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.