经皮肾镜取石术联合二期输尿管软镜手术治疗孤立肾复杂性结石的疗效研究  

Treatment of complex renal stones in solitary kidneys under percutaneous nephrolithotomy combined with retrograde intrarenal surgery

作　　者：曾国华[1] 赵志健[1] 钟文[1] 陈文忠[1] 吴文起[1] 

机构地区：[1]广州医学院第一附属医院微创外科中心泌尿外科广东省泌尿外科重点实验室,510230

出　　处：《中华泌尿外科杂志》2013年第4期268-271,共4页Chinese Journal of Urology

基　　金：国家自然基金（81170652）;卫生部行业科研专项项目（子课题）（201002010）

摘　　要：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（retrogradeintra—renalsurgery，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3．8～6．8cm，平均4．6cm。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3～30d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12～14F输尿管软镜鞘。采用OlympusP5纤维软镜或者电子软镜及200μm钬激光光纤（8～20w）碎石。对于〈2cm残留结石，粉碎后自行排出或套石篮取出。对于〉2cm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45～175min，平均95min。残留结石大小1．0～3．512m，平均1．9cm。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35～95min，平均72min。RIRS术后1d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88～230μmol／L，平�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 kid- ney 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）, contralat- eral nephrectomy in 42.8% （9 cases） , and functional solitry kidneys in 42.8% （9 cases）. Of the 21 pa- tients, the average age was 45 years with 15 males and 6 females. The stones were 8 multiple, 6 partial stag-horn, 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, re- spectively. Mean operation time of PCNL was 95 （45 - 175） min. After 1 day of PCNL, all case had resid- ual stones with a mean size of 1.9 （ 1.0 - 3.5 ） cm. Two case occurred fever after PCNL and one case pres- ented 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 oc- curred 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.

关 键 词：孤立肾 经皮肾镜取石术 输尿管软镜 鹿角形结石 

分 类 号：R699.2[医药卫生—泌尿科学]