微创经皮肾取石术中肾盂内压测量

目的 探讨微创经皮肾取石术(MPCNL)中肾盂内压测量方法及其意义.方法 通过压力传感器连接逆行置入肾盂的5Fr输尿管导管与Mindray PM9000型监护仪有创压力测量通道,实施经皮肾取石术中肾盂内压测量,增加软件模块后的测压系统每秒采集1次数据,并将数据实时导入计算机数据库.结果 共对112例MPCNL术中肾盂内压进行测量,分析了MPCNL术中肾盂内压的影响因素以及肾盂内压与术后发热的关系.结论 MPCNL术中肾盂内压总趋势小于一般所认为的引起肾实质反流的极限[30 mm Hg(1 mm Hg=0.133 kPa)].任何引起灌注液流出受阻的因素,均可引起肾盂内压增高,术者应该在术中注意调整操作手法,降低肾盂内压.术后发热与MPCNL导致的肾盂内压短暂性增高无明显相关,但总手术时间过长,肾盂内高压状态(≥30 mmHg)累积到一定限度(50 s以上),总平均肾盂内压升高(20 mm Hg以上),将引起术后发热率增加.

Abstract：

Objective To introduce a new method to measure renal pelvic pressure in vivo during minimally invasive percutaneous nephrolithotomy (MPCNL), and investigate its clinical significance.Methods Renal pelvic pressure was measured by baroceptor which was connected to Mindray PM9000 monitor IBP channel and ureteric catheter positioned in renal pelvis during MPCNL, and a computer collected the renal pelvic pressure data each second. Results Renal pelvic pressure was measured in 112 cases during MPCNL, and the influence factors of renal pelvic pressure and its correlation with postoperative fever were analyzed. Conclusion Renal pelvic pressure generally remained lower than a level to back-flow [30 mm Hg(1 mm Hg=0.133 kPa)] during MPCNL. Any factors which brought about a bad drainage would result in a temporal elevated intrapelvic pressure greater than 30 mm Hg. It's necessary for the surgeons to adjust their manipulation to keep a low renal peivic pressure. A spurt high renal pelvic pressure greater than 30 mmHg wouldn't cause a postoperative fever, while a status of renal pelvic pressure greater than 30 mmHg(longer than 50 s) or a mean renal pelvic pressure greater than 20 mmHg all through the procedure may lead to an enough back-flow, resulting in a postoperative fever.     

输尿管镜碎石术中肾盂内压力变化对术后发热的影响

目的:探讨输尿管镜碎石术术中肾盂压力的变化对术后发热的影响。方法:采用压力传感器实时测量124例行输尿管镜碎石术的患者肾盂内压力,分析肾盂内压力的变化与术后发热的关系。结果:124例患者术中平均肾盂内压2.07kPa(1kPa=7.5mm Hg),肾盂内压力≥4.00kPa平均累计时间为96.72s。术后有30例(24.2%)患者发热。术后发热与患者年龄(P=0.243)、性别(P=0.135)、尿路感染(P=0.183)、术后血常规白细胞≥10×109/L(P=0.317)、术中肾盂内压力曾经≥5.33kPa(P=0.260)无明显关系。而与感染性结石(P=0.002)、术中平均肾盂内压力≥2.67kPa(P=0.017)、肾盂内压力≥4.00kPa持续时间(P=0.011)相关。结论:术后发热与输尿管镜碎石术导致的肾盂内压力短暂性增高不相关,但术中平均肾盂内压力、肾盂内压力≥4.00kPa持续时间升高将引起术后发热率增高。     

微创经皮肾穿刺取石术中肾盂内压变化的临床研究

目的探讨微创经皮肾穿刺取石(MPCNL)术中肾盂内压变化对术后并发症的影响。方法采用逆行置入肾盂5 F输尿管导管连接测压系统,平均灌注流量300 ml/min,平均灌注压191 mm Hg(1 mm Hg=0.1 33 kPa),监测76例不同口径通道下MPCNL术中肾盂内压变化,每秒钟采集一次数据,数据实时导入计算机并作统计学分析。结果14、1 6、18 F单通道以及16 F双通道下MPCNL术中平均肾盂内压分别为24.85、16.23、11.68及5.83 mm Hg,肾盂压力>30 mm Hg平均累积时间分别为283、96、44、10 s,14 F单通道MPCNL术中平均肾盂内压均高于16、18 F单通道(P<0.05)及16 F双通道(P<0.001)。结论不同口径通道下MPCNL术中肾盂内压均较低,小于引起肾实质返流的压力极限(30 mm Hg)。引起灌注液流出受阻因素均可引起肾盂内压明显增高。手术时间过长,肾盂内高压状态累积致使返流达到一定限度可能会引起菌血症。     

