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。

Cause of second-look PCNL in the management of upper urinary tract calculi

Objective：To improve the skills of PCNL by investigating the reasons of performing second-look PCNL in the management of upper urinary tract calculi.Method：The data of 1 041 cases undergoing PCNL in our hospital were analyzed retrospectively.The reasons of second-look PCNL or more were summarized.Result：Second-look PCNL was performed on 252 sides of the upper urinary tract（20.9%）of patients because of heavy burden of the stones（72.2%）,severe bleeding（11.5%）,pyonephrosis（8.7%）,perforation in the collecting system（1.2%）,solitary kidney or renal insufficiency（2.8%）,failure in placement of an ideal tract（1.2%）,miss the entrance of the calyceal in which the residual stones located（1.6%）,and anesthesia problems（0.79%）.Local anesthesia was performed in 204 sides of the upper urinary tract of patients（81.0%）,and 48 sides of the upper urinary tract of patients（19.0%）received general anesthesia.During the operation 221 sides of the upper urinary tract of patients（87.7%）were in prone position,and 31 sides of the upper urinary tract of patients（12.3%）in lateral position.The total stone clearance rate was 74.1%for the first PCNL and 91.0%for second-look PCNL.The mean hospital stay for the 951 sides of the upper urinary tract of patients who underwent only one procedure of PCNL was 10.8days,but 13.4days for those who underwent two procedures.Conclusion：The main reasons for second-look PCNL are heavy burden of the stones,pyonephrosis and severe bleeding.Second-look PCNL can decrease the risks of bleeding and infection,thus it will increase the stone clearance rate.However,it may contributes to increasing hospital stay and patients＇ discomfort.