复杂性肾结石不同开放手术疗效比较

目的评价不同的开放性手术治疗复杂性肾结石的疗效,以期降低结石残留率及保护肾功能. 方法回顾性分析采用不同术式治疗154例复杂性结石的临床资料,比较结石取净率、阻断肾血流时间及术后肾功能恢复情况. 结果肾窦内肾盂切开取石61例、肾盂 肾放射状切开取石18例、肾盂肾下段切开取石11例、肾盂肾实质(多处、小切口)切开取石42例、肾实质Brodel线剖开取石10例及肾部分切除术12例,阻断肾血流的时间平均分别为0、31、36、45、162及28 min.肾功能恢复情况:12例肾部分切除取石术肾功能恢复良好,肾窦内肾盂切开取石术、肾盂肾下段切开取石术、肾实质Brodel线剖开取石术各有1例未恢复,肾盂 肾放射状切开取石术有2例、肾盂肾实质多处、小切口切开取石术有6例未恢复. 结论对复杂性肾结石开放手术需根据结石的大小、肾盂形态、积水程度、所需时间及难度确定术式,同时选择静注肌苷或(/和)局部低温下进行.尽可能选用对肾功能损害小的肾窦内肾盂切开取石术或加作肾实质切口,减少肾实质Brodel线剖开取石术的应用.     

肾窦内肾盂及肾后唇实质弧形切开取石术治疗复杂性鹿角形肾结石

目的 探讨肾窦内肾盂及肾后唇实质弧形切开取石术治疗复杂性鹿角形肾结石的疗效。方法 采用自行设计的肾窦内肾盂及肾后唇中下1／3肾实质弧形切开取石术治疗复杂性鹿角形肾结石86例97侧；右侧42例，左侧33例，双侧11例。合并输尿管结石17例，肾上盏、中盏和（或）多发性肾结石54例。肾功能不全25例，BUN12．3～76．0mmol／L，Scr 231～1721μmol／L。术中游离肾窦内肾盂后，2-0可吸收线在肾后唇中下1／3肾实质交界处作两排链扣式缝合肾实质全层，达肾下盏大组开口平面后继续弧形向上部作两排链扣式缝合，经肾中盏大组至其开口平面。沿此切口切开肾实质和肾盂及下中肾盏，边切边缝，用肾盂拉钩拉开肾实质即可取净肾盂、肾盏内结石。结果 86例97侧均一次取净结石。手术时间105～187min、平均129min。术中出血量120～460ml，平均220ml。43例输血．输血量120～200ml，平均140ml。术后1个月复查B超和KUB加IVU未几几残留结石，肾积水减轻，肾盏颈无狭窄。结论 肾窦内肾盂及肾后唇实质弧形切开取石术具有操作简单、安全，术野清晰，出血少，对肾损伤轻，一次性取净肾结石等优点，是治疗复杂性鹿角形肾结石较为理想的方法。     

镰刀状肾实质切开术治疗复杂性鹿角状肾结石

目的：探讨镰刀状肾实质切开术治疗复杂性鹿角状肾结石的疗效。方法：采用自行设计的镰刀状肾实质切开术治疗复杂性鹿角状肾结石37例。具体方法：分离肾窦内肾盂后，用2-0肠线在肾后唇中下1/3连接处作两排扣锁式缝合肾实质全层，达肾大盏下组开口平面，继续用2-0肠线斜行向中上部作两排扣锁式缝合，斜形向上的肾实质切口经肾大盏中组开口平面达肾大上组开口平面。肾实质切口形状类似镰刀状，沿此切口切开肾实质及肾盂和各组肾，即可取净各肾盏及肾盂内结石。结果：37例均一次取净结石。术中输血21例，平均输血120ml；术后4周KUB IVU复查，手术侧肾脏显影正常，积水减少，无肾盏狭窄及结石残留。结论：镰刀状肾实质切开取石术具有术中出血少、肾功能受损轻、便于一次取净结石等优点，适用于治疗肾内型肾盂复杂性鹿角状肾结石。     

肾盂肾后唇切开术治疗复杂性肾结石(附16例报告)

目的：探讨复杂性肾结石手术取石方法，方法：对16例巨大鹿角状结石或并发上，中，下盏多发结石患者，采用肾盂，肾后唇切开取石术，结果：全部病例均顺利取出结石，术后肾功能恢复好，术中务后段血管1例，残留小结石2例，并发尿漏1例，结论：肾盂，肾后唇切开石术具有显露充分，结石取净率高，损伤少等优点。     

