内镜联合超声与单纯超声引导建立皮肾通道在多镜联合术中的应用

Endoscopic combined ultrasound-guided access vs.ultrasound-guided access in endoscopic combined intrarenal surgery

目的:评估多镜联合(endoscopic combined intrarenal surgery,ECIRS)治疗上尿路结石术中内镜联合超声引导(endoscopic assisted ultrasound-guided access,EUGA)和单纯超声引导(ultrasound-guided access,UGA)建立皮肾通道的效果。方法:选择2017年1月至2019年10月首都医科大学附属北京朝阳医院采用ECIRS治疗复杂上尿路结石的病例进行回顾性分析,共收集病例53例,分析其建立皮肾通道的方法。患者全身麻醉下斜仰卧截石位实施手术,根据术中输尿管软镜能否有效观察目标肾盏并引导皮肾通道的建立分为2组,其中25例采用输尿管软镜联合超声引导,穿刺和通道扩张全过程于输尿管软镜直视下完成,28例采用单纯超声引导建立皮肾通道。对两组术前基线情况、结石大小、受累肾盏数量、肾积水比例进行统计。对数据进行对比分析,手术相关数据包括手术用时,建立皮肾通道用时、通道建立重复操作比例,血红蛋白变化、围手术期并发症以及清石率等。结果:53例多镜联合手术均成功完成,EUGA组与UGA组年龄、性别比例差异无统计学意义。EUGA组与UGA组BMI分别为(29.21±3.14)kg/m^2和(28.53±2.56)kg/m^2,结石负荷分别为(37.68±6.89)mm和(35.53±6.52)mm,受累肾盏数量分别为2.72±0.68和2.86±0.71,肾积水病例所占比例分别为56.0%和46.4%,组间差异均无统计学意义(P>0.05)。EUGA组与UGA组手术相关数据中手术用时分别为(93.0±12.2)min和(96.8±14.2)min,血色素下降分别为(6.56±2.16)g/L和(7.54±2.64)g/L,清石率分别为92%和92.8%,住院时间分别为(5.52±0.59)d和(5.64±0.62)d,术后并发症分别为8.0%和7.2%,EUGA组血尿和泌尿系感染各1例,UGA组泌尿系感染2例,2组均无输血病例,组间比较差异均无统计学意义(P>0.05)。EUGA组与UGA组建立皮肾通道用时分别为(4.0±0.7)min和(6.8±2.6)min,EUGA组用时少于UGA组(P<0.01),EUGA组无重复通道建立病例,UGA组4例出现重复通道建立,EUG组通道建立重复操作比例低于UGA组(P<0.05)。结论:多镜联合手术中采用内镜联合超声引导建立皮肾通道安全有效,可以缩短建立皮肾通道用时,提高通道建立一次性成功率。

Objective:To compare the outcomes of endoscopic combined ultrasound-guided access(EUGA)with the conventional ultrasound-guided access(UGA)to achieve percutaneous renal access in endoscopic combined intrarenal surgery(ECIRS).Methods:A retrospective review of 53 patients undergoing ECIRS to treat upper urinary tract calculi between January 2017 and October 2019 was con-ducted.All of the cases were of complex upper urinary tract stones larger than 2 cm in diameter.The com-plex stone situations,such as multiple renal calyces calculi or staghorn calculi necessitated ECIRS.Under general anesthesia,the patients were placed in the galdakao-modified supine valdivia(GMSV)position,thus allowing both antegrade and retrograde accesss.The patients were divided to UGA and EUGA groups according to the protocol of achieving percutaneous renal access.In 28 cases,endoscopic combined ultrasound-guided accesss were obtained.Puncture and dilation were performed under direct flexible ureteroscopic visualization,while percutaneous renal access of 25 cases were performed with the conventional technique employing ultrasound guidance.Demographic and perioperative information,such as stone burden,presence of hydronephrosis and number of calyces involved was compared.Primary outcomes included total operative time,renal access time,repeat puncture,hemoglobin level,perioperative complications,and stone-free rate.Results:No major intra-operative complication was recorded in all the 53 ECRIS.No significant difference was observed between the groups in age and gender.There was no significant difference in body mass index[BMI(29.21±3.14)kg/m^2 vs.(28.53±2.56)kg/m^2],stone burden(37.68±6.89)mm vs.(35.53±6.52)mm,number of calyces involved 2.72±0.68 vs.2.86±0.71,presence of hydronephrosis(56.0%vs.46.4%),total operative time(93.0±12.2)min vs.(96.8±14.2)min,hemoglobin level reduction(6.56±2.16)g/L vs.97.54±2.64)g/L,stone-free rate(92.0%vs.92.8%),hospital stay(5.52±0.59)d vs.(5.64±0.62)d,perioperative complication rate(8.0%vs.7.2%).Two patients in EUGA group experienced perioperative complications(one urinary tract infection and one hematuria)while two patients in UGA group experienced perioperative urinary tract infection.None in both groups received blood transfusion.The patients undergoing EUGA had shorter renal access time[(4.0±0.7)min vs.(6.8±2.6)min,P<0.01]and less repeat puncture(0 vs.4 cases,P<0.05).Conclusion:EUGA is an optimal technique to establish percutaneous renal access in ECIRS,which minimizes access time and repeated procedures.