局麻下微创经皮肾镜取石术治疗肥胖合并高危因素的肾、输尿管上段结石

Minimally invasive percutaneous nephrolithotomy for treating renal or upper urinary calculi under local anesthesia in obese patients with high-risk factors

目的:探讨局麻下微创经皮肾镜取石术(mPCNL)在肥胖合并高危因素的肾、输尿管上段结石中应用的安全性及有效性。方法:选取2015年4月～2017年2月我院收治的53例肥胖合并高危因素的肾、输尿管上段结石患者,BMI 24～35kg/m^2,合并高血压病21例,合并糖尿病14例,合并肾功能不全1例,同时合并高血压病、糖尿病9例,合并心肺功能不全5例,孤立肾3例,均采用超声引导局麻下mPCNL。术中以1%～2%盐酸利多卡因10～20ml自穿刺点皮肤开始沿穿刺方向行浸润麻醉,深达肾筋膜区域。术中采用视觉模拟评分法(VAS)"0～10"疼痛强度量表评估疼痛程度。结果:53例均一期穿刺造瘘成功,52例一期mPCNL成功,1例患者因肾功能不全及感染行二期mPCNL,一期手术结石取净率为98.1%。手术时间为17～77min,平均(43±12)min,无大出血、胸腹损伤等严重并发症。结论:局麻下mPCNL治疗肥胖合并高危因素的肾、输尿管上段结石患者具有麻醉并发症少、恢复快、医疗费用低等优点,并可以保证结石取净率,可作为肥胖合并高危因素的肾、输尿管上段结石患者的治疗方法。

Objective:To assess the safety and effectivness of minimally invasive percutaneous nephrolithotomy(mPCNL)for treating renal or upper urinary calculi under local anesthesia in obesity patients with high-risk factors.Method:From April 2015 to February 2017,53 obese patients with high-risk factors(BMI 24-35)suffered from renal or upper ureteral stones underwent mPCNL in our hospital.The high risk factors included 21 cases of hypertension,14 cases of diabetes mellitus,1 case of renal dysfunction,9 cases of hypertension combined with diabetes mellitus,5 cases of severe cardiopulmonary diseases and 3 cases of solitary kidney.The puncture and tracts were created using local anesthesia and guided through ultrasound.Intraoperative 10-20 ml 1%-2%lidocaine hydrochloride was used for infiltration anesthesia since puncture point of skin along the puncture direction line,deep into the renal fascia area.The VAS was used for pain assessment.Result:All of the 53 mPCNL procedures were performed successfully under local anesthesia.Fifty-two patients were successfully treated in the first phase of the surgury.Only one patient received second phase of mPCNL due to infection and renal insufficiency.The first phase stone-free rate was 98.1%.The mean operation time was(43±12)min.None of the patients encountered injuries to the pleura or other inner organs.Conclusion:MPCNL under local anesthesia was a safe and effective minimally invasive method for treating upper urinary calculi in obese patients with high-risk factors.