小通道经皮肾镜取石术术中动脉损伤的原因分析

Causes of bleeding due to arterial injury after minimally invasive percutaneous nephroclithotomy

目的探讨小通道经皮肾镜取石术（mPCNL）术中动脉损伤的原因。 方法回顾性分析2012年1月至2017年1月我院2 980例行B超引导下mPCNL的肾结石和梗阻性输尿管上段结石患者的临床资料，男1 853例，女1 127例。年龄（45.7±24.1）岁，范围17～76岁。结石大小（2.62±1.08）cm，范围1.5～4.2 cm。肾结石2 478例，输尿管上段结石502例。肾积水程度：轻度727例，中度1 971例，重度282例。480例合并尿路感染，术前应用抗生素控制感染；103例合并肾积脓或急性肾衰，术前行肾造瘘或双J管引流。63例既往有心脑血管支架植入病史，术前停用抗凝药，采用低分子肝素钠替代治疗1周。214例合并糖尿病，术前血糖控制平稳。本研究2 980例均成功建立经皮肾通道。肾盏穿刺2 535例，肾盂穿刺445例。穿刺成功后，将通道扩张为F16～22。肾盏穿刺中F16～18通道1 446例，F20～22通道1 089例；肾盂穿刺中F16～18通道253例，F20～22通道192例。单通道穿刺2 653例，多通道穿刺327例。 结果术后出血117例，88例止血成功，29例肾造瘘管引流液为鲜红色，考虑为动脉损伤出血，行数字减影血管造影（DSA）检查。DSA检查示20例为急性动脉损伤、5例为假性动脉瘤、4例为动静脉瘘，予超选择性肾动脉栓塞治疗，术后29例均治愈出院。肾盏穿刺和肾盂穿刺的动脉损伤率分别为0.39%（10/2 535）和4.27%（19/445），差异有统计学意义（P〈0.05）。穿刺位置位于肾下盏、肾中盏、肾上盏的动脉损伤率分别为0.38%（1/267）、0.40%（6/1 516）、0.40%（3/752），差异无统计学意义（P〉0.05）。肾盏穿刺中F16～18通道和F20～22通道动脉损伤率分别为0.35%（5/1446）和0.46%（5/1 089），差异无统计学意义（P〉0.05）。肾盂穿刺中F16～18通道和F20～22通道动脉损伤率分别为1.98%（5/253）和7.29%（14/192），差异有统计学意义（P〈0.05）。单通道和多通道的动脉损伤率分别为0.94%（25/2653）和1.22%（4/327），差异无统计学意义（P〉0.05）。 结论B超引导下PCNL中，多通道、肾盏穿刺、肾盏通道大小、肾盏穿刺部位均不是动脉损伤的危险因素，肾盂穿刺及肾盂通道大小是动脉损伤的危险因素。

ObjectiveTo investigate the causes of bleeding due to arterial injury after minimally invasive percutaneous nephrolithotomy （mPCNL）. MethodsWe retrospectively analyzed the clinical data of 2 980 patients who underwent ultrasound-guided mPCNL between January 2012, and January 2017, in our hospital. Among them, 1 853 were male and 1 127 were female. Age from17 to 76 years old, average age was （45.7±24.1） years. The calculi size was from 1.5 to 4.2 cm, average of （2.62±1.08）cm. There were 2 478 kidney stones and 502 cases of ureteral calculi. Besides, 727 cases with mild hydronephrosis, 1 971 cases with moderate hydronephrosis, 282 cases with severe hydronephrosis; 480 patients with urinary tract infection; 103 patients with renal empyema or acute renal failure; 63 patients with cardiovascular and cerebrovascular stent implantation; 214 patients with diabetes mellitus. ResultsIn this study, all of the patients were established percutaneous renal tract successfully, indwelling drainage tube （6±2）d, and postoperative hemorrhage in 117 cases, of which 29 patients suffered from bleeding due to arterial injury and DSA showed 20 cases with acute arterial injury, 5 cases with pseudo-aneurysm, and 4 cases with arteriovenous fistula. However, all these cases were rehabilitated after the treatment of super-selective renal artery embolization. The rates of arterial injury of renal calyx access and pelvic access were 0.39% （10/2 535） and 4.27% （19/445）, respectively. The rate of arterial injury in renal pelvic access was significantly higher than renal calyx access of PCNL （P〈0.05）. The rates of arterial injury in lower, middle, upper calyx access were 0.38% （1/267）, 0.40% （6/1 516）, 0.40% （3/752）, respectively. There was no significant effect of different renal calyx on postoperative arterial injury rate of mPCNL（P〉0.05）. All the percutaneous renal accesses were dilated with Amplatz sheaths, and the arterial injury rate of F16-18 and F20-22 tracts in the calyx access were 0.35% （5/1 446）, 0.46% （5/1 089）, respectively, with no significant difference in size of calyx access associated with rate of arterial injury after mPCNL（P〉0.05）. The arterial injury rates of F16-18 and F20-22 tracts in the pelvic access were 1.98% （5/253） and 7.29% （14/192）, respectively. There was significant difference in the size of the pelvic access in the rate of arterial injury after mPCNL（P〈0.05）. In addition, the arterial injury rate of single tract PCNL was 0.94% （25/2 653） as compared to 1.22% （4/327） in multi-tracts PCNL. There was no significant difference in the rate of arterial injury between single and multi-tracts PCNL（P〉0.05）. ConclusionsThe puncture of the renal pelvis and size of renal pelvis tract significantly increased the probability of postoperative bleeding due to arterial injury.