经皮肾镜下碎石术用于抗凝/抗血小板药物治疗患者的有效性及安全性

Safety and Efficacy of Percutaneous Nephrolithotomy in Patients Receiving Anticoagulant or Antiplatelet Therapy

目的:评估在需要长期应用抗凝/抗血小板药物治疗患者中行经皮肾镜下碎石术(percutaneous nephrolithotomy,PCNL)的有效性和安全性。方法:回顾分析2004年3月—2012年10月在复旦大学附属华东医院泌尿外科行PCNL的402例患者的临床资料,其中21例患者应用抗凝/抗血小板药物,21例中2例应用华法林、4例应用氯吡格雷,15例应用拜阿司匹林。应用华法林患者于术前5 d停药,术后5 d恢复用药;应用氯吡格雷和拜阿司匹林患者于术前10 d停药,术后5 d恢复用药。分析21例患者术前及术后的血红蛋白、血肌酐的变化,结石清除情况,以及术中、术后出血或者血栓形成情况。结果:21例患者平均手术时间为(95.8±5.7)min,其中行二期手术患者2例,1个月后患者的结石清除率为95.2%(20/21);血红蛋白平均下降(7.5±1.4)g/L,肌酐平均下降(7.7±1.8)μmol/L。2例患者需要输血,其中1例发生大出血,行肾动脉栓塞;1例发生深静脉血栓,安装下腔静脉滤网治疗。结论:对于应用抗凝/抗血小板药物的患者,在做好围手术期抗凝/抗血小板药物管理后行PCNL是相对安全、有效的,但需要充分评估停药后发生血栓并发症的风险。

Objective：To assess the safety and efficacy of percutaneous nephrolithotomy （PCNL） in patients receiving longterm anticoagulant or antiplatelet therapy.Methods：The clinical data of 402 patients undergoing PCNL from Mar 2004 to Oct 2012 were retrospectively analyzed,of whom 21 patients were treated with anticoagulant or antiplatelet therapy including 2 cases with warfarin,4 cases with clopidogrel,and 15 cases with aspirin.Warfarin was withheld 5 days preoperatively and was resumed 5 days postoperatively in patients applying warfarin.Aspirin and clopidogrel were stopped 10 days preoperatively and were resumed 5 days postoperatively in patients treated with aspirin and clopidogrel.The changes of hemoglobin,serum creatinine,and stone clearance rate were analyzed preoperatively and postoperatively. Complications such as thrombogenesis or hemorrhage were subsequently analyzed either intraoperatively or postoperatively.Results：The average operating time of PCNL was （95.8 ± 5.7）min.Second-stage operation happened in 2 patients.One month after surgery,the stone clearance rate was 95.2% （20/21）.Mean hemoglobin decrease was （7.5 ± 1.4）g/L and mean change in serum creatinine was （7.7 ± 1.8）μmol/L.Two patients needed blood transfusion.Massive hemorrhage happened in one case,which was controlled by renal arterial embolization.The other suffered from deep vein thrombosis and inferior vena cava filter was inserted.Conclusions：With carefully perioperative management of anticoagulant or antiplatelet therapy,percutaneous nephrolithotomy can be performed safely and efficiently in properly selected patients receiving anticoagulant or antiplatelet therapy.However,More attention should be paid to the risk of thromboembolic complications due to the cessation of anticoagulant or antiplatelet agents.