无管化经皮肾镜取石术可行性和安全性及疗效的随机对照研究

目的 通过随机对照临床试验,研究无管化PCNL的可行性、安全件和疗效. 方法 2010年5-8月行PCNL患者,术中取石完毕,随机数字法将患者随机分为试验组(无管化PCNL,即只留置双J管,不留置肾造瘘管)与对照组(传统PCNL,留置双J管及肾造瘘管).排除标准:严重出血需输血者;明显结石残留需行二期碎石取石i者;重度肾积水,肾实质厚度＜5 mm者;肾盂穿刺液为脓件者;合并输尿管狭窄或肾盂输尿管连接处狭窄;集合系统严重穿孔者.共50例患者被纳入研究,试验组和对照组各25例,两组患者的年龄、性别、结石大小差异均正统计学意义(P＞0.05).所有手术均由一位医生主刀.评价指标包括术后疼痛、Hb下降量、输血率、发热发生率、肾周血肿发生率、住院时间等. 结果 术后第1天试验组疼痛视觉模拟评分(VAS)为2.24,对照组为5.04(P＜0.01);试验组术后平均住院时间3.04 d,对照组6.88 d,两组差异有统计学意义(P＜0.01);两组术后Hb下降量、结石清除率差异无统计学意义(P＞0.05).两组输血率(1/25与3/25,P＞0.05)、肾周血肿发生率(6/27与7/27,P＞0.05)、发热发生率(3/25与4/25,P＞0.05)比较差异亦无统计学意义.两组患者术后穿刺通道部位均无漏尿发生. 结论 无管化PCNL安全,能显著减轻患者术后疼痛不适,缩短住院时间,且不增加出血、漏尿等并发症发生率,但需恰当掌握其适应证,对术中大出血、肾积脓、输尿管梗阻、集合系统严重穿孔、结石残留需二期手术者禁用.     

完全无管化和不置肾造瘘管部分无管化经皮肾镜取石术的对照研究

目的比较完全无管化组（既不留置肾造瘘管也不留置双J管）与不置造瘘管（部分无管化,单置双J管）的经皮肾镜取石术（PCNL）的临床效果,评价完全无管化PCNL的临床可行性及应用价值。方法选择2010年11月至2011年9月符合特定筛选条件的上尿路结石患者72例,按手术次序的奇偶数分为完全无管化PCNL组和部分无管化PCNL组。比较两组患者手术时间、术后血红蛋白下降值、镇痛药物的需求、平均住院时间及并发症的发生率、医疗费用、术后恢复正常生活及工作时间等指标的区别。结果 72例患者手术均一期顺利完成,完全无管化PCNL组手术时间、术后血红蛋白下降值、镇痛药物的需求、平均住院时间及并发症的发生率等与部分无管化组PCNL组相当（P〉0.05）,两组在医疗费用分别为（9 566.4±523.7）元和（11 351.2±825.3）元、术后恢复正常生活及工作时间分别为（9.6±1.6）d和（16.8±1.2）d,完全无管化PCNL组要优于部分无管化PCNL组（P〈0.05）。结论有条件地实施完全无管化PCNL是安全的,与部分无管化PCNL相比,并不增加术后相关并发症风险,既节约了医疗成本,又缩短了术后恢复正常生活及工作的时间,有一定的临床应用价值,值得推广应用。     

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。     

无管化经皮肾镜取石术的研究现状及进展

经皮肾镜取石术(PCNL)已经成为治疗肾脏结石及输尿管上段结石的主要手段。传统PCNL术后引流方式为留置肾造瘘管及输尿管支架管,但这一标准操作也会带来相应的并发症,导致国内外学者对无管化PCNL的研究不断深入。本文对近年来无管化PCNL的治疗现状及研究进展作一综述。     

