Impact of percutaneous access point number and location on complication and success rates in percutaneous nephrolithotomy

OBJECTIVES: Percutaneous nephrolithotomy (PNL) is sometimes associated with complications, especially in patients with complex stones. Herein, we review our experience with PNL to determine the impact of percutaneous access number and location on success and complication rates. PATIENTS AND METHODS: During a 2-year period, a total of 275 patients with a mean age of 42.3 +/- 14.8 (range: 13-75) years underwent PNL. Stones were classified as simple in 51.6%, and complex (staghorn calculi or renal pelvis stones coexisting with caliceal stones) in 48.4%. Percutaneous access was done under C-armed fluoroscopy and the tract was formed with a high-pressure balloon dilation system. One single percutaneous access was sufficient in 210 (76.4%), while 2 accesses were utilized in 44 (16%), and > or =3 accesses in 21 cases (7.6%). Supracostal access was performed in 23 (8.4%) patients. RESULTS: An overall success rate of 94.9% was achieved. Stone location, but not the access point location, was the major determinant for success, which was 99.3 and 90.2% in patients with simple and complex stones, respectively (p < 0.01). Significant complications included bleeding necessitating blood transfusion in 28 (10.2%), and hydropneumothorax in 2 (0.7%) patients. Bleeding was observed in 39.1 and 7.5% of patients managed with supracostal access, and subcostal access, respectively (p < 0.01). An increased number of access points significantly augmented the risk for bleeding. Bleeding was encountered in 7.6% of patients managed with 1 percutaneous access point, and in 18.5% of cases managed with > or =2 access points (p < 0.05). Hydropneumothorax occurred in patients with supracostal access. CONCLUSION: Supracostal access as well as multiple punctures may be needed especially in the management of complex stones, and the need for multiple access points and supracostal access significantly increases complication rates.     

Histoacryl®组织胶超选择性栓塞肾动脉分支治疗医源性肾动脉出血

目的 观察以Histoacryl^®组织胶作为栓塞剂超选择性栓塞肾动脉分支治疗医源性肾动脉出血的效果。方法 回顾性分析52例医源性肾动脉出血患者,其中30例为经皮肾镜术后、15例为经皮肾穿刺活检术后、7例为部分肾切除术后;均接受数字减影血管造影（DSA）引导下超选择性栓塞患肾责任分支动脉,栓塞剂为Histoacryl^®组织胶。评价技术成功率、临床成功率、并发症及操作时间,比较栓塞前、后血红蛋白（Hb）、肌酐（Cr）和尿素氮（BUN）。结果 对52例均顺利完成治疗,平均操作时间（38.23±11.51） min,技术成功率、临床成功率均为100%。术前2 h与术后12 h内Hb、Cr及BUN差异均无统计学意义（P均>0.05）。术后4例（4/52,7.69%）出现轻微并发症（发热伴局部腰痛）,经对症及支持治疗后恢复;无肾脓肿、败血症、肾破裂等严重并发症发生。结论 以Histoacryl^®组织胶作为栓塞剂超选择性栓塞肾动脉分支治疗医源性肾动脉出血安全、有效。     

Percutaneous management of large renal stones in a private practice community setting

PURPOSE: Recent evidence suggests that increasing numbers of patients with large renal stones are treated at tertiary care centers. Studies of practice patterns in the community have demonstrated that private practice urologists perform few percutaneous nephrolithotomies (PCNLs) and rely heavily on interventional radiologists to obtain renal access. We reviewed our series of PCNLs performed in a community setting, with a focus on success rates and complications, to compare results and effectiveness rates with those of tertiary care centers. PATIENTS AND METHODS: All patients undergoing PCNL for large renal calculi from 1993 to 2006 were included. All procedures were performed by a single surgeon who obtained percutaneous renal access without the assistance of a radiologist. Data were retrospectively reviewed to determine clinical success rates, intraoperative and postoperative complications, and rate of additional procedures. RESULTS: Two hundred and four PCNLs were performed in 170 patients. In 43 cases, more than one percutaneous tract was created. Mean blood loss was 260 mL (range 50-800 mL), and transfusion was necessary in 2% (4/204). In 194 (95.1%) procedures, treatment was considered successful with asymptomatic fragments of 4 mm or smaller. Of these, there was no significant stone burden after a single procedure in 117. Mean hospital stay was 3 days (range 1-15 days). No intraoperative complications occurred. The overall complication rate was 6.9%. CONCLUSIONS: The high success rate of our single, private practice experience is comparable to that of major academic centers. We believe PCNL can be safely and effectively performed in the private practice setting by urologists trained in the procedure.     

