Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy

OBJECTIVE: To prospectively evaluate the safety and efficacy of the supracostal approach for percu-taneous nephrolithotomy (PCNL), as it is usually avoided because of concerns about potential chest complications. PATIENTS AND METHODS: Between August 1998 and August 2001, 465 patients underwent PCNL. Supracostal access was obtained in 62 patients (63 renal units), comprising 13% of the procedures. The indications for a supracostal approach were staghorn, upper ureteric, superior calyceal stones and high-lying kidneys. The data were analysed for stone clearance, need for additional punctures and the complications associated with supracostal puncture. RESULTS: The supracostal was the only access in 63% of the PCNL procedures. Additional punctures were required mainly for staghorn stones (15 of 23). Overall, 90% of the patients were rendered stone-free or had clinically insignificant residuals with PCNL alone. In patients with staghorn stones, they were completely cleared in 84% of renal units. Significant chest complications developed in three (5%) patients, which required insertion of a chest tube. One (2%) patient developed haemothorax secondary to injury of the intercostal artery. All the patients recovered uneventfully. CONCLUSIONS: These results indicate that supracostal access provides high clearance rates with acceptable complications; it should not be avoided for fear of chest complications. A chest X-ray after surgery should be routine, to detect any complication.     

Critical analysis of supracostal access for percutaneous renal surgery

PURPOSE: Percutaneous renal surgery is currently performed for complex renal calculi as well as for various other endourological indications. In many patients an upper pole nephrostomy tract allows direct access to most of the intrarenal collecting system. Upper pole percutaneous access may be obtained via the supracostal or subcostal approach. The preferred route depends on the location and size of the specific stone or lesion. Previously others have cautioned against the supracostal approach above the 12th rib and many have discouraged an approach above the 11th rib due to concern about the increased risk of intrathoracic complications. We retrospectively assessed the morbidity associated with supracostal percutaneous renal surgery and compared and analyzed the morbidity of the supracostal and subcostal approaches. MATERIALS AND METHODS: The records of all patients who underwent upper pole percutaneous renal surgery between November 1993 and July 1999 were retrospectively reviewed. A total of 240 patients underwent percutaneous renal procedures, including 225 for managing symptomatic renal or ureteral stones, that is nonstaghorn calculi in 157, staghorn calculi in 41, proximal ureteral calculi in 12, calculi within a caliceal diverticulum in 6, calculi associated with primary ureteropelvic junction obstruction in 5 and calculi associated with a retained ureteral stent in 4. An additional 15 procedures were done for ureteropelvic junction obstruction (7), intrarenal collecting system tumors (5), a caliceal diverticulum without stones (1), a retained ureteral stent (1) and a ureteral stricture (1). RESULTS: A total of 300 nephrostomy tracts were placed to obtain access to the intrarenal collecting system via the supracostal approach in 98 (32.7%) cases and the subcostal approach in 202 (67.3%). Of the supracostal approaches 72 (73.5%) tracts were above the 12th and 26 (26.5%) were above the 11th rib. The overall complication rate irrespective of percutaneous approach was 8.3% (16.3% for supracostal and 4.5% for subcostal access). Complications included blood transfusion in 7 patients, intraoperative hemothorax/hydrothorax in 5, sepsis/bacteremia in 3, atrial fibrillation in 2, delayed nephropleural fistula in 2, renal artery pseudoaneurysm in 2, deep venous thrombosis/pulmonary embolus in 2, pneumothorax in 1 and subcapsular hematoma in 1. Seven of 8 intrathoracic complications (87.5%) developed in supracostal cases. CONCLUSIONS: Percutaneous renal surgery remains an important option for managing complex renal calculi and other upper urinary tract lesions. In our experience it is generally associated with low morbidity. The supracostal approach is often preferred for obtaining intrarenal access to complex renal and proximal ureteral pathology. Because supracostal access tracts are associated with significantly higher intrathoracic and overall complication rates compared to subcostal access tracts, this approach must be used with caution when no other alternatives are available.     

Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

INTRODUCTION

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years.

METHODS

All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications.

RESULTS

PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion.