无管化经皮肾镜碎石取石术临床应用进展

<正>经皮肾镜碎石取石术(percutaneous nephrolithotomy,PCNL)有两种发展趋势,一是更微创化,即微创经皮肾镜碎石取石术(minimally percutaneous nephrolithotomy,MPCNL),二是无管化(tubeless PCNL),即手术中有选择性地对患者不留置肾造瘘管和/或双J管,其中术后不留置肾造瘘管,而常规留置双J管为"部分无管化(tubeless)";术后既不     

微创经皮肾镜碎石取石术中快速康复外科理念的应用

目的探讨快速康复外科理念（ERAS）在微创经皮肾镜碎石取石术中（MPCNL）的应用价值。 方法回顾性分析我院2016年6月1日至2017年11月30日收治的243例肾及输尿管上段结石患者,根据处理措施不同分为快速康复外科组（ERAS组,n=116）和传统组（n=127）,比较两组术后气管导管拔管时间、首次肛门排气时间、首次进食时间、拔除肾造瘘管及尿管时间、发生低体温及术后发热情况、术后住院时间等临床指标。 结果两组患者年龄、性别、结石大小和位置、术前泌尿系统感染情况及手术时间的差异无统计学意义。所有患者均成功完成MPCNL。与传统组相比,ERAS组气管导管拔管时间[（10.6±5.2）min vs（28.4±9.5）min,P<0.01]、术后拔除肾造瘘管时间[（4.7±1.5）d vs（7.8±1.2）d,P<0.01]、拔除尿管时间[（5.1±1.2）d vs ( 8.3±1.4) d,P<0.01]、术后住院时间[（5.2±0.6）d vs （7.3±0.8）d,P<0.01]均缩短,两组差异比较均有统计学意义。ERAS组术后首次肛门排气时间、进食时间明显提前。ERAS组术中发生低体温和术后发热的患者明显减少。 结论在MPCNL围手术期应用快速康复外科理念进行指导,可明显加速术后康复,改善患者预后,值得推广应用。     

经皮肾镜取石术后留置单J管22例报告

目的探讨经皮肾镜取石（percutaneous nephrolithotomy,PCNL）术后留置单J管作为肾造瘘和输尿管支架的安全性和可行性。方法 2007年1月～2010年10月,对22例PCNL术中无明显出血并配合B超检查确定无残留的结石后,在导丝引导下顺行留置单J管作为肾造瘘和输尿管支架管。结果术后无一例出现大出血等严重并发症,穿刺部位无明显疼痛和不适。平均住院时间7 d（6～8 d）。术后4周随访,无一例出现漏尿或迟发性出血。结论对于小体积上尿路结石,PCNL术后留置单J管替代肾造瘘和输尿管支架管安全、有效。     

无管化经皮肾镜取石术

一、无管化经皮肾镜取石术(PCNL)的主要形式 PCNL后不放置肾造瘘管,很可能出现出血.不少专家尝试了很多方法以减少出血,包括使用不同种类的止血药封闭经皮肾通道、在通道内烧灼出血点或放置暂时性的造瘘管并于术后拔除等.但也有研究表明,止血剂在减低术后并发症和镇痛药需求量方面没有临床优势,更可能导致医疗费用增加和手术时间延长.对于无管化PCNL,如何处理通道有以下几种形式:①不留置肾造瘘管,但放置输尿管内支架管(双J管);②不留置造瘘管,放输尿管外支架管,贯通皮肤至膀胱或者留置于输尿管从尿道引出1;③放置输尿管内支架管,丝线留于皮肤外并固定,以后通过丝线拔除内支架2;④只放置1根导丝,贯穿于皮肤、肾输尿管膀胱;⑤不放置任何管,伤口用止血凝胶固定;⑥什么都不用处理.     