微创经皮肾输尿管镜碎石术中肾盂内压与术后康复的关系

目的介绍微创经皮肾输尿管镜碎石术（MPCNL）中肾盂内压力监测的方法,观察肾盂内灌注压力对术后康复的影响。方法用自制连接器密闭连接F5输尿管导管的尾端与无菌的换能器,建立肾盂内压测定装置,对46例肾结石患者术中即时监测肾盂内压,统计术后早期并发症,如发热、疼痛指数及血红蛋白的下降值,并观察住院时间和远期结石清除率,探讨其与压力变化的关系。高压冲洗组（n=20）为术中肾盂内压力≥30mm Hg（1mm Hg=0．133 kPa）,持续时间≥10min,其余情况归入低压冲洗组（n=26）。结果术中肾盂压力为3～50mmHg。高压冲洗组术后发热、血红蛋白的下降值、疼痛指数和平均住院时间均高于低压冲洗组（P〈0．05）,两组间术后1个月结石清除率差异无统计学意义（P〉0．05）。结论MPCNL术中常规监测肾盂内压变化,控制术中压力≥30mm Hg持续时间〈10min,以获得平稳的术后康复,减少术后并发症的发生,可有效缩短住院时间。     

持续肾盂内压监测在微创经皮肾镜碎石术中的应用及其临床意义

目的 介绍持续肾盂内压监测在微创经皮肾镜碎石(MPCNL)术中的应用,并探讨其临床意义.方法 将100例行MPCNL手术的肾结石患者随机分成两组:实验组(50例)术中行持续肾盂内压监测,尽量避免肾盂内压力≥30mmHg;对照组(50例)术中无肾盂内压监测.统计术后发热、疼痛指数及血红蛋白的下降值等相关临床指标,探讨其与肾盂内压监测的关系.结果 实验组患者术后发热、血红蛋白的下降值及疼痛指数均明显低于对照组(P<0.05),两组间的结石清除率差异无统计学意义(P>0.05).结论 MPCNL术中常规监测肾盂内压变化可以减少术后并发症,且不影响结石清除率.     

单通道低肾盂内压微创经皮肾穿刺取石手术的临床观察

目的探讨微创经皮肾穿刺取石术中控制肾盂内压升高的方法。方法选择80例行单通道MPCNL的肾结石患者,分为两组,控压组(40例):术中实时监测肾盂内压力,术者采取调控灌注液体入出量,控制肾盂内压升高;对照组(40例)仅记录肾盂内压。比较两组平均灌注液用量、平均肾盂内压、肾盂内压≥30 mmHg累计时间、手术时间及术后并发症。结果两组术中平均灌注液用量(L)为14.33±3.72、28.40±5.52;平均肾盂内压(mmHg)为14.5±3.8、26.8±6.5;肾盂压力30 mmHg平均累积时间(s)分别为42.4±5.7、118.4±20.8,存在显著差异(P0.05);手术时间(min)为110±20、103±31,无显著性(P0.05),对照组术后疼痛、发热、白细胞增高患者人数发生显著高于控压组(P0.05)。结论术中调控灌注液体出入量,能够降低MPCNL术中肾盂内压,提高手术安全性。     

二期微创经皮肾镜术中肾盂内压的监测及其临床意义

目的：研究二期微创经皮肾镜碎石（MPCNL）术中肾盂内压力的变化及其对术后并发症的影响。方法：行MPCNL手术的60例肾结石患者术中均行持续肾盂内压监测,试验组（30例）为二期手术患者,对照组（30例）为一期手术患者。统计术后发热、疼痛指数及血红蛋白的下降值等相关临床指标,探讨其与肾盂内压监测的关系。结果：二期MPCNL术中肾盂内压明显低于一期MPCNL者,二期手术患者术后发热、血红蛋白下降值及疼痛指数均明显低于对照组（P〈0．05）。结论：二期MPCN手术由于有成熟的经皮通道,通过减少术中高压灌注时间,可以显著降低术后并发症发生率。     

