超声引导下经皮肾镜碎石术治疗肾盏憩室伴结石

Ultrasound Guided Percutaneous Nephrolithotomy for Caliceal Diverticular and Calculi

目的探讨超声引导下经皮肾镜碎石术(percutaneous nephrolithotomy,PCNL)治疗肾盏憩室伴结石的可行性。方法2009年9月~2017年8月对13例肾盏憩室伴结石行超声引导下PCNL。应用超声进行定位和跨憩室穿刺,即穿刺针到达憩室内后继续贯穿憩室到达邻近肾盂或肾盏内。结果3例出现导丝滑出或扩张通道偏离,需行二期跨憩室PNCL;其余10例均一次性完成超声引导下PNCL,其中4例采用跨憩室穿刺法,6例未采用跨憩室穿刺法。手术时间78~180min,平均125min。术后症状缓解率100%,均未出现明显出血,均未输血。10例随访10~70个月,平均49个月(3例在随访1年后失访,在随访期间症状均缓解),2例<3mm小结石碎块残留,结石清除率84.6%(11/13),1例随访2年后出现小结石复发,余未发现结石和憩室复发。结论超声引导下PNCL治疗肾盏憩室伴结石可行、安全有效,对于憩室较小或者憩室壁较薄者,采用跨憩室穿刺法可提高手术成功率。

Objective To investigate the feasibility of ultrasound-guided percutaneous nephrolithotomy( PCNL) by transdiverticular puncture for caliceal diverticulum( CD) combined with stones. Methods Between September 2009 and August 2017,ultrasound-guided PCNL was performed in 13 patients with stone-bearing CD. During the procedure of PCNL,transdiverticular puncture was employed to prevent the safety wire from being inadvertently withdrawn and reduce the risk for loss of access. Results Three patients suffered from guide wire slipping out or deviated dilatation channel and were treated by a secondary PNCL with transdiverticular puncture. The other 10 patients were treated by ultrasound-guided PCNL on one session, including 4 with transdiverticular puncture and 6 without transdiverticular puncture. The mean operative time was 125 min( range,78-180 min). The postoperative symptom-free rate was 100%. No major complications such as significant hemorrhage was observed and none received blood transfusion. Ten patients had a follow-up for a mean of 49 months( range,10-70 months). Three cases were lost after 1 year of follow-up and the symptoms alleviated during the follow-up period. Two patients were found small residual stones < 3 mm in size.The stone-free rate was 84. 6%( 11/13). One patient experienced recurrent stone event after 2 years of follow-up. The other patients had no residual stones or recurrence of diverticulum. Conclusion Ultrasound-guided PCNL is a safe and effective mode of therapy for CD with calculi. A technique of transdiverticular puncture can be employed to improve the safety and efficacy of procedure,if the cavity is small or overlying renal parenchyma is significantly thin.