超微通道经皮肾镜取石术治疗成人和儿童上尿路结石的疗效分析

Evaluation of super-mini-percutaneous nephrolithotomy(SMP)for upper urinary stone of adults and children

目的探讨完全B超引导下超微通道经皮肾镜取石术(SMP)治疗成人和儿童(年龄<14周岁)上尿路结石的疗效。方法回顾性分析2015年5月至2018年7月新疆维吾尔自治区人民医院采用完全B超引导下SMP治疗的152例成人和儿童上尿路结石患者的临床资料。儿童81例(53%),男53例,女28例,共85个通道。年龄10个月~14岁,平均(56.0±39.7)个月。结石最长径0.8~3.5 cm,平均(1.7±0.7)cm。肾盂结石42例,肾盂及肾盏结石25例,肾盏结石5例,输尿管上段结石7例,输尿管上段及肾盏结石1例。合并双肾盂双输尿管畸形1例。术前泌尿系感染发生率86.4%(70/81),尿培养阳性率39.5%(32/81)。成人71例(47%),男43例,女28例。年龄18~81岁,平均(44.1±15.4)岁。结石最长径1.0~3.0 cm,平均(1.7±0.6)cm。肾盂结石19例,肾盂及肾盏结石13例,肾盏结石7例,输尿管上段结石24例,输尿管上段及肾盏结石3例,肾盏憩室内结石4例。合并双肾盂双输尿管畸形1例。术前泌尿系感染发生率87.3%(62/71),尿培养阳性率26.8%(19/71)。两组的结石大小、结石复杂程度、泌尿系感染发生率比较差异无统计学意义(P>0.05)。手术均采用全麻,患者均先取截石位,输尿管镜下逆行留置F5输尿管导管,膀胱留置导尿管。改俯卧位,B超引导下用18G穿刺针穿刺目标肾盏穹窿部,穿刺部位选择第11肋间及12肋下的肩胛线至腋后线之间的区域。穿刺成功后,置入0.032英寸斑马导丝,沿导丝用筋膜扩张器扩张为F12~14通道(若扩张为F12,直接用鞘扩张;扩张至F14,先用F12筋膜扩张器扩张,然后置入F14鞘),置入相同大小的负压吸引"卜"形鞘,连接标本收集瓶及负压吸引器。沿鞘插入超细肾镜观察肾盂、肾盏及结石情况,采用钬激光或气压弹道碎石。比较两组的碎石时间(开始碎石到手术结束)、术后第1天和术后1个月的净石率、术后第1天血红蛋白和血细胞比容变化值、术后并发症发生率、无管化率(完全无管化定义为未留置双J管和肾造瘘管;无管化定义为留置双J管,不留置肾造瘘管)、术后住院天数等指标的差异。结果儿童组碎石时间5~60 min,平均(27.7±13.0)min;术后第1天净石率96.3%(78/81),术后1个月净石率98.8%(80/81);术后第1天血红蛋白下降幅度0~41 g/L,平均(8.0±9.1)g/L,血细胞比容(HCT)变化值为0.026±0.029;完全无管化率86.4%(70/81);术后住院天数1~5 d,平均(2.5±0.9)d;术后9例出现并发症,包括ClavienⅠ级8例(发热4例、血尿1例、肾周血肿1例、术后同侧输尿管末端结石1例、肠功能恢复慢1例,均经保守治疗好转)、Ⅲb级1例(为术中大量腹腔积液,予穿刺引流后治愈)。成人组碎石时间7~80 min,平均(31.2±15.3)min;术后第1天净石率97.2%(69/71),术后1个月净石率98.6%(70/71);血红蛋白下降幅度0~32 g/L,平均(11.9±8.7)g/L,HCT变化值为0.030±0.027;完全无管化率87.3%(62/71);术后住院天数为1~8 d,平均(2.4±1.1)d;术后4例出现并发症,包括ClavienⅠ级3例(血尿2例、肠功能恢复慢1例,保守治疗好转)、Ⅲb级1例(术后同侧输尿管结石,行输尿管镜手术治愈)。两组血红蛋白下降幅度差异有统计学意义(P<0.05);碎石时间、术后第1天及1个月净石率、HCT变化值、完全无管化率、术后住院天数、手术并发症发生率差异无统计学意义(P>0.05)。结论SMP治疗上尿路结石安全、有效、恢复快,不仅可作为成人上尿路结石的首选治疗手法,同样可作为儿童上尿路结石的首选治疗手法之一。

