双肾结石俯卧与仰卧位经皮肾镜术的对比研究

目的：探讨俯卧位与仰卧位采取经皮肾镜取石术（percutaneous nephrolithotomy,PCNL）的安全性和疗效比较。方法：对9例双肾结石患者,分别分期行采用B超引导一侧俯卧和另一侧仰卧位PCNL。结果：9例患者18侧肾全部取石成功,其中3例5侧肾行二期取石。俯卧和仰卧位的手术时间、术后住院时间及一次清石率分别为（108．2土45．6）min,（116．5±31．2）min;（5．6±1．8）天,（5．8±1．5）天;66．7％（6／9）,77．8％（7／9）。术中血气均无显著变化,未出现严重手术并发症。俯卧位时恶心、呕吐者8例,呼吸困难4例,肩痛5例,术中因不适药物干预7例,其中2例因不能耐受终止手术2例;仰卧位肩痛2例,未出现药物干预和因不能耐受终止手术。结论：PCNL仰卧位较俯卧位患者耐受性好、痛苦小,而两者疗效无差异,是更好的PCNL治疗体位的选择。     

高危及肥胖患者经皮肾镜碎石术采用腰肋悬空仰卧位效果观察

目的 提高高危及肥胖肾结石患者经皮肾镜碎石术(PCNL)的安全性.方法 将40例行PCNL的高危及肥胖患者随机分成观察组和对照组各20例.对照组取传统的俯卧位;观察组取腰肋悬空仰卧位,即于患侧肩部、臀部分别用3L水袋或气囊垫高14～18 cm,使患侧腰肋部悬空.结果 观察组PCNL耐受性显著好于对照组(P＜0.01);...     

Minimally invasive percutaneous nephrolithotomy with multiple mini tracts in a single session in treating staghorn calculi

There has been continuing controversy regarding multiple tracts in a percutaneous nephrolithotomy (PCNL) session that may bring more complications, especially severe bleeding need for transfusion, even nephrectomy. Little tracts may bring less trauma to renal parenchyma than standard PCNL tracts. We carried minimally invasive PCNL (MPCNL) in treating staghorn calculi with multiple 16Fr percutaneous tracts in a single session, in an attempt to get high stone free with little trauma, and compared the morbidity of standard PCNL procedures in a prospective trial. A total of 54 consecutive patients with staghorn calculi were prospectively randomized for MPCNL (29) and PCNL (25). The size and location of stone, operative parameters, number of tracts, stone-free rate, operating time, hospital stay and complications were analyzed. In MPCNL group, a total of 67 percutaneous tracts were established in 29 renal units, while 28 tracts in 25 renal units in PCNL group. Compared to PCNL, MPCNL was associated with higher clearance rate (89.7 vs. 68%, p = 0.049), less chance need for adjunctive procedure of SWL or second-look PCNL (24.1 vs. 60%, p = 0.007), while a similar complication rate (37.9 vs. 52%, p = 0.300). In conclusion, with the development of instruments and increased experience, judiciously made multiple percutaneous tracts in a single session of MPCNL for treating staghorn calculi were safe, feasible and efficient with an acceptable morbidity.     

Kidney displacement in complete supine PCNL is lower than prone PCNL

To compare the amount of the kidney displacement in the complete supine percutaneous nephrolithotripsy (PCNL) to the prone PCNL during getting renal access. Thirty-three patients were randomly divided into two groups. The patients in group A were placed in the complete supine position and the patients in group B in the prone position. Amounts of the kidney displacement in three states and other data were analyzed. The mean amount of the kidney displacement in the complete supine PCNL was 10.1 ± 7.9 mm in stage 1, 10.7 ± 8.28 mm in stage 2 and 12.2 ± 10.4 mm in stage 3. The mean amount of the kidney displacement in prone PCNL was 16.6 ± 5.8 mm in stage 1, 16.2 ± 6.3 mm in stage 2 and 17.6 ± 6.7 mm in stage 3. In stages 1 and 2, a significant difference between the two groups derived from the mean amount of the kidney displacement, but the difference was not statistically significant in stage 3. Adjusted for age, gender, BMI, stone burden and position of PCNL, prone position was a predictor caused significantly more displacement in all three stages. Among other predictors, only BMI had a significant effect on the amount of the kidney displacement (in stages 2 and 3). Performing PCNL in the complete supine position is safe and effective and leads to less kidney displacement during getting renal access and therefore, it may be considered in most patients requiring PCNL.     

