可视化穿刺术在无积水经皮肾镜取石术中的临床研究
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摘要
目的:探讨可视化穿刺术在PCNL术中治疗无积水肾结石的安全性。方法:2016年6月~2017年3月采用可视化穿刺术治疗无积水肾结石21例。21例术前CT及静脉肾盂造影评估患肾均无积水,先截石位输尿管逆行插管,滴注生理盐水形成人工肾积水利于超声定位。在超声的引导下,利用可视穿刺肾镜系统辅助直视下进行穿刺,确认进入集合系统之后,根据结石的大小分别扩张至F_(12)超细通道、F_(18)微通道或F_(24)标准通道,通道建立成功后进行碎石取石。结果:包括第二操作通道共25例通道穿刺,其中22例一次穿刺成功,3例在穿刺过程中见肾实质明确出血,更换穿刺部位后成功进入集合系统;手术时间25~90 min,平均(45±22)min;与术前对比血红蛋白无明显变化;无栓塞止血治疗;发热1例,经积极抗炎对症处理后好转;无肾盂穿孔、腹腔脏器损伤及胸膜损伤发生;术后5~7d行KUB或超声检查,19例(90.5%)结石完全清除,2例(9.5%)残留小结石。结论:可视化穿刺术治疗无积水肾结石,能明显提高肾穿刺成功率,有效避免集合系统、血管及脏器损伤,减少出血、显著降低手术时间及感染发生率,安全可行,尤其对于经验不足的年轻医生,能提高肾穿刺和手术的成功率。
Objective:To study and explore the safety of the visual auxiliary puncture in percutaneous nephrolithotomy without hydrocele to treat the kidney stones.Methods:From June 2016 to March 2017,our department has treated 21 cases of non-hydrocele kidney stones by the techniques of the visual auxiliary puncture.For all of the 21 cases,no hydrocele has been detected by the preoperative computed tomography(CT)and intravenous pyelography.First ureteral retrocatheterism was implemented in the lithotomy position,and then normal saline was instilled to form the artificial hydronephrosis to make way for ultrasonic location.Under the guidance of ultrasound,the puncture was done with the aid of the visual nephroscope system.After confirming the entrance into the collecting system,according to the size of the kidney stones,F12 ultrafine channels,F18 micro channels or F24 standard channels were established.When the channels were set up successfully,the steps of removing calculus were carried out.Results:Among the 25 cases of channel puncture,including the second operative channel,22 succeeded in a one-time success.In the rest 3 cases,renal parenchyma had bleeding in direct vision during the puncture,but a change in the position of puncture finally led to the success in entering the collecting system.Duration of the operation was 25-90 min,with an average of(45±22)min.There was no obvious change in hemoglobin before and after operation.No treatment for the thromboembolic hemostasis was given.Fever occurred in 1 case,and improved after positive anti-inflammatory treatment in accordance with the symptoms.No pelvic perforation or enterocoelia visceral organic injuries occurred.At 5 th-7 th day postoperation,KUB or B-ultrasonography revealed the kidney stones were removed completely in 19 cases(90.5%),and 2 cases(9.5%)had residual small stones.Conclusions:The visual auxiliary puncture in percutaneous nephrolithotomy without hydrocele to treat the kidney stones can significantly increase the success rate of the operations,effectively avoiding the injuries of the collecting system and blood vessels as well as the inside organs,with less bleeding,shorter operation time and less infections.It is proved to be safe to carry out the visual auxiliary puncture in percutaneous nephrolithotomy without hydrocele to treat the kidney stones,esp.when the young doctors are not so experienced,with the benefit of increasing the success rate for the kidney puncture in the operations.
Objective:To study and explore the safety of the visual auxiliary puncture in percutaneous nephrolithotomy without hydrocele to treat the kidney stones.Methods:From June 2016 to March 2017,our department has treated 21 cases of non-hydrocele kidney stones by the techniques of the visual auxiliary puncture.For all of the 21 cases,no hydrocele has been detected by the preoperative computed tomography(CT)and intravenous pyelography.First ureteral retrocatheterism was implemented in the lithotomy position,and then normal saline was instilled to form the artificial hydronephrosis to make way for ultrasonic location.Under the guidance of ultrasound,the puncture was done with the aid of the visual nephroscope system.After confirming the entrance into the collecting system,according to the size of the kidney stones,F12 ultrafine channels,F18 micro channels or F24 standard channels were established.When the channels were set up successfully,the steps of removing calculus were carried out.Results:Among the 25 cases of channel puncture,including the second operative channel,22 succeeded in a one-time success.In the rest 3 cases,renal parenchyma had bleeding in direct vision during the puncture,but a change in the position of puncture finally led to the success in entering the collecting system.Duration of the operation was 25-90 min,with an average of(45±22)min.There was no obvious change in hemoglobin before and after operation.No treatment for the thromboembolic hemostasis was given.Fever occurred in 1 case,and improved after positive anti-inflammatory treatment in accordance with the symptoms.No pelvic perforation or enterocoelia visceral organic injuries occurred.At 5 th-7 th day postoperation,KUB or B-ultrasonography revealed the kidney stones were removed completely in 19 cases(90.5%),and 2 cases(9.5%)had residual small stones.Conclusions:The visual auxiliary puncture in percutaneous nephrolithotomy without hydrocele to treat the kidney stones can significantly increase the success rate of the operations,effectively avoiding the injuries of the collecting system and blood vessels as well as the inside organs,with less bleeding,shorter operation time and less infections.It is proved to be safe to carry out the visual auxiliary puncture in percutaneous nephrolithotomy without hydrocele to treat the kidney stones,esp.when the young doctors are not so experienced,with the benefit of increasing the success rate for the kidney puncture in the operations.
