双侧肾输尿管结石同期或分期经皮肾镜取石术的选择

目的 探讨双侧肾输尿管结石同期或分期经皮肾镜取石术的选择.方法 2008年1-12月收治双侧肾输尿管结石患者60例.其中双侧肾结石30例、一侧肾结石合并对侧输尿管结石12例、双侧输尿管结石8例、双侧肾结石并一侧输尿管上段结石10例.结石直径1.0～6.5 cm,平均2.0 cm.根据手术时间、血红蛋白及血压变化、血气分析结果 和患者耐受程度等判定是否同期行双侧手术.根据手术完成情况分为同期组51例和分期组9例,分期组二期手术在3～6周后进行.比较2组患者一般情况、结石特征及手术情况.结果 手术分期原因:首侧手术时间＞3 h 4例,血红蛋白＜100 g/L或下降＞30 g/L 3例,收缩压＜90 mm Hg或下降＞30 mm Hg 2例,动脉血pH值＜7.35或动脉氧饱和度＜95% 2例,患者不耐受3例.同期组首侧结石负荷、总结石负荷分别为(480.4±375.3)mm2及(858.8±426.0)mm2,分期组分别为(1271.7±928.1)mm2及(1667.0±811.2)mm2,2组比较差异有统计学意义(P＜0.05).同期组首侧平均手术时间、总手术时间分别为(119.3±25.1)min及(212.7±25.5)min,分期组分别为(153.7±42.4)min及(254.8±44.9)min,2组比较差异有统计学意义(P＜0.05).2组患者性别、年龄、体质指数、术前血红蛋白、总血红蛋白降低值、手术开始侧别、结石数量、第二侧结石负荷等差异均无统计性意义(P＞0.05).2组总结石清除率分别为87.3%与88.9%,并发症发生率分别为17.6%与16.7%,2组差异均无统计性意义(P＞0.05).同期组术后出现发热(体温＞38.5 ℃)4例、迟发出血4例、肾盂穿孔1例;分期组术后发热1例、迟发出血1例、尿外渗1例.结论 首侧手术时间过长、术中出血及患者不耐受是双侧结石经皮肾镜取石分期手术的主要因素.

Abstract：

Objective To evaluate the of the decision process to perform staged or synchronous bilateral percutaneous nephrolithotripsy (PCNL) in the treatment of bilateral upper urinary tract calculi. Methods Patients with an indication for bilateral PCNL were enrolled in the study from Jan. 2008 to Dec. 2008. The decision to perform staged or synchronous bilateral PCNL was based on the initial side operative time, the changes of hemoglobin level and systolic arterial pressure, the results of blood gas analysis and the patient′s tolerance at the end of initial side operation. The patients were divided into two groups, patients who underwent synchronous bilateral PCNL were in group one. Patients where the PCNL procedure was stopped after the initial side and subsequently underwent staged bilateral PCNL three to six weeks later were placed in group two. The success and complication rates of two groups were compared and analyzed. Results Of 60 planned simultaneous bilateral PCNLs, nine were stopped after the initial side, due to prolonged operative time in four cases, a hemoglobin level ＜100 g/L or the decrease of more than 30 g/L in three cases, a systolic arterial pressure lower than 90 mm Hg or the decrease more than 30 mm Hg in two cases, an arterial blood pH lower than 7.35 or the arterial oxygen saturation lower than 95% in two cases or the patients were intolerant to the surgery in three cases. Between the two groups, the differences of patient gender, age, BMI, preoperative hemoglobin level, the total hemoglobin decrease, the side initiated operation, stone number and second side stone burden were insignificant. However, there were significant differences in the first operative side stone burden, total stone burden, the first operative side operative time and total operative time. The stone-clearance rate was 87.3% in group one and 88.9% in group two. There was no difference in complication rate of two groups. Conclusions Prolonged operative time, large blood loss during the first operation side and patient intolerance are the main causes of staged bilateral PCNL.

Selection of staged or synchronous percutaneous nephrolithotomy for the treatment of bilateral upper urinary tract calculi

Objective To evaluate the of the decision process to perform staged or synchronous bilateral percutaneous nephrolithotripsy (PCNL) in the treatment of bilateral upper urinary tract calculi. Methods Patients with an indication for bilateral PCNL were enrolled in the study from Jan. 2008 to Dec. 2008. The decision to perform staged or synchronous bilateral PCNL was based on the initial side operative time, the changes of hemoglobin level and systolic arterial pressure, the results of blood gas analysis and the patient′s tolerance at the end of initial side operation. The patients were divided into two groups, patients who underwent synchronous bilateral PCNL were in group one. Patients where the PCNL procedure was stopped after the initial side and subsequently underwent staged bilateral PCNL three to six weeks later were placed in group two. The success and complication rates of two groups were compared and analyzed. Results Of 60 planned simultaneous bilateral PCNLs, nine were stopped after the initial side, due to prolonged operative time in four cases, a hemoglobin level ＜100 g/L or the decrease of more than 30 g/L in three cases, a systolic arterial pressure lower than 90 mm Hg or the decrease more than 30 mm Hg in two cases, an arterial blood pH lower than 7.35 or the arterial oxygen saturation lower than 95% in two cases or the patients were intolerant to the surgery in three cases. Between the two groups, the differences of patient gender, age, BMI, preoperative hemoglobin level, the total hemoglobin decrease, the side initiated operation, stone number and second side stone burden were insignificant. However, there were significant differences in the first operative side stone burden, total stone burden, the first operative side operative time and total operative time. The stone-clearance rate was 87.3% in group one and 88.9% in group two. There was no difference in complication rate of two groups. Conclusions Prolonged operative time, large blood loss during the first operation side and patient intolerance are the main causes of staged bilateral PCNL.