A study on comparative outcomes of percutaneous nephrolithotomy in prone, supine, and flank positions

Purpose

To compare percutaneous nephrolithotomy (PCNL) safety and efficacy in prone, supine, and flank positions.

Methods

A total number of 150 candidates for PCNL were randomly assigned into prone, supine, and flank groups. Patients in groups 1 and 2 underwent fluoroscopy-guided PCNL in prone and supine positions, respectively, while patients in group 3 underwent ultrasonography-guided PCNL in lateral position.

Results

The success rates were 92, 86, and 88 % in prone, supine, and flank positions, respectively (P = 0.7). The mean access duration was 6.9 ± 4.2, 11.1 ± 5.8, and 10.8 ± 4.1 min (P = 0.08), and the mean operation time was 68.7 ± 37.4, 54.2 ± 25.1 and 74.4 ± 26.9 min (P = 0.04) in prone, supine, and flank groups, respectively. Pyelocaliceal perforation occurred in 2 (4 %), 2 (4 %), and 3 (6 %) patients in prone, supine, and flank positions, respectively (P = 1).

Conclusion

We believe that PCNL in both supine and flank positions are as safe and relatively effective as prone position in experienced hands. Preference of the surgeon and proper case selection for each procedure is very important and necessary.     

PCNL在融合肾、异位肾、旋转不良、萎缩肾、肾盂肾盏畸形等异常肾结石中的应用

目的:探讨经皮肾镜取石术(PCNL)治疗融合肾、异位肾、旋转不良、萎缩肾和肾盂肾盏畸形等异常肾脏中的复杂结石的临床效果。方法:回顾性分析2015年至2019年在汉川市人民医院行PCNL治疗的48例肾结石患者的临床资料。其中,14例存在肾脏旋转不良,12例有重复肾盂伴有完全或不完全性重复输尿管,10例为马蹄肾,8例单侧肾...     

Multi-tract percutaneous nephrolithotomy for large complete staghorn calculi

INTRODUCTION: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2-3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm(2)) complete staghorn calculi. PATIENTS AND METHODS: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. RESULTS: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089-6,012 (mean 4,800) mm(2). 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5-5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). CONCLUSION: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.     

Percutaneous nephroscopic with holmium laser and ultrasound lithotripsy for complicated renal calculi

The aim of this work is to validate the clinical efficacy of the high-power holmium:YAG laser with percutaneous nephrolithotripsy (PCNL) in combination with ultrasound lithotripsy for complicated renal calculi. From November 2006 to December 2007, 60 patients with complicated renal calculi were treated with PCNL, where an F24 standard renal access tract was established by percutaneous renal puncture under the guidance of B-mode ultrasound, and stones were fragmented and cleared by high-power holmium laser in combination with ultrasound under an F20.8 nephroscope. Of the 60 patients with complicated renal calculi, 20 were complete staghorn calculi and 30 were partial staghorn calculi, of which six patients were accompanied with renal insufficiency; two were solitary calculi, and eight were caliceal diverticular calculi. Calculi were removed by one attempt in 49 patients and by two attempts in 11 patients; through one tract in 50 patients and through two and three tracts in ten patients. The stone-free rate was 81.7%. No injury to the pleura and abdominal organs occurred during the intraoperative puncture. No postoperative blood transfusion was needed in any patient, nor did fever and secondary hemorrhage occur. The mean operation duration was 98 min (range, 60–150 min), and the mean lithotripsy time was 45 min (range, 30–85 min). Additional postoperative extracorporeal shock wave lithotripsy (ESWL) was performed on six patients. High-power holmium laser PCNL in combination with ultrasound lithotripsy is safe, effective, and minimally invasive, with a high stone-free rate, especially for complicated renal calculi.     

