微创经皮肾镜取石术治疗方案的选择：附视频

目的通过探讨适宜的微创经皮肾镜取石术（MPCNL）方案，以提高上尿路结石的疗效。方法根据术前美国麻醉医师协会（ASA）评分，将872例上尿路结石患者分为高危组（ASA．III或IV）（218例）和低危组（ASA—I或II）（654例），依据结石位置、形态、梗阻程度等将上尿路结石分为3种类型：I型155例，结石位于输尿管上段、肾盂输尿管连接处或肾盂，合并中重度肾积水；II型302例，结石位于输尿管上段、肾盂输尿管连接处、肾盂或肾盂和1～2个肾盏，合并轻度或肾无积水；Ⅲ型415例，结石呈鹿角状，除肾盂外，多个肾盏内都充塞结石者。所有患者均行微通道（16～20F）PCNL钬激光或气压弹道碎石术。记录并比较两组手术时间、结石取净率及手术并发症。结果高危组和低危组分别接受235次和1117次PCNL手术。高、低危组各对应结石类型患者平均年龄差异有统计学意义（P〈0．05），而结石大小、平均手术时间差异无统计学意义（P〉0．05）。高、低危组患者平均伴随疾病数量有显著统计学差异（2．6和0．7种，P〈0．05），两组总的并发症发生率相当。高、低危组I型结石清除率均为100％，Ⅱ型分别为97．8％和98．2％，差别均无统计学意义（P〉0．05），Ⅲ型分别为69．2％和85．6％，差别有统计学意义（P〈0．05）。结论不同患者及不同类型上尿路结石MPCNL手术难度差异大，按结石类型、患者自身情况等选择适宜的MPCNL方案，能提高手术成功率，减少并发症。

The selection of treatment program in minimally invasive percutaneous nephrolithotomy

Objective To explore an appropriate minimally invasive percutaneous nephrolithotomy （MPCNL）for upper urinary stones. Methods From May 2006 to October 2012, 872 cases were performed MPCNL for upper urinary calculi in our department. According to preoperative American Society of Anesthesiologist （ASA） scores, patients were divided into a high-risk group with ASA Ⅲ or Ⅳ （n=218） and a low-risk group with ASA I or Ⅱ （n=654）. Based on the location, shape of the calculi and the severity of urinary obstruction, the patients were classified into three types： Type I （155 cases）, the calculi located at the upper ureter,ureteropelvic junction （UPJ）, or renal pelvis, complicated with moderate or severe hydronephrosis; Type Ⅱ （302 cases）, the calculi located at the upper ureter, UPJ, renal pelvis or renal pelvis with one or two calices, with mild hydronephmsis or not; Type Ⅲ （415 cases）, the renal pelvis and all the calices were filled with staghorn calculi. All patients underwent PCNL with holmium laser or pneumatic ballistic power through mini-nephrostomy tracts （16-20 F）. Operative time, stone-free rate and surgical complications were recorded and compared between two groups, Results 235 procedures were performed in the high-risk group, and 1117 in the low-risk group. There were significant differences in age （P〈0.05）, but no in the mean cumulative stone size and mean operative time （P〉 0.05） between the same type in two groups. The mean number of comorbidities in high-risk group was 2.6 and 0.7 in low- risk group, the difference was significant （P〈 0.05）. The overall complication rate had no difference between the high-risk （5.9%）and low-risk（5.5% ） （P〉 0.05）. The stone-free rate was 100% for type I , 97.8% and 98.2% for type lI in high- and low-risk group respectively. There was no significant difference （P〉 0.05）. For type Ⅲ, the 69.2% stone-free rate in the high-risk group was lower than 85.6% in the low risk group （P〈 0.05）. Conclusion The dificulties of MPCNL for upper urinary stones vary with the individual needs and type of the calculi. Therefore, the therapeutic schedule shall be determined by the individual needs and the stone types in order to increase the success rate of the procedure, and reduce complication rate.