B超引导下肾囊肿穿刺要点

目的 探讨彩色多普勒超声引导下肾囊肿穿刺要点.方法 对126例原发性肾囊肿患者进行了彩色多普勒超声引导经皮穿刺治疗.结果 所有患者均一次性穿刺成功,成功率100％,其中肾盂旁囊肿26例,随访0.5～2年,121个囊肿均治愈,治愈率96.03％,均未出现出血与感染等并发症.结论 彩色多普勒超声引导下经皮穿刺治疗肾囊肿,成功率和治愈率高,并发症少.     

肾移植受者HLA特异性抗体的监测及临床应用

目的：探讨人类白细胞抗原（HLA）群体反应性抗体（PRA）对肾脏移植效果的影响。方法：采用酶联免疫吸附法（ELISA）和微量补体依赖性细胞毒试验（CDC）对897例例次肾移植受者的PRA进行动态监测。结果856例初次肾移植受者中术前PRA阳性者121例,占11％,而33例次2次移植和8次3次移植受者术前PRA阳性分别为58％和87％,与初次肾移植受者组比较,PRA阳性受者比例均显著增高（P＜0．001）。PRA阳性组受者肾移植术后排斥发生率为40％,而阴性组受者仅17％,两组比较有显著性（P＜0．01）。PRA阳性组受者的移植物存活率则明显低于阴性组（P＜0．001）,尤其是PRA＞40％的高效敏受者的1、3、5年和7年多移植物存活率与阴性组比较分别下降了24％、38％、57％和56％,均为P＜0．001。ELISA法与CDC法的双盲试验发现,319份受者血清中CDC－PRA的假阳性和假阴性率分别为3．8％和3．1％。结论PRA是预测受者致敏状态的敏感指标,对移植后排斥反应和移植物存活率均有明显影响。     

利用3D模型选择经皮肾镜取石术路径对结石清除率和预后的影响

目的研究利用3D模型选择经皮肾镜取石术路径对结石清除率和预后的影响。方法回顾性分析郑州大学附属洛阳中心医院在2017年5月至2019年1月收治的150例采用经皮肾镜碎石术治疗的肾结石患者-.般资料,其中82例行常规经皮肾镜手术(常规组),68例使用3D模型进行穿刺路径选择的经皮肾镜手术(3D组)。比较两组患者的手术时间、术中出血量.术后住院时间、手术结石清除率、术后疼痛情况.并发症发生率等围手术期指标。结果3D组术中的结石清除率高于常规组(P<0.05),而出血量,并发症发生率明显低于常规组(P<0.05),两组患者在手术时间、术后住院时间和术后疼痛程度等方面相比较,差异无统计学意义(P>0.05)。结论应用3D打印模型选择经皮肾镜取石术的路径能够提高结石清除率,同时降低相关并发症发生率。     

肝门胆管癌两种姑息性治疗方法并发症及适应证的比较

目的:比较经内镜逆行胆道支架置入术与经皮经肝穿刺胆道支架置入术对肝门胆管癌的近期治疗效果及适应证。方法:回顾性将肝门胆管癌患者60例按不同治疗方法分为经皮经肝穿刺胆道支架置入术组(35例)及经内镜逆行胆道支架置入术组(25例),比较经不同治疗方法后肝门胆管癌患者近期肝功能的恢复、相关并发症发生率及不同类型肝门胆管癌行不同治疗方法的成功率。结果:经内镜逆行胆道支架置入术同经皮经肝穿刺胆道支架置入术成功率分为80%和92%,在术后胆道出血及胰腺炎并发症方面,两种治疗方法存在明显差异(P0.05);Ⅳ型肝门胆管癌治疗成功率经皮经肝穿刺胆道支架置入术存在明显优势(P0.05);经内镜胆道支架置入术与经皮经肝穿刺胆道支架置入术在支架术后胰腺炎方面未见明显差异(P0.05)。两组治疗在减黄,肝功能恢复方面未见明显差异。结论:在并发症方面两种治疗方法各有优缺点,在Ⅳ型肝门胆管癌治疗中以经皮经肝穿刺胆道支架置入术为佳,Ⅰ型及Ⅱ型肝门胆管癌以内镜逆行胆道支架置入术治疗为佳,Ⅲ型肝门胆管癌根据具体情况而定。     

