瞬时X线定位联合术中逆行造影在经皮肾镜碎石术中的临床价值

目的:探讨瞬时X线定位联合术中逆行造影在经皮肾镜碎石术(percutaneous nephrolithotomy,PCNL)中的安全性、实用性及其临床价值。方法:回顾性分析我院2014年1~12月采用瞬时C臂X线定位联合术中逆行造影引导下行PCNL治疗118例肾结石患者的临床资料,对患者首次目标肾盏穿刺成功率、通道建立时间、术中X线暴露次数、结石Ⅰ期清除率等进行分析。结果:118例患者有116例在瞬时X线定位联合术中逆行造影引导下准确建立理想的工作通道,成功率为98.3%,其中首次目标盏穿刺成功率为77.9%(92/118),另外2例患者因肾积水较轻,建立通道失败,改为连续C臂X线定位,透视下成功建立通道;所有患者均建立F18~20通道,通道建立时间10~35min,术中X线暴露次数2~5次。平均手术时间74(72.26±20.26)min。结石一期清除率为85.59%(101/118);术后行二期碎石术或EWSL治疗者占11.86%(14/118)。结论:采用瞬时X线定位联合术中逆行造影引导下PCNL治疗肾结石能明显提高首次目标盏穿刺成功率,缩短通道建立时间,提高结石Ⅰ期清除率高,同时减少患者及医生在手术中X线的暴露时间,值得临床推广使用。     

瞬时X线联合B超在复杂经皮肾镜取石术中的应用体会

目的:探讨瞬时X线联合B超引导经皮肾穿刺定位在较为复杂的经皮肾镜取石术(PCNL)中的应用价值。方法:回顾2012年3月~2013年10月我院收治的69例肾结石患者临床资料,其中肾脏轻度积水25例,肾脏旋转不良12例,肾脏无明显积水8例,完全鹿角形结石6例,重复肾6例,术中逆行造影及人工积水肾建立失败4例,肾结石术后瘢痕肾5例,肥胖患者2例,肾下垂患者1例。术中常规给予输尿管置管行逆行造影并建立人工积水肾,采用C型臂瞬时X线照相联合B超引导建立经皮肾穿刺通道。结果:69例患者均穿刺成功,建立F14~18通道,建立时间10~35min,术中X线暴露次数2~5次。其中肾脏轻度积水25例、肾脏无明显积水8例、完全鹿角形结石6例由间断瞬时X线定位为主,辅助B超定位以避开主要血管及领近器官或辅助建立多通道;肾脏旋转不良12例、重复肾6例、肾结石术后瘢痕肾5例、肥胖患者2例、肾下垂患者1例由B超定位为主,辅助瞬时X线定位以确保穿刺线通过肾盏穹窿部;术中逆行造影及人工积水肾建立失败4例,由B超定位穿刺针进入肾脏集合系统,经穿刺针推注造影剂显示肾盂肾盏,用第二穿刺针在瞬时X线定位下建立目标肾盏的穿刺通道。64例为Ⅰ期手术,5例行Ⅱ期手术,清石率为96.8%,无严重并发症发生。结论:对于较为复杂的PCNL,瞬时X线联合B超的定位技术能够结合两种定位方法的优势,建立安全、有效的穿刺通道,提高清石率,减少手术并发症的产生,同时减少患者及医生在手术中X线的暴露时间。     

C臂X线机联合B超在经皮肾镜碎石术治疗复杂肾结石中的临床价值

目的:探讨C臂X线机联合B超在经皮肾镜碎石术治疗复杂肾结石中的安全性、实用性及其临床价值。方法:回顾性分析2009年6月~2012年6月采用C臂X线机联合B超引导下行经皮肾镜碎石术治疗复杂性肾结石患者206例的临床资料,对患者手术时间、输血率、结石Ⅰ期清除率、术中术后并发症等进行分析。结果:206例均在C臂X线机联合B超引导下准确建立理想的工作通道;平均手术时间74min。术中术后输血率13.5%(28/206);结石一期清除率为92.2%(190/206);术后行二期碎石术或ESWL治疗者占7.8%(16/206)。结论:采用C臂X线机联合B超引导下经皮肾镜碎石术治疗复杂性肾结石是安全、实用、高效的手段,结石Ⅰ期清除率高,且术中术后并发症少。     

