【作者】 徐桂彬；

【导师】 郑少斌；

【作者基本信息】 南方医科大学 ， 泌尿外科， 2013， 博士

【摘要】 第一章单通道微创经皮肾镜取石术联合二期输尿管软镜治疗复杂性肾结石目的：探讨单通道微创经皮肾镜取石术联合逆行输尿管软镜治疗复杂性肾结石的有效性及安全性。方法：自2011年1月至2012年2月采用“一期单通道微创经皮肾镜取石术、二期截石斜仰卧位下联合逆行输尿管软镜碎石取石术”治疗方法79例复杂性肾结石患者,其中左侧肾结石40例,右侧肾结石32例,双侧肾结石7例；铸型肾结石25例,肾多发结石54例,结石直径1.2-4.8cm,功能性孤立肾24例,血肌酐及尿素氮有不同程度升高的31例。16例有开放取石病史,合并高血压病21例,糖尿病12例,泌尿系感染33例。结果：所有手术均成功建立20F工作通道并行一期经皮肾镜碎石取石,一期手术时间32-176min,平均(85+16)min。术后第2天复查KUB,中盏结石残留21例,上盏结石残留13例,下盏结石残留12例,多发结石残留33例。术后第3-5天行二期逆行输尿管软镜取石术,术中均可探及结石,采用钬激光碎石治疗,其中68例联合应用套石蓝套取结石至肾盂内,经原经皮肾工作通道进行碎石取石,二期手术时间18-134min,平均(46±21)min,二期结石清除率为92.4%(73/79)。6例结石残留患者行术后1月行体外冲击波碎石治疗,4例碎石后结石完全排出,2例残留结石直径均小于1.Ocm。未出现气胸、肠道损伤及大出血等严重并发症。随访时间1～13月,残留结石未见移位,未引起梗阻。结论：单通道经皮肾镜取石术联合逆行输尿管软镜治疗复杂性肾结石有利于减少手术并发症并提高结石清除率,方法安全、有效,值得临床推广。第二章微创经皮肾镜取石术一期联合输尿管软镜治疗复杂性肾结石目的：探讨微创经皮肾镜取石术一期联合逆行输尿管软镜治疗复杂性肾结石的有效性及安全性。方法：自2012年1月至2012年12月,采用微创经皮肾镜取石术一期联合逆行输尿管软镜治疗复杂性肾结石62例。其中左侧肾结石29例,右侧肾结石33例,完全性铸型结石17例,不完全性铸型结石31例,多发性结石14例,直径2.1-4.9cm。13例患侧肾脏有开放取石病史,合并高血压病8例,糖尿病7例,泌尿系感染16例。首先建立经皮肾镜工作通道并一期碎石取石,应用微创肾镜取出所能探及的所有结石后,C臂X线机透视检查残留结石,若残留结石直径大于20mm,采用多通道取石,穿刺结石所在肾盏并建立经皮肾镜通道,取出结石；对于残留结石直径小于20mm的,采用逆行输尿管软镜取石。结果：所有手术均成功建立经皮肾镜工作通道并一期碎石取石,其中单通道取石46例,双通道取石16例。经皮肾镜取石术后残留上盏结石残留14例,中盏结石残留21例,下盏结石残留12例,多发结石残留15例。62例患者中,3例应用输尿管软镜无法探及结石,余59例逆行输尿管软镜均探及残留结石并采用钬激光碎石治疗。47例联合应用套石蓝套取结石至肾盂内,经原经皮肾工作通道进行碎石取石。平均手术时间(125±18)min,术后第2天结石清除为72.6%(45/62),术后1月结石清除率为91.9%(57/62)。未出现气胸、肠道损伤、大出血或尿源性脓毒血症等严重并发症。结论：微创经皮肾镜取石术一期联合逆行输尿管软镜治疗铸型肾结石安全、有效,值得临床推广。第三章单通道微创经皮肾镜取石术联合二期逆行输尿管软镜治疗孤立肾铸型结石目的：探讨分期单通道微创经皮肾镜取石术联合逆行输尿管软镜治疗孤立肾铸型结石的有效性及安全性。方法：回顾性分析2007年4月份至2010年3月份应用微创经皮肾镜取石术及输尿管软镜钬激光碎石手术治疗孤立肾合并铸型结石患者24例。24例孤立肾患者中,先天性孤立肾2例,对侧肾切除5例,对侧肾脏无功能17例。完全性铸型结石16例(66.7%),不完全性铸型结石8例(33.3%),结石平均表面积1501.8±899.7mm2(512-5630mm2)。术前平均血肌酐1.7±0.8mg/dl(0.5-4.9mg/d1),11例患者术前血肌酐大于1.4mg/dl。合并高血压病4例,糖尿病3例,泌尿系感染11例。手术均由同一泌尿外科医师进行操作,微创经皮肾镜取石通道限制为单通道。建立20F微创经皮肾取石通道,F12李逊微创肾镜经工作通道进入肾集合系统,应用气压弹道碎石器或钬激光击碎结石,利用鳄鱼嘴钳取出较大结石,小结石可通过微创肾镜连接负压吸引器吸出。术毕保留输尿管外支架管及肾造瘘管,一期术后3-5天,肾造瘘管引流液转清后行二期手术治疗。二期手术操作中,患者取截石斜仰卧位,输尿管置入12F输尿管软镜工作鞘,7.2F的输尿管软镜经工作鞘进入肾集合系统内寻找结石后并应用200um钬激光碎石,较大结石应用套石篮套取结石至肾盂内,经原经皮肾取石通道碎石并取出。结果：本组病例中,2例患者一期单通道微创经皮肾取石术取净结石,余22例患者均行二联合输尿管软镜取石。22例结石残留患者,一期微创经皮肾镜取石术后平均结石表面积降至235.8±353.3mm2。微创经皮肾镜取石平均手术时间64.2±25.5min(32-180min),二期联合逆行输尿管软镜手术时间116.2±33min (24-173min)。二期术后总结石清除率83.3%,仅4例术后结石残留。术中及术后无明显的手术并发症发生,平均血红蛋白浓度下降1.1-3.7g/dl。3例患者需要输血治疗,其中有2例合并术前贫血。一期术后发热患者4例,均经抗炎治疗后缓解。本组平均随访时间21.3±3.2月(9-38月),平均血肌酐水平从术前1.7±0.8mg/dl下降至术后1.3±0.4mg/dl(P<0.05)。术前11例肾功能不全患者中,4例术后肌酐降至正常水平,7例患者肌酐水平稳定在1.4-2.7mg/dl之间,没在患者肾功能明显恶化或需要血透治疗。结论：单通道经皮肾镜取石术联合逆行输尿管软镜治疗孤立肾铸型结石安全、有效,值得临床推广。第四章CT三维重建在微创经皮肾镜取石联合输尿管软镜处理肾结石中的应用目的：探讨CT三维重建在微创经皮肾镜取石术联合输尿管软镜处理肾结石中的应用价值。方法：自2012年1月至2012年8月,对微创单通道经皮肾镜取石术后残留结石42例患者行上尿路CT三维重建,充分了解肾脏集合系统结构、结石分布及结石与肾盂肾盏间的关系,测量结石所在肾盏长轴与经皮肾造瘘通道及肾盂间的夹角,指导二期输尿管软镜处理结石。结果：CT发现单发肾结石17例,多发肾结石25例,结石直径0.4-2.1cm。测得结石所在肾盏长轴与肾盂长轴间的夹角为8-207°,平均夹角870；结石所在肾盏长轴与经皮肾造瘘通道的夹角为0-1350,平均夹角43°。选取夹角较大的通道作为输尿管软镜入镜路径。所有患者术中均可探及结石,采用钬激光碎石治疗,经输尿管工作鞘软镜取石34例次,经皮肾造瘘通道输尿管软镜取石14例次。手术时间16-112min,平均(52+11)min,结石清除率为95.2%(40/42),2例结石残留直径均小于1cm。本组无改开放手术病例,未出现感染性休克、气胸及大出血等严重并发症。结论：上尿路CT三维重建可形象直观地显示肾脏的解剖结构及与结石间的关系,有助于指导输尿管软镜寻找结石、减少手术时间并提高结石清除率和手术安全性。第五章多通道微创经皮肾镜取石术与单通道微创经皮肾镜取石术联合输尿管软镜治疗复杂性肾结石的对比研究目的：比较多通道微创经皮肾镜取石术与单通道微创经皮肾镜取石术联合输尿管软镜治疗复杂性肾结石的临床疗效。