肾上盏入路经皮肾镜取石术的安全性及效果分析

目的 总结肾上盏入路经皮肾镜取石术(PCNL)的安全性和有效性.方法 回顾性分析237例应用肾上盏入路PCNL治疗肾或输尿管上段结石的患者资料.男135例,女102例.年龄8-76岁,平均42岁.其中结石长径＞1.5 cm或嵌顿性输尿管上段结石94例,长径≥2.0 cm或嵌顿性肾盂结石26例,鹿角形结石或多发性结石68例,复杂性肾下盏结石13例,不适合行体外冲击波碎石术(ESWL)或输尿管镜碎石术(URS)的肾上盏结石12例,肾上盏憩室结石3例,肾结石并肾盂输尿管连接部(UPJ)梗阻或输尿管上段狭窄8例,过度肥胖结石患者3例,马蹄肾肾结石6例,移植肾肾输尿管结石4例.其中经第12肋上入路175例(73.8％),第11肋上入路46例,第12肋下入路12例,移植肾患者经下腹部入路4例.结果 采用单一通道结石完全清除176例(74.3％),同期或分期建立多通道取石55例,联合ESWL 6例.术后3个月复查结石清除209例(88.2％).出现胸膜损伤16例(6.8％),行胸腔穿刺术8例,行胸腔闭式引流术5例,保守治愈3例.拔除肾造瘘管后出现胸膜刺激征12例(5.1％),予对症处理.无肺及其他内脏损伤.输血5例,其中行选择性肾动脉造影及拴塞术2例.结论 肾上盏入路PCNL操作视野开阔、硬镜操作方便、结石清除率高,可选择性地应用于治疗输尿管上段结石和部分复杂性肾结石.     

Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy

PURPOSE: To evaluate the feasibility and safety of supracostal access in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From September 2004 to November 2005, tubeless PCNL using supracostal access was done for 72 patients at our institute. Patients requiring more than two percutaneous tracts or with significant intraoperative bleeding or residual stone burden were excluded from the study. The outcome of these patients was compared with that of a historic cohort of similar patients having supracostal access with routine placement of a nephrostomy tube. The two groups had comparable demographic data. RESULTS: The differences in the mean drop in hemoglobin concentration, transfusion requirement, and complication rate in the two groups were not statistically significant, with three patients in the study group and four patients in the control group requiring blood transfusion. Patients undergoing tubeless PCNL required less analgesia (P = 0.000) and were discharged a mean of 19 hours earlier (P = 0.000) than those in the control group. Complete stone clearance was achieved in 90.27% of the renal units in the study group and 86.11% of the renal units in the control group. Two patients in the study group and three patients in the control group had postoperative hydrothorax, all of whom, except for one in the control group, were managed conservatively. CONCLUSION: Supracostal access in tubeless PCNL appears to be feasible, safe, and effective, offering the advantages of a lower analgesic requirement and shorter hospital stay without increasing thoracic complications. Studies with larger numbers of patients are needed to confirm these initial findings.     

肾上盏入路经皮肾镜取石术的疗效与安全性探讨

目的 评价经肾上盏入路行PCNL的疗效及安全性.方法 2007年10月至2009年10月行经肾上盏入路PCNL治疗肾结石患者42例.其中鹿角形结石10例,肾盂结石22例,肾上盏结石7例,下盏多发结石3例;合并输尿管上段结石4例,合并肾盂输尿管连接部狭窄(UPJO)2例;结石长径2.0～6.5 cm,平均3.4 cm.B超引导下选取肾上盏穿刺,穿刺点选在第10或11肋间,建立经皮肾通道(16～26 F).经皮肾镜或输尿管镜下气压弹道或钬激光碎石. 结果 42例均一期成功建立经皮肾通道并碎石.单通道取石36例(85.7%),双通道取石6例(14.3%).手术时间30～140 min,平均65 min.术后发热4例(9.5%),输血1例(2.4%),肾盂穿孔1例(2.4%).无气胸、血胸、腹腔脏器损伤.一期结石清除率88.1%(37/42),3例(7.1%)行二次肾镜取石,2例(4.8%)辅助体外冲击波碎石(ESWL)治疗. 结论经肾上盏入路PCNL活动范围大,对于部分复杂性肾结石碎石取石方便,是一种安全有效的方法.