CONCLUSIONS

Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.     

Use of lower pole nephrostomy drainage following endorenal surgery through an upper pole access

PURPOSE: PNL via an UP puncture is efficient for treating complex stone disease. Access via the UP can provide better visualization, allowing greater stone clearance with a rigid instrument due to its more favorable alignment with the axis of the intrarenal collecting system. However, the presence of a NT through the upper pole tract, especially with a supracostal puncture, can generate significant patient discomfort. We reviewed our experience with a technique using tubeless UP access for PNL with concomitant placement of a NT via a LP calix. MATERIALS AND METHODS: We performed a retrospective review of our experience using tubeless UP access for PNL with concomitant placement of an LP NT for postoperative drainage. Patient demographics, the number and location of accesses, stone size, stone-free rates, concurrent/additional procedures and complications were recorded. RESULTS: A total of 63 tubeless UP accesses were performed in 62 patients undergoing PNL, including unilateral access in 61 and bilateral access in 1. Supracostal UP punctures were used in 58 patients, including 40 above the 12th, 17 above the 11th and 1 above the 10th rib. Each patient underwent at least 2 accesses and 3 had 3 or more accesses placed. LP access was nondilated in 37 patients and dilated in 26. Of the patients 56.6% were stone-free after a single procedure, increasing to 96.2% following secondary procedures. Three of the 62 patients (4.8%) required transfusion, 3 (4.8%) required intervention for pleural morbidity and 1 (1.6%) required a stent for a nonsealing upper pole access. CONCLUSIONS: Tubeless UP access provides maximal efficiency for stone clearance during PNL, while minimizing the morbidity of an intercostal tube.     

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.     

肋上入路微创PCNL治疗儿童结石的疗效观察

目的：探讨肋上入路微创经皮肾镜取石术（PCNL）治疗儿童。肾结石的安全性和有效性。方法：回顾性分析采用PCNI,治疗儿童肾结石患者54例的临床资料：54例患者根据手术入路分为A、B两组,A组29例接受12肋上穿刺入路,B组25例接受12肋下穿刺入路,对比A、B两组PCNL的手术结果及并发症情况。结果：A、B两组手术时间分别为124min和128min（P〉0.05）,术后结石清除率分别为91．2％和90．7％（P〉0．05）,术后发热例数分别为1例和2例,血气胸分别为2例和1例,两组均无严重出血或尿外渗等并发症。结论：采用肋上入路PCNL治疗儿童。肾结石安全、有效。     

Supracostal approach in percutaneous nephrolithotomy: experience with 102 cases.

PURPOSE: To assess retrospectively the safety and efficacy of the supracostal approach in percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Among 862 patients who underwent PCNL between April 1986 and December 1999, supracostal puncture was performed in 102. Their stones were either solitary (66.5%), multiple (15.7%), or staghorn (19.6%). Upper ureteral calculi were the commonest indication (32.4%). The interspace between the 11th and 12th ribs was used in all cases. After tract dilatation with telescopic metal dilators, pneumatic or ultrasound lithotripsy was used for fragmentation. RESULTS: Complete clearance was achieved in 79.5%. Ten patients (9.8%) had pleural violation in the form of hydrothorax, pneumothorax, or hydropneumothorax. All of these patients were managed successfully by intercostal chest tube drainage. CONCLUSION: Supracostal puncture in a safe and effective approach with acceptable morbidity in selected cases of staghorn, upper ureteral, and upper caliceal calculi.     