方法：选取本单位应用单通道微创经皮肾镜取石术后肾结石残留患者进行手术治疗,要求残留结石为多发,且单个结石直径≤2cm。2012年3月至2012年12月32例患者入选本组资料,其中男19例,女13例,平均年龄45.6±10.5岁(21-69岁)。32例患者随机分为A组和B组,每组各16例,A组采用多通道微创经皮肾取石,B组在原微创经皮肾镜取石通道的基础上联合逆行输尿管软镜进行取石。两组二期手术操作均在一期术后第3-5天肾造瘘管引流液变清后进行。分析对比两组资料的手术时间、血红蛋白浓度下降值、结石清除率、住院时间及术前后的血肌酐变化。结果：所有手术均成功探及结石并进行碎石取石,无大出血、败血症、邻近脏器损伤等严重并发症发生。A组二期新建立通道1-3个,平均1.4个。A组和B组的平均手术时间分别为59.6+22.5min和63±24.8min,差异无统计学意义(P>0.05)。A平均血红蛋白浓度下降0.83±0.76g/dl,血红蛋白浓度下降高于B组0.35±0.47g/dl (P<0.01),A组1例患者需要输血治疗,B组无需输血病例。A组16例患者结石完全取净,B组2例残留结石直径分别为1.2cm和0.8cm,均行SWL治疗后结石排清。A组二期术后住院时间明显长于B组(5.8d：1.9d)。术后发热A组2例,B组1例,均经抗炎治疗后缓解。A组术后第1天平均血肌酐1.13±0.8mg/dL,高于术前0.92±0.21mg/dL(P<0.01),而B组手术前后的血肌酐分别为0.96±0.22mg/dL和0.95±0.13mg/dL,变化无统计学意义(P>0.05),术后随访1个月,A组和B组的平均血肌酐水平分别为0.93±0.18mg/dL和0.97±0.14mg/dL,与术前相比无统计学意义(P>0.05)。结论：多通道微创经皮肾镜取石术与单通道微创经皮肾镜取石术联合输尿管软镜两种方法治疗复杂性肾结石均是安全、有效的,其手术治疗时间基本相同,多通道取石术组的结石清除率高于联合输尿管软镜组,但联合输尿管软镜组在减少手术出血量和住院时间方面具有一定的优势。更多还原

【Abstract】 Chapter1:Single-tract minimally invasive percutaneous nephrolithotomy and staged flexible ureteroscopy in the treatment of complicacy kidney stoneObjective:To evaluate the efficacy and safety of staged single-tract minimally invasive percutaneous nephrolithotomy (MPCNL) and flexible ureteroscopy in the treatment ofcomplicacy kidney stone.Methods:From Jan2011ureteroscopy by a single surgeon. Twenty five patients were staghorn (31.6%), and the others were multiple kidney stone (68.4%). All patients underwent single-tract MPCNL througha20F tract and had most of the intrarenal calculi removed at the first stage. The second stage of retrograde flexible ureteroscopy was performed three to five days later after the drainage was cleared. The preoperative patient, characteristics, stone size, operative time and postoperative outcomes were then evaluated.ResuIt:All operationwere successful and no major complications were noted in all patients. Theaverage operation time was(85±16) minutes at first stage and (46±21) minutes at second stage. The overall stone-free rate was92.4%after the second-stage procedures and only six patients had significant residue.Conclusion:Staged single-tract MPCNL and flexible ureteroscopy are safe and effective for the management of complicacy kidney stone. Chapter2:Combined minimally invasive percutaneous nephrolithotomy and retrograde flexible ureteroscopy in the treatment of complicacy kidney stoneObjective:To evaluate the efficacy and safety ofcombined minimally invasive percutaneous nephrolithotomy (MPCNL) andretrograde flexible ureteroscopy in the treatment of complicacy kidney stone.Methods:From Jan2012to Nov2012, a total of62patients withcomplicacy kidney stone, including17complete staghorn calculi,31partial staghorn calculiand14multiple calculi, were treated with minimally invasive percutaneous nephrolithotomy and retrograde flexibleureteroscopy. All patients underwent MPCNL and removedmost of the intrarenal calculi. Mutip-MPCNL was performed when the the residual stones large than20mm in diameter. After the residual stones less than20mm in diameter, retrograde flexible ureteroscopy was performed. The preoperative patient, characteristics, stone size, operative time and