Abstract：

Objective To evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL)guided by ultrasonography through upper pole access. Methods From October 2007 to October 2009, 42 patients with upper urinary tract calculi underwent PCNL through upper pole access.Among these cases, there were 10 cases of staghorn calculi, 22 cases of renal pelvis calculi, 7 cases of the upper calyx calculi, 3 cases of the lower calyx calculi, 4 cases combined with ureter calculi and 2 cases combined with ureteropelvic junction obstruction. The stone measured from 2.0 to 6.5 cm (average: 3.4 cm) in length. Working tunnels (F16-F26) were established through the 10th or llth intercostals. Pneumatic or holmium laser lithotripsy was used to disintegrate and remove stones by nephroscopy or ureteroscopy. Clinical data including operation time, complications and stone free rate were analyzed retrospectively. Results All the operations were completed in one session, single tract was used in 36 cases(85.7%), double tracts were used in the other 6 cases(14.3%). The stonefree rate after one session was 88.1% (37/42), 3 cases(7.1%) received a second-session PCNL, 2 cases (4.8%)underwent ESWL after operation. The mean operative time was 65 min(30- 140 min).Postoperative surgery-related infection rate was 9. 5% (4/42). One patient (2. 4%)required blood transfusion. Perforation of the pelvis occurred in 1 patient(2.4 %). No pleural or important organ injury occurred. Conclusion The upper pole access for PCNL can be convenient to remove stones,this method is a highly efficient and safe technique.     

Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

INTRODUCTION

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years.

METHODS

All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications.

RESULTS

PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion.

CONCLUSIONS

Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.     

多通道微造瘘经皮肾输尿管镜钬激光碎石术治疗复杂肾结石

目的 评估多通道微造瘘经皮肾输尿管镜钬激光碎石或气压弹道术碎石术治疗复杂肾结石的安全性和有效性.方法 回顾分析2001年到2009年间利用多通道微造瘘经皮肾输尿管镜钬激光碎石术或气压弹道碎石治疗复杂肾结石58例患者的临床资料.结果 58例患者共62个肾脏接受微造瘘经皮肾输尿管镜碎石术,共建立130条经皮肾通道,最多3个通道,一般仅为2个.58%的通道建立在第11肋间,其余分别位于第12肋下或第10肋间.12例患者术中术后需输血,5例患者出现感染性休克.48例患者经多期手术结石完全清除,清除率达77.4%.结论 多通道经皮肾镜取石术安全、有效,是复杂肾结石的治疗方式之一.     

经皮肾输尿管镜下气压弹道碎石术治疗儿童肾结石

目的探讨经皮肾输尿管镜下气压弹道碎石术治疗儿童肾结石的疗效与安全性。方法肾结石患儿15例,均为14岁以下,其中单侧8例,双侧7例,共22个肾脏。全部病例使用全身麻醉下经皮肾输尿管镜下气压弹道碎石术治疗。术后行X线摄片观察疗效,术后48h查血红蛋白。所有病例均行代谢评估,术后使用枸橼酸钾预防结石复发。术后随访2～3年。结果20个肾脏（91％）的结石完全清除。2个有残石的肾脏经体外冲击波碎石术治疗,结石完全清除。14例患儿术后有轻、中度发热（〈39℃,〈2d）,1例术后高热（〉39℃,〉2d）。患儿术后血红蛋白较术前平均下降10．0g／L。无输血病例。平均住院5．2d。全部病例术后半年行静脉肾盂造影检查,肾功能均平稳或有改善。无远期并发症。结论对儿童肾结石行经皮肾输尿管镜下气压弹道碎石术安全、有效。     

Safety and efficacy of tubeless percutaneous nephrolithotomy in patients on anti-platelet therapy and cirrhotic patients

