微创经皮肾取石术治疗独立肾结石

目的：探讨微创经皮肾取石术治疗孤立肾结石的临床疗效与手术技巧。方法：利用微创经皮肾取石术治疗孤立肾结石18例，14例患者行一期微创经皮肾取石．4例行经皮肾穿刺造瘘术，5～7天后行二期取石术。结果：结石清除15例（83．3％）。在结石残留的3例患者中，1例残留结石下移至输尿管下段，用输尿管镜将结行取出；余2例结石残留。肾内，未作进一步处理，本组患者术后肾功能基本恢复正常或好转。结论：微创经皮肾取石术治疗独立肾结石是一种安全、有效的方法。     

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。     

CT引导下经皮肾镜钦激光治疗肾及输尿管上段结石36例报告

目的:探讨CT引导下经皮肾穿刺钬激光治疗肾及输尿管上段结石的方法及效果.方法:回顾分析为36例肾及输尿管上段结石患者在CT引导下建立经皮肾通道行经皮肾镜碎石术的临床资料.结果:36例患者在CT引导下共建立肾造瘘通道49个,行经皮肾镜一期取石术36次,二期取石术12次.CT引导下建立皮肾通道时间为10～50 min,平均...     

腹腔镜联合经皮肾穿刺取石术治疗肾囊肿并肾多发性结石

目的 介绍腹腔镜联合经皮肾穿刺取石术治疗肾囊肿并肾多发性结石的技术要点和初步经验。 方法 选取20例肾囊肿并肾多发性结石患者行腹腔镜联合经皮肾穿刺取石术治疗肾囊肿并肾多发结石。结石最大4x3cm,最小1x0.5cm。先用腹腔镜行肾囊肿去顶术。然后根据术前CTA+CTU片制定手术方案和穿刺部位。在腹腔镜监视下行经皮肾穿刺,建立F18取石通道取石。 结果 20例患者均获得成功。结石全部取尽,手术效果满意。手术平均时间90min。没有出现出血、尿漏、肾盏颈撕裂和输尿管狭窄等严重并发症。术后平均住院时间5d。 结论 腹腔镜联合经皮肾穿刺取石术可以同时处理肾脏多种疾病。在处理肾盏内结石或肾盏颈细长,肾内型肾盂的患者较腹腔镜肾盂切开取石术容易操作,盏颈损伤小和结石清除率高。是腹腔镜肾盂切开取石术有益的补充和支持。     

微创经皮肾穿刺取石术治疗马蹄肾结石

目的：探讨微创经皮肾穿刺取石术治疗马蹄肾结石的可行性与效果。方法：回顾性分析在2001年3月～2004年5月期间接受微创经皮肾穿刺取石术治疗的10例马蹄肾结石患者的疗效及并发症。结果：在10例患者中,4例为双侧马蹄肾结石。本组结石一期清除率为80％（8／10）,2例需要二期取石。所有患者均为单通道取石,仅1例患者为上盏通道,其余患者均为中盏通道。平均手术时间110min,术中平均出血量115ml,平均住院天数17d,没有患者需要输血,没有大的并发症出现。结论：采用微创经皮肾穿刺取石术治疗马蹄肾结石是安全有效的。     

泌尿外科——肾脏、输尿管

20061540 微创经皮肾穿刺取石术治疗泌尿系结石19例临床分析／王玉杰…∥新疆医科大学学报．-2005，28（10）．-918-920 对19倒尿路结石患者采用在B超或X线引导下微创经皮肾穿刺取石术一期治疗，其中15例患者采用B超引导下定位手术，4例采用在X线引导下定位手术。结果：所有患者均成功建立经皮肾通道。一期结石清除率47．4％，平均手术时间30-240min，无严重并发症发生。结论：微创经皮肾穿刺取石术是安全、高效的上尿路结石治疗方法，对肾功能影响很小，对复杂结石尤其适用，微创穿刺建寺皮肾工作通道是碎石成功的关键技术。参9     

CT引导微造瘘经皮肾镜治疗无积水复杂性肾结石的研究

目的 探讨CT引导下经皮肾穿刺微造瘘治疗无积水复杂性肾结石的方法及效果.方法 回顾性分析12例无积水复杂性肾结石患者在CT引导下建立经皮肾通道行微创经皮肾镜碎石取石术.结果 该组16例次均成功建立理想的穿刺通道,无通道建立过程中的常见严重并发症发生,术后结石梗阻均获解除.结论 CT引导建立经皮肾通道行微创经皮肾镜取石术安全可行,对于无积水复杂性肾结石尤其具有优势.     