不置肾造瘘管和常规微创经皮肾镜取石术的对照研究

目的:通过与常规留置肾造瘘管的微创经皮肾镜取石术(mini-percutaneous nephrolithotomy,MPCNL)的效果比较,评价不置肾造瘘管的MPCNL(tubeless MPCNL)的临床价值。方法:选择2003年1月～2009年7月收治的上尿路结石患者345例,115例行tubeless MPCNL(A组),230例行常规留置肾造瘘管的MPCNL(B组)。并比较两组患者的手术时间、术中出血量、结石清除率、术后对镇痛药的需求、住院天数、并发症和医疗费用等指标。结果:A组均获得成功,其中11例行完全无管化的MPCNL(不留置肾造瘘管和双J管),13例行双侧同期tubeless MPCNL。其结石大小、手术时间、结石清除率、平均失血量及并发症发生率等与B组相当(P0.05),但术后疼痛评分、镇痛药的需求、医疗费用及住院时间等均优于B组(P0.05)。结论:对有适应证的上尿路结石患者行tubeless MPCNL安全、可行,部分患者还可行完全无管化的MPCNL。与常规留置肾造瘘管的MPCNL相比,tubeless MPCNL术后疼痛轻,恢复快,费用低,住院时间短。     

经皮肾取石术后不留置肾造瘘管的适应证和安全性

目的探讨经皮肾取石术（percutaneous nephrolithotomy,PCNL）后不留置肾造瘘管的适应证和安全性。方法根据PCNL术前、术中情况选择合适病例。入选标准：术前B超报告肾盂积水〈4 cm,血清肌酐值正常;单一穿刺通道;术前、术中无尿路感染征象;术中无出血,集合系统无大面积穿孔;无结石残留,或虽有小结石残留但不需要行二次经皮肾手术者;术中顺利置入双J管;手术时间〈2 h。共入选240例输尿管上段及肾结石,按手术次序的奇偶数分为2组（各120例）：A组术后不放置肾盂造瘘管,B组术后放置F14肾盂造瘘管。结果240例均一期手术成功。2组结石清除率分别为98.3%（118/120）和96.7%（116/120）,二者相比无统计学差异（χ^2=0.171,P=0.679）。2组术中、术后均无输血病例;术后18例发热（A组8例,B组10例,χ^2=0.240,P=0.624）,均无感染性休克。术后48 h B超检查2组患者均未见肾周积液。结论对于经过严格选择的患者,经皮肾取石术后不放置肾盂造瘘管安全而有效。     

Tubeless percutaneous nephrolithotomy in patients with previous ipsilateral open renal surgery: a feasibility study with review of literature

PURPOSE: To present our initial experience of tubeless percutaneous nephrolithotomy (PCNL) in patients with previous ipsilateral open renal surgery. PATIENTS AND METHODS: Twenty-five patients with previous ipsilateral open renal surgery underwent tubeless PCNL at our institute. Patients with large renal and/or upper ureteral calculi, irrespective of the number and size of the stones, amount of hydronephrosis, or the renal parameters, were selected for the procedure. Exclusion criteria were patients needing more than two percutaneous tracts, significant bleeding, and a significant residual stone burden that would necessitate a staged PCNL. The perioperative outcome of these patients (study group) was retrospectively compared with an historic cohort of the same number of patients with a history of open surgery for renal calculi who underwent ipsilateral PCNL with routine placement of a nephrostomy tube (control group). RESULTS: The two groups had comparable demographic data. Patients in the study group needed less postoperative analgesia (P = 0.000). They were discharged a mean of 10 hours earlier (P = 0.000). Two patients in both groups required blood transfusion. No urinoma or urinary leak from the nephrostomy site occurred in the study group. The incidence of other postoperative complications was comparable in both groups. Complete stone clearance was achieved in 88% of patients in the study group and 84% patients in the control group. CONCLUSION: The tubeless approach in patients with a history of open renal surgery is associated with decreased analgesia requirement and hospital stay without compromising stone-free rates or increasing the complications.     

