标准通道经皮肾镜取石术治疗孤立肾肾结石的长期安全性和有效性

Long-term analysis of safety and efficacy of standard percutaneous nephrolithotomy in patients with solitary kidneys

目的:探讨超声引导下标准通道经皮肾镜取石术(percutaneous nephrolithotomy,PCNL)治疗孤立肾肾结石患者的长期有效性和安全性。方法:回顾性分析2008年9月至2014年6月于北京大学人民医院行PCNL治疗的22例孤立肾肾结石患者临床资料以及5年以上随访资料,记录围手术期相关指标、术后无石率(stone free rate,SFR)及并发症发生率,采用超声检查评估远期结石复发率,通过血肌酐及估计肾小球滤过率(estimated glomerular filtration rate,eGFR)评估肾功能情况。结果:本组22例患者中,平均年龄为(50.3±11.8)岁,10例解剖性孤立肾,12例功能性孤立肾,中位结石直径为1.65(1.1~3.9)cm,全部为多发结石,包括7例鹿角形结石。术前的中位血肌酐为104.5(60.0~460.0)μmol/L,平均eGFR为(60.3±29.4)mL/min。平均手术时间为(88.2±42.0)min,各有11例单通道和双通道PCNL。术后第一天的中位血肌酐为102.0(63.0~364.0)μmol/L,平均eGFR为(58.0±25.1)mL/min,与术前相比差异均无统计学意义。术后平均住院时间为(8.7±5.2)d。本组有5例(22.7%)患者出现短期并发症,其中4例患者同时出现术后感染和大量出血,保守治疗后好转,1例患者出现胸膜损伤,行胸腔闭式引流后好转;2例(9.1%)患者出现长期并发症,术后3个月发生输尿管狭窄,行球囊扩张术后好转;其余15例(68.2%)患者均未见并发症。中位随访时间为6.2(4.7~11.1)年,最近一次随访的中位血肌酐为104.0(72.4~377.0)μmol/L,平均eGFR为(60.1±23.7)mL/min,与术前相比差异均无统计学意义,6例(27.3%)患者出现肾功能减退。术后初始和最终SFR分别为72.7%和100%;6.2年的随访时间内9例(40.9%)患者结石复发,复发后共进行13次取石手术,最近一次随访的SFR为63.6%。结论:本研究目前是国内外已有报道中关于孤立肾肾结石患者PCNL术后随访时间最长的研究,超声引导下标准通道PCNL治疗孤立肾肾结石是安全有效的,可以达到理想的SFR。长期随访结果表明仍有较高的结石复发率,但术后患者远期肾功能稳定,部分患者出现轻度肾功能减退。

Objective:To evaluate the long-term efficacy and safety of ultrasound-guided percutaneous nephrolithotomy(PCNL)in the treatment of patients with solitary kidney stones.Methods:The clinical data of 22 patients with solitary kidney stones treated with PCNL in Peking University People’s Hospital from September 2008 to June 2014,with the follow-up data of more than 5 years were analyzed retrospectively.Perioperative indicators,postoperative stone free rate(SFR)and incidence of complications were recorded.Ultrasonography was used to evaluate the long-term stones recurrence rate.Serum creatinine and estimated glomerular filtration rate(eGFR)were used to assess the long-term renal function.Results:In this group of 22 patients,the average age was(50.3±11.8)years,with 10 cases of anatomic solitary kidneys,12 functional solitary kidneys,and the median stone diameter was 1.65(1.1-3.9)cm.All the patients had multiple stones,including 7 cases of staghorn stones.The median pre-operative serum creatinine was 104.5(60.0-460.0)μmol/L,and the mean eGFR was(60.3±29.4)mL/min,showing no statistically significant difference compared with that before surgery.The mean operative time was(88.2±42.0)min,and there were 11 cases of single-channel and double-channel PCNL.The median serum creatinine on the first day after surgery was 102.0(63.0-364.0)μmol/L,and the mean eGFR was(58.0±25.1)mL/min.The mean postoperative hospital stay was(8.7±5.2)days.In this group,5 patients(22.7%)presented short-term complications,among which 4 patients presented postoperative infection and massive hemorrhage at the same time,which improved after conservative treatment,and 1 patient presented pleural injury and improved after closed thoracic drainage.Two patients(9.1%)developed long-term complications,and ureteral stricture occurred 3 months after operation,which improved after balloon dilatation.The median follow-up time was 6.2(4.7-11.1)years.The median serum creatinine at the last follow-up was 104.0(72.4-377.0)μmol/L,and the mean eGFR was(60.1±23.7)mL/min,showing no statistically significant difference compared with that before surgery.Renal function decreased in 6 patients(27.3%).Initial and final SFR were 72.7%and 100%,respectively.During the 6.2-year follow-up,9 patients(40.9%)experienced recurrence of kidney stone.After stone recurrence,13 lithotomy surgeries were performed,and the SFR by the latest follow-up was 63.6%.Conclusion:This study had the longest follow-up time for patients with solitary kidney stones after PCNL reported at home and abroad.Ultrasound-guided standard PCNL was safe and effective in the treatment of solitary kidney stones.Long-term follow-up results showed that the recurrence rate of kidney stones was still high,but the long-term renal function was stable after operation,and some patients showed mild renal function decline.