指间阻断肾血流肾实质切开治疗复杂性肾结石

目的:探讨肾实质切开治疗复杂性肾结石的效果。方法:采用静脉滴注肌苷2.0,指间阻断肾血流肾实质切开治疗复杂性肾结石30例。十二肋缘下切口,游离肾脏,沿Brodel氏线纵行切开肾实质全层,直视下取石,冲洗。用4-0肠线或可吸收缝合线间断缝合肾盂肾盏粘膜,1-0肠线或可吸收缝合线缝合肾实质全层。结果:28例结石一次取净,2例小结石残留,经ESWL(体外冲击波碎石)治愈,1例为肾盂钙化灶。结论:手指间阻断肾血流肾实质切开适合于肾内型肾盂鹿角形(铸形)结石和复杂性肾结石手术治疗。     

低温下肾蒂阻断肾实质切开取石术治疗复杂性肾结石25例报告

目的：探讨低温下肾蒂阻断肾实质切开取石术在复杂性肾结石治疗中的应用。方法：选择复杂性肾结石患者25例,阻断前静脉注射肌苷2．0g,均采用低温下阻断肾蒂,沿Brodel线作肾实质切开取石术。结果：25例肾蒂阻断17～45min,术中出血150～450ml,手术时间100～160mln,结石残留2例。术后随访6个月～4年,术后肾功能恢复良好。结论：低温肾蒂阻断肾实质切开取石术是治疗复杂性肾结石的重要方法,结石取净率高,并发症少,对肾功能无影响。     

肾窦内肾盂切开取石38例临床研究

目的探讨肾窦内肾盂切开治疗复杂性鹿角状或铸状及多发性肾结石疗效。方法沿肾盂外间隙分离肾窦内肾盂，于肾中下1／3下盏上方无血管区用2-0合成可吸收缝线扣锁式全层缝合肾实质2排，其间切开肾实质，由肾上、下盏间作一弧形切口，取出较大的结石，直视下探查取出肾盏内小结石。结果30例结石一次性取净，占80％；8例有1—2粒小结石残留，术中仅2例输血200ml。随访6个月-6年，29例无肾积水，2例结石复发。结论肾窦内肾盂切开取石术具有出血少，不分离肾周脂肪，不阻断肾血流，肾功能受损轻，结石取净率高，无漏尿、易于掌握等优点。是肾内型肾盂内鹿角状或铸状及多发性结石的理想术式。     

肾窦内肾盂加肾后唇切开术治疗鹿角状肾结石

目的探讨肾窦内肾盂加肾后唇切开术治疗鹿角状肾结石的疗效。方法鹿角状肾结石患者40例，单侧36侧，双侧4侧，肾盂均为肾内型，肾实质无明显萎缩，肾功能均正常，均施行肾窦内肾盂加肾后唇中下段无血管区切开取石术。结果本组均在常温下手术，未阻断肾蒂，结石均安全取出，无术中严重并发症发生。平均手术时间115(90～140)min，平均失血量为100(90～120)ml，术后1月拔除双J管，复查3例(7．5％)有肾盂内小结石残留。结论肾窦内肾盂加肾后唇中下段区切开取石术适合肾鹿角状结石的治疗．具有操作较简单、易掌握．取石容易且结石一次性取出率高，出血少的优点。     

肾Brodel线小切口切开取石术治疗鹿角状结石疗效观察(附32例报告)

目的:探讨肾Brodel线小切口切开取石术治疗肾鹿角状结石的疗效.方法:选择肾鹿角状结石患者32例,经患侧11肋间切口分离肾动脉,在低温下阻断肾动脉,取.肾外侧缘Brodel线上切开肾实质至结石,取出结石.结果:低温下肾动脉阻断时间15～32 min,平均19 min手术时间90～180 min,平均140 min;Brodel线切口长4～5 cm;出血量平均120 ml,有6例输血200～400 ml,术后漏尿2例,结石残留3例,经相应处理治愈.术后随访3～12个月,肾功能恢复良好.结论:低温下阻断肾动脉作肾Brodel线小切口取石术是治疗肾鹿角状结石的理想术式,结石取净率高,并发症少,肾功能恢复良好.     