超声引导经皮肾穿刺的临床经验

目的 总结在经皮肾穿刺取石术(percutaneous nephrolithotomy,PCNL)中应用超声引导行经皮肾穿刺经验.方法 在实时B超引导下用18G穿刺针经皮肾穿刺至肾盏或肾盂43例,将穿刺针道扩张后建立皮肾工作通道,镜下完成对肾盂及输尿管上段结石的碎石和取石.结果 本组43例中,肾穿刺成功率100%.1例经皮肾穿刺后出血不止改开放手术,建立皮肾工作通道成功率97.7%(42/43).总的结石取净率为100%(42/42),其中38例一期取石成功,4例二期取石成功.无大出血及周围器官损伤.术后1个月B超或KUB未见结石残留.结论 超声引导经皮肾穿刺成功率高、创伤小、安全、可靠.正确使用超声引导经皮肾穿刺技术是保证能顺利建立皮肾工作通道、完成对上尿路结石PCNL的关键.     

多通道微创经皮肾穿刺取石术治疗复杂性肾结石

目的探讨多通道微创经皮肾穿刺取石术治疗复杂性肾结石的安全性和临床疗效。方法回顾性分析笔者所在医院2006年1月～2010年10月期间行多通道微创经皮肾穿刺取石术治疗复杂性肾结石20例患者的临床资料。先建立经皮肾取石通道,5～7d后再以F8/9.8输尿管硬镜采用气压弹道碎石,取出肾盂出口处及部分结石后,再建立第2或第3通道取出分散在各盏内的结石。术后观察患者结石清除率、手术前后血肌酐的变化、术后并发症。结果 20例患者共作经皮肾穿刺通道42条,其中双穿刺通道18例,三穿刺通道2例。共作32次取石,其中一次取石6例,二次取石21例,三次取石5例。全部病例肾盂及主要肾盏结石均被取出,8例患者全部取净,其余只有散在结石者术后作ESWL辅助治疗,大部分能陆续排出,结石清除率达80%。术后无严重并发症。结论多通道微创经皮肾穿刺取石术治疗复杂性肾结石安全性好临床疗效肯定。     

经皮肾穿刺取石术三种麻醉方法的比较

目的：探讨经皮肾穿刺取石术中三种麻醉方法的优缺点。方法：在581例经皮肾穿刺取石术中采用全身麻醉（全麻）62例,均为一期手术;椎管内阻滞麻醉（椎麻）442例,437例为一期手术,5例为二期手术;局部浸润麻醉（局麻）77例,32例为一期手术,45例为二期手术。结果：使用全麻者术中均较舒适,但术后有2例发生严重的呼吸障碍,胸腹腔引流出大量液体。椎麻者俯卧位手术时间较长,时有不同程度的不适感,22例主动要求停止手术,其中侧卧位患者则无明显不适感。局麻者手术时间短,均顺利完成手术。结论：在经皮肾穿刺取石术中,全麻没有比较性优势;在体位的配合下,椎麻可以满足所有患者;对于比较单纯的肾结石及第三腰椎以上的输尿管结石,局麻也能满意解决。随着结石体积的减小、技术的提高及碎石工具的改进,可以预见局麻下经皮肾镜取石术将会得到更广泛的应用。     

测量器和方向角度指示器在经皮肾穿刺取石术中的应用

目的:研究在无“人工肾积水”情况下,使用测量器和方向角度指示器进行无肾积水的肾结石的经皮肾穿刺取石术的可行性。方法:用C臂机水平和垂直位透视结石,用测量器准确测量穿刺点至结石背部投影点的水平距离和穿刺点至结石腰部投影点的垂直距离,并“计算”出穿刺的角度及深度。在方向角度指示器辅助下,进行穿刺扩张建立手术通道,用钬激光碎石。结果:29例患者成功建立35条手术通道,顺利完成手术,无一例失败。结论:在无“人工肾积水”情况下,无肾积水的肾结石在测量器和方向角度指示器辅助下,可以顺利进行经皮肾穿刺取石术。     

"十字定位法"建立手术通道在经皮肾穿刺取石术中的应用

目的探讨经皮肾穿取石术中通过简单精确的定位建立手术通道的方法。方法术中用C臂机垂直和水平透视,确定穿刺点与结石的水平和垂直距离,计算出进针的角度和深度,精确穿刺。结果86例患者的102条手术通道均一次快速穿刺成功,准确建立。结论“十字定位穿刺法”能确保经皮肾穿刺取石术中快速安全建立手术通道。     

经皮肾镜通道建立的临床研究

目的：总结经皮肾镜通道建立的经验、体会。方法：回顾性分析因结石住院行经皮肾镜碎石术的1200例患者临床资料,1200例均行经皮肾镜碎石术。结果：1192例患者均1次通道建立成功,另8例患者中2例择期2次穿刺成功、3例要求转院,另外3例在专家指导下穿刺成功,该8例患者均在开展该项目的早期阶段。结论：经皮肾镜是治疗上尿路结石的较好方法,具有创伤小、恢复快的优点,其关键是通道的建立,注重术中的经验体会及刻意的B超水平训练是成功建立通道的关键。     

