B超引导下经皮肾镜钬激光联合超声碎石清石术治疗上尿路结石

目的探讨B超引导下经皮肾镜钬激光联合超声碎石清石术治疗上尿路结石的安全性和有效性。方法上尿路结石患者376例,其中肾结石患者287例,输尿管上段结石65例。结石最大径0.8～7.5 cm。B超引导下经皮肾穿刺,建立F20工作通道,使用钬激光联合第四代EMS超声碎石清石系统治疗。总结分析手术方法、手术时间、结石清除率及并发症等。结果 376例患者B超引导下1次穿刺成功建立经皮通道,5例因穿刺或扩张时出血明显,及时终止手术。碎石清石总成功率为93.6%(352/376)。287例肾结石患者一期结石清除率为70.0%(201/287),65例输尿管上段结石患者一期结石清除率为95.4(62/65)。二期碎石48例,残留结石最大径0.5～1.0 cm。23例患者行体外震波碎石治疗,残留结石最大径≤0.4 cm。23例患者经体位排石等保守治疗排净。平均手术时间(110.5±28.6)min,术中平均出血量(104±37.2)ml;输血5例。肾造瘘管留置时间平均8 d,术后平均住院时间9 d。大出血3例行选择性肾动脉栓塞治疗后痊愈;术后气胸1例行胸腔闭式引流后痊愈;术后肾周巨大血肿1例,行保守治疗后好转。术后低、中度发热者31例,高热者5例。结论 B超引导下经皮肾镜钬激光联合第四代EMS碎石清石系统治疗上尿路结石创伤小、恢复快、安全高效、并发症少,疗效可靠,是治疗上尿路结石的优先选择。

Clinical Effects of B Ultrasound-Guided Percutaneous Nephrolithotomy and Pneumatic Lithotripsy with Holmium Laser and Ultrasound on Upper Urinary Tract Stones

Objective To investigate the efficacy and safety to treat upper urinary tract calculi with B ultrasound-guided percutaneous nephrolithotomy and pneumatic lithotripsy(PCNL) in conjunction with holmium laser and ultrasound. Methods From January 2006 to June 2011,381 patients with upper urinary tract calculi underwent PCNL under the guidance of B ultrasound,and a F20 working channel was established.A combination of holmium laser and ultrasonic lithotripsy was adopted in the therapy.The procedures,stone clearance rate,operative time and complications were analyzed respectively. Results Of the 381 cases,376 patients underwent PCNL at Phase I lithotripsy.The puncture from skin to kidney succeeded and the F20 renal channels were established successfully in these patients.The operation ended in five cases due to the bleeding of the percutaneous renal tract established.The total stone-free rate was 93.6%(352/376).Of the 287 cases of kidney stone,the stone-free rate after Phase I operation was 70.0%(201/287).As to the 65 cases of upper ureter stone,the stone-free rate after Phase I operation was 95.4%(62/65).Phase Ⅱ lithotripsy was performed in 48 cases.Twenty-three cases with residual stones of 0.5-1.0 cm received adjuvant extracorporeal shock wavelithotripsy while 23 cases with stones less than 0.4 cm discharged stones completely after conservative therapy.The average operative time was(110.5±28.6)min.The average blood loss was(104±37.2)ml.Five patients were given blood transfusion.The duration of nephrostomy tube indwelling averaged 8 days and the postoperative hospital stay 9 days.Three patients with severe hemorrhage were cured with superselective angiographic embolization.Giant perirenal hematoma occurred in one case and was cured with conservative therapy.One patient suffered pneumothorax after the operation,which was cured with closed thoracic drainage.Low fever(<39℃) was found in 31 patients after the operation,and high temperature occurred in 5 cases. Conclusions Treating upper urinary tract calculi with B ultrasound-guided percutaneous nephrolithotomy and pneumatic lithotripsy(PCNL) in conjunction with holmium laser and ultrasound features minor trauma,high success rate and few complications and is a safe and reliable therapy for upper urinary tract calculi.