经皮肾镜手术并发症及防治

目的应用经皮肾镜取石术(PCNL)治疗复杂性肾结石和输尿管上段结石,并对并发症进行分析,探讨并发症的预防和处理。方法对262例患者进行PCNL,对术中和术后出现的并发症进行观察和处理,并进行回顾性分析,探讨并发症发生的原因。结果 PCNL术疗效满意,对并发症处理的结果满意。结论 PCNL术疗效肯定,是治疗复杂性肾、肾盂和输尿管上段结石的理想方法之一,但有一定的并发症。合理选择患者,充分术前准备,术中操作轻柔,术后严密观察病情变化并及时处理是PCNL成功的关键。     

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...     

亚甲蓝注射液在经皮肾镜手术中的应用

经皮肾镜手术在穿刺时常存在一定的困难,医生只能通过穿刺时流出的液体来判断穿刺是否成功。我科应用亚甲蓝稀释液来判断穿刺部位,大大提高了穿刺的成功率与有效性,取得较好效果,介绍如下。     

不同手术体位在经皮肾镜碎石取石术中的应用研究

目的探讨俯卧位、侧卧位及平卧位对经皮肾镜碎石患者的影响,选择适宜的手术体位。方法将60例上尿路结石患者随机分成3组,即侧卧位20例,俯卧位20例和平卧位20例。比较3组不同手术体位的手术时间和患者的舒适度、Ⅰ期结石清除率、住院天数、肾造瘘管留置时间的情况。结果手术时间平卧位最长,侧卧位次之,俯卧位最短,舒适度平卧位最佳,侧卧位次之,俯卧位最差,差异有统计学意义（P〈0．05）。俯卧位与侧卧位及平卧位在Ⅰ期结石清除率、住院天数、肾造瘘管留置时间比较差异无统计学意义（P〉0．05）。结论经皮肾镜碎石取石术（PCNL）,俯卧位手术时间最短,平卧位舒适度最佳,三者在Ⅰ期结石清除率、住院天数、肾造瘘管留景时间无明显差异。     

开放手术与经皮肾镜手术治疗复杂性肾结石疗效分析

目的分析比较开放手术与经皮肾镜手术治疗复杂性肾结石的临床效果。方法将92例复杂性肾结石患者随机分为观察组与对照组,各46例。观察组行经皮肾镜手术治疗,对照组行开放手术治疗。比较2组的临床效果。结果观察组结石清除率95.65%,对照组67.39%,2组比较,差异有统计学意义(P<0.05)。观察组术后并发症发病率13.00%,对照组34.78%,2组比较,差异有统计学意义(P<0.05)。结论经皮肾镜手术治疗复杂性肾结石较开放手术结石清除率高,并发症少,值得临床应用。     

经皮肾镜碎石取石术围手术期护理进展

经皮肾镜碎石取石术(percutaneous nephrolithotomy,PCNL)是指在硬膜外麻醉或气管插管麻醉后,在超声或X光定位下建立从腰部皮肤到肾集合系统的手术通道,应用内窥镜进入肾盏、肾盂和输尿管内,应用激光、超声、气压弹道等碎石工具对肾、输尿管内的结石进行击碎并取出的一种手术方法。它已取代传统的开放手术取石,成为肾结石治疗的一线方案。为保障患者及手术安全,国内外护理学者对PCNL围手术期护理进行了大量研究,现将护理进展综述如下。     

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。     

经皮肾镜取石术患者的围手术期护理

目的探讨经皮肾镜取石术患者的围手术期护理。方法回顾总结对68例经皮肾镜取石术的患者进行有针对性的术前心理护理、术后的特殊护理和出院时的康复指导。结果 68例患者经精心治疗与护理后痊愈出院,平均住院时间8 d。结论对经皮肾镜取石术患者实施有效的围手术期护理,可以使患者顺利度过手术期。     

新型软性肾镜在经皮肾镜取石术中的应用

目的:探索新型软性肾镜在经皮肾镜取石术(percutaneous nephrolithotomy, PCNL)中的应用效果。方法:回顾性分析2022年1月—2023年2月海军军医大学第一附属医院通过标准通道PCNL治疗的肾结石患者临床资料,依据术中是否使用新型软性肾镜将患者分为联合软性肾镜组和单用硬镜组;比较2组患者手术相关临床数据。结果:联合软性肾镜组52例,单用硬镜组42例,2组患者年龄[(55.9±11.3)岁vs (53.7±13.7)岁,P=0.407]、体重指数(BMI)[(24.7±3.3) kg/m² vs (24.6±3.3) kg/m²,P=0.915]及结石最大径[(33.5±13.6)mm vs (39.0±17.0) mm,P=0.085]比较差异无统计学意义。联合软性肾镜组11例患者术中通过软性肾镜成功寻找到硬镜无法处理的残余结石并成功碎石取石。联合软性肾镜组结石清除率显著高于单用硬镜组的患者(84.6%vs 57.1%,P=0.003)且术后住院时间更短[(3.4±1.4) d vs (4.81±2.2) d,P...     

