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目的:探讨螺旋CT三维重建联合肾脏血管造影(CTA)辅助彩色多普勒超声引导下精准穿刺建立皮肾通道在经皮肾镜取石术(PCNL)术中应用的可行性及价值。方法:对2012年9月~2013年10月采用CTA辅助彩色多普勒超声引导下精准穿刺在PCNL术治疗的96例肾结石患者进行回顾性分析。术前行CTA检查,制定手术方案,术中在彩色多普勒超声定位下避开血管精准穿刺建立F16~18的皮肾通道行经皮肾镜钬激光碎石术。结果:CTA可提供肾血管的清晰图像,有利于术中彩色多普勒超声引导下精准穿刺建立皮肾通道,96例患者均成功行PCNL术,时间50~160min,平均(96±47)min。术后复查腹部平片,11例显示残余结石>5 mm,行二期PCNL术,一期净石率约88.5%。术中发生较明显出血而影响手术视野1例,予留置肾造瘘管1周后进行二期PCNL术。本组患者发生术后延迟性大出血2例,但2例均经保守治疗血尿消失,痊愈出院。结论:CTA可提供肾盂肾盏集合系统、肾实质血管分布的清晰图像,明确结石与集合系统的关系,有利于术中彩色多普勒超声引导下精准确定经皮肾穿刺的部位及穿刺通道的建立,CTA辅助彩色多普勒超声引导下精准穿刺PCNL术具有定位精准、损伤轻、出血少及并发症少等优点,CTA辅助彩色多普勒超声引导下精准穿刺可作为经皮肾镜引导穿刺的首选方法。
Objective: To investigate the feasibility and value of using spiral CT three-dimensional reconstruction combined with renal angiography (CTA) assisted with color Doppler ultrasound to establish precise percutaneous puncture in the percutaneous nephrolithotomy (PCNL). Methods: Ninety-six patients with nephrolithotomy treated by PCNL under the guidance of CTA-assisted color Doppler ultrasound were retrospectively analyzed from September 2012 to October 2013. Preoperative CTA examination, the development of surgical options, intraoperative color Doppler ultrasound positioning to avoid the precise puncture of blood vessels to establish F16 ~ 18 of the renal access to Percutaneous nephrolithotomy holmium laser lithotripsy. Results: CTA could provide clear images of renal vessels and facilitate the accurate puncture of renal arteries guided by intraoperative color Doppler ultrasound. All 96 patients underwent PCNL successfully, with an average time of 96 ± 47 minutes . Postoperative abdominal plain film review, 11 cases showed residual stones> 5 mm, the second PCNL surgery, a net stone rate of about 88.5%. Intraoperative bleeding occurred more obvious impact of surgical field in 1 case, to be placed in renal fistula for 1 week after the second PCNL. Two patients had postoperative delayed massive hemorrhage in this group of patients, but two patients were hematuria disappeared after conservative treatment and were discharged. Conclusions: CTA can provide a clear picture of renal pelvis calyx collecting system and renal parenchyma, clarify the relationship between stones and collecting system, and help to accurately determine percutaneous renal puncture site and puncture channel under the guidance of intraoperative color Doppler ultrasound CTA-assisted color Doppler ultrasound-guided precision puncture PCNL surgery has the advantages of precise positioning, less damage, less bleeding and fewer complications, accurate puncture under CTA-assisted color Doppler ultrasound can be used as percutaneous nephrolithotomy The preferred method.