经皮肾镜碎石术治疗无积水肾结石

Percutaneous Nephrolithotomy for Treatment of Renal Stone in Non-dilated Collecting System

目的探讨经皮肾镜碎石术（percutaneous nephrolithotomy，PCNL）治疗无积水肾结石的临床疗效和安全性。方法回顾性分析采用PCNL术治疗72例无积水肾结石患者的临床资料。C臂X线引导下穿刺目标肾盏，建立皮肤肾脏通道，输尿管镜下采用钬激光碎石。对穿刺时间，手术时间，手术并发症，结石清除率等临床资料进行分析。结果72例患者均完成PCNL治疗。穿刺针一次穿刺成功的患者12例，其余60例患者需要多次穿刺尝试，穿刺时间2～30min（平均18．3min）。72例患者共建立85个经皮肾通道，其中59例患者通过单一经皮肾通道碎石，13例患者一期建立两个经皮肾通道碎石，包括2个无效的经皮肾通道。另有16个失败的通道，占所有通道数的15．8％。手术时间40～180min（平均95min）。55例患者一期取净结石，一期净石率76．4％。12例接受二期PCNL治疗。二期PCNL术后总净石率为88．9％。3例（4．2％）患者需输血治疗。1例患行高选择性肾动脉介入栓塞治疗。1例（1.4％）患者发生腹腔积液，但无腹腔脏器损伤。无患者出现感染性休克，胸膜损伤等并发症。结论PCNL治疗无积水肾结石穿刺难度大，容易发生经皮肾通道建立失败。但只要掌握手术技巧，PCNL治疗无积水肾结石安全、有效。

Objective To evaluate the efficacy and safety of management of renal stone in nondilated collecting system by percutaneous nephrolithotomy （ PCNL ）. Methods The clinical data o f 72 patients treated by PCNL was retrospectively analyzed. Antegrade percutaneous renal access was established by fluoroscopic guidance. Holmium laser was used to disintegrate and remove stone under direct vision by ureteroscopy. Clinical data including puncture time, operation time, complications and stone free rate were analyzed. Results The percutaneous renal access was successfully established in all patients. Except for 12 patients achieving successful puncture at first time in, the other 60 patients （83.3%） needed puncture attempt more than one time. Mean puncture time was 18.3 min （2-30 min）. 85 percutaneous renal accesses in 72 patients were created, including 2 percutaneous renal accesses out of disintegrating stones. 16 percutaneous renal accesses were aborted. Mean operation time was 95 min （40-180 min）. Stones were cleared in 55 paitients during immediate phase. A 76.4% of stone-free rate was obtained. 12 patients received second PCNL. Stone free rate increased to 88.9% after second PCNL. 3 patients needed blood transfusion. One patient was treated by selective artery embolization. One patient occurred peritoneal effusion without abdominal visceral injury. Conclusion There is a certain degree of difficulty in puncture for the management of renal stone in non-dilated collecting system using PCNL. Percutanous renal access creating failure is also a challenge. But PCNL for renal stone in non-dilated collecting system is efficacious and safe under fluoroscopic guidance in a skilled urologist.