原位低温肾动脉阻断下无萎缩性肾实质切开取石术治疗复杂性肾结石

采用原位低温、阻断肾动脉下无萎缩性肾实质切开取石术治疗16例复杂性肾结石,结石全部取出,出血量平均140ml。无严重并发症,受损的肾功能术后均有不同程度改善。本术式具有出血少,取石彻底,安全,及对肾功能影响小的优点。     

Renal pseudoaneurysm successfully treated by superselective embolization as a complication of percutaneous nephrolithotomy: report of a case]

A case of renal pseudoaneurysm which occurred as a complication of percutaneous nephrolithotomy (PNL) for right renal staghorn calculi is presented. A 59-year-old man, who previously had left nephrectomy due to renal staghorn calculi and right pyelolithotomy due to renal calculi, was admitted to our hospital for treatment of recurrent right renal staghorn calculi on March 29, 1990. Laboratory data on admission revealed no significant abnormality except for a mild elevation on blood glucose (116 mg/dl). Pseudomonas aeruginosa (10(6) CFU/ml) was cultured from urine. Preoperative plain abdominal film showed right partial staghorn calculi extending to the lower calyx and pelvis. Three sessions of PNL were performed. Two nephrostomy tubes were placed in the upper and middle calyces at the first session. Although all calculi were removed completely, massive renal bleeding with bladder tamponade occurred several times postoperatively and blood transfusion was necessary. Renal angiography was performed, and it was demonstrated renal pseudoaneurysm at the upper nephrostomy tract. At the same time the pseudoaneurysm was treated by superselective embolization with an absorbable gelatin sponge. We reviewed the related literature on complications of PNL. Etiology and treatment of a renal vascular injury associated with PNL are also discussed.     

肾实质肾盂分层切口治疗复杂性肾鹿角状结石

目的 探讨肾实质肾盂分层切口治疗复杂性肾鹿角状结石的效果。方法 采用肾实质肾盂分层切口治疗复杂性肾鹿角状结石２４例,具体方法是作１２肋缘上切口,游离肾脏,分离肾窦内肾盂,用１－０合成可吸收缝线在肾中下１／３交界处于血管区从肾后唇向外侧缘作两排扣锁式缝合肾实质全层,切开肾实质,从肾上颈经肾盂输尿管交界处向肾下颈作一弧形切口,即可取出结石,直视下探查各肾,用４－０可吸收缝线缝合肾盂,１－０可吸收缝线间     

Laparoscopic anatrophic nephrolithotomy: feasibility study in a chronic porcine model

PURPOSE Anatrophic nephrolithotomy performed via open surgery involves incising the renal parenchyma along an avascular plane to remove a large, complex renal stone. We determined the feasibility of performing laparoscopic anatrophic nephrolithotomy in a survival porcine model. Furthermore, we present a novel technique of creating a staghorn calculus in the porcine model.MATERIALS AND METHODS After developing the technique in 3 pigs the survival study was performed in 10 consecutive animals. The procedure comprised 2 aspects. 1) We developed an animal model for staghorn calculi by retrograde injection of polyurethane (Fomo Products, Inc., Norton, Ohio) into the renal pelvis through a ureteral catheter. For a 2-week period the staghorn calculus was allowed to create hydronephrosis. 2) Laparoscopic anatrophic nephrolithotomy was done, involving control of the renal artery and vein, in situ renal hypothermia with ice slush in 1 animal, lateral renal parenchymal incision, stone extraction and suture repair of the incised collecting system and renal parenchyma.RESULTS Synthetic stone formation and laparoscopic anatrophic nephrolithotomy were successful in all 10 animals, including 1 that underwent staged bilateral anatrophic nephrolithotomy. Mean operative time for anatrophic nephrolithotomy was 125 minutes. Mean blood loss was 68 cc and mean warm ischemia time was 30 minutes (range 23 to 39). A residual small pelvicaliceal calculus was noted postoperatively in the initial 3 cases only. Thereafter, routine intraoperative ultrasonography and flexible endoscopy were done for stone localization, resulting in a stone-free rate of 100% in all 7 remaining animals. Diethylenetriamine pentaacetic acid renal scans documented improvement in the glomerular filtration rate from a mean of 26.4 ml. per minute after stone creation and hydronephrosis to 54.8 ml. per minute 4 to 5 weeks after laparoscopic anatrophic nephrolithotomy.CONCLUSIONS Laparoscopic techniques can be applied to complex stone surgery such as anatrophic nephrolithotomy with encouraging surgical and functional outcomes. To our knowledge this report represents the initial study of in situ creation of experimental staghorn calculi and laparoscopic anatrophic nephrolithotomy performed completely intracorporeally in a chronic porcine model.     

