目的 探讨一期经皮肾镜取石术(PCNL)联合二期输尿管软镜手术(retrograde intrarenal surgery,RIRS)治疗孤立肾复杂性结石的临床疗效.方法 回顾性分析2008年4月至2012年5月收治的21例孤立肾鹿角形结石或多发性结石患者的临床资料,男15例,女6例.年龄19～76岁,平均45岁.其中先天性孤立肾3例,对侧肾切除孤立肾9例,功能性孤立肾9例.鹿角形结石13例,多发性结石8例.结石最大径3.8 ～6.8 cm,平均4.6 cm.全麻下,行C臂X线定位下PCNL,采用第四代EMS超声碎石系统碎石.术后常规留置6F双J管及肾造瘘管.术后1d复查KUB及CT评估残留结石部位及大小.PCNL术后3～30 d行RIRS.全麻下,先取截石位,拔除双J管,在C臂X线引导下置入斑马导丝及12 ～14 F输尿管软镜鞘.采用Olympus P5纤维软镜或者电子软镜及200μm钬激光光纤(8～20 W)碎石.对于＜2 cm残留结石,粉碎后自行排出或套石篮取出.对于＞2 cm的残留结石,以钬激光击碎结石后,用套石篮将较大的碎石片转移至肾盂,改俯卧位,行二期PCNL取石,术后均留置双J管.术后1d复查KUB,术后1～2d拔除肾造瘘管,2～3周拔除双J管.术后3个月复查KUB或CT,评估结石清除率.结果 本组21例PCNL中采用单通道18例,双通道2例,3通道1例.手术时间45 ～175 min,平均95 min.残留结石大小1.0～3.5 cm,平均1.9 cm.结石残留在下盏7例、上盏及下盏4例、中盏及下盏6例、上中下盏均残留4例.PCNL术后发热2例,1例迟发性出血患者采用超选择性肾动脉栓塞治愈.RIRS手术时间35 ～ 95 min,平均72 min.RIRS术后1 d结石清除率为85.7％(18/21).3例残留结石患者中,1例经二期PCNL、2例经ESWL治疗后,结石清除率95.2％ (20/21).2例RIRS术后发热和输尿管石街形成,采用输尿管硬镜取石术治愈.术后3个月随访,患者肌酐为88 ～ 230 μmol/L,平均(138.7±38.3) μmol/L,平均下降了(16.8±25.4)μmol/L,肾功能改善15例,稳定5例,恶化1例,与术前比较差异有统计学意义(P＜0.05).结论 一期PCNL联合二期RIRS治疗孤立肾复杂性结石安全有效,出血量少,可有效保护肾功能.
目的 探討一期經皮腎鏡取石術(PCNL)聯閤二期輸尿管軟鏡手術(retrograde intrarenal surgery,RIRS)治療孤立腎複雜性結石的臨床療效.方法 迴顧性分析2008年4月至2012年5月收治的21例孤立腎鹿角形結石或多髮性結石患者的臨床資料,男15例,女6例.年齡19～76歲,平均45歲.其中先天性孤立腎3例,對側腎切除孤立腎9例,功能性孤立腎9例.鹿角形結石13例,多髮性結石8例.結石最大徑3.8 ～6.8 cm,平均4.6 cm.全痳下,行C臂X線定位下PCNL,採用第四代EMS超聲碎石繫統碎石.術後常規留置6F雙J管及腎造瘺管.術後1d複查KUB及CT評估殘留結石部位及大小.PCNL術後3～30 d行RIRS.全痳下,先取截石位,拔除雙J管,在C臂X線引導下置入斑馬導絲及12 ～14 F輸尿管軟鏡鞘.採用Olympus P5纖維軟鏡或者電子軟鏡及200μm鈥激光光纖(8～20 W)碎石.對于＜2 cm殘留結石,粉碎後自行排齣或套石籃取齣.對于＞2 cm的殘留結石,以鈥激光擊碎結石後,用套石籃將較大的碎石片轉移至腎盂,改俯臥位,行二期PCNL取石,術後均留置雙J管.術後1d複查KUB,術後1～2d拔除腎造瘺管,2～3週拔除雙J管.術後3箇月複查KUB或CT,評估結石清除率.結果 本組21例PCNL中採用單通道18例,雙通道2例,3通道1例.手術時間45 ～175 min,平均95 min.殘留結石大小1.0～3.5 cm,平均1.9 cm.結石殘留在下盞7例、上盞及下盞4例、中盞及下盞6例、上中下盞均殘留4例.PCNL術後髮熱2例,1例遲髮性齣血患者採用超選擇性腎動脈栓塞治愈.RIRS手術時間35 ～ 95 min,平均72 min.RIRS術後1 d結石清除率為85.7％(18/21).3例殘留結石患者中,1例經二期PCNL、2例經ESWL治療後,結石清除率95.2％ (20/21).2例RIRS術後髮熱和輸尿管石街形成,採用輸尿管硬鏡取石術治愈.術後3箇月隨訪,患者肌酐為88 ～ 230 μmol/L,平均(138.7±38.3) μmol/L,平均下降瞭(16.8±25.4)μmol/L,腎功能改善15例,穩定5例,噁化1例,與術前比較差異有統計學意義(P＜0.05).結論 一期PCNL聯閤二期RIRS治療孤立腎複雜性結石安全有效,齣血量少,可有效保護腎功能.