上尿路结石二次经皮肾镜取石术操作的原因探讨

目的:总结上尿路结石行二次(或二次以上)经皮肾镜取石术(PCNL)操作的原因,提高PCNL技能。方法:回顾性分析我院行PCNL治疗的1 041例上尿路结石患者的资料,对其中进行二次(或二次以上)PCNL操作的病例,根据其行二次PCNL操作的原因进行总结和分析。结果:1 041例上尿路结石患者(共1 203侧上尿路)中进行二次(或二次以上)PCNL操作的病例共252侧(20.9%),行二次PCNL操作的理由包括:结石负荷大、分布广182侧(72.2%);通道或肾集合系统黏膜出血29侧(11.5%);脓肾(感染)22侧(8.7%);孤立肾或肾功能不全7例(2.8%);集合系统穿孔3侧(1.2%);未发现或未能进入残留结石所在肾盏的盏颈口4侧(1.6%);通道建立失败以及不合理3侧(1.2%);麻醉意外等2例(0.79%)。二次PCNL操作时行局部麻醉204侧(81.0%),全麻48侧(19.0%);俯卧位221侧(87.7%),侧卧位31侧(12.3%)。1 203侧上尿路行一次PCNL操作的清石率为74.1%;行二次PCNL操作后的清石率为91.0%;252侧行二次PCNL操作的患者清石率为80.9%。1 203侧上尿路仅行一次PCNL操作的951侧上尿路患者的平均住院时间是10.8d,行二次PCNL操作的252侧上尿路患者的平均住院时间是13.4d。结论:结石负荷大、分布广,脓肾(感染)以及出血是上尿路结石行二次PCNL操作的主要原因。二次PCNL操作对于减轻第一次PCNL出血和感染的风险,提高清石率有很好的作用。但其增加患者的痛苦和住院时间。     

Upper-pole puncture in percutaneous nephrolithotomy: a retrospective review of treatment safety and efficacy

OBJECTIVE

To review the safety and efficacy of supracostal puncture during percutaneous nephrolithotomy (PCNL) for renal calculi.

PATIENTS AND METHODS

Over a 12‐year period, 66 patients had either an upper‐pole puncture alone or combined with middle‐ or lower‐pole puncture during PCNL for renal calculi. All punctures were made by an experienced uroradiologist and were either supra‐ or subcostal. We retrospectively reviewed all case notes and radiographs to determine stone‐clearance rates and complications associated with the site and number of punctures.

RESULTS

There was an overall stone‐free rate of 78% with upper‐pole puncture alone or combined with middle‐ or lower‐pole puncture. There was a 3% thoracic complication rate with upper pole punctures, and an overall complication rate of 30% for both thoracic and non‐thoracic complications.

CONCLUSION

Upper‐pole puncture in PCNL is associated with minimum morbidity if done by an experienced urologist or radiologist. The stone‐free rate appears to be more dependent on stone size and complexity than the site of puncture.     

肾上盏入路经皮肾镜取石术的疗效与安全性探讨

目的 评价经肾上盏入路行PCNL的疗效及安全性.方法 2007年10月至2009年10月行经肾上盏入路PCNL治疗肾结石患者42例.其中鹿角形结石10例,肾盂结石22例,肾上盏结石7例,下盏多发结石3例;合并输尿管上段结石4例,合并肾盂输尿管连接部狭窄(UPJO)2例;结石长径2.0～6.5 cm,平均3.4 cm.B超引导下选取肾上盏穿刺,穿刺点选在第10或11肋间,建立经皮肾通道(16～26 F).经皮肾镜或输尿管镜下气压弹道或钬激光碎石. 结果 42例均一期成功建立经皮肾通道并碎石.单通道取石36例(85.7%),双通道取石6例(14.3%).手术时间30～140 min,平均65 min.术后发热4例(9.5%),输血1例(2.4%),肾盂穿孔1例(2.4%).无气胸、血胸、腹腔脏器损伤.一期结石清除率88.1%(37/42),3例(7.1%)行二次肾镜取石,2例(4.8%)辅助体外冲击波碎石(ESWL)治疗. 结论经肾上盏入路PCNL活动范围大,对于部分复杂性肾结石碎石取石方便,是一种安全有效的方法.

