超声引导下微通道与标准通道经皮肾镜取石术治疗肾结石的前瞻性对照研究

摘要 目的：对比超声引导下微通道经皮肾镜取石术（mPCNL）与标准通道经皮肾镜取石术（sPCNL）治疗肾结石的疗效。方法：选择空军第九八六医院2020年1月~2022年5月期间收治的肾结石患者127例,根据随机数字表法将患者分为sPCNL组（63例）和mPCNL组（64例）。对比两组临床指标、结石清除率、疼痛情况、肾功能、应激情况、炎症因子水平和并发症发生率。结果：mPCNL组的肾盂结石、肾盏结石清除率均高于sPCNL组（P<0.05）。两组肾铸形结石、鹿角形结石清除率比较无差异（P>0.05）。mPCNL组的手术时间长于sPCNL组,术中出血量、术中输液量少于sPCNL组,住院时间短于sPCNL组（P<0.05）。两组术前、术后3 d尿素氮（BUN）、血肌酐（Scr）组间及组内对比,差异均无统计学意义（P>0.05）。mPCNL组术后3 d皮质醇（Cor）、促肾上腺皮质激素（ACTH）低于sPCNL组（P<0.05）。mPCNL组术后3 d白介素-6（IL-6）、肿瘤坏死因子（TNF-α）、降钙素原（PCT）低于sPCNL组（P<0.05）。mPCNL组术后3 d视觉疼痛模拟评分（VAS）评分和P物质（SP）、前列腺素E₂（PGE₂）水平低于sPCNL组（P<0.05）。两组并发症发生率对比无统计学差异（P>0.05）。结论：与sPCNL相比,超声引导下mPCNL治疗肾结石虽会延长手术时间,但可降低术中出血量、术中输液量,缩短住院时间,减轻患者疼痛反应、应激反应和炎性反应,同时对患者的肾功能影响较小。     

微通道经皮肾镜碎石取石术治疗复杂性肾结石的临床疗效及安全性观察

目的:探讨标准通道及微通道经皮肾镜取石术(PCNL)对复杂性肾结石患者的临床疗效及安全性。方法:140例行PCNL治疗的复杂性肾结石患者,根据手术通道的不同分为(对照组,n=70)及(研究组,n=70),比较两组治疗效果、手术情况、手术前后肾小球滤过率变化、术后并发症及手术前后血清炎性因子水平变化。结果:研究组治疗效果显著优于对照组(P<0.05);研究组术中出血量明显少于对照组(P<0.05),但手术持续时间明显长于对照组(P<0.05);研究组术后下床活动时间、住院天数均明显短于对照组(P<0.05);研究组结石清除率与对照组比较差异无统计学意义(P>0.05);研究组术后并发症发生率低于对照组(P <0.05);两组术前的肾小球滤过率比较,无差异(P>0.05);两组术后肾小球滤过率均有升高,研究组术后的肾小球滤过率高于对照组(P<0.05);与术前比较术后3 d两组血清降钙素原(PCT)以及研究组血清C反应蛋白(CRP)水平均升高,且研究组上述指标均高于对照组(P<0.01)。结论:微通道经皮肾镜碎石取石术治疗复杂性肾结石的效果显著,具有创伤小、术中出血少、术后恢复快且并发症发生率低等优点,可更有效改善血清炎性因子水平,值得推广应用。     

微通道经皮肾镜与输尿管软镜碎石取石术对输尿管上段结石患者血液流变学及男性性功能指标的影响

摘要 目的：以血液流变学及男性性功能指标为主要观察指标分析微通道经皮肾镜取石术（MPCNL）与输尿管软镜碎石取石术（FURL）在输尿管上段结石（UUC）中的应用价值。方法：将80例男性UUC患者按简单随机化法分MPCNL组、FURL组各40例;比较两组清石率、血液流变学、性功能指标及不良反应。结果：两组术后1w（82.50% vs 85.00%）、术后1mo（92.50% vs 97.50%）、术后3mo（100.00% vs 100.00%）的清石率无统计学意义（P＞0.05）。FURL组术后1天、术后7天的血液流变学指标水平均低于MPCNL组（P＜0.05）。两组术后男性性功能指标较术前显著改善,但FURL组术后3mo、6mo的男性性功能指标改善更显著（P＜0.05）。结论：对于UUC患者,MPCNL和FURL均能有效清除结石,都是安全有效的方法,但FURL较MPCNL对患者术后血液流变学的影响更小,且更利于术后性功能的恢复。     

