经皮肾镜/输尿管镜取石术中、术后感染性休克15例报告

目的 总结经皮肾镜/输尿管镜取石术中、术后感染性休克的救治经验.方法 回顾分析2004年1月～2009年4月432例微创经皮肾镜取石术及645例输尿管镜碎石取石术中、术后发生感染性休克15例(男4例,女11例)的临床资料,其中11例发生在经皮肾镜取石术,4例发生于输尿管镜碎石术,术中1例,术后14例.感染性休克诊断明确...     

经皮肾镜取石术处理肾结石

目的探讨经皮肾镜取石术(PCNL)处理肾结石的方法与效果。方法回顾性分析118例采用PCNL治疗的肾结石患者资料。男86例,女32例。平均年龄39岁。其中单纯肾盂结石11例,单纯肾盏结石16例,肾盂和肾盏多发结石35例,肾铸形或鹿角形结石54例。双侧肾结石2例。结石大小2.0 cm×1.0 cm～4.5 cm×4.0 cm,平均2.5 cm×1.5 cm。结果112例患者一期取石,6例二期取石。单通道取石114例,双通道取石4例。1次取石60例,2次取石42例,3次取石16例。结石清除率81.4%(96/118),平均手术时间120 min,平均住院15 d。术中均未输血。1例术后4 d并发出血,出血量约500 ml,经输血、抗炎等保守治疗治愈,其余未见严重并发症。结论MPCNL具有创伤小、出血少及并发症少等优点,治疗肾结石安全有效,尤其对肾结石再次手术治疗有较大优越性。     

经皮肾镜取石术中监测及控制肾盂内压力的研究进展

肾结石是泌尿外科常见病之一,其发病率呈逐渐上升趋势.随着医疗腔镜技术的发展和设备的更新,肾结石的治疗已经由传统的开放手术转变为现代的微创手术.在行经皮肾镜取石术(percutaneous nephro-lithotomy,PPCNL)治疗肾结石时,为了能使手术视野保持清晰以及将碎石冲出体外,通常需对肾盂进行灌注冲洗,但...     

经皮肾镜取石术

随着手术设备的更新以及经验的积累,经皮肾镜取石术日趋成熟,尽管也存在一些争议,但很多方面已基本达成了共识。俯卧位下X线定位穿刺,建立F18~F24通道,运用气压弹道、钬激光、超声碎石等工具综合清理结石构成经典的经皮肾镜取石术(PCNL),但微通道经皮肾镜取石术(ultra-mini PCNL)、无管化经皮肾镜取石术(tubeless PCNL)等技术的发展也有一定的临床应用前景。不论如何,采用科学的态度,遵循基本操作原则,才能保证PCNL手术的安全有效。     

经皮肾镜取石术手术体位的研究进展

经皮肾镜取石术(PCNL)被广泛应用于治疗肾和输尿管上段结石.经过40余年的发展,PCNL手术体位从最初的俯卧位逐步发展为俯卧位、仰卧位和侧卧位三种体位.在这三种体位下实施PCNL都是安全有效的,它们各具优势,也有不足.为了适应复杂病例的手术需求,每种体位都经历改良而衍生出多种改良体位,改良后的体位或改善了术中操作的空...     

经皮肾镜取石术并发症的分析及处理

目的探讨经皮肾镜取石术(percutaneous nephrolithotomy,PCNL)并发症及处理方法。方法回顾性分析2006年2月~2009年月10月410例PCNL中35例发生并发症的临床资料,其中大出血10例(其中迟发2例),肾集合系统穿孔9例,术后高热、感染12例,体液大量外渗与吸收致休克4例。结果 10例大出血中,开放手术1例,介入手术2例,7例保守治疗。肾盂穿孔,感染,体液大量外渗致休克患者行保守治疗。35例均治愈出院,无一例死亡。32例随访3~6个月,2例行超选择性肾动脉栓塞者显示术侧部分肾功能丧失,其余患者分肾功能均正常。结论 PCNL可发生大出血、肾集合系统穿孔、术后感染、体液大量外渗与吸收等并发症,规范操作,术中、术后密切观察可能发生的并发症,及时处理才能提高PCNL疗效。     