模拟手术体位CT检查在经皮肾镜碎石术中的应用

目的 探讨模拟手术体位行CT检查在经皮肾镜碎石（PCNL）穿刺定位中的价值.方法 总结回顾58例肾、输尿管上段结石PCNL的临床资料,术前模拟手术体位进行CTU检查,综合分析CT的平扫、增强和三维重建影像资料,预先确定穿刺点,测量穿刺角度和深度,进行穿刺建立皮肾通道.结果 58例中,53例穿刺成功,平均穿刺2.3次,其中5例结合B超和C臂机引导下定位穿刺成功.结论 模拟手术体位行CT检查,术前确定穿刺点、测量穿刺方向和深度能有效提高建立皮肾通道的成功率.     

超声引导下经皮肾镜碎石术治疗复杂性肾结石

目的探讨超声引导下经皮肾镜碎石术（PCNL）治疗复杂性肾结石的临床应用。方法在超声引导下对89例上尿路结石患者行经皮肾穿刺建立碎石通道,经通道于输尿管镜下行气压弹道碎石取石术。结果所有患者均穿刺成功,经单通道或双通道行Ⅰ期或Ⅱ期PCNL,结石总清除率94.19%,手术平均时间80 min,未出现严重并发症。结论超声引导下,选择合适穿刺点和穿刺路径建立经皮肾镜碎石通道,有助于提高PCNL治疗上尿路结石的手术时效,拓宽其适应证范围。     

微创经皮肾镜超声与x线定位方式的临床对比

目的比较微创经皮肾镜碎石取石术中x线与B超引导建立经皮肾通道的效果。方法对132例肾结石的患者,分别随机采用X线C臂机及B超引导建立经皮肾通道一期碎石取石治疗,其中采用x线引导组58例,B超引导组74例。结果X线引导组和B超引导组建立通道时间分别为（30．2±14．6）min和（10．6±6．2）min,手术前后血红蛋白下降值分别为（18±9）g／L和（11±5）g／L,结石残留率分别为36．2％（21／58）和44．6％（33／74）,发生出血等并发症分别为8例和3例;均无死亡患者。结论虽然两种方法各有优缺点,但B超引导下经皮肾镜手术穿刺简单、成功率高、损伤小、并发症少、出血少,多通道建立简便、设备要求低,是今后经皮肾镜发展的方向。     

CTA辅助彩色多普勒超声引导下精准穿刺在PCNL术中的应用研究

目的:探讨螺旋CT三维重建联合肾脏血管造影(CTA)辅助彩色多普勒超声引导下精准穿刺建立皮肾通道在经皮肾镜取石术(PCNL)术中应用的可行性及价值。方法:对2012年9月~2013年10月采用CTA辅助彩色多普勒超声引导下精准穿刺在PCNL术治疗的96例肾结石患者进行回顾性分析。术前行CTA检查,制定手术方案,术中在彩色多普勒超声定位下避开血管精准穿刺建立F16~18的皮肾通道行经皮肾镜钬激光碎石术。结果:CTA可提供肾血管的清晰图像,有利于术中彩色多普勒超声引导下精准穿刺建立皮肾通道,96例患者均成功行PCNL术,时间50~160min,平均(96±47)min。术后复查腹部平片,11例显示残余结石5 mm,行二期PCNL术,一期净石率约88.5%。术中发生较明显出血而影响手术视野1例,予留置肾造瘘管1周后进行二期PCNL术。本组患者发生术后延迟性大出血2例,但2例均经保守治疗血尿消失,痊愈出院。结论:CTA可提供肾盂肾盏集合系统、肾实质血管分布的清晰图像,明确结石与集合系统的关系,有利于术中彩色多普勒超声引导下精准确定经皮肾穿刺的部位及穿刺通道的建立,CTA辅助彩色多普勒超声引导下精准穿刺PCNL术具有定位精准、损伤轻、出血少及并发症少等优点,CTA辅助彩色多普勒超声引导下精准穿刺可作为经皮肾镜引导穿刺的首选方法。     

