其中儿童5例、体外冲击波碎石（ESWL）和/或软性输尿管镜治疗失败11例、孤立肾3例.结石位于下盏、中盏、上盏、肾盂、肾盂合并下盏、肾盂合并输尿管上段分别为12、2、1、7、6、3例.结石最大直径（1.9±0.6） cm. 结果 单通道28例,双通道3例.手术时间25～140 min,平均（54±30）min,术后血红蛋白下降（12.2±9.5） g/L.术后第1天结石清除率为94％（29/31）,其中1例需二期SMP取石,1例上盏残留结石直径0.5 cm,需要ESWL辅助治疗;1个月总结石清除率达100％.2例（6％）出现术后发热,无需输血者.术后住院时间为（1.8±0.8）d.31例术后均未留置肾造瘘管,27例术后无须留置双J管,2例患者因需要同时处理同侧输尿管中段和下段结石留置输尿管外支架管24 h,2例因同时行同侧肾盂输尿管连接处狭窄内切开留置双J管8周. 结论 SMP治疗小于2 cm肾结石安全、有效,尤其适用于儿童肾结石、PCNL术后残留平行盏结石和ESWL及软镜治疗失败肾结石的治疗.

Objective To describe our novel modified technique of super-mini percutaneous nephrolithotomy （SMP） and to report the safety,indication,and technique of this procedure for the treatment of kidney stones.Methods SMP was performed on 31 patients after proper consents were obtained.The procedure was done using a 7 F mini-nephroscope with 3.3 F working channel （Hawk,China） and a 10 or 12 F nephrostomy sheath that possessed suction-evacuation function.The sheath was connected to a specimen container then onto a negative pressure aspirator.Lithotripsy was performed using holmium：YAG laser and/or pneumatic lithotripter.Among our 31 patients,5 were children,11 were failed extracorporeal shock wave lithotripsy （ESWL） or retrograde intrarenal surgery,and 3 patients had solitary kidney.The stones in low pole,mid pole,upper pole,pelvic,pelvic-low pole,pelvic-upper ureter were 12,2,1,7,6,3 cases,respectively.The mean stone size was （1.9±0.6） cm.Results The average operative time was 54±30 （25-140） min.The mean hemoglobin drop was （12.2±9.5） g/L.Three cases require two nephrostomy tracts,and the remaining 28 required only single tract.The stone-free rate after 1 day was 94％ （29/31）.One patient required a second look SMP,and another one required auxiliary ESWL.The stone-free rate at 1 month was 100％.Fever occurred in 2 cases.No one needed blood transfusion.The mean postoperative hospital stay was （1.8±0.8） d.None of the patients had nephrostomy tube and 27 patients had neither double J stent nor Foley catheter placed.Two patients had both renal stone and ipsilateral ureteral stone treated simultaneously,and these 2 patients had ureteral catheter for 24 h.There were 2 patients underwent concurrent endopyelotomy for ureteropelvic junction obstruction and these 2 patients had indwelling ureteral stents for 8 weeks.Conclusions Our SMP with a suction-evacuation system is a safe and efficacious procedure for renal stones smaller than 2 cm.It might be particularly suitable for children,patients with lower pole stones,and residual stonse after previous surgical interventions.