X线与超声在经皮肾镜治疗复杂性肾结石中的应用比较

目的对比分析C臂X线和超声定位在微创经皮肾镜碎石取石术（PCNL）治疗复杂性肾结石中的优劣性。 方法回顾性分析我科2015年7月至2017年7月156例行MPCNL的复杂性肾结石患者（89例在C臂X线引导下,67例在超声引导下）的临床资料,对患者首次目标盏穿刺成功率,两组手术后血红蛋白下降值、结石Ⅰ期取净率、手术并发症等进行分析比较。 结果Ｘ线组89例患者,首次目标盏穿刺成功69例,手术后血红蛋白下降值为（16.2±7.4）g/L,结石Ⅰ期取净62例,发生手术并发症12例,超声组67例患者,首次目标盏穿刺成功31例,手术前血红蛋白下降值为（19.5±8.2）g/L,结石Ⅰ期取净42例,发生手术并发症10例。两组患者在首次目标盏穿刺成功率、手术后血红蛋白下降值的差异均有统计学意义（P<0.05）;结石Ⅰ期取净率及手术并发症的差异无统计学意义（P<0.05）。 结论在MPCNL治疗复杂性肾结石中,X线引导相对于超声能明显提高首次目标盏穿刺成功率,减少术中出血,是治疗复杂性肾结石的较好方法。医师应根据其医疗设备、手术技能和临床经验的特点,为患者制定最优穿刺定位方案。     

42例输尿管上段结石的经皮肾造瘘输尿管镜碎石治疗

目的:探讨经皮肾造瘘输尿管镜碎石术(PCNL)治疗输尿管上段结石的方法和疗效.方法:PCNL治疗42例输尿管上段结石,对其方法和疗效进行分析.结果:38例I期PCNL,残石率15.78%(6/38).2例I期经皮肾造瘘(PCN),Ⅱ期PCNL.2例因术中Peel-away鞘连同安全导丝一并脱出,改开放手术.结论:PCNL治疗输尿管上段结石具有创伤小、安全、操作相对简单、残石率低、出血少、恢复快、并发症少的优点.     

改良单扩张技术建立皮肾通道的应用研究

目的 探讨改良的单扩张技术在建立皮肾通道中的应用效果.方法 回顾性分析2010年3月至2011年6月应用改良的单扩张技术建立皮肾通道行微创经皮肾取石术231例.其中轻度积水72例,中度积水101例,重度积水58例.结果 231例患者共建立293个皮肾通道,均一次建立成功,成功率100%,通道扩张的平均时间3.1±1.6 min、扩张时无需X线监视,无穿孔发生,输血率3.8%.结论 改良的单扩张技术操作简单,安全,可避免穿孔及穿孔引起的出血、外渗,减少X线暴露时间,提高手术的安全性.     

