针道法辅助标准经皮肾镜取石术治疗复杂性上尿路结石的临床研究

Clinical research about needle-tract assisted standard percutaneous nephrolithotomy for thetreatment of complicated upper urinary tract calculi

目的探讨针道法辅助标准经皮肾镜取石术（PCNL）治疗复杂性上尿路结石的有效性及安全性。方法回顾性分析2013年12月至2017年12月在厦门大学附属第一医院泌尿外科接受PCNL术治疗的1562例复杂性上尿路结石患者的临床资料，其中256例于术后超声探查到较大残留结石，标准通道内肾镜无法探及结石。120例建立16F微通道处理残留结石（微通道组）；126例建立针道，引导标准通道内肾镜寻找并处理残留结石（针道组）；另有10例通过针道仍无法探及残留结石，则中转针道为微通道处理残留结石。术后统计两组手术时间、术后血红蛋白水平变化、术后并发症发生率、住院时间、清石率等指标。组间比较采用t检验、Wilcoxon秩和检验或χ2检验。结果微通道组建立l-3条微通道[M（QR）：1（1）]，针道组建立1-7条针道[M（QR）：3（2）]；针道组手术时间[（62．0±18．0）min比（84．0±15．5）min，t=10．242，P=0．000]、住院时间[（4．40±0．86）d比（5．20±0．81）d，t=7．570，P：0．049]、术后血红蛋白下降幅度[（1．31±0．47）g／L比（2．74±0．63）g／L，t=20．12，P=0。000]、术后并发症发生率[7．9％（10／126）比19．2％（23／120），χ2=6．674，P=0．010均低于微通道组；术后一期清石率针道组高于微通道组（89．7％比76．7％，χ2=7．497，P=0．006）。两组患者均未发生胸膜损伤、气胸、肾脏穿通伤、腹腔器官损伤等严重并发症。结论针道法辅助PCNL术治疗复杂性上尿路结石可提高一期结石清除率，节省手术时间．降低肾脏及周围器官损伤风险。

Objective To investigate the safety and efficacy of needle-tract assisted standard percutaneous nephrolithotomy （PCNL） for the treatment of complicated upper urinary tract calculi. Methods The clinical data of 1 562 patients with complicated upper urinary calculi who received standard PCNL from December 2013 to December 2017 at Department of Urology, the First Affiliated Hospital of Xiamen University were retrospectively analyzed. There were large residual stones in 256 patients through B-ultrasound exploration after standard PCNL, could＇t be detected with nephoscope in standard PCNL tracts. 16 F mini PCNL tract were established in 120 cases for treatment of residual stones, while needle-tract were established in order to guide nephroscope to find residual stones in 126 cases. Needle-tract were transferred to 16 F mini PCNL tract for treatment of residual stones in l0 patients if these residual stones could＇t be detected through needle-tract. Operation time, change of hemoglobin level after operation, incidence of postoperative complications, time of hospitalization and rate of stone clearance were measured in two groups. The statistical methods used included t test, Wilcoxon rank sum test, and χ2 test. Results There were 1 to 3 mini tracts （M（QR） ： l（1）） established in the mini tracts group and 1 to 7 needle-tracts （M（QR） ： 3（2） ） established in the needle-tract group （Z=-10. 57, P=0. 000）. Compared with mini tract group, the operation time （ （62.0±18. O） minutes vs. （84.0±15.5） minutes, t= 10. 242, P=O. 000）, hospitalization time （ （4.40±0. 86） days vs. （ 5.20±0. 81 ） days, t = 7. 570, P = O. 049）, hemoglobin dropped （ （ 1.3l ± O. 47 ） g/L vs. （ 2. 74±0. 63 ） g/L, t = 20. 12, P = O. 000 ） , and incidence of postoperative complications （7.9% （10/126） vs. 19. 2% （23/120）, X2 = 6. 674, P= O. 01） of needle-tract group were lower, whilepostoperative stone clearance rate was higher （ 89. 7% vs. 76. 7%, χ2 = 7. 497, P = 0. 006 ） . No perioperative severe complications such as pleura1 injury, pneumatothorax, perforation of renal, trauma of abdominal organ occurred in two groups. Conclusion Needletract assisted standard PCNL for the treatment of complicated upper urinary calculi can significantly improve stone clearance rate, reduce operation time, decrease risk of kidney and surrounding organs damage.