Posición óptima para la nefrolitotomía percutánea en el riñón en herradura: ¿prono tradicional o supino?

ObjectiveAlthough it was stated that supine percutaneous nephrolithotomy (PCNL) was associated with relatively shorter surgical times and comparable success and complication rates, there is no consensus in the current literature concerning the safety and efficacy of supine PCNL in patients with horseshoe kidneys. We aimed to compare supine and prone PCNL regarding safety and efficacy in patients with horseshoe kidneys.MethodsData of the patients with horseshoe kidneys who underwent PCNL for renal stones larger than 2 cm between January 2010 and May 2021 were retrospectively reviewed. The study patients were categorized as Group 1 (i.e., supine PCNL-SPCNL) and Group 2 (i.e., prone PCNL-PPCNL). Both groups were compared regarding demographic, clinical, and surgical data.ResultsSixty-five patients were included. Among these patients, 31 (47.7%) were in Group 1, while 34 (52.3%) were in Group 2. Both groups were statistically similar in terms of demographic data, stone characteristics, perioperative parameters, and complication rates (P > .05). There was no statistical difference in terms of additional treatment rates, stone-free rates in the postoperative second-day and third-month evaluations (P > .05). Mean surgical time was significantly longer in Group 2 (113 ± 17.1 minutes) than in Group 1 (90.6 ± 11.3 minutes) (P = .000).ConclusionAlthough it is traditionally performed in the prone position, the supine approach is as safe and effective as the prone approach. In addition, the supine approach is associated with significantly shorter surgical times.     

Endoscopic combined intrarenal surgery in prone split-leg and inclined supine positions to treat renal cast and multiple calyx stones: An invited commentary

This Invited Commentary discusses the following article:Mulay A, Mane D, Mhaske S, Shah AS, Krishnappa D, Sabale V. Supine versus prone percutaneous nephrolithotomy for renal calculi: Our experience. Curr Urol 2022;16 (1):25-29. doi: 10.1097/CU9.0000000000000076.

Urolithiasis is a common disease encountered in urology. Its incidence is 0.1%-14.8% in Western countries and 5.94%-9.15% in China, with a significantly higher incidence in South China than in North China. In some areas of South China, the incidence of calculi exceeds 20%.^[1] Currently, percutaneous nephrolithotomy (PCNL) is the preferred treatment option for patients with multiple complex, renal cast, and multiple calyx stones.^[2] Complex multiple stones are associated with a lower stone clearance rate and a higher complication rate.^[3] Multichannel lithotripsy and endoscopic combined intrarenal surgery (ECIRS) in prone split-leg and inclined supine positions can improve the stone clearance rate.^[4] The 2016 American Urological Association guidelines established multi-channel PCNL as a safe and effective treatment for complex stones. In a previous study, the stone-free rate in a single operation was 79%, but the size and number of channels increased, followed by an increased risk of bleeding.^[5]In the article “Supine versus prone percutaneous nephrolithotomy for renal calculi—Our experience,” Mulay et al. evaluated the efficacy and safety of PCNL in modified supine and prone positions and showed that PCNL and ECIRS can be performed simultaneously in the supine position. In 1992, Ibarluzea et al. introduced ECIRS in the modified supine position.^[6] With the improvement and development of various urological surgical techniques and instruments, retrograde intrarenal surgery (RIRS) is no longer just an adjunctive or alternative surgery but an important part of clinical treatment. Better clinical outcomes and minimization of surgery-related complications can be achieved by combining RIRS with PCNL. A systematic review of 14 ECIRS cases showed that ECIRS had a stone-free rate of 61%-97%, a complication rate of 5.8%-42%, and a reduced risk of bleeding. Moreover, the bleeding risk was not correlated with the PCNL puncture channel size.^[7] Modified supine ECIRS has the following advantages over multichannel PCNL:

