基于肾脏血管解剖建立经皮肾通道的临床研究

Clinical study on the establishment of percutaneous renal access based on renal vascular anatomy

目的:分析融合肾锥体解剖结构对经肾盏路径穿刺建立经皮肾通道的影响。方法:收集2018年1月—2020年6月武汉大学人民医院行超声引导下微通道经皮肾镜取石术(mini-PCNL)患者的临床资料,最终490例患者符合纳入标准。根据对患者选用的穿刺方法分为2组。A组:统计2018年1月—2019年1月在普通B超引导下,通过肾盏轴线,即穹窿顶点与盏颈平面的中心线路进行穿刺的mini-PCNL,总共有274例;B组:统计2019年2月—2020年6月在普通B超识别到目标肾盏后,然后调整为彩色多普勒模式,当目标肾盏相对应的肾锥体内没有明显的血管分布时,旋转超声探头,确保目标肾盏和2个肾柱血管在同一平面上,并且在目标肾盏平面的轴向方向上进行穿刺的mini-PCNL。如果穿刺路径中有明显的血流,则将探头横向移动,直到穿刺路径中没有明显的血流信号时再进行穿刺,总共有216例。结果:2组患者在年龄、术前积水、结石类型、结石位置和术前肌酐方面比较差异无统计学意义(P>0.05)。2组患者在术中穿刺部位、管径大小方面比较差异无统计学意义(P>0.05)。2组患者在术后血红蛋白下降量、术后肌酐水平或结石清除率方面比较差异无统计学意义(P>0.05)。2组患者术后并发症在持续性疼痛、包膜下血肿、发热、休克和全身炎症反应综合征(SIRS)方面比较差异无统计学意义(P>0.05)。B组的结石最大径明显大于A组,差异有统计学意义(P=0.044)。B组的住院时间、输血率及栓塞率明显低于A组,差异有统计学意义(P=0.002、P=0.002及P=0.048)。结论:融合肾锥体是一个不可忽视的解剖因素,在建立肾盏通道时可能会导致出血。多普勒超声可以识别融合肾锥体内的异位血管,以辅助减少mini-PCNL术中经肾盏穿刺建立通路导致的出血。

Objective: To analyze the influence of fused renal pyramids anatomy on the establishment of percutaneous renal access through calyx pathway puncture. Methods: Clinical data of patients undergoing ultrasound-guided minimally invasive percutaneous nephrolithotomy(mini-PCNL) in Renmin Hospital of Wuhan University from January 2018 to June 2020 were collected, and finally 490 patients met the inclusion criteria. The patients were divided into two groups according to the puncture method selected for them. From January 2018 to January 2019, 274 cases were included in group A. The mini-PCNL was performed under the guidance of general ultrasound through the axis of the renal calyces, the central line between the apex of the fornix and the plane of the calyces neck. From February 2019 to June 2020, 216 cases were included in group B. The target renal calyces were identified by general ultrasound, and then adjusted to color Doppler mode. When there was no obvious vascular distribution in the renal pyramids corresponding to the target calyx, we rotated the ultrasound probe to ensure that the target calyx and the two renal column vessels were in the same plane. Then the mini-PCNL was performed with puncture in the axial direction of the target calyx plane. If there was obvious blood flow in the puncture path, the probe was moved laterally until there was no obvious blood flow signal in the puncture path when the puncture was performed again. Results: There was no statistically significant difference between the two groups in terms of age, preoperative effusion, stone type, stone location or preoperative creatinine(P>0.05). There was no statistically significant difference between the two groups in terms of intraoperative puncture site or canal size(P>0.05). There was no statistically significant difference between the two groups in terms of postoperative hemoglobin drop, postoperative creatinine level or stone clearance(P>0.05). There was no statistically significant difference in postoperative complications between the two groups in terms of persistent pain, subperitoneal hematoma, fever, shock or SIRS(P>0.05). The maximum diameter of stones in group B was significantly larger than that in group A, with a statistically significant difference(P=0.044). The length of hospital stay, transfusion rate and embolization rate in group B were significantly lower than those in group A, with a statistically significant difference(P=0.002, P=0.002 and P=0.048). Conclusion: The fused renal pyramids is a non-negligible anatomical factor that may lead to bleeding when using calyx access. Doppler ultrasound can identify ectopic vessels within the fused renal pyramids to assist in reducing bleeding due to transmural calyx puncture to establish access during mini-PCNL.