SonixGPS导航超声与普通超声引导下经皮肾镜治疗肾结石的疗效比较

目的比较SonixGPS导航超声系统与普通超声穿刺定位引导下经皮肾镜碎石取石术（PCNL）治疗肾结石的疗效。 方法选取2016年1月至2016年12月我院确诊为肾结石患者115例,男75例,女40例,年龄（45±10）岁;左肾结石50例,右肾结石65例,均伴有不同程度肾积水;结石最大径（4.3±1.6） cm。全部患者均行经皮肾镜钬激光碎石术,其中59例采用SonixGPS导航超声系统建立经皮肾通道,56例采用超声引导下建立通道,比较两组患者在穿刺时间、穿刺出血量、一次性穿刺建立通道成功率、败血症发生率、迟发性出血率、一期结石清除率等。 结果115例患者除2例超声引导下建立通道时出现通道迷失改二期手术外,其余113例手术过程顺利,无肠道及胸膜损伤,SonixGPS导航组及超声组手术穿刺时间分别为（3.9±1.0）min及（5.0±2.0）min,穿刺出血量分别为（26±9）ml及（28±12）ml,一次性穿刺成功率分别为96.6%及82.1%,术后败血症发生率分别为1.69%及1.78%,迟发性出血率分别为3.4%及8.9%,一期结石清除率分别为94.9%及82.1%。两组患者在性别、年龄、结石位置、肾积水程度及结石大小方面差异无统计学意义（P>0.05）;而在穿刺时间、一次性穿刺成功率及一期结石清除率指标差异存在统计学意义（P<0.05）。 结论SonixGPS导航超声系统引导下行PCNL是安全有效的,相比普通超声定位具有明显优势,是一种值得推荐的穿刺引导方法。     

微通道经皮肾镜与组合式输尿管软镜碎石术治疗肾结石比较性研究

目的 比较微通道经皮肾镜与组合式输尿管软镜碎石术两种方式治疗肾结石的疗效和并发症.方法 100例体外冲击波碎石无效的肾结石患者,分为两组,51例患者行微通道经皮肾镜碎石术,49例患者行组合式输尿管软镜碎石术,比较两组患者的手术时间、术中出血量、术后并发症、术后住院时间、术后清除率.结果 51例微通道经皮肾镜组手术时间(53.5±19.6)min,术中出血(75.0±18.5) mL,术后住院时间为(8.0±1.5)d;术后总并发症发生率80.4％:47例结石清除,总清石率为92.16％.49例输尿管软镜组手术时间为(49.0±25.6)min,术中出血(15.2±2.9) mL,术后住院时间为(4.5±0.6)d;术后总并发症发生率为30.6％;32例结石清除,总清石率为65.31％.两者比较手术时间无明显差别;术中出血量、术后住院时间、术后并发症发生率、总清石率微通道经皮肾镜组大于组合式输尿管软镜组;但分组分层发现在多部位、多发结石方面清石率组合式输尿管软镜组优于微通道经皮肾镜组.结论 微通道经皮肾镜在治疗结石负荷＜2 cm、下盏结石、单个结石优于组合式输尿管软镜,但在多部位、多发结石方面清石率组合式输尿管软镜优于微通道经皮肾镜.     

Percutaneous management of calculi within horseshoe kidneys

PURPOSE: Percutaneous treatment of patients with calculi in a horseshoe kidney can be challenging due to the altered anatomical relationship in the retroperitoneum. Therefore, we performed a multi-institutional review to assess the safety and efficacy of this minimally invasive technique. MATERIALS AND METHODS: Of 37 patients identified with calculi in a horseshoe kidney at 3 institutions 24 (65%) underwent percutaneous nephrolithotripsy as primary treatment. Average patient age was 48.4 years and 75% of the patients were male. In 3 patients with staghorn calculi mean stone size as measured by computed digitized stone surface area was 448 mm2. Mean followup was 5.8 months. The stone-free rate, complication rate, need for secondary intervention and stone composition were evaluated. RESULTS: Renal access was obtained through an upper pole calix in 63% of the cases, a lower calix in 25% and a middle calix in 4%. Access location was not documented in 1 patient (4%). Of the 24 patients 21 (87.5%) were rendered stone-free after primary or second look procedures. Flexible nephroscopy was used in 84% of cases. Minor complications occurred in 4 patients (16.7%), whereas 3 (12.5%) experienced major complications, including significant bleeding necessitating early cessation, nephropleural fistula and pneumothorax. No deaths occurred as a result of this treatment choice. Stone analysis was available for 21 cases (87.5%). Calcium stones predominated (87.5%), followed by uric acid (9.5%) and struvite (4.8%). CONCLUSIONS: Percutaneous treatment of patients with renal calculi in a horseshoe kidney is technically challenging, usually requiring upper pole access and flexible nephroscopy due to the altered anatomical relationships of the fused renal units. The success rate based on stone-free results and a relatively low incidence of major complications suggest that this minimally invasive management option is an effective means of stone management in this complex patient population.     