通道大小对经皮肾镜取石患者出血的影响

目的:探讨通道大小对经皮肾镜取石患者围手术期出血的影响及治疗策略。方法:回顾性分析2016年1月至2017年1月在我院行F24和F18通道的经皮肾镜取石术的189例患者临床资料,分别比较具有不同临床特征患者围手术期出血的发生情况。结果:95例F24通道患者平均出血量为125±19.6 m L,其中5人进行输血治疗;94例F18通道患者平均出血量为103±17.6m L,其中3人进行输血治疗。F18通道经皮肾镜取石术的出血组和非出血组糖尿病、高血压的发生率、结石表面积、通道数量、手术时间比较差异均具有统计学意义(P0.05)。F24通道经皮肾镜取石术的出血组和非出血组孤立肾、高血压发生率、结石面积、肾实质厚度、通道数量和手术时间比较差异均具有统计学意义(P0.05)。F18通道经皮肾镜取石围手术期出血量显著少于F24通道(P0.05)。结论:孤立肾、高血压、结石面积大、肾实质厚、肾积水轻、通道数量多和手术时间长均会导致经皮肾镜围手术期出血几率和出血量增加,并且F24通道相较于F18通道出血量更多。     

微创经皮肾镜取石术治疗上尿路结石

目的:探讨微创经皮肾取石术(MPCNL)治疗上尿路结石的效果.方法:分别应用激光碎石术和气压弹道超声碎石术通过经皮肾镜通道治疗76例、82例上尿路结石,分析比较其结石清除率、出血量、手术时间等指标.结果:①微创经皮肾镜气压弹道超声碎石术Ⅰ期结石清除率为95.12%,高于激光碎石术的88.16%Ⅰ期结石清除率,差异具有显著性(P＜0.05).②气压弹道超声碎石术平均手术时间(74 min)和平均出血量(35 ml),显著少于激光碎石术的平均手术时间(92 min)和平均出血量(65 ml),差异具有显著性(P＜0.05).③两种治疗方法在造瘘管置留时间、平均住院时间、积水好转率、术后复发率上差异无统计学意义(P＞0.05).结论:微创经皮肾镜气压弹道超声碎石术相较于微创经激光碎石术在上尿路结石治疗中更为安全有效.     

彩色多普勒超声引导下经皮肾镜取石术（PCNL）治疗复杂性肾结石的临 床分析

摘要目的：总结彩色多普勒超声引导下经皮肾镜取石术（percutaneous nephrolithotomy,PCNL) 治疗的复杂性肾结石的经验及其 安全性、有效性以及常见并发症。方法：回顾性分析我院2011 年7 月～2012 年8 月采用彩色多普勒引导下经皮肾镜治疗复杂性 肾结石患者56 例的临床资料。结果：所有患者均I期建立经皮肾通道,平均手术时间(107.5± 27.5)分钟,24 例行EMS 气压弹道联 合超声碎石(101.0± 27.9)分钟,20 例行钬激光联合超声碎石(119.4± 23.6)分钟,10 例行单纯超声碎石(108.2± 30.2)分钟,EMS 气 压弹道联合超声碎石组的手术时间少于钬激光碎石组,差异有统计学意义（P<0.05,单纯超声碎石组与另外两组比较无统计学意 义P>0.05)。术前肾功能损伤患者术后随访,肾功能明显改善。结石完全清除率91%,结石部分残留率9%。术中均无严重出血,无 周边脏器损伤。术后出现迟发出血5 例,反复发热4 例,均经对症治疗后缓解。结论：彩色多普勒超声引导除了具有普通超声引导 的优势外,还可有效避开肾实质大血管损伤,减少术中及术后出血风险。彩色多普勒超声引导下经皮肾镜碎石取石术是一种治疗 复杂性肾结石安全、有效的方法。     