留置输尿管外支架的无管化经皮肾镜取石术的安全性和效果分析

目的：探讨留置输尿管外支架的无管化经皮肾镜取石术（tubeles spercutaneous nephrolithotomy,tubelessPCNL）的安全性和有效性。方法：回顾性分析43例留置输尿管外支架的tubelessPCNL治疗肾或输尿管上段结石的患者资料。男23例,女20例,平均年龄44．9岁。其中肾盂结石22例,输尿管上段结石18例,肾多发性结石3例。结石最大径为（2．4±1．1）cm。合并患肾轻度积液4例,中度积液21例,重度积液18例。在经皮肾镜取石术结束时,通过B超和c臂x线证实结石已经完全清除,然后把逆行插入的输尿管导管的头端调整至肾盂的中央,让扩张鞘退至肾造瘘通道以外,证实瘘道无活动性出血,最后拔除扩张鞘,并用丝线缝合皮肤伤口。结果：43例患者,其中41例结石完全清除,2例为无意义残留结石。手术时间30～75min,平均45min。手术引起血红蛋白平均下降6．5g／L。术后第1天视觉疼痛评分为（3．0±1．4）分。术后平均住院天数为3d。术后出现急迫性尿失禁1例,。肾周血肿1例,发热2例,持续性肉眼血尿2例,轻度尿外渗2例。结论：在严格掌握手术适应证的前提下,留置输尿管外支架的tubeless PCNL是安全和有效的。     

Simultaneous bilateral tubeless percutaneous nephrolithotomy: A report of 2 cases and review of the literature

Percutaneous nephrolithotomy (PCNL) is currently the standard of care to remove large renal calculi. Traditionally, a large-bore nephrostomy tube is placed postoperatively. However, the necessity of this practice has been recently challenged. Theoretically, bilateral tubeless PCNL offers advantages of lower postoperative discomfort, shorter hospital stay and thus lower cost. We review the literature and present two cases of simultaneous bilateral tubeless PCNL from two patients who were referred to a tertiary stone centre from remote areas.     

Totally tubeless percutaneous nephrolithotomy

PURPOSE: We evaluated the requirement for routine placement of a ureteral stent and a nephrostomy tube following percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: A total of 43 patients underwent totally tubeless PCNL and was compared with a control group of 43 age-, sex-, weight-, and procedure-matched patients who had previously undergone PCNL with placement of a ureteral stent and a nephrostomy tube. Exclusion criteria for the tubeless approach were more than two percutaneous accesses, significant perforation of the collecting system, a large residual stone burden, significant postoperative bleeding, ureteral obstruction, and renal anomaly. The incidence of complications, length of hospitalization, analgesia requirements, and interval to return to normal activities were compared in the two groups. RESULTS: All 43 percutaneous procedures were performed without significant complications. None of the patients demonstrated urinoma in postoperative renal ultrasound scans. The average length of hospital stay was 1.6 days, with two-thirds of the patients staying <1 day for the study group, and 5.2 days for the controls (P < 0.001). The average analgesia requirement was 9.8 mg and 28.4 mg of morphine, respectively (P < 0.001). Patients returned to normal activities with 12.7 days v 24.6 days for the controls (P < 0.001). CONCLUSION: Totally tubeless PCNL is a safe and effective procedure. The hospitalization and analgesia requirements are less and the return to normal activities faster with this technique.     

无管化经皮肾镜治疗肾结石的研究进展

尿石症是泌尿外科常见疾病之一。经皮肾镜碎石取石术已经成为治疗肾结石的主要手术方式。标准的经皮肾镜碎石取石需要肾造瘘管及输尿管内支架管来进行引流及压迫止血。然而,这一手术也会带来出血、疼痛、住院时间延长、住院费用升高等缺点。无管化经皮肾能减少上述相关风险。笔者将对无管化经皮肾镜碎石取石的研究进展进行综述。     

