【摘要】：目的：自1976年Femstram經(jīng)皮腎鏡取石術(shù)(PCNL)成功后PCNL開始廣泛應(yīng)用于治療腎結(jié)石，國內(nèi)從1998年提出中國特點的B超引導(dǎo)下經(jīng)皮腎鏡取石術(shù)，其后PCNL逐步推廣應(yīng)用至全國，使經(jīng)皮腎鏡取石技術(shù)的應(yīng)用領(lǐng)域逐步擴大。雖然PCNL的安全性得到了廣泛的驗證，并發(fā)癥明顯較開放手術(shù)少且嚴(yán)重程度低。但作為一種有創(chuàng)操作，PCNL術(shù)中及術(shù)后所帶來的并發(fā)癥亦不容忽視，了解并發(fā)癥的原因，是預(yù)防和減少其發(fā)生的重要前提；而如何及時處理并解決已經(jīng)發(fā)生的并發(fā)癥至關(guān)重要。本課題通過回顧性分析的方法對B超引導(dǎo)下經(jīng)皮腎鏡碎石取石術(shù)治療腎結(jié)石并發(fā)癥影響因素與對策進行探討。 方法： 使用Excel軟件制成表格，記錄本院119例患者的各項臨床資料：年齡、性別、平均住院時間、結(jié)石大小、結(jié)石位置、單側(cè)/雙側(cè)結(jié)石、基礎(chǔ)病、術(shù)前尿路感染、中段尿細菌培養(yǎng)、術(shù)前腎功能、腎積水量、術(shù)中出血量、手術(shù)時間、使用單/雙/多通道完成手術(shù)、I期結(jié)石清除率、是否存在殘石及殘石大小、術(shù)后腎功能、造瘺時間、術(shù)后KUB結(jié)果、術(shù)中、術(shù)后并發(fā)癥、術(shù)后結(jié)石成分分析結(jié)果，并計算出相應(yīng)并發(fā)癥發(fā)生率。使用Excel軟件將歐洲泌尿外科雜志2007年發(fā)表大樣本PCNL手術(shù)并發(fā)癥發(fā)生率數(shù)據(jù)繪制成表。使用統(tǒng)計學(xué)分析對上述兩者進行比較并得出結(jié)論。 對本院119例患者的各項臨床資料：年齡、術(shù)前尿路感染、尿細菌培養(yǎng)陽性、結(jié)石大小、鹿角型結(jié)石、糖尿病、手術(shù)時間超過90分鐘、性別、是否存在腎積水、雙腎結(jié)石、開放手術(shù)病史進行統(tǒng)計，并對術(shù)中、術(shù)后出現(xiàn)并發(fā)癥進行統(tǒng)計，使用SPSS16.0軟件采用χ2檢驗，P＜0.05表示結(jié)果具有統(tǒng)計學(xué)意義。 結(jié)果： 我院出現(xiàn)嚴(yán)重并發(fā)癥與歐洲泌尿外科雜志發(fā)表大樣本PCNL手術(shù)并發(fā)癥百分率基本相符。我院119例接受經(jīng)皮腎鏡超聲碎石取石術(shù)患者，手術(shù)均成功，I期清除率為87.39%（104/119），平均手術(shù)時間為58.67±29.2分鐘，術(shù)中平均出血量為70.23±46.77ml。共發(fā)生嚴(yán)重并發(fā)癥8例,所有嚴(yán)重并發(fā)癥均出現(xiàn)于I期完成結(jié)石清除患者，發(fā)生率為6.72%（8/119）：分別為嚴(yán)重出血2例；胸膜損傷2例，灌注液外滲1例；術(shù)后延遲出血1例；術(shù)后重度感染2例。術(shù)后出現(xiàn)發(fā)熱（體溫＞38℃）35例,占29.41%,其中38-39℃之間21例,比例為17.64%（21/119）。12例在39-40℃之間，比例為10.08%（12/119）。2例大于40℃，比例為1.68%（2/119）。且發(fā)熱以混合型結(jié)石者合并術(shù)前尿培養(yǎng)陽性者居多。輸血7例，比例為5.88%（7/119）。無中轉(zhuǎn)開放手術(shù)病例，未發(fā)生腎貫通傷、腸管及腹腔臟器損傷等嚴(yán)重并發(fā)癥。 就產(chǎn)生發(fā)熱影響因素進行統(tǒng)計分析，結(jié)果表明年齡、術(shù)前尿路感染、尿細菌培養(yǎng)陽性者、結(jié)石大小、鹿角型結(jié)石、糖尿病、手術(shù)時間超過90分鐘具有統(tǒng)計學(xué)意義（P0.05，a=0.05）。而性別、是否存在腎積水、雙腎結(jié)石、開放手術(shù)病史無統(tǒng)計學(xué)意義（P0.05）。可以看出影響PCNL出現(xiàn)并發(fā)癥的危險因素為年齡、術(shù)前尿路感染、尿細菌培養(yǎng)陽性者、結(jié)石大小、鹿角型結(jié)石、糖尿病、手術(shù)時間超過90分鐘。 結(jié)論：腎結(jié)石的治療目前首選PCNL，且其具備對周圍臟器損傷小、術(shù)后恢復(fù)快、可多次手術(shù)等優(yōu)點，，并且術(shù)后殘石的治療可以選擇通過ESWL或輸尿管鏡進行后續(xù)治療。但是PCNL仍存在出血、損傷周圍臟器、發(fā)熱、感染等并發(fā)癥，只有通過對各種并發(fā)癥做出預(yù)防和正確的處理，才能使手術(shù)更加順利，安全的開展。泌尿外科醫(yī)師更加熟練的運用B超定位，并且結(jié)合CT、X線進行合理的穿刺通道選擇，可以減少出血；而優(yōu)秀的超聲碎石清石系統(tǒng)（EMS），可以將碎石與吸出結(jié)石同步完成，并且能通過負(fù)壓吸引取出視野外及掉落到輸尿管中的碎石渣，可以極大的縮短術(shù)中處理結(jié)石時間，提高手術(shù)效率；圍手術(shù)期抗生素的合理應(yīng)用可以有效預(yù)防感染，尤其是根據(jù)藥敏試驗合理用藥可以明顯降低術(shù)后發(fā)熱等并發(fā)癥的出現(xiàn)。嚴(yán)格掌握手術(shù)適應(yīng)癥是減少并發(fā)癥的前提，另外遵循學(xué)習(xí)曲線規(guī)律，提高術(shù)者的微創(chuàng)水平是減少并發(fā)癥的關(guān)鍵保證。