彩色多普勒超声引导下经皮肾镜取石术（PCNL）治疗复杂性肾结石的临床分析

目的：总结彩色多普勒超声引导下经皮肾镜取石术（percutaneousnephrolithotomy,PCNL）治疗的复杂性肾结石的经验及其安全性、有效性以及常见并发症。方法：回顾性分析我院2011年7月-2012年8月采用彩色多普勒引导下经皮肾镜治疗复杂性肾结石患者56例的临床资料。结果：所有患者均I期建立经皮肾通道,平均手术时间（107．5±27．5）分钟,24例行EMS气压弹道联合超声碎石（1001．0±27．9）分钟,20例行钬激光联合超声碎石（119．4±23．6）分钟,10例行单纯超声碎石（108．2±30．2）分钟,EMS气压弹道联合超声碎石组的手术时间少于钬激光碎石组,差异有统计学意义（P〈0．05,单纯超声碎石组与另外两组比较无统计学意义P〉0．05）。术前肾功能损伤患者术后随访,肾功能明显改善。结石完全清除率91％,结石部分残留率9％。术中均无严重出血,无周边脏器损伤。术后出现迟发出血5例,反复发热4例,均经对症治疗后缓解。结论：彩色多普勒超声引导除了具有普通超声引导的优势外,还可有效避开肾实质大血管损伤,减少术中及术后出血风险。彩色多普勒超声引导下经皮肾镜碎石取石术是一种治疗复杂性肾结石安全、有效的方法。     

侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的临床应用价值

目的：探讨侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的可行性及临床应用价值。方法：回顾性分析2009年8月至2011年9月我院采用侧卧体住下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石患者52例的临床资料：患者同时存在肾脏铸型结石或多发结石和或输尿管上段结石,单个结石最大径8-30mm。结果：平均手术时间60分钟（50—120分钟）;术前血红蛋白116±30g／L,术后第一天复查105±26g／L,无大出血需要输血病例;一次结石取净率为86．5％（45／52）,总取净率为92．3％（48／52）。结论：侧卧体位下经皮肾穿刺取石术及经尿道输尿管镜取石术两种术式联合应用具有可行性及互补性,在预防及减少术中出血、获得清晰的手术视野、减少灌注液外渗、增加结石清除速度及碎石成功率、缩短手术时间、减少术后发热等方面疗效显著,为治疗复杂上尿路结石提供了一个可行的新方法。     

经皮肾微造瘘输尿管镜取石术治疗复杂鹿角形肾结石

目的:探讨经皮肾穿刺微通道法(M PCNL-mini percutaneous nephrolithotomy)在治疗复杂鹿角形肾结石的临床应用价值.方法:使用F16-F18左右的肾筋膜扩张器建立经皮肾微通道,通过气压弹道碎石及输尿管镜取石治疗复杂鹿角形肾结石,并对采用此法手术的478名患者的治疗效果进行回顾性分析.结果:通过经皮肾穿刺建立微通道(M PCNL)治疗复杂鹿角形肾结石的478名患者,术中及术后均无严重并发症发生,结石取净率达93.143%.结论:经皮肾穿刺微通道技术治疗复杂鹿角形肾结石具有创伤小、出血少、并发症少、住院时间短的优点,具有良好的临床应用价值.     

舒适护理干预对经皮肾镜碎石取石术的临床效果观察

目的探讨舒适护理干预在经皮肾镜碎石取石术后患者康复中的临床应用效果。方法选取2015年1~10月我院泌尿外科收治行经皮肾镜碎石取石术(PCNL)的肾多发结石患者88例为研究对象,随机分为观察组和对照组各44例,对照组给予术后常规护理,观察组在常规护理上,同时进行体位训练和加强背部皮肤护理等干预措施,观察比较两组出血发生情况、肾造瘘管拔除时间、尿管拔除时间、住院时间、患者护理舒适度和满意度情况。结果观察组患者出血发生率低于对照组(P0.05),肾造瘘管拔除时间、尿管拔除时间、住院时间等均少于对照组(P0.05),舒适度和满意度均高于对照组(P0.05)。结论对经皮肾镜碎石取石术后患者实施舒适护理干预,可有效降低出血发生率,提高患者的舒适度和满意度,缩短了住院时间,节约卫生资源,提高了手术疗效。     