超声引导下经皮肾镜取石术中肾盂内压变化与术后发热的关系

目的：探讨超声引导经皮肾镜取石术术中肾盂内压力的变化及与取石术后发热的关系。方法：回顾性分析96例接受经皮。肾镜取石术治疗的肾结石患者临床资料,通过压力感受器实时监测术中肾盂内压力及对术后发热的影响。结果：筛选纳入的96例患者术中肾盂内压力≥30mmHg（1mmHg0．133kPa）平均累计时间为83．17s,平均肾盂内压力为14．79mmHg。术后有26（27．1％）例患者出现发热,与感染性结石、术中平均肾盂内压力≥20mmHg、肾盂内压力≥30mmHg持续时间相关（P〈O．05）。而术后发热与患者性别、年龄、尿路感染（UTI）、术后血常规白细胞≥10×10。／L、术中肾盂内压力≥35mmHg无明显关系（P〉0．05）。结论：经皮。肾镜取石术术中平均肾盂内压力、肾盂内压力≥30mmHg持续时间与术后发热的发生率呈正相关,而肾盂内压力短暂性升高（≥35mmHg）与术后发热无明显关系。     

经皮肾穿刺造瘘后输尿管镜钬激光碎石肾盂内压力变化及临床意义

目的 探讨经皮肾穿刺造瘘后输尿管镜钬激光碎石术术中肾盂内压力变化及对术后并发症的影响.方法 回顾性分析输尿管镜碎石术治疗上尿路结石64例的临床资料,其中术前行肾脏穿刺造瘘28例(实验组);术前未行肾脏穿刺造瘘36例(对照组).采用压力传感器实时测量行输尿管镜碎石术的患者肾盂内压力,统计术后发热、疼痛指数及肾功能等相关临床指标.结果实验组术中平均肾盂压力(17.4±3.5)mm Hg(1mm Hg=0.133kPa),对照组为(22.3±5.7)mm Hg.实验组术后发热、早期一过性肾功能减退发生率及肾区疼痛均明显低于对照组,差异有统计学意义.结论 术前肾造瘘能够降低输尿管镜钬激光碎石术中的肾盂压力及术后的并发症.     

微创肾镜经皮肾穿刺取石术中通道与肾盂内压变化的关系

目的 探讨采用新型李逊微创肾镜行微创经皮肾穿刺取石术(MPCNL)通道大小及数目与肾盂内压变化的关系.方法　对203例肾结石患者行MPCNL,采用新型李逊微创肾镜(8.5/12F),高压脉冲灌注泵生理盐水冲洗,气压弹道碎石,通过逆行置入肾盂的6F输尿管导管连接测压系统,监测167例16F～24F单通道及36例多通道PCNL术中肾盂内压的变化,作统计学分析.结果　共有单通道PCNL 156例及多通道PCNL 33例进入数据统计分析,16F、18F、20F、22F以及24F通道下PCNL术中平均肾盂内压分别为(38.96±5.39) cmH2O、(32.11±7.35) cmH2O、(29.42±4.53)cmH2O、(22.67±5.22)cmH2O及(17.25±5.12) cmH2O(1cmH2O=0.098 kPa),双通道、三通道以及四通道下PCNL术中平均肾盂内压分别为(17.62±4.72)、(16.01±5.54)及(13.93±3.48)cmH2O.16F通道PCNL术中平均肾盂内压高于20F、22F、24F通道(P＜0.05),20F单通道PCNL术中肾盂内压高于多通道(P＜0.01).结论 16F～24F微通道微创肾镜PCNL术中平均肾盂内压均低于引起肾实质反流的压力安全值(40 cmH2O),处理铸型结石采用多通道PCNL可降低肾盂内压.18 ～20F可作为微创肾镜PCNL的首选通道.     