四种穿刺方法建立经皮肾通道行经皮肾镜取石术治疗上尿路结石116例报告

目的：评价不同穿刺方法建立经皮肾通道的优缺点。方法：对116例上尿路结石患者采用不同穿刺方法建立经皮肾通道，其中采用C臂X线机定位穿刺65例，B超定位穿刺35例，盲穿刺16例，小切口手指引导穿刺4例。结果：成功建立通道112例，改行开放手术4例。结石残留率为15．2％。术后平均住院天数为6．5d。结论：各种定位穿刺方法各有优缺点，可根据患者具体情况进行选择。     

集合系统CT三维重建精准指导经皮肾镜手术目标肾盏选择和穿刺的临床研究

目的探讨集合系统CT三维重建帮助经皮肾镜手术(PCNL)精准进行目标肾盏选择和目标肾盏穿刺的可行性和安全性。方法肾结石PCNL患者196例,均行术前腹部泌尿系平片(KUB)、静脉肾盂造影(IVU)、CT平扫和增强扫描,分别获取肾结石、集合系统及肾脏周围器官的CT三维影像,在集合系统三维重建后面观影像上确定最佳PCNL目标肾盏,将确定的目标肾盏通过影像转化技术标识在IVU影像上,C臂机引导下穿刺该目标肾盏建立手术通道。结果所有PCNL手术均按术前的规划实现了精准穿刺目标肾盏建立手术通道,196例患者术中、术后无严重出血、邻近器官损伤等并发症,均未输血。鹿角形肾结石手术无石率为88%,肾盂肾盏结石94.1%。结论通过对影像的技术转化,将CT集合系统三维重建确定的目标肾盏准确标识在IVU影像上,指导PCNL术中对目标肾盏进行精准选择和精准穿刺,建立更加安全的手术通道,最大程度降低PCNL出血和器官损伤等并发症。     

超声引导下经皮肾镜气压弹道联合超声碎石术治疗肾结石的临床价值

目的:讨论超声引导下经皮肾镜气压弹道联合超声碎石术(PCNL)治疗肾结石的准确性、安全性。方法:采用超声引导的方法,在超声实时监视下对36例肾结石患者建立经皮肾镜工作通道,行气压弹道联合超声碎石术,并对其操作方法及并发症进行分析。结果:36例患者均在超声引导下建立理想的工作通道,无胸膜损伤、腹腔脏器损伤、肾盂撕裂、肾脏穿通伤等并发症,损伤小,出血少,取石率为94.4(%34/36)。结论:在超声引导下准确的建立经皮肾工作通道,对手术成功与否具有重要的临床应用价值。超声引导实时、安全、与传统X线机定位比较具有一定的优越性。     

X线下Ⅱ期经皮肾镜弹道联合超声清石系统治疗残余肾结石

目的探讨X线定位经皮肾镜取石术(percutaneous nephrolithotomy,PCNL)治疗残余肾结石的临床应用价值。方法2005年7月～2008年11月,采用X线下定位Ⅱ期PCNL治疗残余肾结石90例,其中单侧肾结石81例,双侧肾结石9例。结果76例结石直接完全清除,6例仍有直径1cm残余结石,余8例因建立盏间通道出血,Ⅲ期清除结石。术后无严重并发症,无术后出血及感染症状。90例中失访8例,82例随访3～6个月,平均4.5月,术后无严重并发症。结论X线下Ⅱ期经皮肾镜碎石术是治疗残余肾结石的一种安全、有效方法,具有较高的结石清除率,并发症少。     