Treatment of Colonic Injury During Percutaneous Nephrolithotomy

Colonic injury during percutaneous nephrolithotomy (PCNL) persists despite the advances in technical equipment and interventional radiology techniques. According to the Clavien-Dindo classification of surgical complications, colonic injury is regarded as a stage IVa complication. Currently, the rate of colonic injury ranges between 0.3% and 0.5%, with an unremarkable difference in incidence between supine and prone PCNL procedures. Colon injury is the most significant complication of PCNL. Colonic injury can result in more complicated open exploration of the abdomen, involving colostomy construction. The necessity of a second operation for the closure of the colostomy causes financial and emotional burden on the patients, patients’ relatives, and surgeons. Currently, the majority of colonic injuries occurring during PCNL are retroperitoneal. The primary treatment option is a conservative approach. It must be kept in mind that the time of diagnosis is as important as the diagnosis itself in colonic injury. Surgeons performing PCNL are advised to be conservative when considering exploratory laparotomy and colostomy construction during treatment of colonic injury. We present the case of a 49-year-old woman who underwent left prone PCNL that resulted in retroperitoneal colonic injury, along with a review of the current literature.Key words: Colonic injury, Percutaneous nephrolithotomy, Clavien, Complication, Prevention, Urolithiasis, ManagementPercutaneous nephrolithotomy (PCNL) is a standard, safe, and effective method used in the management of large kidney stones. PCNL was first described by Fernstrom and Johansson in 1976.¹ Currently, PCNL offers a 78% to 95% success rate in the treatment of kidney stones. However, the rate of major and minor complications related to the procedure is as high as 83%.² The major complication rate for PCNL varies between 1.1% and 7%,³ despite improvements in endourologic equipment and the development of new treatment modalities, such as mini-micro PCNL, supine PCNL, and laparoscopically assisted PCNL. A wide range of complications can arise from PCNL, ranging from those requiring simple medical therapies and follow-up to more severe conditions resulting in death, and have been categorized according to the Clavien-Dindo classification system. The most common complication is hemorrhage, accounting for 1% to 12% of cases. However, the rate of hemorrhage requiring blood transfusion is less than 2.5% in the latest series reported in the literature,⁴ and the rate of grade V mortality is less than 0.1%. Colon injury during PCNL is classified as a grade IVa complication, and rarely occurs (in only 0.2%–0.8% of cases). However, colon injury is of great significance, due to its diagnostic challenges, as well as severe and fatal complications.²     

经皮肾镜碎石术后发热相关因素的研究进展

经皮肾镜碎石术（PCNL）已成为处理复杂上尿路结石最常用的手术方式之一。尽管术前可以预防性使用广谱抗菌素,但严重尿路感染、发热仍是PCNL术后常见并发症。虽然PCNL术后发热常能较快消退,在一些患者中仍可发生严重并发症。PCNL术后发热或者严重的尿路感染可增加患者死亡率、住院时间及医疗成本,因此,越来越多的医生开始关注可能导致PCNL术后发热的相关因素。本文主要综述了PCNL术后发热的可能机制及明确术前及术中可能导致PCNL术后发热的相关因素。根据近年国内外数据、文献可以得出,可能影响PCNL术后发热的因素包括糖尿病、术前肾造瘘管的使用、结石成分及形状、肾盂积脓、手术时间及灌注液量,术前尿路感染的适当治疗虽然不能阻止术后炎性反应或发热,但可以降低细菌感染率及促进从全身炎症反应综合征（SIRS）中的恢复。术前尿培养、结石细菌培养及肾盂尿培养均为术后发热的预测因子,能够为术后发热的抗菌素选择提供重要依据。     

