B超引导降低经皮肾取石术中胸膜损伤的探讨（附1424例报告）

目的：总结B超引导下微造瘘经皮肾取石术（mini-percutaneous nephrolithotomy,mPCNL）中行肋间穿刺所致胸膜损伤的发生率,探讨其手术的安全性.方法：回顾性分析2003年11月～2009年4月间施行的1424例B超引导下mPCNL,其中第11肋间穿刺组598例,第12肋下穿刺组826例.B超引导过程中避开肺内气体反射区域.实时监视下用18GPTC针穿刺进入目标肾盏,经针鞘置入0.965 mm导丝,沿导丝分别引入F6～16同轴扩张鞘进行扩张,建立F14～18手术通道,置入F8 Storz输尿管镜或F9.8 Wolf输尿管镜,采用钬激光和（或）双频激光进行碎石.结果：第11肋间穿刺组中,1例（0.17%）发生胸膜穿孔伴液胸,第12肋下穿刺组中无胸膜损伤,2例（0.24 %）发生液胸,两组间比较,差异无统计学意义（P＞0.05）.结论：mPCNL时,B超引导能明确辨析肺内气体回声.实时监视下穿刺扩张可直接避免因肺损伤而造成的气胸,同时可显著降低术中11肋间穿刺胸膜损伤的发生率,减少液/气胸发生率.

Ultrasound-Guidance Could Reduce the Pleural Injury in Mini-Percutaneous Nephrolithotomy with the 11th Intracostal Puncture(Report of 1424 cases)

Objective：To evaluate the pleural injury rate in the mini percutaneous nephrolithotomy （mPCNI.） with the 11th intra-costal puncture and to summarize its safety. Methods： From November 2003 to April 2009, 1424 cases of ultrasound guided mPCNL were undergone in the department. There were 598 cases in the 11th intracostal puncture group and 826 cases in the 12th subcostal puncture group. Under the monitoring of ultrasound, after the puncture with the 18G PTC needle and the catheterization of the 0. 038 guide wire, we dilated with F6 -16 coaxial sheath and then a F 14-18 Peel-away sheath was placed. With the F8 Storz or F9.8 Wolf ureteroscope, the Holmiu or FREEDY laser lithotripsy was carried out. For the cases presenting chest pain after the procedure, the chest X-ray and ultrasound were done. Results：In the llth intracostal puncture group, there was 1 pleural perforation（0.17%） with pleurisy and in the 12th subcostal puncture group, there were 2 pleurisy（0.24%）, P〉0.05. For all the cases, with the oxygen therapy and antibiotics, the pleurisy was absorbed spontaneously in 1-3 days. There was no pneumothorax in either group. Compared to other studies, the pleural injury rate was lower than mPCNL under the monitoring of fluoroscopy. Conclusions： In mPCNL, since the ultrasound can identify the air resonance, the ultrasound-guidance could avoid the pleural injury and decrease the pleurisy and pneumothorax incidence, especially for the intracostal puncture position procedure.