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目的:探讨微创经皮肾镜取石术(mPCNL)治疗合并重度肾积水的上尿路结石的安全性及可行性。方法:本组342例,B超提示肾集合系统分离4.0~16.2cm。患肾积脓或超过1 000ml巨大肾积水均在术前B超引导下行肾造瘘,3个月后复查CT、ECT,肾皮质平均厚度>2mm,GFR>10ml/min,肾造瘘管引流量>400ml,尿比重>1.010再施行手术。术中在B超引导下穿刺并扩张建立16~20号经皮肾通道,采用科医人钬激光I期或Ⅱ期、Ⅲ期粉碎结石并冲出体外。结果:Ⅰ期手术结石清除时间20~180min,平均45min,术中出血约10~350ml,平均40ml。术后5天KUB复查,在肾区与输尿管走行区未发现结石影为结石取净。单纯输尿管上段结石Ⅰ期手术结石取净术为100%;肾铸型或多发结石、肾门结石、肾结石合并输尿管上段结石I期手术结石取净率76.3%。39例术后短期发热,3例术后出现较严重出血。237例随诊1个月~5年,输尿管狭窄4例,输尿管闭锁2例。结论:微创经皮肾镜取石术治疗合并重度肾积水的上尿路结石具有微创、安全和技术难度低的特点,但术后残石率和输尿管狭窄、闭锁的发生率较高,术中寻找肾门出口困难值得临床重视。
Objective: To investigate the safety and feasibility of minimally invasive percutaneous nephrolithotomy (mPCNL) in the treatment of upper urinary tract stones with severe hydronephrosis. Methods: This group of 342 cases, B ultrasound prompted renal collection system separation 4.0 ~ 16.2cm. Patients with pyometra or more than 1000ml of giant hydronephrosis were guided by preoperative B-ultrasonography. CT and ECT were reviewed after 3 months. The average thickness of renal cortex was> 2mm, GFR> 10ml / min, Flow> 400ml, urine specific gravity> 1.010 and then surgery. Surgery in the B-guided puncture and expansion of the establishment of 16 to 20 percutaneous renal access, the use of medical Holmium laser I or II, III crushed stones and out of the body. Results: Stage Ⅰ operation stone removal time 20 ~ 180min, an average of 45min, intraoperative bleeding about 10 ~ 350ml, an average of 40ml. KUB was reviewed 5 days after operation. No stones were found in the kidney area and ureteric area as stones. Simple ureteral calculi on stage Ⅰ surgical stone removal of 100%; renal cast or multiple stones, nephrolithiasis, kidney stones with upper ureteral calculi I stone surgery to take rate of 76.3%. 39 cases of short-term fever, postoperative more serious bleeding in 3 cases. 237 cases were followed up for 1 month to 5 years, 4 cases of ureteral stricture, 2 cases of ureteral atresia. Conclusion: Minimally invasive percutaneous nephrolithotomy for the treatment of upper urinary tract stones with severe hydronephrosis has the characteristics of minimal invasion, safety and low technical difficulty. However, the incidence of postoperative residual stone and ureteral stricture and occlusion is high, Surgery to find the export of renal portal deserves clinical attention.