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2018单通道微创经皮肾镜联合输尿管软镜治疗复杂性肾结石临床效果探讨

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发表于 2018-8-14 18:07:22 | 显示全部楼层 |阅读模式
  [摘要] 目的 探?单通道微创经皮肾镜联合输尿管软镜碎石取石术治疗复杂性肾结石的临床效果及安全性。 方法 系统回顾性分析2014年1月~2017年6月我院收治的98例复杂性肾结石患者,根据手术方式不同分组。研究组采用单通道微创经皮肾镜联合输尿管软镜(顺行和逆行,1期和2期)碎石取石术治疗(42例),对照组采用多通道微创经皮肾镜碎石取石术治疗(56例),比较两组复杂性肾结石的治疗效果(结石清除率)、手术操作时间、术中总出血量、术后住院时间和并发症发生情况。 结果 研究组治疗复杂性肾结石术后3~5 d结石清除率与对照组比较,差异无统计学意义(P>0.05);但研究组术后3个月结石清除率明显高于对照组(P0.05)。两组大出血、术后发热、感染性休克、肾功能受损等并发症发生率相比较,研究组总的并发症发生率低于对照组(P /6/view-10121887.htm
  [关键词] 单通道微创经皮肾镜;输尿管软镜;复杂性肾结石
  [中图分类号] R699 [文献标识码] B [文章编号] 1673-9701(2018)06-0038-04
  [Abstract] Objective To investigate the clinical effect and safety of single-channel minimally invasive percutaneous nephrolithotomy combined with ureteroscopic lithotripsy in the treatment of complex renal calculi. Methods A retrospective analysis of 98 cases of complicated renal calculi admitted to our hospital from January 2014 to June 2017 was performed. The patients were divided into different groups according to different surgical methods. The experimental group was treated with single-channel minimally invasive percutaneous nephrolithotomy combined with ureteroscope (prograde and retrograde, stage I and stage 2) lithotripsy (42 cases). The control group was treated with minimally invasive percutaneous nephrolithotomy lithotripsy(56 cases). Complicated renal calculi (calculi removal rate), operation time, total intraoperative blood loss volume, postoperative hospitalization time and complications were compared between the two groups. Results There was no significant difference in calculi removal rate between the study group and the control group in 3-5 days after the treatment of complex nephrolithiasis(P>0.05); however, the calculi removal rate in the experimental group at 3 months after operation was significantly higher than that in the control group(P0.05). Bleeding, postoperative fever, septic shock, impaired renal function such as complications of the two groups were compared. The overall incidence of complications in the study group was lower than that in the control group(P    [Key words] Single-channel minimally invasive percutaneous nephrolithotomy; Ureteroscope; Complicated renal calculus
  经皮肾镜碎石手术是治疗复杂性肾结石首选治疗方案,但受肾盏解剖特点影响,单通道经皮肾镜无法一次性完全发现和清除各个肾盏及肾盂结石[1]。多通道取石虽然可提升结石清除率,但可导致肾实质损伤、出血量及手术并发症增加。输尿管软镜可弯曲,方便进入各个肾盏,且可探查到各个集合系统,不存在视野盲区。而钬激光技术的发展使得输尿管软镜钬激光碎石成为肾结石有效微创处理方法,结石清除率高[2]。本研究分析了单通道微创经皮肾镜联合输尿管软镜治疗复杂性肾结石临床效果,现报道如下。
  1 资料与方法
  1.1 一般资料
  系统回顾性分析2014年1月~2017年7月在我院行手术的98例复杂性肾结石患者,根据手术方式不同分为对照组(n=56)与研究组(n=42)。纳入标准:均符合复杂性肾结石的诊断标准:完全性及不完全性肾铸型结石或者多发性肾结石,且结石直径>2 cm;无手术禁忌证。排除标准:有输尿管、肾手术或肾盂输尿管连接部梗阻或输尿管狭窄。两组基本情况差异无统计学意义(P>0.05)。见表1。
  1.2方法
  对照组采用双(多)通道经皮肾镜碎石,研究组采取单通道微创经皮肾镜联合输尿管软镜治疗。患者患侧输尿管逆行插管之后改为俯卧位,B超下用17.5G肾穿刺针在11肋间或12肋下腋后线到肩胛线之间通过穹隆部位穿刺到目标肾盏,成功穿刺之后将斑马导丝置入,将针鞘退出,并用筋膜扩张器进行逐级扩张,扩张到F16-18,给予peeraway鞘留置,并建立经皮肾通道。置入经皮肾镜用五代EMS碎石清除系统碎石后,将结石取出或冲出。尽可能将经皮肾镜能触及的所有结石清除干净。术中通过B超检查对结石清除情况进行了解,根据不同组别进行下一步处理,方式如下。
  1.2.1 对照组 采用双(多)通道经皮肾镜碎石,根据B超检查结果,建立2个及以上经皮肾通道,再次进行碎石、取石,术后给予F14-16肾盂造瘘管和F5双J管留置。
  1.2.2 研究组 采取单通道微创经皮肾镜联合输尿管软镜治疗。通过单通道PCNL碎石、取石之后,从第1个通道顺行置入输尿管软镜,给予科以人钬激光碎石,尽量使其粉未化和套石篮取石。一期或者二期改为截石斜仰卧位,在硬性输尿管镜的引导下逐渐置人斑马导丝,在导丝引导下放人F12-14输尿管软镜工作鞘,输尿管软镜进入肾集合系统内,发现残留结石后,入目标肾盏,予以钬激光碎石,尽量使其粉末化和套石篮取石。
  所有患者术后3~5 d和术后3个月进行腹部平片或CT?筒椋?若残留结石≥4 mm说明结石残留。残留结石的患者在1周后进行二期手术治疗或进行体外碎石治疗[3]。
  1.3观察指标
  比较两组复杂性肾结石治疗效果(早期和晚期结石清除率)、总体手术操作时间、术中总出血量、平均住院时间、术后并发症等
  结石清除:术后3~5 d和术后3个月进行腹部平片或CT复查,若残留结石0.05);但研究组术后3个月结石清除率明显高于对照组(P0.05)。见表3。
  2.3两组并发症发生率比较
  研究组仅1例术后大出血,术后予止血、输血等治疗后治愈。对照组中有3例大出血,其中1例保守治疗无效,予行肾血管介入治疗后治愈。两组大出血、术后发热、感染性休克、肾功能受损等并发症发生率相比较,研究组总的并发症发生率低于对照组(P    mPCNL常见的严重并发症有大出血?p术后发热、感染性休克?p肾功能受损?p上尿路穿孔、腹腔脏器损伤?p血胸等,严重出血者需要行介入栓塞治疗。本研究认为术中出血多与经皮肾通道数目有关。对照组的出血量明显多于双镜联合组(P0.05),这得益于输尿管软镜更低的创伤和更小的并发症。
  综上所述,单通道微创经皮肾镜联合输尿管软镜结合了mPCNL和RIRS的优势。虽然手术时间较长,但能有效减少经皮肾通道的数目,其创伤小,并发症少,临床效果确切,结石清除率高,安全性和有效性高,也弥补了单通道方式下结石残留多的不足,值得大力推广应用。
  [参考文献]
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  (收稿日期:2017-10-24)
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