Abstract：

Objective To evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL)guided by ultrasonography through upper pole access. Methods From October 2007 to October 2009, 42 patients with upper urinary tract calculi underwent PCNL through upper pole access.Among these cases, there were 10 cases of staghorn calculi, 22 cases of renal pelvis calculi, 7 cases of the upper calyx calculi, 3 cases of the lower calyx calculi, 4 cases combined with ureter calculi and 2 cases combined with ureteropelvic junction obstruction. The stone measured from 2.0 to 6.5 cm (average: 3.4 cm) in length. Working tunnels (F16-F26) were established through the 10th or llth intercostals. Pneumatic or holmium laser lithotripsy was used to disintegrate and remove stones by nephroscopy or ureteroscopy. Clinical data including operation time, complications and stone free rate were analyzed retrospectively. Results All the operations were completed in one session, single tract was used in 36 cases(85.7%), double tracts were used in the other 6 cases(14.3%). The stonefree rate after one session was 88.1% (37/42), 3 cases(7.1%) received a second-session PCNL, 2 cases (4.8%)underwent ESWL after operation. The mean operative time was 65 min(30- 140 min).Postoperative surgery-related infection rate was 9. 5% (4/42). One patient (2. 4%)required blood transfusion. Perforation of the pelvis occurred in 1 patient(2.4 %). No pleural or important organ injury occurred. Conclusion The upper pole access for PCNL can be convenient to remove stones,this method is a highly efficient and safe technique.     

一期输尿管软镜联合经皮肾镜治疗鹿角形结石合并脓肾的疗效和安全性

目的探讨一期输尿管软镜(FURS)联合经皮肾镜取石术(PCNL)治疗鹿角形结石合并脓肾的可行性、有效性和安全性。方法回顾性分析北京大学第三医院2017年5月至2019年12月采用一期FURS联合PCNL治疗的13例鹿角形结石合并脓肾患者的病例资料,男7例,女6例。年龄52.5(33~68)岁。临床表现为间断发热9例,腰部不适6例,肉眼血尿1例,2例无明显临床表现。8例合并糖尿病。CT检查示完全型鹿角形结石6例,部分型7例;结石位于左侧7例,右侧6例;4例伴中/重度肾积水,9例伴轻度肾积水。影像学检查评估结石负荷(1070.9±397.0)(507.4~1809.5)mm^2。13例术前均行尿细菌培养及药敏试验。4例住院时有发热症状者术前留置患侧输尿管支架管≥1周。所有病例术前应用抗菌药物≥1周,待感染症状及感染相关指标恢复正常后接受手术治疗。手术采用全麻,患者取改良Valdivia体位。先经尿道置入FURS到达患侧肾盂,B超及FURS引导下在患侧腋中线和肩胛旁线之间、12肋下建立经皮肾标准通道,单通道PCNL下采用负压吸引装置吸出脓液并处理视野范围内的结石,再联合FURS处理其他肾盏结石。术中PCNL穿刺成功后,均可见肾内浑浊脓性尿液排出,留取肾内尿液送检细菌培养及药敏试验。本组13例均经术中肾盂尿细菌培养结果确诊为脓肾。术后常规留置输尿管支架管和肾造瘘管,继续抗感染治疗。术后第1~3天行影像学检查,评估结石清除率,残留结石≥4 mm为有意义的结石残留。结果本组13例手术均顺利完成,手术时间(94.2±21.8)(65~135)min。一期结石清除率76.9%(10/13)。术后6例出现全身炎症反应综合征,无脓毒血症及≥Clavien-DindoⅢ级并发症发生。术后中位随访12(3~24)个月,4例患侧结石复发,2例患侧轻度肾萎缩,随访期间无患侧上尿路感染复发。结论FURS联合PCNL是治疗鹿角形结石合并脓肾的有效方法,具有良好的疗效和安全性。     