Feasibility of percutaneous nephrolithotomy under assisted local anaesthesia: a prospective study on selected patients with upper urinary tract obstruction

OBJECTIVE: To evaluate the feasibility of performing percutaneous nephrolithotomy (PCNL) under local anaesthesia in selected patients. METHODS: Twenty-four patients with unilateral renal obstruction due to pelvic stones > or =2.0 cm were enrolled in our study. First a percutaneous nephrostomy to decompress the obstructed kidney was performed using local anaesthesia (lignocaine). A 16-Fr nephrostomy tube was left in place for 1 wk, and then the second stage was carried out. After having infiltrated the tract and the renal parenchyma with lignocaine, dilatation of the nephrostomy tract was performed. Subsequently, PCNL was done using a 24-Fr rigid nephroscope and a ballistic lithotripter. All patients were premedicated with pethidine HCl intramuscularly 30 min before the beginning of both stages. Diazepam was given (0.1mg/kg orally) to patients before the second stage. Pain scores were collected using 10-cm linear visual analogue scale (VAS) after the completion of both procedures. RESULTS: The procedure was well tolerated. One patient needed further treatment with midazolam during PCNL. The mean VAS score was 38 mm (range: 17-60 mm) for the first stage and 36 mm (13-69 mm) for the second stage. The mean operative time, including both stages, was 127 min (85-155 min). No anaesthesia-related complications occurred. CONCLUSION: Our study indicates that PCNL under assisted local anaesthesia is safe and effective in selected patients.     

Nephrostomy tube after percutaneous nephrolithotomy: large-bore or pigtail catheter?

BACKGROUND AND PURPOSE: A nephrostomy tube is an integral part of any percutaneous renal surgery. Commonly, a nephrostomy tube that is 2F to 3F smaller than the percutaneous tract is used after percutaneous nephrolithotomy (PCNL). In our experience, quite a few patients have pain at the nephrostomy tube site, and many patients complain of a prolonged urinary leak after tube removal when a large nephrostomy tube is used. This prospective study was planned to document whether these symptoms could be attributed to the size of the nephrostomy tube and whether a small pigtail catheter could reduce these problems without increasing complications. PATIENTS AND METHODS: Forty well-matched patients in whom a one-stage PCNL was done for calculus disease were studied prospectively. Alternate patients had a 28F nephrostomy tube or a 9F pigtail catheter placed at the end of the procedure. Patients were observed for the duration of hematuria, number of analgesic injections needed, and the duration of urinary leak after tube removal. RESULTS: The groups were comparable in the amount and duration of hematuria after PCNL. There was a statistically significant difference in the analgesic need and the duration of urinary leak after tube removal, both of which were less in patients having a pigtail catheter. CONCLUSIONS: A pigtail catheter nephrostomy tube after PCNL reduces the hospital stay by reducing the duration of the urinary leak. The postoperative course is smooth, as patient has less pain and needs less analgesic support. There is no statistically significant increase in the postoperative bleeding secondary to use of a pigtail catheter. Second-look nephroscopy was easy in the one patient with a pigtail nephrostomy catheter who needed the procedure.     

