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一期输尿管软镜联合经皮肾镜治疗鹿角形结石合并脓肾的疗效和安全性

Single-stage percutaneous nephrolithotomy combined with flexible ureteroscopy for the management of staghorn calculi with pyonephrosis

摘要:

目的:探讨一期输尿管软镜(FURS)联合经皮肾镜取石术(PCNL)治疗鹿角形结石合并脓肾的可行性、有效性和安全性。方法:回顾性分析北京大学第三医院2017年5月至2019年12月采用一期FURS联合PCNL治疗的13例鹿角形结石合并脓肾患者的病例资料,男7例,女6例。年龄52.5(33~68)岁。临床表现为间断发热9例,腰部不适6例,肉眼血尿1例,2例无明显临床表现。8例合并糖尿病。CT检查示完全型鹿角形结石6例,部分型7例;结石位于左侧7例,右侧6例;4例伴中/重度肾积水,9例伴轻度肾积水。影像学检查评估结石负荷(1 070.9±397.0)(507.4~1 809.5)mm 2。13例术前均行尿细菌培养及药敏试验。4例住院时有发热症状者术前留置患侧输尿管支架管≥1周。所有病例术前应用抗菌药物≥1周,待感染症状及感染相关指标恢复正常后接受手术治疗。手术采用全麻,患者取改良Valdivia体位。先经尿道置入FURS到达患侧肾盂,B超及FURS引导下在患侧腋中线和肩胛旁线之间、12肋下建立经皮肾标准通道,单通道PCNL下采用负压吸引装置吸出脓液并处理视野范围内的结石,再联合FURS处理其他肾盏结石。术中PCNL穿刺成功后,均可见肾内浑浊脓性尿液排出,留取肾内尿液送检细菌培养及药敏试验。本组13例均经术中肾盂尿细菌培养结果确诊为脓肾。术后常规留置输尿管支架管和肾造瘘管,继续抗感染治疗。术后第1~3天行影像学检查,评估结石清除率,残留结石≥4 mm为有意义的结石残留。 结果:本组13例手术均顺利完成,手术时间(94.2±21.8)(65~135)min。一期结石清除率76.9%(10/13)。术后6例出现全身炎症反应综合征,无脓毒血症及≥Clavien-Dindo Ⅲ级并发症发生。术后中位随访12(3~24)个月,4例患侧结石复发,2例患侧轻度肾萎缩,随访期间无患侧上尿路感染复发。结论:FURS联合PCNL是治疗鹿角形结石合并脓肾的有效方法,具有良好的疗效和安全性。

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abstracts:

Objective:To evaluate the feasibility, safety and efficacy of single-stage percutaneous nephrolithotomy (PCNL) combined with flexible ureteroscopy (FURS) for the management of staghorn calculi with pyonephrosis.Methods:A total of 13 patients of staghorn renal calculi with pyonephrosis, which was diagnosed by intraoperative pelvic urine bacteria culture, were treated by PCNL combined with FURS from May 2017 to December 2019. Of all the 13 patients, 7 were males and 6 were females, with mean age of 52.5 years, ranged from 33 years to 68 years. The mean stone burden was (1 070.9±397.0) mm 2, ranged from 507.4 mm 2 to 1 809.5 mm 2. Bacteria culture and microbial sensitivity test was performed for all the patients. Four patients with fever on admission accepted ureteral stenting at least a week before the surgeries. All the patients received preoperative antibiotic therapies for at least a week, and the infective symptoms and inflammatory indexes was normal before the surgeries. Under general anesthesia, the procedures were performed in a modified supine Valdivia position. After the transurethral FURS was performed, the standard percutaneous track was placed at the subcostal point between mid-axillary line and scapular line under the FURS and ultrasounic guide. The purulence and the stones were shattered and removed by PCNL with negative pressure system, and FURS helped to shatter and move out the stones beyond the PCNL reach through the same tract. A double-J tubes and a nephrostomy tube was routinely indwelled postoperatively. A radiological imaging was performed within three days after the operation to evaluate the stone free rate. The residual stone was defined as the stone larger than 4 mm. Results:All the procedures were successful. The one-stage stone free rate was 76.9% (10/13). The mean operation time was (94.2±21.8) min, ranged from 65 to 135 min. Six patients suffered postoperative systemic inflammatory response syndrome, and no patient occurred sepsis or complications of Clavien-Dindo classification Ⅲ or above. They were followed up for 3-24 months with median of 12 months.Four cases with recurrence of ipsilateral stones, two cases with ipsilateral mild renal atrophy, no recurrent ipsilateral upper uninary infection were found in the followup.Conclusions:Single-stage PCNL combined with flexible ureteroscopy could be feasible for the management of staghorn calculi with pyonephrosis with safety and efficacy.

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作者: 刘余庆 [1] 邱敏 [1] 刘可 [1] 卢剑 [1] 肖春雷 [1] 马潞林 [1]
期刊: 《中华泌尿外科杂志》2020年41卷4期 267-271页 ISTICPKUCSCD
栏目名称: 泌尿系结石合并感染的诊治
DOI: 10.3760/cma.j.cn112330-20200130-00048
发布时间: 2024-03-19
基金项目:
北京健康促进会课题项目 Beijing Health Promotion Association Project
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