Percutaneous nephrolithotomy outcomes: Re‐audit in 2005

Aim: To evaluate the outcomes of percutaneous nephrolithotomy (PCNL) for upper urinary tract stones in 2005 in our hospital and to compare with the results obtained in 2000. Methods: The present study reviewed the outcomes of standardized PCNL, a one‐stage procedure under sedo‐analgesia, for upper urinary tract stones in 2000 and 2005 in Queen Elizabeth Hospital. In 2000, 74 PCNL were carried out using holmium laser, Swiss lithoclast or electrohydraulic lithotripsy (EHL) for stone fragmentation. Thirty to 40% of staghorn stones and 80–100% of complicated renal and upper ureteric stones achieved stone‐free clearance after single‐session PCNL. In 2005, 82 PCNL were performed after the introduction of three strategies, namely: multiple tract access, flexible nephroscopic exploration and the new‐generation ultrasonic lithotripter. The outcomes were evaluated and compared to those in 2000 according to the different categories of stones. Results: The results in 2005 were improved in terms of increased overall stone‐free rates (20% in single session and 5% after the final session), retreatment rate reduction (15%), and raised efficiency quotient (21.5), while the overall complication rate remained low (13.9%) compared to that in 2000. In 2005, in particular, the single‐session stone‐free rates of staghorn stones and renal pelvis stones were significantly improved to 70–80% (30–40% in 2000) and 100%, respectively (50–60% in 2000). Single‐session stone‐free rates for other stones remained at 90–100%. Conclusion: Our outcomes improvement could be attributed to the maturation of the PCNL technique, use of multiple tract access, use of flexible nephroscopy, and ultrasonic lithotripsy.     

Paediatric percutaneous nephrolithotomy: setting new frontiers

OBJECTIVE: To assess the safety and outcome of paediatric percutaneous nephrolithotomy (PCNL) for atypical cases and compare the results with 'standard' unilateral paediatric PCNL. PATIENTS AND METHODS: We retrospectively reviewed children who had had a PCNL between December 1997 and December 2004. Patients were grouped as follows: group 1, aged >5-16 years with normal anatomy and normal renal function undergoing unilateral PCNL or staged bilateral PCNL; group 2, < or = 5 years with normal anatomy and renal function undergoing unilateral PCNL; group 3, undergoing bilateral simultaneous PCNL; group 4, impaired renal function in addition to renal stone disease; group 5, renal anatomical abnormality with calculi in the same kidney. Demographics, stone profile, procedure and outcome indicators were analysed for each group. RESULTS: In all, 188 consecutive PCNLs in 169 children were included (mean age 3.3-10.3 years, mean stone burden 19.1-33.3 mm in the five groups). The mean duration of PCNL was 69-115 min. Stone clearance was satisfactory with single tract access in 90-100% of patients. Transient postoperative fever was the commonest complication (12.5-51%) followed by hyponatraemia and hypokalaemia. Blood transfusion was required in 0-7.7%. The mean stone clearance rates were 47-90% in the five groups; additional extracorporeal shockwave lithotripsy increased the cumulative clearance rates to 90-100%. CONCLUSION: PCNL is safe for treating renal stones, with excellent results and minimal complications. Comparable results are achieved in the very young child, children with anatomically abnormal kidneys, children with impaired renal function and children with bilateral renal stones undergoing simultaneous bilateral PCNL. Hence none of these factors should be considered as relative contraindications.     

Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches

BACKGROUND AND PURPOSE: The advantage of upper-pole access for nephrolithotomy is direct access to most of the intrarenal collecting system and upper ureter. Upper-pole access can be achieved either supracostally and subcostally. Because of the anatomic location of the kidneys, the supracostal approach is associated with a higher rate of pulmonary complications. We compared the efficacy and safety of the supracostal and infracostal upper-pole approaches. PATIENTS AND METHODS: A total 464 patients were treated with percutaneous nephrolithotomy (PCNL) via the upper pole, of which 170 punctures (group I) were performed supracostally and 294 (group II) subcostally. In both groups, PCNL was done by the standard technique with fluoroscopic guidance. The operative time, success rate, hospital stay, and complications in the two groups were compared. RESULTS: Patients were stone free in 82.2% and 77.1% of the cases in groups I and II, respectively, and had stone fragments <4 mm in 10.7% and 14.7%, respectively. The operative time, success rate, and septic and hemorrhagic complications were not significantly different in the two groups. Hydrothorax was found in 26 patients (15.3%) of group I and 4 (1.4%) of group II. Only 9 patients (5.3%) in group I needed intercostal drainage. CONCLUSION: Percutaneous nephrolithotomy via the upper pole is effective using both supracostal and infracostal approaches, with acceptable rates of complications. The rate of pulmonary complications is higher with the supracostal approach. If the supracostal approach is indicated, it should be used with caution.     

