摘要
目的 探讨经皮肾镜取石术中皮肾通道丢失的处理措施,并进行原因分析。方法 回顾性分析2009年9月至2015年12月微通道经皮肾镜取石术（mPCNL）456例,术中因各种原因致皮肾通道丢失13例（2.85%）,其中通道建立过程中丢失5例（38.4%）,通道建立后丢失8例（61.6%）,术中采用组织层次辨别法或美蓝示踪法找回皮肾通道,通道找回失败者重新穿刺建立通道或二期手术处理。结果 13例皮肾通道丢失病例,导丝移位致丢失3例（23.1%）,剥皮鞘拖出致丢失7例（53.8%）,扩张过深致丢失3例（23.1%）。其中学习曲线早期（〈100例）、中期（100~300例）、后期（〉300例）者分别为8例（61.5%）、4例（30.8%）、1例（7.8%）。采用两种方法成功找回通道9例（69.2%）,通道找回失败者4例重新穿刺成功3例（23.1%）,因持续出血终止手术者1例（7.7%）。一期找回通道9例及重新穿刺3例均成功实施手术,术中出血量约50~300（121.0±64.6）mL,通道重新建立时间5~60（24.7±16.0）min,总手术时间85~225（116.0±34.2）min,肾造瘘管留置时间4~30（7.9±9.5）d,术后住院时间5~12（6.4±2.5）d,结石残留3例,一次性清石率75%,其中1例于术后1周二期手术取石,2例术后1月辅助体外冲击波碎石（ESWL）,术后3月复查均无结石残留,总清石率100%。1例终止手术者,术后保守治疗,3月后再次mPCNL成功。结论皮肾通道丢失多发于学习曲线早期,多由术中操作不当导致,通道丢失后,采用组织层次辨别法或美蓝示踪法重新找回通道是可行的,如不成功可重新穿刺或二期手术。
percutaneous nephrolithotomy; percutaneous-renal pathway loss; renal stone; upper ureter stone
出处
《现代泌尿外科杂志》
CAS
2016年第12期943-946,共4页
Journal of Modern Urology
关键词
经皮肾镜取石术
皮肾通道丢失
肾结石
输尿管上段结石
ObjectiveTo explore the causes of percutaneous-renal pathway loss in percutaneous nephrolithotomy （PCNL），and to analyze its management. MethodClinical data of 456 patients with minimally invasive PCNL （mPCNL） treated during Sept. 2009 and Dec. 2015 were retrospectively analyzed. Of them，13 cases （2.85%） had percutaneous-renal pathway loss due to various causes. The pathway was lost in 5 cases （38.4%） when it was established，and in 8 cases after it was established （61.6%）. The pathway was regained using identification of tissue layer or methylene blue tracer technique. In failed cases，the pathway was reestablished by re-puncture or two-stage operation. ResultsThe causes of pathway loss included moving of guidewire in 3 cases （23.1%），pulling out of the sheath in 7 cases （53.8%），unsuitable dilatation in 3 cases （23.1%）. The loss occurred in early learning curve in 8 cases （61.5%），in middle learning curve in 4 cases （30.8%），in later learning curve in 1 case （7.8%）. The pathway were regained in 9 cases （69.2%） using the two methods，in 3 cases （23.1%） using re-puncture. One patient was forced to end operation because of continuous bleeding （7.7%）. The intraoperative bleeding volume was 50-300（121.0±64.6）mL，time to reestablish pathway was 5-60（24.7±16.0）min，the total operation time was 85-225（116.0±34.2）min，nephrostomy tube indwelling time was 4-30（7.9±9.5）d，postoperative hospital stay was 5-12（6.4±2.5）d. Residual stones were found in 3 cases. The stone clearing rate was 75%. One patient underwent two-stage operation and two patients underwent excorpereal shock wave lithotripsy （ESWL） after 1 week，and no residual stones were found 3 months after operation. One patient who ended operation underwent conservative treatment and re-mPCNL 3 months later. ConclusionPercutaneous-renal pathway loss happened in early learning curve and was caused by unsuitable manipulation during operation in most cases. It is feasible to use identification of tissue layer or methylene blue tracer technique in order to get back pathway. Re-puncture or two-stage operation can be used when the identification failed.