1. No position adjustment is required after anesthesia.
2. Direct vision puncture can be performed, and the puncture needle and dilator can enter the collecting system without being too deep under the direct vision of the transurethral ureteroscope, ensuring the safety and effectiveness of the puncture and reducing the incidence of complications when the channel is established.
3. The first choice for percutaneous renal puncture in ECIRS is the inferior calyx approach, and flexible ureteroscopy is performed to treat stones in the middle and upper calyces, which are relatively easy to access. Simultaneously, the advantages of flexible ureteroscopy for exploration include treating parallel calyx stones. For lower parallel calyx stones, the stone basket under the flexible scope can be used to move the stone to a position that can be treated with nephroscopy, after which the stone can be crushed and extracted.
4. Stone fragments entering the ureter can be treated without position adjustment, thereby reducing the rate of reoperation.
5. Combined PCNL and RIRS can treat ureteral and kidney stones simultaneously.
6. The stone clearance rate improves without increasing the risk of bleeding.
7. Combined with ureteral twisting and stenosis, it is difficult to insert the double J stent tube from the PCNL channel after lithotripsy. The double J stent tube can be placed retrogradely through the urethra using the ECIRS without position adjustment.

ECIRS can also be performed in the prone split-leg position, which has several advantages compared to the modified supine position as follows:

1. The prone split-leg position fully exposes the percutaneous renal puncture area of the affected kidney at the waist.
2. This position is simpler than the modified supine position and effectively reduces the workload of medical staff.
3. The peripheral organs, such as the intestines, are lowered by gravity, reducing the risk of organ damage.
4. The intrarenal perfusion effect is better in the prone position; therefore, the operative field of view is unaffected.
5. The modified supine position typically has a longer PCNL tract, particularly in patients with obesity, with decreased nephroscopic mobility and greater renal parenchymal mobility; thus, the bleeding risk is high, and extra-long devices should be provided.

However, the prone split-leg or inclined supine position is not significantly superior in terms of urological parameters, such as the stone clearance or complication rate.^[8]PCNL technology has evolved mainly owing to improvements in puncture technology, endoscopic instruments, lithotripsy devices, and drainage management. The introduction of the split-leg prone and improved supine positions is also part of the development. The development of ECIRS reflects the individualized management of patients with stones. ECIRS in split prone and modified supine positions is associated with a higher stone clearance rate, less blood loss, shorter operative time, and reduced perioperative complications when treating renal cast and multiple calyx stones. This is a new, safe, and effective procedure for PCNL.     

侧卧位B超引导经皮肾镜取石术治疗复杂性肾结石

目的 评价侧卧位B超引导下经皮肾镜取石术(PCNL)治疗复杂性肾结石的疗效及安全性. 方法 复杂性肾结石患者650例.男512例,女138例.平均年龄38(11～78)岁.结石位于左肾366例,右肾284例.单发121例,多发42例,部分鹿角形结石392例,全鹿角形结石95例.肾结石平均长径31(20～58)mm.均行侧卧位B超引导下PCNL治疗. 结果 650例手术顺利.B超引导下穿刺均成功,Ⅰ期微通道气压弹道碎石术493例,标准通道气压弹道和(或)超声联合碎石清石术157例.Ⅰ期结石取净563例(86.6 0%),Ⅱ期取净65例(10.0%),Ⅲ期取净6例,有残余结石者16例联合使用ESWL治疗.Ⅰ期PCNL平均手术时间72(35～145)min.未发生气胸、结肠损伤、肾盂穿孔、水中毒、肾周感染等合并症.平均住院时间18(9～32)d. 结论 侧卧位B超引导下PCNL治疗复杂性肾结石安全有效,患者耐受性好,便于麻醉管理,医护人员和患者避免x线辐射损伤,是一种值得推荐的微创治疗方法.     