侧卧位微创经皮肾镜碎石术治疗肾结石的临床应用价值

目的:探讨侧卧位在微创经皮肾镜手术中的临床应用价值.方法:回顾性分析2007年1～12月采用侧卧位微创经皮肾镜手术治疗肾结石患者56例的临床资料:单侧结石48例,双侧结石8例.肾单发结石38例,肾鹿角形结石18例.结石最大经2.4～6.7 cm.结果:平均手术时间85 min,平均住院12天.45例次单发肾结石手术中,38例次行单通道一期手术;7例次因术中发现肾积脓,留置造瘘管后改二期手术;19例次肾鹿角形结石均采用双通道取石,其中一期手术取石8例次,二期手术取石11例次.术前血红蛋白112±28 g/L,一期手术后1～3天检查血红蛋白为102.5±31.5 g/L.术后需用ESWL辅助治疗17例.总结石排净率为92.3%.结论:侧卧位是泌尿外科医生最熟悉的手术体位,也是进行微创经皮肾镜手术的理想手术体位,特别是B超定位穿刺技术的广泛应用,更应该推广使用侧卧位进行微创经皮肾镜手术.     

斜卧位与侧卧位超声引导微创经皮肾镜取石术的对比研究

目的 比较斜卧位与侧卧位超声引导微创经皮肾镜碎石取石术治疗肾及输尿管上段结石的安全性和疗效.方法 肾和(或)输尿管上段结石患者62例,随机分成2组,斜卧位组32例,侧卧位组30例,在超声引导下进行微创经皮肾镜碎石取石术,监测记录经皮肾工作通道数目、术中出血量、手术时间、结石清除率及术中患者舒适度等,并进行统计学分析.结果 术前斜卧位组与侧卧位组在性别、年龄、结石类型、术前的合并症方面均无统计学意义(P＞0.05).斜卧位组手术时间为105±24.6 min,而侧卧位为162±40.8 min,P＜0.05.术中出血量斜卧位组为106±35ml,而侧卧位为150±45 ml,P＜0.05.斜卧位组的结石清除率(95.6％)高于侧卧位组(90.8％),两组比较有统计学意义(P＜0.05).术中患者舒适度斜卧位组明显优于侧卧位组.结论 斜卧位经皮肾镜取石术在手术时间、术中出血量、结石清除率、患者术中舒适度等方面优于侧卧位,是可供选择的经皮肾镜取石术体位.     

Management of nephrolithiasis after Cohen cross-trigonal and Glenn-Anderson advancement ureteroneocystostomy

PURPOSE: Ureteroneocystotomy is frequently performed for ureteral injury or vesicoureteral reflux. The Glenn-Anderson technique advances the ureteral orifice distal to its native position, while the Cohen technique crosses the orifice to the opposite trigone. Each treatment can alter access to the upper genitourinary tracts. We report our experience with subsequent nephrolithiasis in these patients. MATERIALS AND METHODS: We performed a retrospective chart review of all patients treated with ureteroneocystotomy since 1980 who had nephrolithiasis. RESULTS: Nephrolithiasis developed in 9 patients with prior Cohen ureteroneocystotomy and in 15 with prior Glenn-Anderson ureteroneocystotomy. Stones size was 2 to 20 mm (mean 6.4). In the Cohen group ureteroscopy was attempted and failed in 2 patients, requiring percutaneous nephrolithotomy. Attempted shock wave lithotripsy failed in 2 patients, of whom 1 required percutaneous nephrolithotomy and 1 required observation. Primary percutaneous nephrolithotomy was performed in 1 patient. One patient required nephrectomy for chronic pyelonephritis related to nephrolithiasis. Two patients had active stone disease and were awaiting further treatment, while 1 passed the stone. In the Glenn-Anderson group ureteroscopy was successful in all 4 attempts. Attempted shock wave lithotripsy in 2 patients was successful in 1. The other patient required subsequent percutaneous nephrolithotomy. Primary percutaneous nephrolithotomy was required in 2 patients. All other patients were asymptomatic and under observation. CONCLUSIONS: Treatment for upper tract nephrolithiasis is effected by prior ureteroneocystotomy. Minimally invasive treatments were less successful after Cohen ureteroneocystotomy than after Glenn-Anderson ureteroneocystotomy. In this study patients with prior cross-trigonal ureteroneocystotomy required more invasive therapies for symptomatic nephrolithiasis.     