postoperative outcomes were then evaluated.Result:All operationwere successful and no major complications were noted in all patients. Only3patients can’t search the residual stones, the other59patients can search the residual stonesand were performed retrograde flexible ureteroscopy in on session.Theaverage operation time was(125±18) minutes.Theoverall stone-free rate was72.6%after the operation and91.9%at1month later.Conclusion:Combined minimally invasive percutaneous nephrolithotomy and retrograde flexible ureteroscopy are safe and effective for the management of staghorn calculi in one session. Chapter3:Staged single-tract minimally invasive percutaneousnephrolithotomy and flexible ureteroscopy in the treatmentof staghorn stone in patients with solitary kidneyObjective:The aim of this study was to evaluate the outcome of staged single-tract minimally invasive percutaneous nephrolithotomy (MPCNL) and flexible ureteroscopyas a minimally invasive option in the treatment of staghornstone in patients with a solitary kidney.Methods:A total of24patients with staghorn stone in a solitary kidney weretreated with single-tract MPCNL and flexible ureteroscopyby a single surgeon. All the patients underwent single-tractMPCNL through a20F tract and had most of the intrarenalcalculi removed at the first stage. The second stage ofretrograde flexible ureteroscopy was performed3-5dayslater, after the drainage was cleared. The preoperativepatient, characteristics, stone size, operative time, renalfunctional status and postoperative outcomes were thenevaluated.Result:Sixteen patients were partial staghorn (66.7%),and other eight were complete staghorn (33.3%). Theoverall stone-free rate was83.3%after the second-stageprocedures, and only four patients had significant residue.The hemoglobin drop ranged from1.1to3.7g/dl, and threepatients required blood transfusion. The mean serum creatinine value was1.7±0.8mg/dl before surgery and1.3±0.4mg/dl at the end of the follow-up period withstatistical significance (P<0.05). None of the patients hadincreased serum creatinine, and needed dialysis at the endof the follow-up period. Conclusion:Staged single-tract MPCNL and flexible ureteroscopy are safe and effective for the management of staghorn stone in patients with a solitary kidneyand even in patients with impaired renal functions. Chapter4:Clinical application of three-dimensional CT reconstruction for flexible ureteroscopy in the treatment of residual renal calculi after percutaneons nephrolithotomyObjective:To evaluate the clinic effect of three-dimensional CT reconstruction for flexible ureteroscopy in the treatment of residual renal calculi after percutaneons nephrolithotomy.Methods:From Jan2012to Aug2012, a total of42patients with renal calculi, including17single calculi and25mutiple calculi which residual after single tract minimally invasive percutaneous nephrolithotomy, were performed upper urinary tract non-enhanced CT scanning and three dimensional reconstruction. Flexible ureteroscopy was performed for the treatment of residual renal calculi by the directionof three-dimensional CT reconstruction. Stone