无管化经皮肾镜的病例选择和术中决策

目的探讨无管化经皮肾镜的病例选择和术中决策。 方法2017年1月至2018年3月，我院泌尿外科共收治上尿路结石患者364例，根据术前综合评估标准筛选拟行无管化经皮肾病例，根据术中情况决定是否留置肾造瘘管，分为无管化经皮肾镜组和传统经皮肾镜组，分别评价两组的术后住院天数、结石清除率、术中出血量、可视化疼痛评分（VAS）及围手术期并发症。 结果经术前评估，42例患者符合拟行无管化经皮肾镜条件，根据术中评估，最终37例实行了无管化。术后两组患者的结石均清除干净。两组患者Ⅰ级并发症发生率差异无明显统计学意义（P=0.424），无Ⅱ级以上并发症。两组的平均手术时间（P=0.207）、术中出血量（P=0.450）差异无统计学意义。手术当天（P=0.029）、术后第一天（P<0.001）及出院当天（P=0.025）无管化组的可视化疼痛评分（VAS）均比传统组明显减轻。无管化组平均住院天数比传统组明显缩短（P<0.001）。 结论术前需从四个方面选择合适病例，术中注意四个关键操作，做到五个确认，无管化经皮肾镜是安全的，并且术后疼痛明显减轻，住院时间明显缩短。

Case selection and intraoperative decisions in tubeless percutaneous nephrolithotomy

ObjectiveTo explore the case selection and intraoperative decisions in tubeless percutaneous nephrolithotomy(PCNL). MethodsFrom January 2017 to March 2018, the data of 364 consecutive cases were analyzed before PCNL. According to the comprehensive preoperative evaluation, some patients were selected for tubeless PCNL. The selected patients were divided into two groups according to whether the nephrostomy tube was placed in the final. The postoperative hospitalization days, stone clearance rate, intraoperative blood loss, visual pain score and perioperative complications were evaluated. Results42 cases were selected for tubeless PCNL before operation, and 37 cases were done in the final. Stone clearance rate was 100% in both groups. No differences in grade Ⅰ complications (P=0.424). The mean operative time (P=0.207) and intraoperative blood loss (P=0.450) between the two groups were not different significantly. The visual pain score in the tubeless PCNL was lower than that in tube group, no matter on the day of surgery (P=0.029), on the first day after surgery (P<0.001) or on the day of discharge (P=0.025). The postoperative hospitalization days in the tubeless PCNL were shorter than that in tube group (P<0.001). ConclusionThe tubeless PCNL is safe as long as we select the patients according to 4 criteria before operation, and should pay attention to 4 key procedures and make 5 times of confirmation during operation. The postoperative pain is significantly relieved and the postoperative hospitalization days were significantly shortened in the tubeless percutaneous nephrolithotomy.