超声引导经皮肾镜取石术治疗孤立肾肾结石的安全性分析

Safety and curative effects of ultrasound-guided percutaneous nephrolithotomy for renal calculi in solitary kidneys

目的：探讨超声引导经皮肾镜取石术（percutaneous nephrolithotomy,PCNL）治疗孤立肾肾结石的安全性及临床疗效。方法：回顾性分析2005年7月~2012年12月在我科行PCNL治疗的孤立肾合并肾结石患者138例,其中解剖性孤立肾16例,功能性孤立肾122例（对侧肾GFR〈10 m L/min）。肾功能异常35例。鹿角状结石41例,多发结石85例,单发结石12例,其中有同侧开放手术史者11例。采用实时彩色多普勒超声引导经皮肾穿刺,建立F18微创通道或F24标准通道,使用气压弹道超声碎石清石系统或钬激光清除结石。结果：138例均一期建立通道。采用单通道125例（90.6%）,双通道13例（9.4%）。平均通道建立时间（4.7±0.9）min,平均手术时间（49.5±12.6）min。术后血常规Hb平均下降5.8 g/L。6例患者接受输血,其中3例行超选择性肾动脉介入栓塞控制出血。35例肾功能异常者中,术后第1天SCr增高者32例（91.4%）,平均增高（19.8±7.4）μmol/L;术后第7天降至正常水平者26例（74.3%）。一期PCNL结石清除117例（84.8%）,术后1月复查结石总清除率91.3%（127例）。12例有残石者行体外震波碎石（extracorporeal shock wave lithotripsy,ESWL）治疗或保守观察。15例（10.9%）患者术后出现发热（体温〉38.5℃）,本组无脏器损伤和感染性休克病例。结论：超声引导经皮肾镜取石术治疗功能性或解剖性孤立肾合并肾结石是安全和有效的。

Objective： To evaluate the safety and curative effects of ultrasound-guided percutaneous nephrolithotomy （PCNL） for renal calculi in solitary kidneys. Methods： The clinical data of 138 renal calculi with functional or anatomic solitary kidney undergone PCNL in our department from July 2005 to December 2012 were retrospectively analyzed. They comprised of 16 anatomical solitary kidneys and 122 functional solitary kidneys （the GFR of contralateral kidney 〈 10 mL/min）. The total renal function was abnormal in 35 cases. There were staghorn calculi in 41 cases, multiple calculi in 85 cases, and single stone in 12 cases. 11 cases had a history of open nephrolithotomy. Percutaneous nephrostomy was performed to establish F 18 minimally invasive channels or F24 standard channel with the guide of color Doppler ultrasound, and all calculi were broken and extracted by EMS lithotripsy and clearance system or holmium laser. Results： The percutaneous renal accesses were successfully established in 138 cases, including single access in 125 cases （90.6%） and double accesses in 13 cases （9.4%）. the mean access setting time was （4.7±0.9） min, and the mean operation time was （49.5±12.6） min. Postoperative hemoglobin averagely declined for 5.8 g/L. Due to intra- or postoperative hemorrhoea, 6 patients received blood transfusion, and superselective renal angiographic embolization was performed to control bleeding in 3 of them. Of 35 cases of renal dysfunction, serum creatinine increased for （19.8±7.4） μmol/L in 32 cases （91.4%） on postoperative day 1, and declined to normal limits in 26 cases （74.3%） on postoperative day 7. Stones were cleared in 117 cases （84.8%） only by one time of PCNL. Total stone-free rate was 91.3% on postoperative month 1, and the remaining 12 cases with residual stones underwent ESWL and watchful follow-up. 15 cases （10.9%） had postoperative fever （temperature 〉38.5 ℃）, but there were no cases with organ injury and septic shock in this group. Conclusion： Ultrasound-guided percutaneous nephrolithotomy is safe and effective to treat renal calculi in functional or anatomical solitary kidneys.