One-stage nephrostomy and subsequent two-stage simultaneous percutaneous nephroscope combined with flexible ureteroscope for treatment of complex renal calculi with obstructive calculous pyonephrosis
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摘要: 目的 探讨一期肾造瘘后二期于斜仰卧截石位下肾镜联合输尿管软镜同期治疗伴有肾积脓的复杂型肾结石的临床应用和疗效。方法 对2016年1月—2021年6月46例结石梗阻性肾积水感染后形成肾积脓的复杂型肾结石患者，一期于彩超引导下行经皮肾穿刺造瘘引流，感染控制后，二期同时行肾镜联合输尿管软镜钬激光碎石取石术。分析结石清除情况及相关并发症发生情况。结果 46例患者均成功完成手术，无周边脏器损伤、尿脓毒症、术后出血、死亡等严重并发症发生。除体位摆放时间外，平均手术时间(55.58±14.37) min。术后住院天数(8.50±2.11) d。术后无一例患者需接受输血治疗，有2例出现发热，6例结石残留。结石一次完全清除率达86.96%。结论 对合并结石梗阻性肾积脓的复杂型肾结石，一期肾穿刺造瘘引流是治疗成功的关键，可以提高后续治疗的安全性。在安全的基础上，二期同时行经皮肾镜联合输尿管软镜钬激光碎石取石术，可以明显提高结石的清除率，临床效果显著、创伤小、术后恢复好，对肾积脓性复杂型肾结石的治疗有重要意义。Abstract: Objective To investigate the clinical application and effectiveness of one-stage nephrostomy and subsequent two-stage simultaneous percutaneous nephrolithotripsy combined with flexible ureteroscopic lithotripsy in the oblique supine lithotomy position for complex renal calculi with obstructive calculous pyonephrosis.Methods From January 2016 to June 2021, one-stage percutaneous nephrostomy guided by ultrasonography were performed on 46 patients with complex renal calculi with pyonephrosis secondary to calculous obstructive infectious hydronephrosis. After the infection was controlled, two-stage simultaneous percutaneous nephrolithotripsy combined with flexible ureteroscopic lithotripsy in the oblique supine lithotomy position were performed. Stone clearance rate as well as relevant complications were observed retrospectively.Results All 46 operations were performed successfully. None of the serious relevant complications such as splanchnic injuries, urosepsis, postoperative hemorrhage or deaths were observed. Excluding patient positioning time, mean operative time was (55.58±14.37) minutes. Postoperative hospital stay was (8.50±2.11) days. After the operation, no patient needed blood transfusion. Two patients had fever and 6 patients were examined with residual stone. One-step stone-free rate amounts to 86.96%.Conclusion One-stage nephrostomy is the key to successful treatment for complex calculi with calculous obstructive pyonephrosis. It provides safety for subsequent treatment. On the basis of safety, subsequent two-stage simultaneous percutaneous nephrolithotripsy combined with flexible ureteroscopic lithotripsy in the oblique supine lithotomy position improves initial stone-free rate for complex renal calculi with pyonephrosis secondary to calculous obstructive infectious hydronephrosis, with considerable clinical effect, minor surgical trauma and preferred postoperative recovery. It attaches great significance to the treatment of complex calculi with pyonephrosis.
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Key words:
- pyonephrosis /
- renal calculi /
- nephrostomy /
- percutaneous nephroscope /
- flexible ureteroscope
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表 1 2组患者一般资料比较
例(%)，X ± S 项目 观察组
(n=46)对照组
(n=40)χ2/t P值 性别 0.688 0.407 男 32(69.57) 31(77.50) 女 14(30.43) 9(22.50) 平均年龄/岁 55.76±12.25 53.17±13.11 0.947 0.347 BMI/(kg·m-2) 22.23±3.22 23.51±2.88 -1.93 0.056 肾积水 31.87 ＜0.001 无 0 4(10.00) 轻度 0 14(35.00) 中度 28(60.87) 20(50.00) 重度 18(39.13) 2(5.00) 结石位置 1.367 0.713 左肾 多发结石 19(41.30) 14(35.00) 鹿角形结石 5(10.87) 4(10.00) 右肾 多发结石 13(28.26) 16(40.00) 鹿角形结石 9(19.57) 6(15.00) 结石大小/cm 4.45±2.32 4.89±2.18 -0.902 0.37 
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表 2 2组患者手术相关指标比较
例(%)，X ± S 项目 观察组(46例) 对照组(40例) χ2/t P值 一期肾造瘘 46(100) 0 术中建立通道数 11.56 ＜0.001 单通道 46(100) 31(77.50) 双通道 0 9(22.50) 术中扩张通道大小 9.333 0.002 16F 46 (100) 40(100) 14F 0 9(22.50) 平均手术时间/min 55.58±14.37 104.33±29.82 -9.86 ＜0.001 二期术后血红蛋白下降＞10 g 2(4.35) 10(25.00) 7.6 0.006 术后住院时间/d 8.50±2.11 10.13±2.41 -3.34 0.001 1个月内再入院手术碎石 0 6(15.00) 7.418 0.006 术后并发症 ＜0.001 周围脏器损伤 0 0 术后发热＞38.5℃ 2(4.35) 6(15.00) 术后出血 0 5(12.50) 术后输血 0 5(12.50) 术后血管介入栓塞止血 0 2(5.00) 结石清除率 17.935 ＜0.001 完全清除 40(86.96) 20(50.00) 残余结石＜0.5 cm 4(8.70) 4(10.00) 残余结石0.5~1.0 cm 2(4.35) 8(20.00) 残余结石＞1.0 cm 0 8(20.00)
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