经皮输尿管镜激光肾囊肿去顶术治疗肾囊肿的安全性和有效性

The safety and efficacy for percutaneous ureteroscopic laser deroofing in the management of renal cysts

目的探讨经皮输尿管镜激光肾囊肿去顶术治疗肾囊肿的安全性、可行性及有效性。方法2014年11月至2016年8月收治的59例经影像学检查确诊为肾囊肿且满足手术指征的患者，男36例，女23例。年龄35～64岁，平均46岁。41例因腰胀或隐痛就诊，18例为体检发现。囊肿直径4.9～9.1 cm,平均6.3 cm。其中6例为肾盂旁囊肿，4例合并同侧肾结石，结石表面积3.4～9.8 cm2，平均5.7 cm2。手术采用蛛网膜下腔＋硬膜外联合麻醉或椎旁神经阻滞麻醉，患者取俯卧位。B超引导下行经皮肾穿刺至囊腔内，留置金属导丝，沿导丝建立F26～28通道，置入F9.8输尿管镜。将peel－away鞘退至囊壁外，利用镜体及水压对囊壁进行游离，异物钳牵拉囊壁，直视下用钬激光（功率60～70 W）或铥激光（连续波模式，功率40～50 W）切除大部分囊壁，囊腔内放置引流管。肾盂旁囊肿患者先截石位患侧留置输尿管导管，然后改为俯卧位行经皮肾穿刺至囊腔内，留置导丝，建立F24通道。输尿管镜直视下，激光切除与肾盂相邻的囊壁，将双J管一端置于囊腔内，另一端置于膀胱进行持续内引流，经囊腔至肾盂放置F22引流管。合并结石患者建立经囊腔的碎石通道，激光碎石后再行囊肿去顶术。以影像学检查囊肿体积较术前减小50%定义为手术有效。观察患者的围手术期并发症、术后住院天数及手术效果。结果59例手术均顺利完成，无活动性出血、尿漏、肾实质或邻近脏器损伤等相关并发症发生。术后住院天数2～4 d，平均2.5 d。术后随访3～12个月，平均8.1个月。42例囊肿完全消失，15例囊肿体积较术前减小≥50%，有2例患者囊肿复发，考虑囊壁不完全切除所致，再次行腹腔镜下肾囊肿去顶术治愈。患者的总体手术有效率为96.6%（57/59）。4例合并结石者，结石均一期清除。结论经皮输尿管镜激光肾囊肿去顶术治疗肾囊肿安全、有效，更加微创。

Objective To assess the safety and efficacy of a novel technology referred to as percutaneous ureteroscopic laser deroofing in the management of renal cysts. Methods From November 2014 to August 2016, 59 patients having surgical indications with renal cysts were enrolled and evaluated by ultrasound and CT scan. Of all the 59 patients, 36 were males and 23 were females. Their mean age was 46 years （ranging 35-64 years）. 41 patients complained about the reported flank and abdominal pain. 18 patients were found by imaging examination. Their mean diameter of cyst was 6.3em（ ranging 4.9-9. lem）. In regards to the 59 patients, include 6 patients suffered with parapelvic cysts and 4 patients suffered with renal cyst complicated with ipsilateral renal calculi. Their mean stone surface area was 5.7 cm2 （ ranging 3. 4-9.8 cm2 ）. All of the patients received combined spinal and epidural analgesia or paravertebral nerve block anesthesia. Patients were placed in the prone position for percutaneous puncture and tract dilation. Under ultrasound guidance, an eighteen gauge needle was placed inside the cyst cavity percutaneously, a metal guidewire was introduced followed by sequential dilation up to F26-28. 9.8F rigid ureteroscope was inserted through the Amplazt access sheath and advanced into the cyst cavity. Then sheath and ureteroscope both returned to the exterior cyst together. Cyst wall was dissociated from perirenal adipose tissue by used ureteroscope. A majority of the collapsed cyst wall was grasped and gently pulled towards the Amplazt sheath interior using grasping forceps and incised using either Thulium （ Power 40 - 50W） or Holmium laser（ Power 60- 70W） and was taken for pathological examination. Nephrostomy tube was left in place for 2-5 days and removed before discharge. For parapelvic cysts patients, ureter stent was inserted into the renal pelvis in the dorsal lithotomy position firstly. Patients were then placed in the prone position for percutaneous puncture and tract dilation. Laser was used to incise cyst wall towards identified pelvis to create a permanent communication between the cyst and adjacent renal collecting system. F6 double-J stent was inserted into the cyst cavity at the end to prevent auto-closure for at most two months. F22 nephrostomy tube was left in renal pelvis for two weeks. For renal cyst complicated with ipsilateral renal calculi patients, a puncture was created targeting the stone through the cyst, after fragmenting and extracting the stone, the same laser was used to deroof the cyst. More than 50% reduction in cyst volume was considered a success. The perioperative complications, hospitalization days and the effective rate of surgery were evaluated. Results All operations were conducted without intraoperative complications such as bleeding, urinary leakage or injury of the renal parenchyma and the adjacent organs. The hospital stay after the surgery was 2-4 days （mean 2. 5 days ）. After 3-12 months follow-up （mean 8. 1 months ）, patients underwent imaging examinations. 42 out of 59 cases were completely resolved, 15 were reduced to less than 50% , the total effective rate for the operation is 96.6% （57/59）. 4 patients with ipsilateral renal calculi were completely clear. However, two cases failed probably due to incomplete resection and follow treated with laparoscopic renal cyst deroofing. Conclusions Percutaneous ureteroscopy renal cyst laser deroofing is a safe, effective, less invasive, which can be performed in any endourological center without the need of special instruments and training.