320排肾脏CTA在“腰肋悬空”仰卧位PCNL中的应用价值

目的:评价320排肾脏CTA(CT血管造影)"在腰肋悬空"仰卧位经皮肾镜碎石术中的应用价值及腰肋悬空仰卧位的影像解剖学特点。方法:2010年9月～2011年7月对23例肾结石患者术前行320排肾脏CTA及三维重建,明确肾脏分支血管分布情况及肾脏与周围脏器毗邻关系,进而设计最佳穿刺路径建立经皮肾穿刺通道。患者平均年龄(49.5±11.5)岁;最大径2～6cm,平均为(2.97±1.29)cm。均采用椎管麻醉;手术体位采用腰肋悬空仰卧位。在B超引导下穿刺肾盂或目标肾盏成功后,依次扩张通道至F16或F20,用钬激光或三代超声将结石完全击碎。术后复查320CTA验证穿刺路径及了解结石残留情况。结果:肾脏320排CTA可清晰显示肾内分支血管分布情况。本组23例患者全部穿刺成功,建立通道满意,一期清石率82.6%(19/23)。所有患者均未输血,无胸膜及内脏器官损伤。术后320排CTA检查显示肾造瘘管位于肾脏无血管区。结论:320排CTA可以明确结石、肾盂肾盏、肾分支血管分布及三者关系,真实反映肾脏与周围器官毗邻关系,以利于设计最佳通道,从而降低大出血及损伤邻近脏器风险。腰肋悬空仰卧位时经腋后线于水平方向进针,可通过肾脏无血管区建立通道。     

Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports

OBJECTIVE: To evaluate the status of tubeless percutaneous nephrolithotomy (PCNL) in managing renal and upper ureteric calculi, from initial experience and a review of previous reports. PATIENTS AND METHODS: From September 2004 to December 2004, 46 patients were scheduled for tubeless PCNL in a prospective study. Patients with solitary kidney, or undergoing bilateral simultaneous PCNL or requiring a supracostal access were also enrolled. Patients needing more than three percutaneous access tracts, or with significant bleeding or a significant residual stone burden necessitating a staged second-look nephroscopy were excluded. At the end of the procedure, a JJ ureteric stent was placed antegradely and a nephrostomy tube avoided. The patients' demographic data, the outcomes during and after surgery, complications, success rate, and stent-related morbidity were analysed. Previous reports were reviewed to evaluate the current status of tubeless PCNL. RESULTS: Of the 46 patients initially considered only 40 (45 renal units) were assessed. The mean stone size in these patients was 33 mm and 23 patients had multiple stones. Three patients had a serum creatinine level of >2 mg/dL (>177 micromol/L). Five patients had successful bilateral simultaneous tubeless PCNL. In all, 51 tracts were required in 45 renal units, 30 of which were supracostal. The mean decrease in haemoglobin was 1.2 g/dL and two patients required a blood transfusion after PCNL. There was no urine leakage or formation of urinoma after surgery, and no major chest complications in patients requiring a supracostal access tract, except for one with hydrothorax, managed conservatively. The mean hospital stay was 26 h and analgesic requirement 40.6 mg of diclofenac. Stones were completely cleared in 87% of renal units and 9% had residual fragments of < 5 mm. Two patients required extracorporeal lithotripsy for residual calculi. In all, 30% of patients had bothersome stent-related symptoms and 60% needed analgesics and/or antispasmodics to treat them. CONCLUSION: Tubeless PCNL was safe and effective even in patients with a solitary kidney, or with three renal access tracts or supracostal access, or with deranged renal values and in those requiring bilateral simultaneous PCNL. The literature review suggested a need for prospective, randomized studies to evaluate the role of fibrin sealant and/or cauterization of the nephrostomy tract in tubeless PCNL.     

B超引导下经皮肾镜钬激光碎石取石术治疗肾盏憩室结石10例报告

目的：探讨经皮肾镜钬激光碎石取石术（PCNL）治疗肾盏憩室结石的安全性及疗效.方法：对接受PCNL治疗的10例肾盏憩室结石患者的临床资料进行回顾性分析总结.结果：9例患者均行单通道一期碎石及取石,平均手术时间90 min,平均留置肾造瘘管7天,平均住院12天,术后住院时间7天.1例患者穿刺失败中转开放手术,均未出现大出血或邻近器官损伤等并发症,术后复查尿路平片示结石全部取净.结论：PCNL术治疗肾盏憩室结石安全、可行,疗效确切,与开放手术相比,能减少术中、术后出血及并发症,结石取净率高.具有创伤小、恢复快等优点.     