Objective To compare the safety and efficiency of totally ultrasonography-guided super-mini-percutaneous nephrolithotomy(SMP)in the treatment of upper urinary stone in adults and children(<14years).Methods From May 2015 to July 2018,81 cases of children(53%)and 71(47%)cases of adults with upper tract stones underwent the SMP by total ultrasound guidance.In the group of children,it’s including 53 male and 28 female with 85 channels in total,the patients age ranged from 10 months to 14 years,[mean(56.0±39.7)months],The stone size ranged from 0.8-3.5 cm,[mean(1.7±0.7)cm].About stone distribution,42 cases of pelvic stones,25 cases of calyceal and pelvic stones,5 cases of calyceal stones,7 cases of upper uretaral stones,1 case of upper ureteral and calyceal stones,1 case of malformation with double renal pelvis and ureter.Urinary infection rate was 86.4%(70/81),positive rate of urinary culture was 39.5%(32/81).In the group of adults,it’s including 43 male and 28 female,the patients aged from 18 to 81 years,[mean(44.1±15.4)years],The stone size ranged from 1.0-3.0 cm,[mean(1.7±0.6)cm].About Stone distribution,19 cases of pelvic stones,13 cases of calyceal and pelvic stones,7 cases of calyceal stones,24 cases of upper uretaral stones,3 cases of upper ureteral and calyceal stones,1 case of malformation with double renal pelvis and ureter.Urinary infection rate was 87.3%(62/71),positive rate of urinary culture was 26.8%(19/71).The patient was placed in the lithotomy position under general anesthesia.A 5F ureteric catheter was retrogradely inserted into the collecting system and urethral catheter was placed in the bladder.The patient was then turned prone.The selected calix was punctured under ultrasound guidance by 18G puncture needle and a 0.032 inch guidewire was inserted into the collecting system.Nephrostomy tract was established using Dilators(it was done in one step for 12F and in two steps for 14F).After the corresponding size of suction-evacuation sheath was placed,the sheath was connected to the specimen collection bottle via the oblique branch of a metal connector.The miniature endoscope was inserted into the sheath to observe the collecting system and stone fragmentation was completed by using YAG laser or pneumatic lithotripter.Stone free rate after surgery at 1day(SFR)and 1 month(1 month SFR),stone size,operative time(from starting fragmentation to the end of the surgery),hemoglobin drop and hematocrit drop in the first day after surgery,rate of surgecal complications,tubeless rate(totally tubless:no ureteric stent and nephrostomy tube;tubeless:no nephrostomy tube but ureteric stent),average length of hospital stay and urinary infection were recorded and compared.Results In children group,mean operative time was(27.7±13.0)min(range 5-60 min),SFR and SFR at 1 month were 96.3%(78/81)and 98.8%(80/81),mean hemoglobin drop was(8.0±9.1)g/L(range 0-41 g/L),mean hematocrit drop was 0.026±0.029(range 0-0.135),totally tubeless rate was 86.4%(71/81),mean hospital stay was(2.5±0.9)days(range 1-5 days).Complications were observed in 9 cases and classified using Calvien grading system,GradeⅠin 8 cases:postoperative fever in 4,hematuresis in 1,perirenal hematoma,postoperative distal ureteral stone in 1 cases and delayed recovery of intestinal function in 1 case,all had a spontaneous recovery without special managements;GradeⅢb in 1 case,massive ascites was discovered during the surgery,and rcovered by puncture drainage.In adult group,mean operative time was(31.2±15.3)min(range 7-80 min),SFR and SFR at 1 month were 97.2%(69/71)and 98.6%(70/71),mean hemoglobin drop was(11.9±8.7)g/L(range 0-32 g/L),mean hematocrit drop was 0.030±0.027(range 0-0.106),totally tubeless rate was 87.3%(62/71),mean hospital stay was(2.4±1.1)days(range 1-8 days),urinary infection rate was 87.3%(62/71),positive rate of urinary culture was 26.8%(19/71).Complications were observed in 4 cases,GradeⅠin 3 cases:hematuresis in 2 and delayed recovery of intestinal function in 1 case,all had a spontaneous recovery without special managements;GradeⅢb in 1 case,postoperative distal ureteral stone in 1 cases and cured by ureteroscopic lithotripsy.According to data about Hb drop,risk of hemorrhage is lower in children than adult significantly(P<0.05).There is not significant difference in stone free rate,stone size,operative time,hematocrit drop,surgery complications,totally tubeless rate,stone complexity,average length of hospital stay and urinary infection(P>0.05).Conclusions With the characteristics of safe,efficacious and rapid recovery,super-mini-percutaneous nephrolithotomy(SMP)can be used as the first choice of the treatment for upper urinary stone both in adults and children.