목적 탐토일기경피신경취석술(PCNL)연합이기수뇨관연경수술(retrograde intrarenal surgery,RIRS)치료고립신복잡성결석적림상료효.방법 회고성분석2008년4월지2012년5월수치적21례고립신록각형결석혹다발성결석환자적림상자료,남15례,녀6례.년령19～76세,평균45세.기중선천성고립신3례,대측신절제고립신9례,공능성고립신9례.록각형결석13례,다발성결석8례.결석최대경3.8 ～6.8 cm,평균4.6 cm.전마하,행C비X선정위하PCNL,채용제사대EMS초성쇄석계통쇄석.술후상규류치6F쌍J관급신조루관.술후1d복사KUB급CT평고잔류결석부위급대소.PCNL술후3～30 d행RIRS.전마하,선취절석위,발제쌍J관,재C비X선인도하치입반마도사급12 ～14 F수뇨관연경초.채용Olympus P5섬유연경혹자전자연경급200μm화격광광섬(8～20 W)쇄석.대우＜2 cm잔류결석,분쇄후자행배출혹투석람취출.대우＞2 cm적잔류결석,이화격광격쇄결석후,용투석람장교대적쇄석편전이지신우,개부와위,행이기PCNL취석,술후균류치쌍J관.술후1d복사KUB,술후1～2d발제신조루관,2～3주발제쌍J관.술후3개월복사KUB혹CT,평고결석청제솔.결과 본조21례PCNL중채용단통도18례,쌍통도2례,3통도1례.수술시간45 ～175 min,평균95 min.잔류결석대소1.0～3.5 cm,평균1.9 cm.결석잔류재하잔7례、상잔급하잔4례、중잔급하잔6례、상중하잔균잔류4례.PCNL술후발열2례,1례지발성출혈환자채용초선택성신동맥전새치유.RIRS수술시간35 ～ 95 min,평균72 min.RIRS술후1 d결석청제솔위85.7％(18/21).3례잔류결석환자중,1례경이기PCNL、2례경ESWL치료후,결석청제솔95.2％ (20/21).2례RIRS술후발열화수뇨관석가형성,채용수뇨관경경취석술치유.술후3개월수방,환자기항위88 ～ 230 μmol/L,평균(138.7±38.3) μmol/L,평균하강료(16.8±25.4)μmol/L,신공능개선15례,은정5례,악화1례,여술전비교차이유통계학의의(P＜0.05).결론 일기PCNL연합이기RIRS치료고립신복잡성결석안전유효,출혈량소,가유효보호신공능.
Objective To evaluate the efficacy and advantages of the technique by combined PCNL and retrograde intrarenal surgery (RIRS) in a second stage to treat the complex renal stones in solitary kidney cases.Methods PCNL most with a single 18-24 F tract was performed first and RIRS was carried out at a second stage in solitary kidneys of 21 patients,of which congenital in 14.3％ (3 cases),contralateral nephrectomy in 42.8％ (9 cases),and functional solitry kidneys in 42.8％ (9 cases).Of the 21 patients,the average age was 45 years with 15 males and 6 females.The stones were 8 multiple,6 partial staghorn,and 7 complete staghorn with a mean size of 4.6 (3.8-6.8) cm.Results Of the 21 PCNL cases,a single tract,double,triple tracts were established in 18 (85.7％),2 (9.5％),1 (4.8％) cases,respectively.Mean operation time of PCNL was 95 (45-175) min.After 1 day of PCNL,all case had residual stones with a mean size of 1.9 (1.0-3.5) cm.Two case occurred fever after PCNL and one case presented bleeding resolved by selective renal artery embolization.The mean operation time of RIRS was 72 (35-95) min.Stone-free rate after RIRS was 85.7％ (18/21).The final stone free rate increased to 95.2％ (20/21) after one case received a second-look PCNL and two cases accepted ESWL.Two cases occurred fever and steinstrasses after RIRS resolved by rigid ureteroscopy.At the 3 months follow-up,renal function became stable,improved and worse in 71.4％ (n=15),23.8％ (n=5),and 4.8％ (n=l) of patients.Conclusions PCNL combined with RIRS could be an effective and safe option for complex stones in solitary kidneys with less bleeding,reduced tracts,minor complications and good renal function preservation.