全麻与腰麻无管化经皮肾镜碎石取石术治疗肾结石的比较

目的探讨全麻与腰麻无管化经皮肾镜碎石取石术(PCNL)治疗肾结石的临床效果。方法前瞻性分析2017年8月至2017年12月我院65例行无管化经皮肾镜钬激光碎石取石术的患者的临床资料,术前采用随机数字表将患者分为全麻组与腰麻组,其中术中发生严重出血需留置肾造瘘管共12例被删除。最终53例行无管化PCNL的患者被纳入研究,其中全麻组28例,腰麻组25例,统计分析两组患者结石的基本特征、术中及术后的参数。结果两组患者在年龄、性别、体质量指数、结石大小、结石位置、手术时间、住院天数、穿刺针数、穿刺位置、血红蛋白下降、出院当天视觉模拟疼痛评分(VAS)及残石率差异无统计学意义(P>0.05),但腰麻组术后的第一天的VAS评分[(4.4±1.8)vs(6.4±2.0),P<0.05]及曲马多镇痛需求量[(56±36) mg vs (112±44) mg,P<0.05]显著小于全麻组。结论腰麻行无管化PCNL是全麻下无管化PCNL的良好替代方案,与全麻相比,腰麻术后疼痛更轻,减少了无管化PCNL患者术后镇痛需求。     

Tubeless percutaneous nephrolithotomy: is it really less morbid?

PURPOSE: To prospectively evaluate and study the role, relative safety, and effectiveness of "tubeless" percutaneous nephrolithotomy (PCNL) and whether it is really less morbid vis-à-vis PCNL with a nephrostomy tube; to compare the postoperative pain, analgesia requirement, hospital stay, return to work time, and other parameters in patients undergoing tubeless PCNL and standard PCNL. PATIENTS AND METHODS: Sixty selected patients underwent PCNL. A single urologist (IS) was the surgeon, and a resident administered random chit numbers, and recorded pain scores and results of all the chosen parameters. Patients who fulfilled the entry criteria for a tubeless PCNL protocol were randomized to either the omission of a nephrostomy tube (tubeless PCNL with Double-J stent) or to the placement of a 22F nephrostomy tube. The recorded data were analyzed with respect to several parameters. RESULTS: The mean age, stone burden, and preoperative hemoglobin, blood urea, and serum creatinine values were not significantly different between the two groups. However, the operative time (P < 0.001), analgesia requirement (P < 0.001), and hospital stay and time to return to normal activity (P < 0.001) were significantly lower in the tubeless PCNL group. CONCLUSIONS: Significantly less pain, lower analgesia requirement, and shorter hospital stay with early return to normal activities were observed in the tubeless PCNL group v the primary nephrostomy tube PCNL group. Tubeless PCNL in selected patients is a secure, effective, and less morbid procedure that does not compromise patient safety and concerns. We recommend that tubeless PCNL be the preferred procedure in selected patients for management of nephrolithiasis.     

Postoperative morbidity of tubeless versus conventional percutaneous nephrolithotomy: a prospective comparative study

Percutaneous Nephrolithotomy (PNL) is an established technique for the treatment of renal calculi. Some reports have challenged the need for a nephrostomy tube at the end of the procedure, arguing that it accounts for a longer hospital stay and increased postoperative pain. During the last years, several series have addressed the feasibility and safety of tubeless PNL, where a double-J ureteral stent is left in place after the end of intervention instead of a nephrostomy tube. The aim of our study was to compare conventional versus tubeless PNL in terms of postoperative morbidity. Eighty-five patients who underwent PNL at a single center met the inclusion criteria (complete intraoperative stone clearance, no evidence of active intraoperative bleeding, single percutaneous access, and operative time shorter than 2 h) and were randomized at the end of the procedure to have placed either a nephrostomy tube (group 1) or a double-J ureteral stent (group 2). Outcomes assessed were postoperative pain, bleeding complications, leakage complications, and length of hospital stay. The patients in the tubeless group had a shorter hospital stay (3.7 vs. 5.8 days; P < 0.001), and less postoperative pain at postoperative days 2 and 3 (P < 0.001). No significant difference in bleeding or leakage complications was observed. This study supports the feasibility and safety of tubeless PNL in a selected group of the patients, suggesting some intraoperative criteria to be considered when performing it. However, further controlled studies will have to determine its impact on stone-free rates prior to be considered the standard technique in these selected cases.     

