全超声监控建立标准通道行经皮肾镜手术的安全性及有效性分析  

Feasibility and safety of tract dilation under ultrasound guidance in standard percutaneous nephrolithotomy

作　　者：苏博兴[1] 王樹 肖博[1] 唐宇哲[1] 付猛[1] 胡卫国[1] 陈松[1] 李建兴[1] Su Boxing;Wang Shu;Xiao Bo;Tang Yuzhe;Fu Meng;Hu Weiguo;Chen Song;Li Jianxing

机构地区：[1]清华大学附属北京清华长庚医院泌尿外科,北京 102218

出　　处：《中华泌尿外科杂志》2019年第8期615-618,共4页Chinese Journal of Urology

基　　金：首都卫生发展科研专项资助(首发2016-1-2241,首发2016-1-2242).

摘　　要：目的探讨全超声监控下建立标准通道行经皮肾镜手术的安全性及有效性,分析通道建立失败的危险因素。方法回顾性分析北京清华长庚医院2014年12月至2018年12月采用全超声监控下球囊扩张建立标准通道行经皮肾镜手术的231例患者的临床资料。男130例,女101例;年龄(52.3±9.8)岁;结石最大径(3.9±1.1)cm;体质指数(25.8±3.1)kg/m2。其中118例为鹿角形结石;33例既往有同侧肾结石手术史。术中在超声引导下精准穿刺目标盏,留置导丝,在超声监控下置入球囊扩张导管,充盈球囊,扩张并建立F24标准皮肾通道后进行碎石。记录患者手术情况及并发症发生情况。比较初次皮肾通道建立失败与成功患者的一般资料,并通过多因素logistic回归分析通道建立失败的危险因素。结果本研究231例中25例初次皮肾通道建立失败,其中通道过浅13例,通道过深4例,偏离目标盏4例,导丝丢失4例;25例均通过安全导丝或重新穿刺最终成功建立通道,初次通道建立成功率为89.2%(206/231)。通道建立中位时间为4.2 min (2.2~8.0 min);中位手术时间为85.5 min(45.0~120.0 min)。术后第1天血红蛋白下降中位值为16.0 g/L (5.0~25.8 g/L)。术后并发症:Clavien Ⅰ级18例,包括7例发热,11例使用镇痛剂;Clavien Ⅱ级3例,均为输血。总并发症发生率为9.1%(21/231)。术后结石清除率为89.6%(207/231)。单因素分析结果显示,有同侧肾脏手术史(P=0.038)、目标盏积水(P<0.001)、目标盏深度(P=0.039)、目标盏位置(P=0.002)在初次皮肾通道建立成功与失败患者间差异有统计学意义。多因素logistic回归分析结果显示下盏穿刺(P=0.014)是通道建立失败的独立危险因素,而目标盏积水可以明显增加通道建立成功率(P<0.001)。结论全超声监控下球囊扩张建立标准通道行经皮肾镜手术的通道建立成功率高,手术并发症发生率低,安全可行。下盏穿刺是通道建立失败的独立危险因素Objective To investigate the feasibility of tract dilation monitored by ultrasound in percutaneous nephrolithotomy (PCNL), and the risk factors for its failure. Methods A retrospective study was conducted on patients underwent PCNL with only one access (F24) using balloon dilator and sequential dilators (Amplatz and telescopic metal dilators) from December 2014 to December 2018 in Beijing Tsinghua Changgung Hospital. A total of 231 patients (130 males and 101 females) underwent ultrasound-guided PCNL with a mean age of (52.3±9.8) years were included in our study. Mean BMI was (25.8±3.1)kg/m2. Mean size of stone was (3.9±1.1)cm, 51.1%(118/231) of which were staghorn stones. Under ultrasound guidance, after puncture of the target calyx, the balloon dilator was advanced through the guide wire, and inflated to establish the F24 standard renal access. Patients’ clinical parameters such as age, gender, BMI, stone diameter, history of open nephrolithotomy were collected. Risk factors for the failure of ultrasound guided balloon dilation were analyzed by logistic regression analysis. Results Tract dilation succeed in 89.2 % cases (206 succeed, 25 failed) at first attempt. Median tract dilation time was 4.2 min (2.2-8.0 min). Mean operation time was 85.5 min(45.0-120.0 min). Median hemoglobin drop at the first postoperative day was 16.0 g/L (5.0-25.8 g/L). The total rate of complication was 9.1%(21 cases), including 18 cases Clavien Ⅰ and 3 cases Clavien Ⅱ. The stone free rate was 89.6%(207/231). Logistic regression analysis revealed that lower pole access (P=0.014) was a risk factor for the failure of access establishment, while the presence of hydronephrosis of target calyx (P<0.001) would significantly increase the success rate. Conclusions Tract dilation using balloon catheter can be safely monitored by ultrasound with high success rate and low complication rate. Lower pole puncture will make tract establishment difficulty. Patients with a hydronephrotic target calyx are more suitable for this procedure.

关 键 词：肾结石 经皮肾镜取石术 超声定位 球囊扩张 

分 类 号：R699.2[医药卫生—泌尿科学]