Renal biopsy: update

PURPOSE OF REVIEW: The renal biopsy is an invaluable tool in the diagnosis, prognosis, and management of patients with kidney disease. As the success of the procedure is defined not only by the ability to obtain adequate tissue but also by the safety profile, significant advances which define risk factors and determine the optimal timing of observation after the percutaneous native renal biopsy merit discussion. Alternative methods of obtaining tissue, such as transvenous renal biopsies, have also been described, especially in patients with contraindications to the percutaneous method. RECENT FINDINGS: The percutaneous renal biopsy has been established as a safe and effective method of obtaining renal parenchyma. Complications, although rare, may occur and the majority of these are related to bleeding. The optimal timing of observation after the biopsy should be determined by when most complications occur, and, as over 33% of complications occur after 8 h, an observation period of at least 24 h is recommended. In patients with contraindications to the percutaneous approach, such as failure of adequate radiologic visualization or a bleeding diathesis, alternative methods of obtaining tissue have been attempted. These include open, laparascopic, transurethral, or transvenous renal biopsy. SUMMARY: Without contraindications, the percutaneous renal biopsy remains the standard method of acquiring renal tissue. At least 24 h of observation is recommended after the percutaneous native kidney biopsy for the development of potential complications. When a contraindication to the procedure exists, other methods of renal biopsy by experienced physicians may be attempted.     

经皮肾镜碎石取石术治疗孤立肾结石的临床分析

目的 探讨经皮肾镜碎石取石术治疗孤立肾结石的临床疗效及分析手术并发症的危险因素.方法 回顾性分析本院2009年11月至2016年1月行经皮肾镜碎石取石术治疗的孤立肾结石患者,记录患者的一般资料、术中及术后情况,记录术前术后血红蛋白、血肌酐并进行比较;Logistic回归分析评估出血及手术并发症的相关危险因素.结果 本组32例,男性9例,女性23例,平均年龄47.75(29 ～ 67)岁,平均BMI 23.7(18.2 ～ 28.4) kg/m2,鹿角形结石1例,多发结石11例,平均结石含量501.25(300 ～ 800) mm2,Guys结石分级:1级11例(34.4％)、2级9例(28.1％)、3级11例(34.4％)、4级1例(3.1％).4例患者建立两个经皮肾通道;平均手术时间73.75(40 ～ 120) min,平均术中估计出血量85 (40～300)mL,26例患者结石完全清除,总的结石清除率81.25％.3例患者发生手术并发症.手术前后血红蛋白、血肌酐均未发生明显变化.Logistic回归分析提示多个经皮肾通道的建立增加出血风险,手术时间延长增加手术并发症的发生.结论 经皮肾镜碎石术治疗孤立肾结石排石率高、手术并发症少.多个经皮肾通道的建立增加手术出血风险.     

C臂数字减影X线引导在建立经皮肾通道的应用

目的:探讨C臂数字减影X线引导在经皮肾镜取石术(PCNL)建立经皮肾通道的应用效果.方法:在C臂数字减影X线机透视下对320例上尿路结石患者一期建立经皮肾通道.结果:320例患者穿刺成功率100%,其中双侧肾穿刺19例,单侧双通道34例.建立经皮肾通道时间10～90 min,平均30 min.无一例发生大出血、肾盂穿孔、脏器损伤等严重并发症.结论:C臂数字减影X线机下在PCNL中建立经皮肾通道穿刺成功率高,并发症少,具有重要的应用价值.     

The feasibility of regional anesthesia in the percutaneous nephrolithotomy with supracostal approach and its comparison with general anesthesia

