经皮肾镜碎石取石术与输尿管软镜碎石术治疗孤立肾肾结石的临床特点及疗效分析

冯勇，陈文章，毛会峰，张军泽，屈卫星，程永毅

(1.陕西省靖边县人民医院，陕西榆林，718500；2.陕西省人民医院，陕西西安，710060）

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摘要：

目的 分析和比较经皮肾镜取石术(PCNL)与输尿管软镜碎石术(RIRS)在孤立肾肾结石手术中的临床疗效及意义。方法 选取我院2010年3月至2016年5月收治的孤立肾肾结石患者61例，38例行PCNL术，患者逆行插管注水形成人工肾积水后改俯卧位，根据结石所在部位和积水程度，B超引导下行经皮肾穿刺，建立经皮肾取石通道。以F8/F9.8输尿管硬镜通过通道进入肾集合系统，采用钬激光碎石并冲洗出来;23例行RIRS术，患者至少术前员周留置D-J管，术中取截石位，取出术前留置D-J管后输尿管后硬镜直视下置入斑马导丝，沿导丝置入COOK输尿管鞘，然后插入输尿管软镜，检查窥见结石，置入钬激光光纤行碎石。两组患者均术后常规放置D-J管，对两组手术平均碎石时间、术后HGB下降程度、输血率、发热率、一/二期结石清除率及平均住院时间、术后月血清肌酐值进行比较。结果 PCNL组平均碎石时间及术后发热率明显少于RIRS 组(P<0.05)，术后HGB下降程度及平均住院时间显著多于RIRS组(P<0.05);术后脓毒血症发生率、输血治疗率、一期清石率、二期清石率(术后1月再次手术或体外碎石)、术后3月血清肌酐值等观察指标两组间比较，未见明显差别(P>0.05)。其中术后输血4例(10.5%)均发生在PCNL组，2例造瘘管夹闭后停止出血，2例行高选择性肾动脉栓塞治疗后未再出血。PCNL组术后发生脓毒血症1例，RIRS组3例，给予美罗培南/亚胺培南治疗后感染控制，安全出院。两组手术均无邻近脏器损伤，未改开放手术，未行肾切除及术后血透治疗。结论 传统的PCNL术治疗孤立肾肾结石具有手术时间短、术后感染几率小等优势，具有重要的临床价值，但是，随着临床医生熟练程度的不断提高，砸陨砸杂术凭借其创伤小、出血少、恢复快，且与PCNL 有类似的结石清除率等优势，在治疗孤立肾肾结石的过程中发挥着越来越重要的作用。

关键词：孤立肾；肾结石；经皮肾镜碎石取石术；输尿管软镜碎石术

中图分类号：R699文献标志码：A文章编号：2096-1413(2017)02-0001-03

Analysis of the clinical characters and effects of percutaneous nephrolithotomy (PCNL) and retrogradeIntrarenal surgery (RIRS) in solitary renal calculi therapy
FENG Yong 1, CHEN Wen-zhang 1, MAO Hui-feng 1, ZHANG Jun-ze 1, QU Wei-xing 2, CHEN Yong-yi 2
(1. Jingbian County People s Hospital of Shaanxi,Yulin 718500; 2. Shaanxi Procincial People s Hospital, Xi an 710060, China)

ABSTRACT: Objective To analyze the clinical characters and effects of percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) on solitary renal calculi therapy. Methods Sixty one cases of solitary renal calculus patients in our hospital from March 2010 to May 2016 were selected as the objects. Thirty-eight patients of them (PCNL group)were treated with PCNL method, of which the patients were placed in the prone position after retrograde catheterization and man -made hydronephrosis succeed. Then an ultrasound guided percutaneous renal access was established and the lithotripsy was performed. Used F8/F9.8 ureter mirror through the channel into the kidney collecting system, then complemented the holmium laser lithotripsy. The other 23 patients (RIRS group)were treated with RIRS method, of which the patients were placed in the lithotomy position, after taking out of the Doubt-J catheter inserted one-week before surgery, then an ureter sheath was introduced along the zebra guide wire, and flexible ureteroscopy lithotomy was conducted. The average gravel time, postoperative HGB decline degree, blood transfusion rate, heating rate, stone clearance rate of phase I andⅡ, and the average length of hospital stay, postoperative serum creatinine levels after three months were observed and analyzed. Results The operation time and fever rates caused by surgery of the PCNL group were significantly lower than those of the RIRS group （P<0.05）; the HGB decline degree in operation and postoperative hospital stay time of the PCNL group were higher and longer than those of the RIRS group; there was no significant difference in post-operation pyemia, the transfusion rate one-session stone free rate, two-session stone free rate and serum creatinine level measured 3 mouths after surgery between the two groups. Four patients (10.5% ) had blood transfusion in PCNL group, two of them stoped bleeding after nephrostomy tube clamped and the other two patients stoped bleeding after high selected kidney artery embolism therapy. One patient in the PCNL group and three patients in RIRS group suffered pyemia, they were discharged safely after meropenem/imipenem therapy. There was no organs hurt by mistake, no open surgery been carried, no nephrectomize and no blood dialysis treatment in all patients. Conclusion The traditional PCNL has the advantages of shorter operation time, smaller infection rate in solitary renal calculi therapy, while the therapy of RIRS makes great deal than before by the advantages of smaller injury, less bleeding and shorter hospital stay. So the RIRS therapy plays an important role in the process of treatment of isolated kidney stones.
KEYWORDS: solitary kidney; renal calculi; percutaneous nephrolithotomy (PCNL); retrograde intrarenal surgery (RIRS)

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