经皮肾镜取石术治疗鹿角形肾结石通道建立技巧的探讨

目的：探讨经皮肾镜取石术（PCNL）治疗鹿角形肾结石术中穿刺点、穿刺径路的合理选择及扩张、通道建立的技巧。方法：总结在X线定位下PCNL治疗36例鹿角形肾结石患者的经皮肾通道建立与治疗效果。结果：Ⅰ期手术穿刺、通道建立、成功碎石率100％;Ⅰ～Ⅲ期结石完全清除率83．33％;单通道26例（72．22％）,双通道7例（19．44％）,三通道3例（8．33％）;无大出血、感染休克等严重并发症发生。结论：PCNL治疗鹿角形肾结石的第一个穿刺点首选中后组盏,径路应与目标盏长径相吻合;带鞘扩张时扩张器应进入集合系统内约2cm,退出扩张器直接完成通道建立;Ⅰ期建立单通道处理。肾盂、中组肾盏结石为主,Ⅱ期先经Ⅰ期通道处理上下盏残留结石,慎重建立第二、三条经皮肾通道。     

标准通道与微通道经皮肾镜碎石取石术治疗肾结石的疗效分析(附视频)

目的 探讨标准通道经皮肾镜取石术(PCNL)与微通道经皮肾镜取石术(MPCNL)治疗肾结石的临床疗效及其优缺点.方法 回顾性分析323例肾结石患者,其中178例采用MPCNL,145例采用标准通道PCNL,对两组手术时间、一期手术成功率、结石清除率、手术并发症、肾功能、输血率、住院时间等指标进行比较分析.结果 两组患者分别成功建立了18 F和24 F肾穿刺通道并一期行碎石术.MPCNL组手术时间较PCNL组延长(P＜0.05),但肾盏多发性结石患者结石清除率高于标准通道PCNL组(P＜0.05),而单纯肾盂结石患者结石清除率则低于标准通道PCNL组(P＜0.05).两组鹿角型结石患者一期结石清除率比较无统计学意义(P＞0.05).两组术后手术并发症、肾功能、输血率、住院时间等均无显著性差异(P＞0.05).结论 MPCNL与标准通道PCNL均具有术中损伤小、住院时间短、结石清除率高、并发症低、对肾功能无明显影响等优点.标准通道PCNL较适合处理较大的肾盂结石,MPCNL较适合治疗肾盏多发结石,两者联合应用可提高鹿角型结石的治疗疗效.     

经皮肾镜取石术治疗肾脏感染性结石的疗效分析(附127例报告)

目的:评价经皮肾镜取石术(PCNL)治疗肾脏感染性结石的方法和疗效。方法:对我院2009年1月~2013年6月127例肾感染性结石患者行PCNL的临床资料进行回顾分析,男52例,女75例,结石直径为2~5cm,均为鹿角形或多发性结石。结果:在B超引导下穿刺建立F20~22通道,采用输尿管镜钬激光碎石,105例一次取净结石,平均手术时间为134min,10例结石残余直径1cm,1周后经原通道取石,12例结石残余直径1cm,选择联合体外冲击波碎石术(ESWL)治疗或药物排石治疗,总住院时间10~17d,平均为13d,1个月后复查KUB,116例未见明显结石残余,结石总清除率91.3%。22例患者术后出现发热,其中8例为寒颤高热(39.5℃),6例为低热(38.0℃),2例为菌血症,1例患者术后出现肾脏持续性出血行栓塞治疗,1例出现尿瘘,未出现脓毒血症、腹腔脏器损伤、腹腔积液、胸腔积液、气胸、肾动静脉瘘等严重并发症发生。结论:通过充分的术前准备,改进术中操作细节,有效的术后护理及抗感染治疗,认为PCNL采用输尿管镜钬激光碎石术具有结石排净率高、创伤小、恢复快、并发症少等优点,是治疗肾脏感染性结石的一种安全有效的方法。     