Pure robotic extended pyelolithotomy: cosmetic replica of open surgery

Percutaneous nephrolithotomy (PCNL) has replaced open pyelolithotomy as the procedure of choice for treating large-burden renal stone disease, especially staghorn calculi. Although it is a minimally invasive procedure, it involves transgressing the renal parenchyma and is thus associated with its unique set of complications. The evolution of laparoscopic pyelolithotomy and robotic assistance has provided an opportunity to the surgeon to revisit pyelolithotomy in a minimally invasive manner following the age-old principles of the era of open renal surgery. We report the feasibility and our experience with this technique in three cases of partial staghorn calculus with intra-renal pelvis.     

经皮肾镜超声弹道碎石术治疗复杂性肾结石

目的：探讨经皮肾镜超声弹道碎石术治疗复杂性肾结石的疗效。方法：采用经皮肾镜联合EMS Ⅲ代超声弹道碎石清石系统治疗48例复杂性肾结石患者,完全性鹿角状结石12例,部分鹿角状结石30例,多发性结石6例。结石直径2．0～6．5cm,平均2．8cm。结果：48例患者中,43例Ⅰ期取净结石;5例完全性鹿角状结石者术后2个月仍有结石残留,结石直径均小于1．0cm,辅助施行ESWL后排净。结石粉碎率100％,结石清除率89．6％（43／48）。手术时间50～120min,平均70min,平均出血量50ml。无严重并发症发生。术后随访3～6个月,肾功能均有不同程度改善。结论：经皮肾镜下使用EMSⅢ代碎石清石系统治疗复杂性肾结石,具有高效、可靠、安全、损伤小、出血少及恢复快等优点,可以作为目前治疗复杂性肾结石的首选方法。     

Extracorporeal shock wave lithotripsy as monotherapy for staghorn calculi--is reduced renal function a relative contraindication?

Extracorporeal shock wave lithotripsy as monotherapy for staghorn calculus is not without complications. We describe a case in which, due to markedly reduced renal function following lithotripsy for a staghorn calculus, broken fragments of calculi forming steinstrasse became cemented together to form a solid calcified tube extending from the renal pelvis to the ureteric orifice. This resulted in further loss of kidney function. The patient eventually required nephro-ureterectomy. Extreme care should be taken when using extracorporeal shock wave lithotripsy to treat staghorn calculi in kidneys with markedly diminished function to prevent further loss of function due to treatment.     

无萎缩性肾切开取石术治疗单功能肾鹿角状结石

目的：探讨无萎缩性肾切开取石术治疗单功能肾鹿角状结石的方法及疗效。方法：回顾性分析18例无萎缩性肾切开取石术治疗单功能肾鹿角状结石病例资料。结果：肾血流阻断时间平均为78min，平均手术时间148min，术中出血量平均为160ml。术后7d经造瘘管肾盂造影，14例结石取净，4例残余小结石，术后2月行ESWL治疗，2周后结石排净。术后患的肾功能均有不同程度的改善。结论：该术式暴露清晰，取石彻底，并能改善肾功能，是单功能肾鹿角状结石首选的手术方法。     

The residual calculi in conservative operation for renal calculi

One hundred and three kidneys with calculi in 100 patients, were treated by conservative renal surgery from Jan., 1980 to Dec., 1982. The operative technique consisted of pyelolithotomy, extended pyelolithotomy, dismembered pyelolithotomy, nephrolithotomy (bivalve or anatrophic nephrolithotomy) partial nephrectomy and pyelo-nephrolithotomy. Intraoperative X-ray and coagulum lithotomy were employed when pyelolithotomy was performed. Thirty-five residual calculi in 20 kidneys were observed on postoperative X-ray film. The rate of residual calculi was 19.4%. Factors causing residual calculi, were analysed on these 103 kidneys. The factors were as follows; the shape of calculi: staghorn calculus with multiple small calculi, the shape of the renal collecting system: narrow pelvis with narrow caliceal neck and dilatated calices, and the operative technique: nephrolithotomy. These results suggested that it would be necessary to minimize residual calculi when performing nephrolithotomy.     

肾窦内肾盂切开取石术治疗巨大鹿角形肾结石

目的　提高手术治疗巨大鹿角形肾结石的疗效。　方法　采用肾窦内肾盂切开取石术治疗巨大鹿角形肾结石患者 2 2例。　结果　 2 2例患者均取石成功。平均手术时间 116min ;术中需输血者 8例 ,平均输血量 5 5 0ml。无术后继发出血和感染等并发症。 12例术后 2～ 6个月内复查B超 ,3例肾内残余结石 ,直径均 <0 .8cm。　结论　肾窦内肾盂切开取石术治疗巨大鹿角形肾结石效果满意 ,操作简便、安全、易掌握