斜仰卧位经皮肾镜治疗上尿路结石

目的探讨斜仰卧位经皮肾取石术（PCNL）治疗上尿路结石的安全性和有效性。方法2004年6月至2008年6月，采用斜仰卧位PCNL治疗上尿路结石126例，其中肾结石77例，输尿管上段结石合并肾盏结石15例，单纯输尿管上段结石34例。患者取斜仰卧位，垫高患侧肩和臀部使身体倾斜30°～45°。超声引导经腋后线12肋下或11肋间穿刺肾脏建立通道。采用气压弹道碎石行一次或分次清除结石。结果126例患者共接受141次PCNL治疗。49例输尿管上段结石和62例肾结石一期PCNL清除结石，一次碎石成功率为88．1％。15例复杂性肾结石因残石需行二期PCNL。平均手术时间为（117±24）min。11例患者因术中或术后大出血需输血治疗，输血率8．7％。无肠道或胸膜损伤并发症发生。结论采用斜仰卧位PCNL治疗上尿路结石安全有效、操作方便，可明显提高患者手术耐受性，值得临床推广应用。     

斜仰截石位下经皮肾镜取石术的临床研究

目的 研究斜仰截石位经皮肾镜取石术( percutaneous nephrolithotomy,PCNL)治疗肾和输尿管上段结石的临床价值. 方法 采用斜仰截石位行PCNL治疗肾输尿管结石患者68例,其中肾结石28例,输尿管上段结石40例.结石最大径平均(2.1 ±1.6) cm. 结果 本组68例患者均手术成功,无一例中转开放手术.采用单通道64例,双通道4例.平均手术时间(88.0 ±36.5) min,术中平均出血量(150.0±70.5) ml.一次性结石清除率为89.7％(61/68),残留结石7例,其中4例二期手术取尽结石,3例行ESWL治疗.术后严重出血3例,行输血治疗;高热2例,予敏感抗生素治疗后痊愈.无胸膜、结肠等腹腔脏器损伤等并发症发生. 结论 斜仰截石位行PCNL术治疗肾输尿管结石安全有效,患者耐受性好.     

斜卧-截石位和俯卧位经皮肾镜碎石术治疗巨大肾结石的疗效比较

【摘要】 目的 对比斜卧-截石位与俯卧位经皮肾镜碎石术治疗巨大肾结石的临床疗效。方法 对2011年3月~2013年3月在阳春市人民医院施行斜卧-截石位(A组)和俯卧位(B组)经皮肾镜碎石术治疗巨大肾结石的84例患者临床资料进行回顾性分析,比较两组的手术时间、术中出血量、并发症和一期结石取净率等资料。结果 84例手术均获成功,无中转开放手术。斜卧-截石位组采用单通道47例,采用双通道1例。俯卧位组36例均采用单通道。手术时间俯卧位组(B组)(168.2±31.4)min,斜卧-截石位组 (126.4±26.4) min,较俯卧位组缩短;出血量俯卧位组(B组)(140.3±52.2)mL,斜卧-截石位组(130.8±55.1)mL;一期结石取净率斜卧-截石位组88.3%,俯卧位组81.2%;俯卧位组术后1例出现继发岀血,经保守治疗后好转;两组术中均无严重并发症发生。结论 斜卧-截石位与俯卧位施行PCNL治疗肾结石的效果相似,但前者在手术时间上明显较后者短,尤其适合合并有输尿管结石患者,并且使患者术中较为舒适,便于术中麻醉观察和术中碎石冲出体外。     

Is the supine position superior to the prone position for percutaneous nephrolithotomy (PCNL)?