size, operative time and postoperative outcomes were then evaluated.Result:All operationwere successful and no major complications were noted in all patients. By the directionof three-dimensional CT reconstruction, flexible ureteroscopywas performed by retrograde in34cases and through the nephrostomy in14cases. Theaverage operation time was(52±11) minutes and the stone-free rate was95.2%.Conclusion:Three-dimensional CT reconstruction provided a good map of the pelvicalyceal system and the accurately located of renal calculi, which was benefit for searching kidney calculi by flexible ureteroscopy, reducing operation time, improving stone-free rate and ensuring operation safety. Chapter5:Comparative study on efficacy of multi-tract minimally invasive percutaneous nephrolithotomy and single-tract percutaneous nephrolithotomy with flexible ureteroscope in the treatment of complex renal calculiObjective:To comparatively analyze the clinical efficacy of multi-tract percutaneous nephrolithotomy lithotomy (multi-tract MPCNL) and single-tract percutaneous nephrolithotomy lithotomy with flexible ureteroscope for the treatment of complex renal calculi.Method:Select the patients which treated with single-tract MPCNLand residual multiple renal stones. Limited the diameter of single residual stones≤2cm. March2012to December2012,32patients were enrolled in this group, including19males and16females, mean age45.6±10.5years (range21-69years). According to the size of stones,32patients were divided into Group A and Group B. Group A was treated with multi-tractMPCNL. Group B was treated with single-tractMPCNLand flexible ureteroscope.After the first stage single-tractMPCNL, the second stage of operations were performed3-5dayslater when the drainage was cleared. Operative data, hospitalization periods, blood loss, serum creatinine changes and complications of the treated patients were recorded.Results:All operations were successful and not serious complications occur. An average of1.4tract was created in group A. The average operative time was59.6±22.5min and63±24.8min in group A and group B (P>0.05). The average hemoglobin concentration decreased was0.83±0.76g/dl ingroup A and0.35±0.47g/dl in group B (P<0.01),1patients need blood transfusion therapy in Group A and none in Group B. Stone clear rate was100%in group A and87.5%in group B. The hospitalization periodswas longer in group A(5.8days:1.9days). In group A, the mean serum creatinine value was1.13±0.8mg/dL after the operation, which is higher than the preoperative,0.92±0.21mg/dL (P<0.01). In group B, the mean serum creatinine value were0.96±0.22mg/dL and0.95±0.13mg/dLbefore and after surgery (P>0.05). However, both group A and group B, compared with preoperative, the mean serum creatinine value were on significantly1month later.Conclusion:Both multi-tractMPCNLand single-tractMPCNLwith flexible ureteroscope are safe and effective for treatment of complex renal calculi. Compare to single-tractMPCNLwith flexible ureteroscope, the single-tractMPCNLwith flexible ureteroscope has certain advantages in reducing operative bleeding and hospitalization time.更多还原