一步扩张法标准通道和大通道建立技术在复杂性肾结石经皮肾镜取石术中的应用

目的:本研究中,我们拟介绍"一步扩张法标准通道建立技术"和"一步扩张法大通道建立技术",同时评估在经皮肾镜取石术(PCNL)中应用这两种通道建立技术的安全性和有效性。方法:回顾性研究2013年7月~2014年6月在我院采用"一步扩张法标准通道建立技术"和"一步扩张法大通道建立技术"PCNL治疗的52例多发性、铸型或鹿角形肾结石病例,按照术中建立的第一通道(主要通道)的大小分为两组,标准通道组(F22)29例,大通道组(F26)23例,两组患者所建立的辅助通道均为F22。比较两组患者第一通道的建立时间、总体手术时间、肾脏出血、总肾功能、通道扩张失败、集合系统穿孔等相关指标。结果:两组患者建立的所有取石通道均采用一步扩张法成功建立标准通道(F22)或大通道(F26),无通道扩张失败者。标准通道组和大通道组平均第一通道建立时间分别为(1.9±0.3)min和(2.5±0.4)min(P0.01),总手术时间分别为(45.2±22.6)min和(39.8±23.3)min(P0.01),术前-术后血红蛋白(Hb)下降值分别为(0.5±0.8)g/dl和(0.7±0.7)g/dl(P0.01),患者术中及术后无需输血治疗。两组患者中无发生集合系统穿孔者。结论:"一步扩张法标准通道建立技术"和"一步扩张法大通道建立技术"均为安全且有效的肾脏取石通道建立方法。在严格经肾盏穹窿沿肾盏颈管走行穿刺的前提下,PCNL手术中采用一步扩张法建立大通道(F26)与建立标准通道(F22)相比肾脏出血略有增多,患者均无需输血。复杂性肾结石患者采用大通道可以缩短手术时间,取石效率更高。     

球囊扩张在超声引导大通道经皮肾镜术中的应用

目的探讨球囊扩张器在超声引导下的大通道经皮肾镜治疗肾结石的临床应用效果。方法回顾性分析60例使用球囊扩张器在超声引导下大通道经皮肾镜治疗肾结石患者的临床资料。统计数据包括患者年龄、性别、结石载量、结石清除率、通道建立时间、出血量等。结果所有的经皮肾镜通道建立均一次成功。通道建立时间（7．52±1．06）min,手术时间（67．46±19．61）min,住院时间5～16d,平均（7．96±1．82）d。结石清除率为95．00％（57／60）。术中血红蛋白下降幅度（6．75±2．86）g／L,其中需要输血者4例。结论经皮肾镜术中在超声引导下应用球囊扩张器创建大通道是安全、有效的。     

单用B超引导建立经皮肾穿刺通道行经皮肾镜取石术(附102例报告)

目的：评估B超引导下建立经皮肾穿刺通道行经皮肾镜取石术（PCNL）的方法及效果。方法：收治102例肾结石患者。前50例先行B超定位下经皮肾微穿制备瘘，置入F10硅胶引流管，1周后经造瘘管放入导丝。B超引导下用Cook扩张器扩张穿刺通道，再行PCNL；对后52例患者行一期B超引导下建立经皮肾穿刺通道PCNL。结果；102例患者1次取净结石69例，1周后经瘘管再行PCNL取净结石23例，再次手术结石总取净率为91.0%。手术时间平均2.5h。术中6例患者输血，输血量平均230ml。早期2例患者出现腹腔积液，1例术后2周出现肾动静脉瘘，1例肾盂输尿管连接处狭窄。经及时治疗后痊愈。结论：单用B超引导建立经皮肾穿刺通道行PCNL技术上可行，能在基层医院推广。