Time-dependent oxidative stress effects of percutaneous nephrolithotomy

Aim of this study was to investigate the effects of operation time of percutaneous nephrolithotomy (PCNL) on renal function and hemodynamic response. Thirty-four patients (14 male, 20 female) with normal renal function who underwent unilateral single-tract PCNL between December 2010 and June 2011 were included in the study. The age, sex, stone size, grade of hydronephrosis, operative time, access pole, shock number of lithotripter, complications, stone-free rate, and hemodynamic parameters during operation were recorded. Total blood count and oxidative stress parameters such as paraoxonase 1 (PON1), total antioxidant status (TAS), total oxidant status (TOS), and malonyldialdehyde (MDA) levels were examined before the operation as baseline levels and then at 30, 60, 90, and 120 min during the operation. The mean age of the patients was 31.4 ± 18.8 (9–66 years) years. Mean stone size was 35.5 ± 15.6 mm. Mean serum BUN and creatinine did not change postoperatively (p > 0.05), whereas mean WBC and 24-h urine cortisol were positively and hematocrite were negatively changed significantly (p < 0.05). Oxidative stress parameters such as PON1 and TAS showed statistically significant decreases, while TOS and MDA showed statistically significant increases with increased operation time, especially after 1 h (p < 0.005). A bivariate correlation test showed correlation between oxidative stress parameters and operation time (p = 0.002), but no correlation was found between oxidative stress parameters and other parameters (p > 0.05). Oxidative stress and response to it increased with increasing operative time during a PCNL procedure, especially after 1 h. Further studies with a larger and longer series should be performed to clarify this issue further.     

经皮肾镜取石术的并发症与对策

目的:探讨经皮肾镜取石术(PCNL)并发症及处理方法。方法:报告在行PCNL的197例中,发生严重并发症7例(10次),发生率为3.2%;分别为严重出血(Hb下降>60g/L)5例,感染1例,腹腔积液1例,肾功能不全1例,结肠穿孔1例,胸腔积液1例;18%(36例)有术后发热(38.5℃以上),且发热以鸟粪石和尿酸结石者居多,但与Ⅰ期、Ⅱ期手术无明显差别。结果:开放手术1例,介入止血1例,余均保守治疗。全部患者均治愈出院,无一例死亡。结论:PCNL并发症中出血及发热最常见,严重并发症发生机率少但多种多样;对PCNL并发症的积极预防、早期发现及合理处理,有赖于对各并发症临床特征的深入了解。     

Factors determining perioperative complications of percutaneous nephrolithotomy: A single center perspective

Objective

To determine factors affecting perioperative complications of percutaneous nephrolithotomy (PCNL) at a tertiary care academic center.

Simultaneous bilateral percutaneous nephrolithotomy in children

In the paediatric section, two papers relating to the upper urinary tract are presented. The first, from Hungary, describes simultaneous bilateral percutaneous nephrolithotomy in 13 patients, where it was deemed feasible; this is the first such report. Authors from London report on unilateral nephrectomy in patients with nephrogenic hypertension, and found that it was successful in normalising blood pressure in patients with renal hypertension with a normal contralateral kidney. OBJECTIVE: To evaluate the efficacy of removing bilateral kidney stones simultaneously from children, in one session. PATIENTS AND METHODS: Thirteen patients (three girls and 10 boys, 26 kidneys; mean age 8 years, range 3-14) underwent simultaneous bilateral percutaneous nephrolithotomy (PCNL) in the same session, under general anaesthesia, starting with ureteric catheter insertion into both kidneys and using a 26 F adult nephroscope. The mean (range) stone diameter was 2 (1-3.5) cm. Three patients had staghorn stones in one of their kidneys. Ultrasonic disintegration was used; two patients had bilateral and two others unilateral endopylotomy, and one patient had percutaneous suprapubic cystolithotomy in the same session. The mean (range) operative duration was 65 (55-90) min. RESULTS: All patients were rendered stone-free; there was no severe bleeding or any other complication. On one side in one of the patients, a second session was needed because of residual stone. The nephrostomy tubes were removed 3 and 4 days after PCNL and the hospital stay was 6 (1-11) days. CONCLUSION: The advantages of simultaneous bilateral PCNL are reduced psychological stress, one cystoscopy and anaesthesia, less medication and a shorter hospital stay and convalescence, with considerable savings in cost. In experienced hands this method can be used not only in adults but also in children. To our knowledge this is the only report of this technique in children.     

