超声引导下针状肾镜联合输尿管软镜治疗小负荷复杂肾结石的有效性和安全性分析

The feasibility and safety of ultrasound-guided needle-perc assisted retrograde intrarenal surgery in the treatment of small but complex renal calcul

目的探讨超声引导下针状肾镜联合输尿管软镜治疗小负荷复杂肾结石的有效性和安全性,并总结临床经验。方法回顾性分析2020年1月至2022年4月清华大学附属北京清华长庚医院行超声引导下针状肾镜联合输尿管软镜治疗36例小负荷复杂肾结石患者的临床资料。男25例,女11例;年龄(54.7±6.1)岁;体质量指数(26.3±3.1)kg/m^(2)。结石最大径(1.8±0.7)cm,均为单侧结石,单纯输尿管软镜难以完全处理。术前无积水28例,轻中度积水8例;肾盏憩室结石4例,肾下盏结石32例;其中10例合并输尿管结石;6例既往有同侧肾结石手术病史,3例为孤立肾肾结石。患者取斜仰卧截石位或俯卧分腿位(女性),先采用输尿管软镜处理结石,对于难以处理的肾下盏或憩室结石,采用超声引导下针状肾镜穿刺目标盏结石,使用钬激光将结石粉末化或碎块化,术中联合使用软镜取石或进一步碎石。记录围手术期各项指标及术后并发症情况,分析结石清除率。结果36例手术均顺利完成。手术时间中位值61.5(59.0,66.8)min,术后第1天血红蛋白下降中位值1.6(0.8,2.0)g/L,术后住院时间中位值1.5(1.0,2.0)d,术中针状肾镜通道数量中位值1(1,2)个。4例(11.1%)出现并发症,均为Clavien-Dindo分级I级,包括术后发热2例,镇痛剂使用2例。一期结石清除率为83.3%(30/36),6例有残石患者术后第3~7天行体外物理排石。治疗后1个月随访,3例排出残石,3例有结石残留者定期观察随访;最终结石清除率为91.7%(33/36)。结论采用超声引导下针状肾镜联合输尿管软镜治疗小负荷复杂肾结石安全、有效,术后结石清石率较高,并发症发生率较低.

Objective To analyze the safety and efficacy of ultrasound-guided needle-perc assisted retrograde intrarenal surgery(RIRS)in the treatment of small but complex renal calculi,and summarize our clinical experience.Methods The clinical data of 36 patients with small but complicated renal stones treated by ultrasound-guided needle-perc assisted RIRS in Beijing Tsinghua Changgung Hospital from January 2020 to April 2022,were retrospectively analyzed.There were 25 males and 11 females._The average age was(54.7±6.1)years,and the body mass index(BMI)was(26.3±3.1)kg/m^(2).The maximum diameter of the calculi was(1.8±0.7)cm.There were 28 patients without renal hydronephrosis before operation,8 patients with mild to moderate renal hydronephrosis,4 patients with caliceal diverticular stones 32 patients with lower pole stones,10 patients with ureteral stones,6 patients with previous surgical history of ipsilateral kidney stones,and 3 patients with stones in the solitary kidneys.Patients were placed in oblique supine lithotomy position or prone split leg position(female).For lower pole stones or diverticular stones that were difficult to be handled by flexible ureteroscope,the needle-perc was used to puncture the stones in target calyx under ultrasound guidance.Holmium laser was then used to pulverize or fragment the calculi,and the flexible ureteroscope was used to remove or further pulverize the stone fragments.Perioperative indexes and postoperative complications were recorded,and stone-free rate was analyzed.Results All 36 cases were successfully operated.The median operation time was 61.5(59.0,66.8)min,with a median decrease in hemoglobin on the first postoperative day of 1.6(0.8,2.0)g/L,a median postoperative hospital stay of 1.5(1.0,2.0)days,and a median needle-perc tract of 1(1,2).The complications were recorded in 4 patients(11.1%),all of which were Clavien-Dindo grade I,including postoperative fever in 2 patients and analgesic use in 2 patients.The primary stone-free rate was 83.3%(30/36).The 6 patients with residual stones were treated by external physical vibration lithecbole on the 3rd to 7th day after surgery.After 1 month follow-up,residual stone expulsion were seen in 3 patients.Three patients with residual stones were followed up regularly.The final stone-free rate was 91.7%(33/36).Conclusions Ultrasound-guided needle-per assisted RIRS is safe and effective in the treatment of small but complex renal calculi,with high postoperative stone free rate and low complication rate.