Tubeless percutaneous nephrolithotomy: call of the day

PURPOSE: We challenge the routine placement of nephrostomy tube after percutaneous nephrolithotomy (PCNL) without taking into consideration the size, burden, and multiplicity of the stones; the degree of obstruction of the pelvicaliceal system, or any anatomic variations of the kidney in shape or position. PATIENTS AND METHODS: Between January 2005 to March 2006, 110 patients underwent PCNL, 77% of whom had multiple stones. The mean size of the single stones was 4.3 cm (range 2.8-6.5 cm), and the mean single-stone burden was 7.2 cm2 (range 5.6-14.3 cm2). The mean burden of multiple stones was 11.4 cm2 (range 8-23 cm2). Among the patients, 18 had had previous renal surgery, 12 had renal insufficiency, and 7 had a solitary functioning kidney. One patient each had horseshoe kidney and malrotated kidney. In 106 patients, no nephrostomy drain was placed, only an externalized 5F ureteral catheter for 16 to 20 hours. Two patients had simultaneous bilateral tubeless PCNL. The outcome was evaluated prospectively. The frequency of complications, length of hospital stay, and stone-free status were assessed. RESULTS: A stone-free rate of 80% was achieved using PCNL as monotherapy. The mean postoperative hospital stay was 16 to 20 hours. Three patients required placement of a nephrostomy tube because of significant bleeding and one because of purulent renal discharge. In four patients, a ureteral catheter was replaced by a stent because of significant residual stone burdens. The initial 18 patients underwent ultrasound examination on the first postoperative day, and none demonstrated any extrarenal collection, so routine ultrasound examination was omitted in succeeding patients. One patient required exploration because of a retroperitoneal hematoma. CONCLUSION: Omission of a nephrostomy tube after PCNL while retaining an externalized ureteral catheter for 16 to 20 hours is sufficient and safe irrespective of the stone characteristics. Shape, position, and function of the kidneys are also irrelevant with regard to tubeless PCNL.     

A randomized comparison of tubeless and standard percutaneous nephrolithotomy

PURPOSE: We present a randomized study of tubeless or nephrostomy-free percutaneous nephrolithotomy (PCNL), a modification of the standard technique, compared with standard PCNL to evaluate the role of tubeless PCNL in minimizing postoperative discomfort and reducing duration of hospital stay. PATIENTS AND METHODS: Two hundred and two patients undergoing PCNL were randomized to two groups: Group A (standard PCNL) with nephrostomy tube placement postoperatively, and group B (tubeless PCNL) with antegrade placement of a Double-J stent without nephrostomy. Inclusion criteria were: normal renal functions, single tract procedure with complete clearance, and minimal bleeding at completion. The two groups were comparable in age and sex and in metabolic and anatomic features. Factors evaluated included postoperative pain, analgesia requirement, blood loss, postoperative morbidity, hospital stay, and time to recovery. RESULTS: All patients had an uneventful postoperative recovery. The average visual analogue scale pain score on postoperative day 1 for group A patients was 59 +/- 5.1 compared with 31 +/- 4.8 in group B (P < 0.01). The mean analgesia requirement for group A (meperidine 126.5 +/- 33.3 mg) was significantly more compared with group B (meperidine 81.7 +/- 24.5 mg) (P < 0.01). The difference in average blood loss and urinary infection for the two groups was not statistically significant. The incidence of urinary leakage from the nephrostomy site was significantly less for the tubeless group (0/101), compared with the standard PNL group (7/101). The average hospital stay in the tubeless group (21.8 +/- 3.9 hours) was significantly shorter than that of the standard PCNL group (54.2 +/- 5 hours) (P < 0.01). Tubeless group patients took 5 to 7 days for complete convalescence whereas standard PCNL patients recovered in 8 to 10 days. No long-term sequelae were noticed in the median follow-up period of 18 months in any patient. CONCLUSION: Nephrostomy-free or tubeless PCNL reduces postoperative urinary leakage and local pain related to the drainage tube. It also minimizes hospital stay; the majority of patients were discharged from the hospital in fewer than 24 hours.