完全无管化与标准经皮肾镜治疗肾结石的Meta分析

目的系统评价完全无管化经皮肾镜碎石取石术(PCNL)与标准PCNL治疗肾结石的有效性和安全性。方法检索PubMed、Embase、Cochrane Library数据库。检索时限为从建库到2018年2月28日关于完全无管化PCNL和标准PCNL治疗肾结石的随机对照试验或回顾性病例对照试验,2名作者独立进行文献筛查和数据提取,运用RevMan 5.3软件进行Meta分析。结果共纳入5篇随机对照研究,2篇病例对照研究,共计781例患者,其中完全无管化PCNL组379例,标准PCNL组402例。Meta分析结果显示:完全无管化PCNL组的手术时间短于标准PCNL组(WMD:-2.72;95%CI:-4.05^-1.39;P<0.001);住院时间短于标准PCNL组(WMD:-1.48;95%CI:-1.84^-1.11;P<0.001);术后镇痛需求低于标准PCNL组(WMD:-6.91;95%CI:-9.00^-4.82;P<0.001);两组在结石清除率、术后血红蛋白丢失量及输血率方面差异均无统计学意义。结论完全无管化PCNL在治疗选择性肾结石患者方面优于标准PCNL,可以明显减少手术时间、住院时间和术后镇痛需求,而且不会增加手术相关的并发症。医师应根据患者的实际情况,个体化选择治疗方案。     

Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

OBJECTIVE:To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy. METHODS: Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis. RESULTS: A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy. CONCLUSIONS: Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.     

侧卧位在经皮肾穿刺取石术中的应用

随着微创外科技术的发展,经皮肾穿刺取石术(PCNL)治疗上尿路结石已经被学者广泛接受。美国泌尿外科学会尿石症治疗指南推荐PCNL作为治疗复杂肾结石的首选方案。传统的PCNL手术多采用俯卧位,但俯卧位存在着较多缺点,如患者对手术耐受性差、体位摆放繁杂等。侧卧位的PCNL可提高患者对手术的耐受性,且给术者的操作带来便利,并未增加手术风险及并发症发生。侧卧位PCNL安全、有效、操作简单,值得临床推广应用。本文归纳近年来国内外关于侧卧位在PCNL手术中的临床研究成果,期望为临床医师提供参考。     

超声引导经皮肾镜碎石术治疗孤立肾肾结石36例

目的探讨超声引导下行经皮肾镜碎石术（PCNL）治疗孤立肾肾结石的疗效,总结治疗经验。方法2003年1月～2007年12月,在超声引导下行PCNL治疗孤立肾肾结石共36例,患者年龄19～71岁,其中11例术前肌酐升高。对结石大小、手术并发症、结石清除率、手术时间及术后血肌酐水平进行分析。结果36例患者中,1例术中出血超过400mL,3例术后出现短暂性高热。平均住院时间（5．8±2．1）d。其中27例Ⅰ期取石成功,Ⅰ期结石清除率75％;9例行Ⅱ期取石或体外冲击波碎石。出院后3个月复查结石均无残留。11例肌酐升高的患者中有8例术后肌酐降至正常。结论PCNL是治疗孤立。肾肾结石的安全有效方法,对于移植肾肾结石同样适用,同时PCNL具有创伤小、易恢复等优点。     

输尿管软镜与经皮肾镜治疗一期经皮肾镜术后多发性残石的比较

目的比较输尿管软镜（RIRS）和经皮肾镜碎石取石术（PCNL）处理一期PCNL术后多发性残石的临床疗效。 方法回顾性分析2016年8月至2018年8月中山大学附属东华医院采用PCNL术后多发性残石78例患者的资料,其中男42例,女36例,平均年龄（46±13）岁,残石2～5个,单个结石直径≤2 cm。78例患者的操作均在一期手术后5～7 d肾造瘘管引流液变清后进行,根据残石的处理方案分为输尿管软镜组（R组）43例和经皮肾镜组（P组）35例,R组进行逆行输尿管软镜取石,P组在原经皮肾镜通道的基础上进行多通道PCNL。 结果所有操作均成功进行,无严重并发症发生,P组和R组的手术时间、结石清除率等差异无统计学意义;P组在平均血红蛋白浓度下降值（0.95±0.86 vs 0.29±0.45 g/dl）、住院时间（5.7±1.9 vs 1.8±1.5 d）和术后第1天疼痛视觉模拟评分（VAS） （5.1±1.1 vs 1.6±0.7）上显著高于R组（P<0.01）;P组和R组术后第1天血肌酐较术前升高值分别为（0.22±0.04）mg/dl和（0.07±0.01）mg/dl,（P<0.05）。 结论RIRS和PCNL处理PCNL术后多发性残石均是安全有效的,输尿管软镜对患者的的影响和术后恢复等方面具有一定的优势。