微通道经皮肾镜取石术中肾盂内高压对机体的影响

经皮肾镜取石术中需持续高压灌注来维持术野清晰,易导致灌注液吸收,从而引发相应的术后并发症。本文就促进术中肾盂内高压发生的相关因素及肾盂内高压对机体的影响作一综述。     

经皮肾镜取石术中两种肾穿刺辅助方法的比较

目的比较经皮肾镜取石术两种肾穿刺辅助方法的穿刺成功率和术后发热发生率的差别,探讨两种辅助方法对术后发热的影响。方法回顾性分析经皮肾镜取石术314例患者的临床资料,采用逆行输尿管插管持续低压滴注生理盐水辅助肾穿刺(低压组)126例,采用逆行输尿管插管高压注入生理盐水辅助肾穿刺(高压组)188例,对穿刺成功率、术后发热的发生率进行分析。结果两组穿刺成功率、通道建立时间和总的手术时间差异均无统计学意义。低压组和高压组术后发热的发生率分别为19.0%和54.3%,两组比较差异有统计学意义。两组肾穿刺时注水压力的差异有统计学意义(P0.05),Logistic回归分析显示,术后发热与性别(P=0.878)、年龄(P=0.307)、术前合并感染(P=0.998)等因素不相关,而与肾穿刺时的注水压力相关(P=0.018)。结论两种肾穿刺辅助方法均能有效的辅助肾穿刺,但低压组术后发热的发生率较低。     

SonixGPS影像穿刺定位系统在经皮肾镜取石术中应用的早期经验

目的 探讨SonixGPS影像穿刺定位系统在PCNL中应用的可行性及安全性.方法 选取2012年5月上尿路结石患者15例,男8例,女7例.年龄33 ～ 72岁,平均43岁.患者术前均行KUB、彩色多普勒超声、CT和(或)IVU等检查.其中11例伴有不同程度的肾积水;合并尿路感染4例,术前给予积极抗炎治疗;孤立肾2例.肾多发性结石7例,鹿角形结石3例,输尿管上段结石3例,肾结石合并输尿管上段结石2例.手术均采用全麻,取俯卧位,在SonixGPS影像穿刺定位系统的引导下,采用系统自带的16G穿刺针穿刺目标肾盏并扩张建立24 F标准皮肾通道,置入肾镜后应用EMS第四代气压弹道联合超声碎石清石系统进行碎石并吸出体外.结果 本组15例均一次穿刺成功并行一期碎石,手术时间30～ 115 min,平均45 min,经皮肾穿刺时间2～ 10 min,平均4 min.术中术后未出现大出血、肠道损伤、气胸等并发症.术后复查KUB,一期清石率为93％ (14/15),1例有残余结石患者行ESWL治疗效果良好.结论 SonixGPS影像穿刺定位系统在PCNL穿刺前可预判和设计穿刺路径及角度,穿刺中可精准地看到穿刺针在组织中的穿刺轨迹,实时记录针尖位置,及时调整穿刺针的角度与深度,缩短了经皮肾穿刺技术的学习曲线.     

Monitoring of irrigating fluid absorption during transurethral prostatectomy

A simple, reliable method to detect absorption of irrigating fluid during transurethral prostatectomy is to tag irrigating fluids with 1% ethanol and monitor expired breath ethanol concentrations. This method correlated well (n = 0.79) with other existing methods of absorption monitoring in 20 anaesthetised patients. Ethanol (1%) tagging does not alter the optical quality of the irrigating fluid and is harmless to the patient. The technique is non-invasive, repeatable, cheap and gives instant results. It can be used in anaesthetised or awake patients and can detect absorption of as little as 100-150 ml in any 10-minute period.     

Monitoring fluid absorption during TURP by marking the irrigating solution with ethanol

Ethanol has been evaluated as a marker of the irrigating fluid during TURP. In nine patients mannitol served as a reference substance (2% ethanol in 5% mannitol) and it could be verified that ethanol enters the body as a result of irrigating fluid absorption. Ethanol is instantly and easily demonstrated in the patient's expired breath with an Alcolmeter. In four healthy volunteers a 500 ml intravenous infusion of the irrigating fluid was given to imitate absorption. These experiments showed that very small amounts gave significant concentrations of ethanol in expired breath and that there was a distinct fall in expired ethanol as soon as the infusion was stopped. Thus marking the irrigating fluid with ethanol is a simple method which may be used to indicate absorption, to follow its course and to tell if preventive steps taken against further absorption are effective.     