There are various approaches for the percutaneous nephrolithotomy (PCNL). Supracostal approach is a well known technique for doing of it. This approach is being done commonly under general anesthesia (GA). In this retrospective study, we evaluated the feasibility of supracostal PCNL under regional anesthesia (RA) and compared it with the same procedure under GA. Since March 2000 to March 2005, a total of 123 renal stone cases underwent PCNL with supracostal access in our center. GA was selected in 69 cases (56 %) (Group 1), spinal anesthesia (SA) in 45 cases (36.5 %), and epidural anesthesia (EA) in 9 cases (7.5 %) (Group 2). The operative time, success rate, hospital stay, and ensuing complications were compared between group 1 and group 2. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, anesthesia time, and hospitalization time (P > 0.05). There was no difference in the rate of complications or success rate between GA and RA cases (P > 0.05). Overall complete stone free rate, regardless of stone size, in relation to type of anesthesia was as follows: 88.4 % for GA, 88.9 % for EA, and 91.1 % for SA (P > 0.05). Conversion to GA was not needed in any patient with RA. The results showed that the supracostal PCNL with regional anesthesia was feasible but without evident advantages versus general anesthesia in this population, and possible advantages of the procedure in patients with pulmonary co-morbidities have still to be evaluated. The anesthesia related complications of RA were negligible and easily controllable.     

CT引导下经皮穿刺活检食管占位性病变的有效性及安全性

目的 观察CT引导下经皮穿刺活检食管占位性病变的有效性及安全性。方法 回顾性分析37例接受CT引导下经皮穿刺活检的食管占位性病变患者（37个病灶）,统计取材成功率、穿刺病理诊断率及诊断准确率（以术后病理诊断或随访诊断为最终诊断）和术中、术后并发症。结果 37个病灶均穿刺取材成功并获明确病理诊断,32个病理结果为阳性（肿瘤性病变）、5个为阴性（炎性病变或正常组织）,穿刺病理诊断率100%。32个阳性病变穿刺病理诊断与最终诊断结果均一致;5个穿刺阴性病变中,3个与最终诊断一致,2个术后病理均为胃肠间质瘤,穿刺诊断准确率为94.59%（35/37）,假阴性率40.00%（2/5）。术后2例出现少量气胸、3例穿刺针道少量出血,1周后均自然吸收,并发症发生率13.51%（5/37）。结论 CT引导下经皮穿刺食管占位性病变安全、有效。     

CT尿路成像及三维重建在微创经皮肾镜取石术中的价值

目的探讨上尿路结石中CT尿路成像(CT urography,CTU)及三维重建在微创经皮肾镜取石术中的应用价值。方法选取2008年1月～2010年12月微创经皮肾镜取石术68例作为研究对象,CTU及三维重建38例(CTU组),静脉肾盂造影(intravenous pyelography,IVP)30例(IVP组)。比较2组手术时间、术中出血量、穿刺通道数目、结石清除率及并发症发生率。结果 2组手术均获成功,无严重并发症发生。CTU组手术时间(95.0±37.4)min,显著短于IVP组(125.8±36.5)min(t=-3.408,P=0.001);CTU组术中出血量(114.3±44.2)ml与IVP组(133.7±35.7)ml无统计学差异(t=-1.952,P=0.055);CTU组单、双通道分别为32、6例,与IVP组25、5例无统计学差异(χ2=0.010,P=0.922);CTU组结石清除率92.1%(35/38)与IVP组73.3%(22/30)无统计学差异(χ2=3.082,P=0.079);CTU组穿刺成功率89.5%(34/38)明显高于IVP组70.0%(21/30)(χ2=4.112,P=0.043)。结论 CTU联合三维重建技术能提高结石检出率,不增加X线的放射剂量,提供精确的穿刺径路,减少穿刺损伤周围脏器的风险,缩短手术时间,提高穿刺成功率,从而减少或避免术后并发症。     

Percutaneous nephrolithotripsy for renal stones in over 1000 patients.

Over a period of 5 consecutive years, 1039 renal units were treated by percutaneous nephrolithotripsy for stone disease of the kidney. The success rate was 93.7%. Residual stones remained in 4.2% of patients and in 2.1% we failed to remove the stones. The complication rate was 17.8%. Complications were treated conservatively in most cases but nephrectomy was required on one occasion to control severe bleeding. The average hospital stay was 6.9 days. Follow-up of 339 renal units (333 patients), for a minimum of 60 months, revealed minor late sequelae such as pelviureteric junction obstruction in 1 patient (0.3%) and post-catheterisation strictures of the anterior urethra in 4 (1.2%). Stone recurrence was observed in 9.1% of patients. Percutaneous nephrolithotripsy is an effective, safe treatment for renal stones with minimal late sequelae and is still required even in the era of extracorporeal shock wave lithotripsy.