瞬时X线联合B超在复杂经皮肾镜取石术中的应用体会

目的:探讨瞬时X线联合B超引导经皮肾穿刺定位在较为复杂的经皮肾镜取石术(PCNL)中的应用价值。方法:回顾2012年3月~2013年10月我院收治的69例肾结石患者临床资料,其中肾脏轻度积水25例,肾脏旋转不良12例,肾脏无明显积水8例,完全鹿角形结石6例,重复肾6例,术中逆行造影及人工积水肾建立失败4例,肾结石术后瘢痕肾5例,肥胖患者2例,肾下垂患者1例。术中常规给予输尿管置管行逆行造影并建立人工积水肾,采用C型臂瞬时X线照相联合B超引导建立经皮肾穿刺通道。结果:69例患者均穿刺成功,建立F14~18通道,建立时间10~35min,术中X线暴露次数2~5次。其中肾脏轻度积水25例、肾脏无明显积水8例、完全鹿角形结石6例由间断瞬时X线定位为主,辅助B超定位以避开主要血管及领近器官或辅助建立多通道;肾脏旋转不良12例、重复肾6例、肾结石术后瘢痕肾5例、肥胖患者2例、肾下垂患者1例由B超定位为主,辅助瞬时X线定位以确保穿刺线通过肾盏穹窿部;术中逆行造影及人工积水肾建立失败4例,由B超定位穿刺针进入肾脏集合系统,经穿刺针推注造影剂显示肾盂肾盏,用第二穿刺针在瞬时X线定位下建立目标肾盏的穿刺通道。64例为Ⅰ期手术,5例行Ⅱ期手术,清石率为96.8%,无严重并发症发生。结论:对于较为复杂的PCNL,瞬时X线联合B超的定位技术能够结合两种定位方法的优势,建立安全、有效的穿刺通道,提高清石率,减少手术并发症的产生,同时减少患者及医生在手术中X线的暴露时间。

Application of transient X-ray combined with B ultrasound in the complicated percutaneous nephrolithotomy

Objective：To investigate the applied value of developing percutaneous renal access for the complicated percutaneous nephrolithotomy（PCNL）under the guidance of transient X-ray and B ultrasound.Method：There are 69cases of renal calculi in this group,including 25cases of mild hydronephrosis,12cases of renal malrotation,eight cases of renal calculi in non-dilated collecting system,six cases of complete staghorn calculi,six cases of duplex kidney,five cases of cicatricial kidney after nephrolithotomy,four cases failing to establish retrograde urography（RGU）and artificial hydronephrosis in operation,two cases of obese patients,and one case of nephroptosis.After retrogressing ureteral catheter to the pelvis,we infused Cardiografin to establish retrograde urography and artificial hydronephrosis by ureteral catheter conventionally,and then developed percutaneous renal tract under the guidance of transient X-ray combined with B ultrasound.Result：The percutaneous renal access was successfully established in 69patients,and F14-18working tracts were established.Tract building time was 10-35minutes,and the time of exposed to X-ray was 2-5times.For 25cases of mild hydronephrosis,eight cases of renal calculi in non-dilated collecting system and six cases of complete staghorn calculi,we selected interruptable transient X-ray localization to determine the site of the aim renal calices,and then made use of B ultrasound in order to evade the main blood vessels and adjacent organs,or assisted to establish other tracts.For 12cases of renal malrotation,six cases of duplex kidney,five cases of cicatricial kidney after nephrolithotomy,two obese patients and one case of nephroptosis,we selected the guide of B ultrasound localization first,and then used transient X-ray to ensure that the puncture line went through the renal calyceal system.For four cases which were failed to establish retrograde urography and artificial hydronephrosis,the needle punctured into the renal collecting system under the guide of B ultrasound locali