Irrigating fluid absorption during percutaneous nephrolithotripsy

BACKGROUND: The most common complication during percutaneous nephrolithotripsy (PNL) is the destruction of organ structures with extravasation of the irrigation fluid into the retroperitoneal space. Consequently, there is an increased risk of a urosepsis and a complicated therapeutic course. In this study we aimed to show that extravascular absorption could be differentiated from intravascular absorption due to their unique absorption characteristics, and that these characteristics enable a prediction of possible post-operative complications. METHODS: In a prospective study of 31 patients with PNL, ethanol was added to the irrigating fluid and blood ethanol concentration (BEC) was measured by gas chromatography during the endoscopic procedure and in the recovery room. Following the guidelines of Hahn, patients were divided into two groups: group EVA, in whom extravasation had occurred with subsequent absorption; group IVA, those with intravascular absorption. Patients' post-operative progress along with diagnoses of renal perforations or bleeding, or signs of infection or sepsis, were comprehensively listed. RESULTS: EVA was diagnosed in 19 cases, and IVA in 12 cases. Maximum BEC levels were achieved after 20 min (median) in the IVA group, and 75 min in the EVA group (P < 0.05). Apart from their significantly higher demand for opioids (P < 0.05), EVA patients had been hospitalised for a substantially and significantly longer period of time (P < 0.01). Although without statistical significance, there was a higher rate of peri-operatively confirmed complications and prolonged intensive therapeutic treatment in the extravasation group. CONCLUSION: Retroperitoneal extravasation can be identified by using ethanol monitoring during and after PNL. Afflicted patients require considerably longer hospitalisation, probably because of the additional injury to surrounding organ structures.     

Case selection and implementation of tubeless percutaneous nephrolithotomy

BackgroundThe tubeless percutaneous nephrolithotomy (PCNL) was proposed to eliminate the side effects of the nephrostomy tube in recent years, such as pain, channel infection, postoperative bleeding, and longer hospital stay. But there is neither clinical guidelines nor consensus about tubeless PCNL in clinical practice. The study is aimed to how to implement the tubeless PCNL step by step, including case selection preoperatively, improving the technique of the surgeon, making the correct decisions at the end of the procedure, which had not been previously examined.MethodsFrom January 2017 to March 2018, 364 consecutive patients requiring PCNL were comprehensively analyzed preoperatively and patients were selected for scheduled tubeless PCNL based on four aspects. The selected patients were divided into two groups according to whether the nephrostomy tube was finally placed. The mean operative time, intraoperative blood loss, stone clearance rate, visual pain score, postoperative hospitalization days and perioperative complications were all evaluated.ResultsBased on the preoperative evaluation, 42 patients were selected for tubeless PCNL, among which there were finally 37 cases of completed tubeless PCNL. Compared with patients undergoing conventional PCNL, there were not statistical differences in the mean operative time (P=0.207) or intraoperative blood loss (P=0.450) in the tubeless group. Stone clearance rate was 100% in both groups. The visual pain scores in the tubeless PCNL group were lower on operation day (P=0.029), first postoperative day (P<0.001) and the day of discharge (P=0.025). The postoperative hospitalization for the tubeless PCNL group was shorter than that of the control group (P<0.001). No significant difference in grade 1 complications was seen (P=0.424), and no grade 2 or higher complications were observed in either group.ConclusionsPostoperative pain was significantly relieved and postoperative hospitalization was significantly shortened in the tubeless PCNL group. Tubeless PCNL is safe if patients are carefully selected using four criteria before operation, attention is paid to four key points and five confirmations are made during operation.     

