无管化经皮肾镜治疗肾输尿管上段结石探讨

Study on tubeless mini-percutaneous nephrolithotomy in treatment of the upper ureteral calculi

目的探讨无管化经皮肾镜碎石取石术（PCNL）治疗肾输尿管上段结石的方法、可行性和临床疗效。方法2014年3月至2015年3月对我院收治的全部的。肾输尿管上段结石患者，排除严重感染、肾积脓和肾皮质厚度〈5mm的病例，随机分为标准通道（24f）组和微通道（18f）组，碎石取石结束后，超声证实无明显残余结石、集合系统明显穿孔和严重尿外渗后，留置输尿管DJ管，肾造瘘通道填塞止血海绵，不留置造瘘管。其中标准通道组26例，微通道组28例，比较两组的手术时间，术前及术后第1天血红蛋白变化，术后第1天疼痛视觉评分（VAS），尿液转清时间，术后有无肾周积液，胸腔积液，发热情况，结石清除率，并对年龄进行分层，〉65岁的患者进行上述参数的组间比较。结果标准通道组与微通道组比较，手术时间为（58．3±21．8）min和（86．4±23．3）min（t=10．836，P〈0．05），血红蛋白下降为（8．3±5．8）g／L和（7．7±5．4）g／L，VAs（3．8±0．8）分和（3．6±1．1）分，尿液转清时间（11．9±4．7）h和（9．6±5．6）h，术后住院时间（5．1±0．8）d和（4．8±1．2）d，完全清石率92．3％和89．2％，各参数相比两组差异均无统计学意义（均P〉0．05）。术后发热（超过38．5℃）1例和2例，少量胸腔积液各1例，两组患者均无输血和明显肾周积液；止血海绵填塞肾造瘘通道的方法，适用于标准通道和微通道的无管化PCNL。结论止血海绵填塞肾造瘘通道的方法，适用于标准通道和微通道的无管化PCNL，对于肾输尿管结石的治疗都是安全可行的，有助于控制出血和尿外渗，对于老年患者同样适用。

Objective To investigate the feasibility and clinical effect of the tubeless mini- percutaneous nephrolithotomy （PCNL） in treatment of upper ureteral calculi. Methods From March 2014 to March 2015, all the patients with upper ureteral calculi except for those with severe infection, pyonephrosis or renal cortex less than 5 mm were randomized into two groups, the standard PCNL group （24 F nephrostomy tube） and the mini-PCNL group （18 F nephrostomy tube）. After PCNL, all the patients received ultrasound examination to check residual stones, perforation and urine leakage. DJ tube was placed and the channel of PCNL was packed with hemostatic sponge without nephrostomy tube. There were 26 patients in standard group and 28 in mini-group. The operation time, postoperative hemoglobin change, postoperative visual analogue pain score （VAS）, the time when urine turned clean, postoperative urinary extravasation, hydrothorax, fever and the stone-free rate were compared between two groups. Particularly, these data were compared in those aged〉65 years. Results The operation time in the standard PCNL and the mini-PCNL group was （58.3± 21.8） and （86.4±23.3） minutes respectively, and had a significant difference （ t= 10. 836, P〈0.05）. The decrease in hemoglobin level was （8.3±5.8） g/L and （7.7±0.5.4） g/L, the VAS scores was （3.8±0.8） and （3.6±1.1）, the time when urine turned clean was （11.9±4.7） h and （9.6± 5.6） h, the postoperative hospital stay was （5.1±0.8） d and （4.8±1.2） d, and the stone free rate was 92.3% and 89.2% in standard PCNL and mini-PCNL group respectively（ P〉 0.05）. No significant difference were found between two groups （all P〉0.05）. There was one patient who gol fever more than 38.5℃ in the standard group and 2 cases in the mini-group. Each group had 1 slight hydrothorax, and no blood infusion and perinephric urinary extravasation were found. The application of packing hemostatic sponge in the nephrostomy channel was feasible and suitable for both the standard and tubeless mini-PCNL groups. Conclusions The application of packing hemostatic sponge in the nephrostomy channel is feasible and suitable in both the standard and tubeless miniPCNL. It is safe for the treatment of renal and ureteral calculi, and it can decrease the hemorrhage and urine leakage, which works for the elderly patients too.