可视穿刺针肾镜系统经超微通道（F12）治疗〈2cm肾结石的初步经验

Preliminary experience in the treatment of renal stones less than 2 cm in diameter with the ＂All- seeing needle set＂ through a super minimal tract （ F12 ）

目的探讨使用可视穿刺针肾镜系统联合钬激光通过超微通道（F12）治疗〈2 cm单发肾结石的初步经验及其临床应用价值。 方法回顾性分析我院2015年1月至2016年12月收治的43例〈2 cm单发肾结石患者的临床资料，男23例，女20例。年龄（43.0±13.6），范围23～65岁。左肾结石22例，右肾结石21例。肾上盏结石8例，肾下盏结石13例，肾盂结石22例，其中肾上盏憩室结石5例。43例患者中体外冲击波碎石失败21例。结石最大径（1.63±0.32）cm，范围1.2～2.0 cm。43例均行经皮肾镜取石术，术中先用彩色多普勒超声定位目标肾盏，应用可视穿刺针进行穿刺。可视穿刺针由成像-导光光纤、针芯、F4.85金属鞘组成。可视穿刺针连接10 ml注射器，由助手推注生理盐水以获得清晰视野，全程直视下由皮肤、皮下组织、肾实质进入目标肾盏、肾盂，以及上段输尿管。穿刺成功后退出针芯及光纤，保留F4.85金属鞘。经F4.85金属鞘置入斑马导丝至输尿管，退出F4.85金属鞘，测量穿刺深度，沿导丝扩张建立F12皮肾通道，由成像-导光光纤与F8金属外鞘组装成的肾镜联合钬激光进行碎石。术后常规留置F6双J管2周，不留置肾造瘘管，留置导尿管3 d。术后第1天查腹部X线片及CT了解碎石情况及双J管位置。 结果本组43例中，41例一次性顺利碎石清石，一期清石率95.3%（41/43）；2例有残留结石，术后行体外冲击波碎石后2周内自行排出。手术时间（从穿刺开始至双J管留置完毕）（31.0±9.2）min，范围23～65 min。术后2 h复查血常规，血红蛋白平均下降（14.0±6.2）g/L，范围6～32 g/L。7例出现并发症，分别为Clavien Ⅰ级4例（2例轻微肾包膜下血肿，2例反应性胸腔积液），Clavien Ⅱ级3例（术后发热〉38.5℃，换敏感抗生素治疗），无≥Ⅲ级并发症发生。结石成份分析结果为一水草酸钙结石10例，二水草酸钙结石9例，混合结石（一水草酸钙、二水草酸钙、碳酸磷灰石）18例，尿酸结石6例。38例术后随访6个月，结石无复发。 结论采用可视穿刺针肾镜系统联合钬激光通过超微通道（F12）治疗〈2 cm肾结石可行、安全、有效，且更微创、精准，可成为治疗〈2 cm肾结石的一种选择。

ObjectiveTo discuss primary experience the clinical use of ＂All-seeing needle set＂ combined with Holmium laser to treat the single renal stone lesser than 2 cm in diameter through a super minimal tract （F12）. MethodsFrom January 2015 to December 2016, 43 patients were enrolled into this retrospective study. There were 23 males and 20 females who were diagnosed as single renal stone less than 2 cm in diameter（age range from 23-65 years） . There were 8 upper pole renal stones, 13 lower pole renal stones and 22 renal pelvis stones. The mean stone size was （1.63±0.32）cm in diameter （range from 1.2 cm to 2.0 cm）. ＂All-seeing needle system＂ was applied during percutaneous puncture. After building a F12 minimal tract by fascia dilator, all patients received lithotripsy with Holmium laser. Indwelling catheters for 3 days and an F6 double-J tube was left for 2 weeks without a tube in the percutaneous tract after operation. Finally, KUB and/or urinary CT were used to check the results on day 1. ResultAll operations were completed successfully. The operation time was 23-65min [averaged （31.0±9.2） min]. 41 cases’ renal stones were store free, and the 2 stone residues was clear with later extracorporeal shock wave lithotripsy. No severe complications occurred. ConclusionAs an alternative to standard procedures for treatment of renal stones less than 2 cm in diameter, adopting ＂All-seeing needle set＂ with Holmium laser through a super minimal tract （F12） is safe, minimally invasive, fast and effective with a low complication rate.