Without the temponade effect over nephrostomy tube, postoperative hemorrhage is a major concern to the safety of tubeless percutaneous nephrolithotomy (PCNL) in patients with bleeding tendency. In this study, we would like to report our experience of performing tubeless PCNLs in these patients. At the end of PCNL, we cauterized the bleeding points in access tract for hemostasis to facilitate the achievement of tubeless PCNL. We identified and reviewed 16 patients under antiplatelet agent therapy and 6 patients with liver cirrhosis from 598 tubeless PCNLs performed in a single institute. Among the 16 patients undergoing anti-platelet therapy, the average stone size was 2.8 cm. The average operation time was 84.7 min. The stone-free rate was 87.5%. The average postoperative hospital stay was 3.8 days. Two patients (12.5%) experienced urinary tract infections after operation. There was no uncontrolled hemorrhage during and after operation and only one patient needed postoperative blood transfusion. No patient experienced any thromboembolic complication. Of the six patients with liver cirrhosis, the average stone size was 3.3 cm. The average operation time was 77.5 min. The stone-free rate is 83.4%. The average postoperative hospital stay was 4.0 days. No patient received blood transfusion after operation. There was no patient experiencing urinary tract infection after operation. Our results suggest that with careful hemostasis, tubeless PCNL is a safety modality in the treatment of urinary stone disease in patients on chronic anti-platelet therapy and cirrhotic patients.     

无管化经皮肾镜取石术的安全性和疗效评价

目的:对无管化经皮肾镜取石术(PCNL)的安全性和疗效进行评价,探讨其优势及应用前景。方法:对我院2010年8月～2011年7月所开展的192例无管化微创PCNL进行回顾性研究,总结分析术后住院时间、疼痛模糊评分(VAS)、止痛药物应用、术后出血、发热、漏尿等数据和指标。结果:依据无管化PCNL的适应证,192例采用无管化方式,无管化率为65.5%。192例无管化PCNL者术后平均住院3.8d,疼痛模糊评分(VAS)为2.4mm。术后严重出血5例(含1例巨大肾周血肿),4例保守治疗,1例行超选择性肾动脉栓塞;输血3例,发热2例;无漏尿者,术后应用止痛药1例。结论:无管化经皮肾镜适合于大多数PCNL,是对传统PCNL术后引流方式的改进,是安全有效的,能有效减轻患者术后疼痛不适,减少对止痛药的需求,缩短住院时间,而并发症也并未明显增加,值得临床推广。     

Efficiency of percutaneous nephrolithotomy in pediatric patients using adult-type instruments

To evaluate the efficiency of percutaneous nephrolithotomy using adult-type instruments in children with kidney stones. Between September 2004 and October 2009, 18 children (19 renal units) underwent percutaneous nephrolithotomy using adult-type instruments. Following percutaneous access under fluoroscopy, 20-30F tract dilatation was performed (1,92,427F), and lithotripters were used. Postoperatively, kidney-ureter-bladder X-ray and antegrade pyelography were performed to evaluate residual stones and contrast passage to the bladder. 8 boys and 10 girls with a mean age of 9.8 ± 4.56 years were evaluated. Mean stone burden was 338 ± 196.21 mm2. Stones were located in the left and right kidneys in 16 (84.2%) and 3 (16.8%) patients, respectively. Horse-shoe kidney was present in one patient. Mean operation (including cystoscopy) and fluoroscopy times were 106 ± 49.60 and 5.2 ± 2.14 min, respectively. Postoperatively, 10(52.6%) patients were stone free and 4 (21.1%) patients had clinically insignificant stones. Saline extravasation developed in three patients and surgery was aborted in one patient. Stone fragments migrated into the ureter in two patients and managed by additional endourological interventions. Nephrostomy catheters were kept for a mean of 2.6 ± 1.12 days. Four patients required blood transfusion due to bleeding. Postoperative fever of <39°C developed in five patients and >39°C in one patient. Mean hospitalization time was 5.3 ± 3.12 days. Overall, 73.7% of our patients were stone free, including patients with clinically insignificant stones. Particularly in children with a high-stone burden, the use of adult-type instruments might have a positive impact on stone-free rate, operation time and fluoroscopy time without increasing the complication rate.     

Management of a colon perforation during pediatric percutaneous nephrolithotomy

Abstract Percutaneous nephrolithotomy (PCNL) is one of the most common treatment options in the management of kidney stones in children. While colon perforation during PCNL is reported as a rare complication in adults, there are scarce data regarding colon perforation during pediatric PCNL. We report the successful management of colon perforation occurring during PCNL and of a renal stone in a 6-year-old child. Moreover, we describe the procedure to be followed for colon perforation in children.