The objective of this study is to update the two previous meta-analyses in order to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) for patients in the prone position versus supine position. An electronic database search of MEDLINE, EMBASE, google scholar, and the Cochrane library was performed up to June, 2013. All studies comparing prone with supine position for PCNL were included. The outcome measures were stone-free rate, operative time, complication and hospital stay. Two randomized controlled trials (RCTs) and 7 non-RCTs, including 6,413 patients (4,956 patients in the prone position group and 1,457 patients in the supine position group), met the inclusion criteria. Meta-analysis of extractable data showed that PCNL in the supine position was associated with a significantly shorter operative time (WMD: 21.7; 95 % CI 2.46–40.94; p = 0.03) but lower stone-free rate (OR: 1.36; 95 % CI 1.19–1.56; p < 0.0001) than PCNL in the prone position. There was no difference between the two positions regarding hospital stay (WMD = 0.05; 95 % CI ?0.16–0.25; p = 0.66) and complication rate (OR: 1.1; 95 % CI 0.94–1.28; p = 0.24). In conclusion, the present study found different results from the two previous meta-analyses results regarding stone-free rate; PCNL in the supine position had a significantly lower stone-free rate than that in prone position.     

X-ray-free percutaneous nephrolithotomy in supine position with ultrasound guidance

Purpose  

Supine percutaneous nephrolithotomy (PCNL) has numerous benefits compared to the prone position, including lower anesthesia risk, shorter operating time, and better ergonomic position for the surgeon. It is also comparable to prone position regarding vascular and bowel injuries. This study was conducted to add some more benefits by omitting X-ray in PCNL in a supine position.     

斜仰截石位微创经皮肾镜联合输尿管镜治疗肾及输尿管结石的临床探讨

目的探讨斜仰截石位微创经皮肾镜或联合输尿管镜取石术治疗肾及输尿管结石的临床疗效。方法2015年10月至2018年10月我院收治48例同侧肾及输尿管结石患者,根据手术方式不同分为Ⅰ组与Ⅱ组,Ⅰ组患者(n=24)采取斜仰截石位微创经皮肾镜碎石取石术(MPCNL)联合输尿管镜碎石取石术(URSL)治疗,Ⅱ组患者(n=24)采取俯卧位MPCNL进行治疗,回顾性对比两组患者的治疗效果。结果两组患者手术时间、术中出血量、并发症发生率比较差异具有统计学意义(P<0.05);两组患者肾结石取石率、输尿管结石取石率、输血率比较差异无统计学意义(P>0.05)。两组患者心率(HR)、心输出量(CO)、每搏输出量(SV)、外周血管阻力(SVR)等指标比较差异无统计学意义(P>0.05),两组患者中心静脉压(CVP)及胸腔液体含量(TFC)指标变化比较差异有统计学意义(P<0.05)。结论斜仰截石位MPCNL联合URL治疗肾及输尿管结石具有一种体位即可同时微创处理肾及输尿管结石,安全性高、手术时间短、术中出血量少、术后并发症少等优势。     

局麻下经皮肾镜取石术治疗上尿路结石1363例报告

目的 探讨局麻下经皮肾镜取石术(PCNL)的可行性及安全性.方法 局麻B超引导下行PCNL 1363例,其中复杂性肾结石475例,肾盂结石520例,输尿管上段结石368例.采用1%～2%盐酸利多卡因10～20 ml自穿刺点皮肤开始沿穿刺方向行浸润麻醉,深达肾筋膜区域.术中采用"0～10"疼痛强度量表评估疼痛程度.结果 1363例均一次穿刺成功并行一期PCNL,其中5通道2例,4通道4例,3通道9例,2通道25例,单通道碎石1323例.肾盂结石取净500例(96.2%),输尿管上段结石均取净(100.0%),复杂性肾结石取净428例(90.1%).疼痛评分0～3分者818例(60.0%),4～6分者409例(30.0%),7～9分者136例(10.0%).10%疼痛评分≥7分者局部予1%～2%盐酸利多卡因5～10 ml或盐酸哌替啶50～75 mg肌肉注射后缓解,无一例因疼痛难以忍受而变动体位或停止手术者,术中未发生肝、脾、胸腔、肠管损伤等严重并发症.结论 局麻B超引导下行PCNL术简单安全有效,值得临床推广运用.

