预留导丝在复杂肾结石患者碎石中的应用

Application of Reserved Guidewire in Percutaneous Nephrolithotomy for Complicated Calculi

目的探讨术中预留斑马导丝在提高复杂性肾结石一次性清石率中的应用价值。方法2011年4月-2014年4月我科收治复杂性肾结石患者49例,在建立通道前除保留拟建立通道的导丝外,视结石分布部位额外预留1根导丝以提高结石清除率。结果本组49例患者均穿刺成功并留置两根导丝,其中41例通过预留导丝找到目标肾盏并碎石成功,8例患者采用了双通道碎石,其中3例肾盏颈口狭窄,5例患者因角度过大无法通过先建立的通道到达预留导丝所在肾盏。结石一次性完全清除共36例,一次性取尽率达73.47%。平均手术时间79.6（52.3-114.5）min,平均术中出血量120（45-510）ml,术后平均住院时间7.3（6-12）d。术后出现高热患者2例,予抗感染治疗后治愈;术后大出血1例,经选择性肾动脉栓塞后治愈。无胸膜损伤、肠管损伤等并发症出现。结论对术前评估通过单通道碎石困难者,在建立经皮肾镜通道前预留导丝可显著提高一次结石清除率,特别对于复杂性结石患者,可在一定程度上减少操作通道,避免多通道手术过程中引起的出血、术后感染等并发症,值得推广。

Objective To study the value of reserved guidewire to improve the stone-free rate of percutaneous nephrolithotomy（ PCNL） for the patients with complicated calculi. Methods From April 2011 to April2014,a total of 49 patients（ 29 males and 20 females） with complicate calculi admitted to our department were enrolled in this study. All patients were placed the second guidwire after the first guidwire used for the PCNL channel establishment. Results All 49 cases were placed two guidewires successfully. Among them,41 cases were performed lithotripsy successful by the reserved guidewire which lead scope to the target renal calices. Dual channel was performed in 8 patients,including 5 cases due to a large pelvic and 3 cases due to a small calyx with a narrow calyx neck. 36 cases achieved stone-free by once clearance and the stone-free rate was 73. 47%. The operative duration was 52. 3 to 114. 5 minutes with an average of 79. 6 minutes,the intra-operative blood loss was45 to 510 ml with an average of 120 ml,and the post-operative hospital stays was 6 to 12 days with an average of7. 3 days. Fever occurred in 2 patients after the operation and was cured by antiinfective therapy. Post-operative hemorrhoea was found in 1 patient and cured by super-selective renal artery embolization. No pleural injury,intestinal injury and other severe complications occurred. Conclusions Higher stone-free rate can be achieved by the beforehand reserved guidewire in the patients with complicate calculi who are estimated difficult to get satisfied stone free rate by single channel. Remaining guidewire beforehand can decrease the intra-operative blood loss and post-operative complications such as infection,residual stones rate,and it is worthy to be recommended.