经皮肾镜碎石术后发热相关因素的研究进展

经皮肾镜碎石术(PCNL)已成为处理复杂上尿路结石最常用的手术方式之一。尽管术前可以预防性使用广谱抗菌素,但严重尿路感染、发热仍是PCNL术后常见并发症。虽然PCNL术后发热常能较快消退,在一些患者中仍可发生严重并发症。PCNL术后发热或者严重的尿路感染可增加患者死亡率、住院时间及医疗成本,因此,越来越多的医生开始关注可能导致PCNL术后发热的相关因素。本文主要综述了PCNL术后发热的可能机制及明确术前及术中可能导致PCNL术后发热的相关因素。根据近年国内外数据、文献可以得出,可能影响PCNL术后发热的因素包括糖尿病、术前肾造瘘管的使用、结石成分及形状、肾盂积脓、手术时间及灌注液量,术前尿路感染的适当治疗虽然不能阻止术后炎性反应或发热,但可以降低细菌感染率及促进从全身炎症反应综合征(SIRS)中的恢复。术前尿培养、结石细菌培养及肾盂尿培养均为术后发热的预测因子,能够为术后发热的抗菌素选择提供重要依据。     

微创经皮肾镜碎石术治疗输尿管上段嵌顿结石

目的:分析微创经皮肾镜碎石术(minimal invasive percutaneous nephrolithotomy,mPCNL)治疗输尿管上段嵌顿性结石的临床疗效.方法:采用B超或X线定位,mPCNL治疗102例嵌顿性输尿管上段结石,其中2例经皮穿刺抽吸脓性尿液,留置造瘘管,抗炎治疗后二期手术.术后生命体征、B超和尿路平片(kindey ureter bladder,KUB)等检查并随访.结果:100例Ⅰ期穿刺成功并气压弹道或钬激光mPCNL,手术时间55-75 min.碎石、取石时间15-35 min.术后住院4-7 d.无穿刺损伤腹腔脏器、术中未有肾孟穿孔和输尿管损伤、无大出血等术中和术后并发症.mPCNL术后2 dKUB检查结石清除率为91.1%(93/102),9例残留结石,术后辅以体外冲击波碎石治疗.术后1个月结石清除率为100%(102/102).结论:微创经皮肾穿刺取石治疗嵌顿性输尿管上段结石创伤小、恢复快且有很高的清除率,值得临床推广应用.     

Regional versus General Anesthesia for Percutaneous Nephrolithotomy: A Meta-Analysis

ObjectiveTo compare the effectiveness and safety of regional anesthesia (RA) and general anesthesia (GA) for percutaneous nephrolithotomy (PNL).ResultsEight randomized controlled trials (RCTs) and six non-randomized controlled trials (nRCTs) involving 2270 patients were included. Patients receiving RA were associated with shorter operative time (−6.22 min; 95%CI, −9.70 to −2.75; p = 0.0005), lower visual analgesic score on the first and third postoperative day (WMD, −2.62; 95%CI, −3.04 to −2.19; p < 0.00001 WMD, −0.38; 95%CI, −0.58 to −0.18; p = 0.0002), less analgesic requirements (WMD, −59.40 mg; 95%CI, −78.39 to −40.40; p<0.00001), shorter hospitalization (WMD, −0.36d; 95%CI, −0.66 to −0.05; p = 0.02), less blood transfusion (RR, 0.61; 95%CI, 0.41 to 0.93; p = 0.02), fewer modified Clavion-Dindo Grade II (RR, 0.56; 95%CI, 0.37 to 0.83; p = 0.005), Grade III or above postoperative complications (RR, 0.51; 95%CI, 0.33 to 0.77; p = 0.001), and potential benefits of less fever (RR, 0.79; 95%CI, 0.61 to 1.02; p = 0.07), nausea or vomiting (RR, 0.54; 95%CI, 0.20 to 1.46; p = 0.23), whereas more intraoperative hypotension (RR, 3.13; 95%CI, 1.76 to 5.59; p = 0.0001) when compared with patients receiving GA. When nRCTs were excluded, most of the results were stable but the significant differences were no longer detectable in blood transfusion, Grade II and more severe complications. No significant difference in the total postoperative complications and stone-free rate were found.ConclusionsCurrent evidence suggests that both RA and GA can provide safe and effective anesthesia for PNL in carefully evaluated and selected patients. Each anesthesia technique has its own advantages but some aspects still remain unclear and need to be explored in future studies.     