Abstract：

Objective To discuss the feasibility of percutaneous nephrolithotomy (PCNL) for treating upper urinary calculi under local anesthesia.Methods One thousand three hundred and sixty-three patients who suffered with upper urinary calculi were treated with PCNL, the puncture and tracts were created using local anesthesia and guided through ultrasound.Of the 1363 patients, 475 patients had complicated renal caluli, 520 patients had kidney pelvic calculi and 368 had upper uretere calculi.Results All of the patients successfully received PCNL under the local anesthesia.Of the 1363 patients five tracts were used in two patients, four tracts were used in four patients, three tracts were used in nine patients, double tracts were used in 25 patents and one tract was used in the remaining patients.The stone-free rate was 96.0% in the kidney pelvic calculi patients, 100.0% in the upper uretere calculi patients, and 90.1% in the complicated renal caluli patients.90.0% patients were find well throught the operation, 10.0% patients find a little pain and solved by another more 5 - 10 ml lidocaine local injection or 50 - 75 mg pethidine hydrochloride intramuscular injection.No case stop operation because of pain or position changed.All without any severe complications such as damaged of liver, spleen, thorax and intestine.Conclusion The PCNL handled under local anesthesia was simple safe and effective, deserved clinical popularizing use.     

Análisis de los factores que influyen en la pérdida hemática en la nefrolitotomía percutánea: registro de la Asociación Española de Urología sobre la posición supina

ObjectivePercutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for removing renal stones larger than 2 cm. This study has aimed to identify the different variables that might influence decrease of hemoglobin during the surgery performed in supine position.Material and methodsA prospective, multicenter, observational study of supine PCNL, based on the Spanish Association of Urology database, was analyzed. The different preoperative and postoperative factors that might affect the decrease of hemoglobin were assessed: demographics and anthropometric data, comorbidities, size and location of the stones, anatomical variants and technical aspects of the procedure.ResultsFrom September 2008 to December 2012, 397 supine PCNL procedures performed in 15 Spanish centers were registered. Mean hemoglobin decrease was 2.3 ± 1.5 g/dl and overall blood transfusion rate was 5.5%. No statistically significant differences were found between genders, body mass index (BMI) and age in terms of blood loss. There were also no differences between patients with cardiovascular, hypertensive, diabetic and anticoagulant treatment background. Blood loss was not significantly influenced by stone size and location. Technical aspects of the procedure as operative time (> 120 min ≤), access to the pelvi-caliceal system (ultrasound, fluoroscopy), percutaneous tract dilation technique (Alken, balloon or Amplatz) or placement of nephrostomy (tube versus tubeless) were not associated with differences in pre-op/post-op hemoglobin. Only multiple percutaneous tracts (≥ 2) and middle calix access were statistically significantly (P = .03 and P = .01) related with less blood loss.ConclusionsPCNL in supine position is a minimally invasive procedure for removal of large (≥ 2 cm) and multiple renal stones, with a low incidence of blood loss and minimal transfusion rate. Multiple percutaneous tracts and middle calix puncture were the only statistically significant variables associated with decrease in hemoglobin levels.     

复杂肾结石经皮肾镜取石术后结石残留的原因与处理

目的:探讨复杂肾结石PCNL术后结石残留的原因及处理方法.方法:回顾分析我院行二期PCNL取石的35例复杂肾结石患者的临床资料,既往有开放手术史17例,2例因术中出血影响视野改二期手术,合并肾盏憩室内结石2例.结果:除2例需辅助ESWL治疗外,其余33例在B超和输尿管镜辅助下,行二期PCNL全部成功取净残留结石.其中3例因残留结石所在肾盏位置远离经皮肾通道或在与皮肾通道平行的肾盏内,重新建立另一通道取石;1例行3通道取石.结论:术中出血、肾盏憩室内结石、既往开放手术史和肾内集合系统解剖异常,是PCNL术后结石残留的主要原因;术中B超及软镜的应用,可以清楚显示有无残留结石及其所在肾盏的位置;了解结石与经皮肾通道的位置关系,帮助引导最大限度地清除结石.