PCNL术中超声引导穿刺有效性和安全性的肾盂造影对比研究

Fluoroscopic assessment of the safety and efficacy of ultrasonography-guided puncture during percutaneous nephrolithotomy

目的:PCNL术中对比超声引导穿刺影像和逆行肾盂造影影像,明确PCNL术中超声引导肾盏穿刺的有效性和安全性。方法:2016年1~6月,顺序进入协和医院泌尿外科准备接受PCNL手术的42例患者被纳入本研究。所有患者均在穿刺前行患侧输尿管逆行插管。结合术前KUB和CT影像,依据术中超声影像确定穿刺目标肾盏。首先在超声影像下确定穿刺路径:目标肾盏的穹窿核心点、盏颈中点及皮肤穿刺点(前两点连线在皮肤的投影点);取穿刺针分两段沿已确定的穿刺路径分别穿刺肾外段(固定段)和肾内段(活动段)进入集合系统,即"三点一线和两段穿刺法"。超声引导穿刺成功后,置入超硬导丝,行术中逆行肾盂造影,对比超声影像和逆行肾盂造影影像所显示的穿刺针走行路径。采用一步扩张法建立取石通道,行碎石取石手术。手术结束前,将工作鞘逐步旋转后撤至肾脏实质取石通道边缘,肾镜直视下观察取石通道是否经肾盏乳头建立。分析取石通道建立成功率、通道建立时间、集合系统穿孔率、术前术后血红蛋白值和血清肌酐浓度值、一次手术结石清除率和并发症的发生率。结果:所有42例患者均成功在超声引导下完成目标肾盏穿刺,采用术中逆行肾盂造影进行对比,证实所有患者超声引导穿刺均成功经目标肾盏穹窿核心点进入集合系统。术中肾镜直视通道观察进一步证实工作鞘是经肾盏乳头中心区域扩张进入集合系统。术后血红蛋白下降值为(0.46±0.72)g/dl,术后平均住院日为(3.3±1.7)d,术中无肾脏周围组织器官损伤。结论:术中逆行肾盂造影和肾镜直视通道观察证实,"三点一线和两段穿刺法"超声引导下目标肾盏穿刺安全有效。

Objective：To explore the procedure and principle of the ultrasonography（US）-guided puncture for percutaneous nephrolithotomy（PCNL）,and assess the safety and efficacy of the renal tract access by intraoperative imaging.Method：A total of 42 patients in our department received PCNL accompanied by US-guided puncture from Jan.2016 to Jun.2016.After the successful puncture was performed under the US guidance,the retrograde urography was conducted immediately by injecting the contrast material via the ureteral catheter inserted preoperatively to visualize the pathway of the needle.Then a 22 Fworking channel was established using our Chinese one-shot dilation technique and PCNL was carried out.Before the end of the procedure,the working sheath was pulled out to the margin of the renal parenchyma under the nephroscope to observe the advance point of the sheath.The successful access rate,nephrostomy tract creation time,pre-and postoperative hemoglobin values and serum creatinine concentrations,stone-free rate and complications were recorded and analyzed.Result：The puncture of the target calyx was successfully performed in all the 42 patients,and the intraoperative retrograde urography confirmed that the needle was introduced into the collecting system exactly via the fornix of the target calyx,which was further verified by the direct observation of the nephroscope.Postoperative hemoglobin values decreased（0.46±0.72）g/dl,and the mean postoperative hospital stay was（3.3±1.7）days.No perinephric tissue or organ injured during the operation.Conclusion：The US-guided puncture advances into the collecting system via the fornix of the calyx,which is identical to the pathway of the fluoroscopy-guided puncture.The fornix of the calyx and infundibulum can be precisely identified intraoperatively with the US guidance,which ensures the puncture as well as the following surgical procedures are performed safely and effectively.The way of US-guided puncture was named＂three points one line and two-stage puncture method＂.