引文
[1]周治军,卢童,徐康,等.可视化穿刺系统在经皮肾镜碎石术中的临床应用.临床外科杂志,2016,24(9):700-702.
[2]程跃,谢国海,严泽军,等.逆行输尿管软镜联合可视微通道经皮肾镜一期治疗鹿角形肾结石的临床分析.中华泌尿外科杂志,2016,37(2):127-130.
[3]Ghani KR,Andonian S,Bultitude M,et al.Percutaneous nephrolithotomy:update,trends,and future directions.Eur Urol,2016,70(2):382-396.
[4]胡卫国,李建兴,杨波,等.改良Guy's肾结石分级法在预测经皮肾镜取石术后清石率中的应用研究.中华泌尿外科杂志,2012,33(10):771-773.
[5]夏磊,薛蔚,陈奇,等.超声引导微通道经皮肾镜下碎石术的应用研究(附896例报告).临床泌尿外科杂志,2008,23(2):85-87.
[6]De Sio M,Autorino R,Quattrone CA,et al.Choosing the nephrostomy size after percutaneous nephrolithotomy.World J Urol,2011,29(6):707-711.
[7]樊胜海,周立权.无管化经皮肾镜取石术的研究现状及进展.临床泌尿外科杂志,2016,31(10):943-946.
[8]李为兵.经皮肾镜碎石取石术并发症及其防治.中华泌尿外科杂志,2012,33(1):10-12.
[9]乔明洲,张海芳,周晨龙.肾结石患者经皮肾镜碎石术后结石残留影响因素分析.中华医学杂志,2015,95(44):3617-3619.
[10]Finelli A,Honey RJ.Thoracoscopy-assisted high intercostal percutaneous renal access.J Endourol,2004,15(6):581-585.
[11]李建兴,胡卫国,杨波,等.伴脊柱畸形上尿路结石的经皮肾镜取石术.中华泌尿外科杂志,2010,31(2):107-109.
[12]那彦群,叶章群,孙颖浩.等.中国泌尿外科疾病诊断治疗指南.北京:人民卫生出版社,2014:166-183.
[13]Oner S,Okumus MM,Demirbas M,et al.Factors influencing complications of percutaneous nephrolithotomy:a single-center study.Urol J,2015,12(5):2317-2323.
[2]程跃,谢国海,严泽军,等.逆行输尿管软镜联合可视微通道经皮肾镜一期治疗鹿角形肾结石的临床分析.中华泌尿外科杂志,2016,37(2):127-130.
[3]Ghani KR,Andonian S,Bultitude M,et al.Percutaneous nephrolithotomy:update,trends,and future directions.Eur Urol,2016,70(2):382-396.
[4]胡卫国,李建兴,杨波,等.改良Guy's肾结石分级法在预测经皮肾镜取石术后清石率中的应用研究.中华泌尿外科杂志,2012,33(10):771-773.
[5]夏磊,薛蔚,陈奇,等.超声引导微通道经皮肾镜下碎石术的应用研究(附896例报告).临床泌尿外科杂志,2008,23(2):85-87.
[6]De Sio M,Autorino R,Quattrone CA,et al.Choosing the nephrostomy size after percutaneous nephrolithotomy.World J Urol,2011,29(6):707-711.
[7]樊胜海,周立权.无管化经皮肾镜取石术的研究现状及进展.临床泌尿外科杂志,2016,31(10):943-946.
[8]李为兵.经皮肾镜碎石取石术并发症及其防治.中华泌尿外科杂志,2012,33(1):10-12.
[9]乔明洲,张海芳,周晨龙.肾结石患者经皮肾镜碎石术后结石残留影响因素分析.中华医学杂志,2015,95(44):3617-3619.
[10]Finelli A,Honey RJ.Thoracoscopy-assisted high intercostal percutaneous renal access.J Endourol,2004,15(6):581-585.
[11]李建兴,胡卫国,杨波,等.伴脊柱畸形上尿路结石的经皮肾镜取石术.中华泌尿外科杂志,2010,31(2):107-109.
[12]那彦群,叶章群,孙颖浩.等.中国泌尿外科疾病诊断治疗指南.北京:人民卫生出版社,2014:166-183.
[13]Oner S,Okumus MM,Demirbas M,et al.Factors influencing complications of percutaneous nephrolithotomy:a single-center study.Urol J,2015,12(5):2317-2323.