Evaluating the Learning Curve for Percutaneous Nephrolithotomy under Total Ultrasound Guidance

Objectives

To investigate the learning curve of percutaneous nephrolithotomy under total ultrasound guidance.

Methods

One hundred and twenty consecutive PCNL operations under total ultrasound guidance performed by a novice surgeon in a tertiary referral center were studied. Operations were analyzed in cohorts of 15 to determine when a plateau was reached for the variables such as operation duration, ultrasound screening time, tract dilation time, stone-free rate and complication rate. Comparison was made with the results of a surgeon who had performed more than 1000 PCNLs. Fluoroscopy was not used at all during procedure.

Results

The mean operation time dropped from 82.5 min for the first 15 patients to a mean of 64.7 min for cases 46 through 60(P = 0.047). The ultrasound screening time was a peak of 6.4 min in the first 15 cases, whereas it dropped to a mean of 3.9 min for cases 46 through 60(P = 0.01). The tract dilation time dropped from 4.9 min for the first 15 patients to a mean of 3.8 min for cases 46 through 60(P = 0.036). The senior surgeon had a mean operating time, screening time and tract dilation time equivalent to those of the novice surgeon after 60 cases. There was no significant difference in stone free rate and complication rate.

Conclusions

The competence of ultrasound guided PCNL is reached after 60 cases with good stone free rate and without major complications.     

微创经皮肾穿刺碎石术（MPCNL）治疗上尿路结石的临床分析

目的：探讨微创经皮肾穿刺碎石术（MPCNL）用于治疗尿路结石的临床效果。方法：选取120例单侧上尿路结石病患者,随机分为两组,每组60人。一组应用微创经皮肾穿刺碎石术（MPCNL）进行一期单通道上尿路取石,另一组采用开放手术治疗。比较并分析两组患者的临床疗效。结果：应用MPCNL治疗的60名患者中,结石清除的有55名,清除率为91．17％,手术时间平均为77分钟,住院时间平均为5-3天。术中平均出血100mL,术后发生大出血者一例,经输血后好转,术后发热者38例,发热比例为63-3％,尿液转清时间平均为2．5天。应用开放式手术的60名患者中,结石清除的有39例,清除率为65．0％,平均手术之间为112分钟,住院时间平均为18．1天,术中平均出血380mL,术后发生大出血者9例,经输血后好转,术后发热者43例,发热比例为71．2％,尿液转清时间平均为8．6天。结论：MPCNL方法治疗上尿路结石的效果明显比开放式手术好,具有清除率高、手术时间短、术后并发症少、术后感染少以及患者恢复快的优点。     

Effectiveness of Ureteroscopy-Assisted Retrograde Nephrostomy (UARN) for Percutaneous Nephrolithotomy (PCNL)

Objective

To determine the impact of ureteroscopy-assisted retrograde nephrostomy (UARN) during percutaneous nephrolithotomy (PCNL).

Materials and Methods

From April 2009 to September 2011, a total of 50 patients underwent PCNL for large renal stones (stone burden >2 cm). We performed UARN in the Galdakao-modified Valdivia position for 27 patients (UARN PCNL) and ultrasonography-assisted percutaneous nephrostomy in the prone position for 23 patients (prone PCNL).

Results

UARN PCNL significantly improved the stone-free rate (81.5% vs 52.2%) and the rate of residual stones (<4 mm, 92.6% vs 65.2%, P<0.05). The median length of the operation was significantly shorter for UARN PCNL, at 160 min, compared to 299 min for prone PCNL (P<0.001). There was one intraoperative complication in prone PCNL, namely a hemorrhage that resulted in stopping the initial treatment, but it was cured conservatively. The postoperative complications included a high grade fever that persisted for three days in two UARN PCNL patients (7.4%) and six prone PCNL patients (26.1%). The Clavien grading scores showed significantly lower postoperative complications for UARN PCNL compared to prone PCNL.

Conclusion

UARN is associated with a higher stone-free rate, shorter operation time, and fewer complications during PCNL than prone PCNL.