Valdivia supine position as the best option for percutaneous surgery of renal calculi in morbidly obese patients

IntroductionTreatment of the morbidly obese patient with symptomatic renal calculi is an interesting urological challenge. Extracorporeal shock wave lithotripsy is frequently not possible for several reasons, and many urological centers match these patients as one of the residual indications for open surgery of kidney lithiasis.Material and methodTwo patients with body mass index more than 50 k/m2 and symptomatic kidney stones were treated with percutaneous nephrolithotomy in the supine position described by Valdivia (slightly lateralized supine decubitus). Standard instrumentation for percutaneous surgery and the semi-rigid ureteroscopy were used, through an Amplatz sheath proximally transfixed with a polypropylene stitch, so to avoid its lost under the fatty skin. Both patients were rendered stone-free without significant morbidity.DiscussionThe advantages of Valdivia position in those patients are clear, both for the commodity of the surgical team, -because time may be spared and help needed to mobilized the patient is less-, as well as for what concerns to the anesthesia, because cardio-respiratory restrictions created by a general anesthesia in prone are greater and more severe in the obese patient. This position seems to be more suitable than other ones recommended for percutaneous nephrolithotomy in the obese patients, such as prone decubitus on a surgical saddle, or lateral decubitus position, that may compromise the radiological control of the operation.     

斜仰半截石位顺行与逆行微创治疗输尿管结石

目的:探讨斜仰半截石位顺行微创经皮肾镜取石术(mPCNL)与逆行输尿管镜共同治疗输尿管多发结石的可行性、疗效与安全性。方法:分析2010年8月～2011年7月采用B超引导行mPCNL与输尿管镜结合同时治疗输尿管多发结石患者10例的临床资料。结果:10例均获得良好疗效,B超引导穿刺全部成功,mPCNL与输尿管镜同时处理输尿管多发结石,无严重并发症发生。结论:斜仰半截石位顺行微创经皮肾镜取石术与逆行输尿管镜共同治疗输尿管多发结石手术创伤小,疗效满意,值得在临床推广应用。     

Low-dose bupivacaine spinal anaesthesia for percutaneous nephrolithotomy: the suitability and impact of adding intrathecal fentanyl

BACKGROUND: Unilateral spinal anaesthesia has been used for lower limb surgery with a stable cardiovascular state and a short recovery unit stay. We sought to test the suitability of low-dose bupivacaine spinal anaesthesia for percutaneous nephrolithotomy, a procedure hitherto performed under general anaesthesia. Furthermore, we hypothesized that adding intrathecal fentanyl to bupivacaine may improve the quality of anaesthesia. METHODS: We randomly allocated, through computer-generated randomization, 108 patients subjected to percutaneous nephrolithotomy to receive either 7.5 mg of hyperbaric bupivacaine 5 mg/ml alone or with the addition of 10 microg of fentanyl. Drugs were given at the L(2)-L(3) interspace with the patient in the lateral decubitus position. The patients remained in this position for 10 min, after which the sensory and motor blocks were assessed. Intra-operative analgesic supplementation, when deemed necessary, was achieved with intravenous fentanyl boluses (25 microg). RESULTS: The sensory and motor blocks after intrathecal bupivacaine and bupivacaine-fentanyl were similar. Sensory block, in both groups, reached the fifth and eighth thoracic dermatomes on the operative and non-operative sides, respectively. Deep motor block occurred on the operative side in all patients and in nearly 50% of patients on the non-operative side. The patients in the bupivacaine-fentanyl group required less intra-operative and post-operative analgesics, and both patients and endoscopists were better satisfied. CONCLUSION: This study demonstrated, for the first time, that intrathecal low-dose bupivacaine and fentanyl offers a reliable neuraxial block for patients subjected to percutaneous nephrolithotomy, with stable haemodynamics, good post-operative analgesia and acceptable patient and endoscopist satisfaction.     

微创经皮肾镜气压弹道碎石术治疗上尿路结石(附706例报告)

目的:探讨与评价微创经皮肾镜气压弹道碎石治疗肾脏与输尿管上段结石的方法与疗效。方法:采用微创经皮肾镜下气压弹道碎石上尿路结石706例。结果:1999年9月～2005年8月,采用Ⅰ期、Ⅱ期或分步微创经皮肾镜手术成功处理706例上尿路结石,其中包括鹿角形结石、多发性肾结石、ESWL治疗失败、孤立肾结石、开放取石手术后复发、输尿管上段结石,肾结石清除率91.6%,输尿管结石清除率98.4%;随访1～12个月,无严重手术并发症发生。结论:微创经皮肾镜气压弹道碎石术治疗上尿路结石具有微创损伤、恢复快、并发症少、安全高效、结石清除率高的优点。