The influence of minimally invasive percutaneous nephrolithotomy on renal pelvic pressure in vivo

OBJECTIVE: To inspect the renal pelvic pressure during minimally invasive percutaneous nephrolithotomy (MPCNL) and to investigate whether the use of the 14 to 18-Fr percutaneous tract, 8/9.8-Fr rigid ureteroscope, and a perfusion with high pressure furnished for MPCNL results in high renal pelvic pressure. PATIENTS AND METHODS: Between July 2005 and February 2006, 76 patients were selected for renal pelvic pressure measurement during MPCNL. The renal pelvic pressure was measured by a baroceptor of the invasive blood pressure channel in a MAIDRAY PM9000 monitor, which was connected to the open-ended ureteric catheter indwelled in the renal pelvis retrogradely. The computer collected the renal pelvic pressure data each second and all the data were evaluated statistically with SPSS 12.0 software. RESULTS: During MPCNL within the 14, 16, 18, and double-16-Fr percutaneous tracts, the average renal pelvic pressures were 24.85, 16.23, 11.68, and 5.8 mm Hg, respectively. The average lasting times of renal pelvic pressure >/=30 mm Hg were 283, 96, 44, and 10 seconds, respectively. A postoperative fever >/=38 degrees C was recorded in 2 (2/12), 3 (3/30), 2 (2/21), and 1 case (1/13), respectively. CONCLUSIONS: Renal pelvic pressure generally remains lower than the level required for a backflow (30 mm Hg), during MPCNL via 14 to 18-Fr percutaneous tract. Any factor, which causes bad drainage, will result in a temporarily elevated renal pelvic pressure greater than 30 mm Hg; and multiple temporary high-pressure episodes can have a cumulative effect, which means that there will be enough backflow to cause a bacteremia.     

Effects of increased renal parenchymal pressure on renal function

OBJECTIVE: Acute renal failure is seen with the acute abdominal compartment syndrome (AACS). The cause of acute renal failure in AACS is thought to be multifactorial, including increased renal venous pressure, renal parenchymal pressure (RPP), and decreased cardiac output. Previous studies have established the role of renal venous pressure as an important mediator of this renal derangement. In this study, we evaluate the role of renal parenchymal compression on renal function. METHODS: Two groups of swine (20-26 kg) were studied after left nephrectomy and placement of a renal artery flow probe and ureteral cannula. Two hours were allowed for equilibration, and an inulin infusion was begun to calculate inulin clearance as a measurement of glomerular filtration. In group 1 animals (n = 6), RPP was elevated by 30 mm Hg for 2 hours with renal parenchymal compression. RPP then returned to baseline for 1 hour. In group 2 (n = 6), the RPP was not elevated. The cardiac index, preload, and mean arterial pressure remained stable. Blood samples for plasma renin activity and plasma aldosterone were taken at baseline and at hourly intervals. RESULTS: Elevation of RPP in the experimental group showed no significant decrease in renal blood flow index or glomerular filtration when compared with control animals. There were no significant elevations of plasma aldosterone or plasma renin activity in the experimental animals when compared with control. CONCLUSION: Elevated renal compression alone did not create the pathophysiologic derangements seen in AACS. However, prior data from this laboratory found that renal vein compression alone caused a decreased renal blood flow and glomerular filtration and an increased plasma renin activity, plasma aldosterone, and urinary protein leak. These changes are partially or completely reversed by decreasing renal venous pressure as occurs with abdominal decompression for AACS. These data strengthen the proposal that renal vein compression, and not renal parenchymal compression, is the primary mediator of the renal derangements seen in AACS.     

微创经皮肾镜治疗多囊肾合并肾结石的疗效分析

目的探讨超声引导下微创经皮肾镜碎石取石术（MPCNL）治疗多囊肾合并肾结石的安全性及疗效。 方法回顾性分析梅州市人民医院自2006年1月至2015年12月采用超声引导下MPCNL治疗多囊肾合并肾结石的临床资料。 结果共计有26例患者纳入研究,1例双侧结石,25例单侧结石,均成功建立了经皮肾通道。25例患者行一期MPCNL,1例患者行二期MPCNL,术后2～5 d复查无石率88.9%（24/27）,3例残留结石患者行体外冲击波碎石术（ESWL）治疗。手术时间20～140 min,平均（68±34）min,术中失血量10～250 ml,平均（57±49）ml。术前、术后平均血肌酐为（292±51） μmol/L、（220±34） μmol/L（t=2.388,P= 0.025）。术后2例患者出现发热,4例患者接受输血治疗,无其他明显并发症。术后平均住院时间（6.8±2.4）d。随访10～24个月,结石均无复发,2例患者最终需血液透析维持治疗,其余患者肾功能稳定。 结论MPCNL治疗多囊肾合并肾结石是安全、有效的,但多囊肾可增加手术难度及并发症。