斜仰卧-截石位经皮肾镜取石术治疗复杂性肾结石

目的 探讨斜仰卧-截石位经皮肾镜取石术治疗复杂性肾结石的手术方法与安全性评价.方法 2007年3月至2011年12月为686例复杂性肾结石施行斜仰卧-截石位经皮肾镜取石术.男474例,女212例,年龄47.7±12.9岁.术中在斜仰卧-截石位下先行患侧输尿管逆行插管,然后超声定位下建立16-22 F的经皮肾工作通道.从经皮肾通道置入8/9.8 F输尿管镜,采用气压弹道碎石器在灌注泵配合下边冲洗边碎石.记录手术时间、出血量、结石取尽率、并发症等资料,与同期施行的340例俯卧经皮肾镜取石术的临床资料相比较.结果 斜仰卧-截石位经皮肾镜取石术均顺利实施,手术时间72.9±28.7 min,比俯卧位经皮肾镜取石术时间缩短;术中估计出血104.3±76.6 ml,输血率1.31％,结石取尽率80.6％,总体并发症发生率2.62％,与俯卧位组无统计学差异.97.7％的患者诉体位舒适,优于俯卧位组(64.1％).结论 斜仰卧-截石位施行经皮肾镜取石术治疗复杂性肾结石患者体位舒适,安全可行,并发症少;利于术中麻醉监护,提高了手术的安全性;便于术中碎石冲洗出体外,手术效果良好.     

以肾中盏为目标肾盏行气压弹道联合超声碎石治疗鹿角形结石的效果及安全性

目的：探讨以肾中盏为目标肾盏,采用气压弹道联合超声碎石方式治疗鹿角形结石的效果及安全性。方法：取俯卧位,采用气压弹道联合超声碎石的方式,以肾中盏为目标肾盏行经皮肾镜碎石术（percutaneous nephrolithotomy,PCNL）治疗鹿角形结石患者145例184侧,其中不完全性鹿角形结石115例侧,完全性鹿角形结石69例侧。观察结石的排除率及并发症。结果：144例侧行一期单通道碎石（中盏）,7例侧行一期双通道碎石（中盏及下盏5例,中盏及上盏2例）;2例侧残留肾盏结石未进一步处理,自动出院;31例侧行二期碎石,单通道者29例,其中4例先行ESWL再行PCNL碎石;双通道者2例（中盏及上盏1例,中盏及下盏1例）。151例侧排尽结石,其中完全性鹿角形结石54例侧,不完全性鹿角形结石97例侧,结石清除率82．1％。手术时间120～330min,平均（147±23）min。血红蛋白下降1～4g／L,平均下降（2．0±0．6）g／L,术中输血22例,术后输血5例;术后肾盂内感染3例,合并肾周感染、单侧分肾功能受损1例。平均住院时间（13．0±3．5）天。结论：以肾中盏为目标肾盏行PCNL治疗鹿角形结石是非常有效和安全的;气压弹道联合超声碎石对鹿角性结石的清除率较高,治疗时问短,并发症少。     

Outcome from percutaneous nephrolithotomy in patients with spinal cord injury, using a single-stage dilator for access

OBJECTIVE: To present our experience of percutaneous nephrolithotomy (PCNL) for treating urolithiasis in patients with spinal cord injury (SCI) using a single-stage dilator for percutaneous access. PATIENTS AND METHODS: A prospective database of patients with SCI having PCNL using the single-stage dilator was assessed, analysing patient data, stone-free rates, morbidity and the follow-up outcome. RESULTS: In all, 26 patients had 54 PCNLs on 32 kidneys; 20 had unilateral and six bilateral stone disease; there were many staghorn calculi (24/54). Major complications occurred in three of 54 PCNLs (6%). The complete stone-clearance rate was 87% for PCNL alone, rising to 29 of 32 kidneys (91%) or 24 of 26 patients (92%) with adjuvant procedures. A further three kidneys required no further treatment and were monitored, having residual fragments of < or = 2 mm. CONCLUSIONS: PCNL has a high success rate and acceptable complication rate compared to extracorporeal shock-wave lithotripsy, and remains a valid first-line treatment option for kidney stones in patients with SCI.