Hormonal and hemodynamic changes during percutaneous nephrolithotomy

The aim of this study was to investigate the hormonal and hemodynamic changes during percutaneous nephrolithotomy (PCNL) procedure. Twenty-one patients between 15–65 years of age were included in the study. Invasive blood pressure and heart rate were monitored during PCNL. Serum sodium, potassium, BUN and creatinine levels were measured before and after the operation. Sodium and potassium levels were also measured during the operation. Arterial blood gases, renin, aldosterone and adrenocorticotrophic hormone (ACTH) levels were measured before and during irrigation. The mean systolic and diastolic blood pressure levels were significantly higher (p < 0.05) during PCNL compared to post-procedure levels while heart rate remained constant. Serum sodium,potassium bicarbonate and base-excess levels were decreased during the operation compared to the base-line levels (p < 0.001). BUN and creatinine levels remained unchanged during the study (p > 0.05). In conclusion, a tendency to hyponatremia and metabolic acidosis developed in addition to significant increases in renin, aldosterone and ACTH levels during PCNL procedures. These changes may be due to the invasive nature of the intervention to the kidney and the continuous irrigation of this vital organ. This should be taken into consideration during PCNL. More detailed studies with larger groups are needed for more precise comments on this topic. This revised version was published online in September 2006 with corrections to the Cover Date.     

X线在经皮肾取石术应用中对医务人员的影响

目的分析经皮肾碎石取石术中X线定位时X线对医务人员的影响,为更好的防治X射线的损伤提供依据。方法回顾2002年至2006年4年间的X线引导经皮肾手术383例的检测资料,分析X线对手术人员的健康影响。结果X线对手术人员的健康方面有显著影响,手术者个人射线照射实时剂量为0．76±0．90mGy／例,定期剂量（3个月）为7．78±7．35mSv。随访追踪2位手术人员出现辐射损害。结论经皮肾手术中x线对医务人员大部分是安全的,但是X线暴露对身体是有危害的,不管是身体或心理都有很大的影响,应当采取有效措施来减少或防止这一损害。     

1％乙醇标记法连续定量监测TURP术灌洗液吸收的初步研究

目的　用 1%乙醇标记经尿道前列腺切除 (TURP)术灌洗液 ,研究呼出气乙醇浓度与血管内吸收量的关系。方法　 2 5例TURP术患者 ,3%甘露醇膀胱灌洗液加乙醇 (终浓度 1% ) ,采用偶联酶法和Evan氏蓝染料稀释法测定呼出气乙醇浓度和血浆容量 ,以血浆容量变化值估计血管内吸收量 ,分析吸收量与呼出气乙醇浓度的相关性。结果　吸收量与呼出气乙醇浓度明显相关 (r =0 842 ,P <0 0 1) ,回归方程R2 =0 90 2 ,P <0 0 0 1;将冲洗时间加入多元分析 ,回归方程R2 =0 92 7,P <0 0 0 1。结论　乙醇标记监测法安全、简便、无创、无污染 ,与灌洗液吸收入血量相关性好 ,考虑时间因素的多元回归方程可用于临床定量监测TURP术灌洗液吸收。     

经皮肾镜碎石术中及术后出血需输血治疗的风险因素分析

目的探讨经皮肾镜碎石(PCNL)术中及术后出血患者需输血治疗的风险因素。方法回顾性分析2010年1月至2013年12月复旦大学附属上海市第五人民医院应用PCNL术治疗肾结石的129例患者(共139次手术)的临床资料。对患者自身因素,如年龄、性别、体质量指数(BMI)、结石大小类型、是否合并高血压、糖尿病、肾功能不全、泌尿道感染以及手术相关因素如穿刺定位方式、穿刺肾盏位置、通道大小、手术时间及术者经验等相关因素进行单变量及多变量回归分析,分析上述各因素与是否输血之间的关系,找出影响手术出血的风险因素。结果 139例次手术均由同一名主刀医师顺利完成,均行单通道PCNL术,术中或术后输血治疗的患者有13例,输血率9.4%。单变量分析中,鹿角形结石(P0.001)、合并糖尿病(P=0.002)、通道大小(P=0.035)及手术时间(P=0.003)是影响出血的主要因素;而患者年龄、性别、BMI、合并高血压、肾功能不全、泌尿系感染、穿刺定位方式、穿刺肾盏位置及术者经验不是出血的风险因素。多变量回归分析中,鹿角形结石(OR=5.47)、合并糖尿病(OR=6.16)及手术时间过长(OR=1.03)可显著增加PCNL出血的风险。结论患者合并有糖尿病史、鹿角形结石、及手术时间过长均能增加PCNL术中、术后出血风险。