[Abstract]:Objective: Since the success of Femstram percutaneous nephrolithotomy (PCNL) in 1976, PCNL has been widely used in the treatment of renal calculi. In 1998, Chinese ultrasound guided percutaneous nephrolithotomy (PCNL) was proposed in China, and PCNL has been gradually extended to the whole country. Although the safety of PCNL has been achieved. Complications of PCNL can not be ignored as an invasive procedure. Understanding the causes of complications is an important prerequisite for preventing and reducing the occurrence of PCNL. How to deal with and solve the complications in time is very important. Objective To explore the influencing factors and Countermeasures of complications of percutaneous nephrolithotomy guided by B-ultrasound through retrospective analysis.
Method:
The clinical data of 119 patients were recorded by Excel software: age, sex, average hospitalization time, stone size, stone location, unilateral/bilateral calculi, underlying diseases, preoperative urinary tract infection, urinary bacteria culture, preoperative renal function, hydronephrosis, intraoperative bleeding volume, operation time, single/double/multi-channel operation. Surgery, stage I stone clearance, residual stone size, postoperative renal function, fistula time, postoperative KUB results, intraoperative and postoperative complications, postoperative stone component analysis results, and the corresponding complication rate were calculated. Excel software was used to draw large sample data of PCNL complication rate published in European Journal of Urology in 2007. Statistical analysis was used to compare the above two and draw a conclusion.
The clinical data of 119 patients in our hospital included age, preoperative urinary tract infection, positive urinary bacterial culture, stone size, staghorn calculi, diabetes mellitus, operation time over 90 minutes, sex, presence of hydronephrosis, double kidney calculi, open operation history, and complications during and after operation. SPSS16.0 software was used to analyze the complications. Chi square test was used. P < 0.05 showed that the result was statistically significant. 2.
Result:
The incidence of serious complications in our hospital was basically consistent with that of the large sample PCNL published in European Journal of Urology. 119 patients who underwent percutaneous nephrolithotomy were all successful. The clearance rate of stage I was 87.39% (104/119), the mean operation time was 58.67 (+ 29.2 minutes) and the mean intraoperative bleeding volume was 70.23 (+ 46.77 ml). Severe complications occurred in 8 cases, and all of them occurred in stage I patients, the incidence rate was 6.72%(8/119): 2 cases of severe hemorrhage, 2 cases of pleural injury, 1 case of perfusion extravasation, 1 case of delayed hemorrhage, 2 cases of severe infection, 35 cases (29.41%) of fever (body temperature > 38 39 C) occurred after operation. There were 21 cases (17.64%(21/119). 12 cases (10.08%(12/119). 2 cases (1.68%(2/119). Most of the cases with fever and mixed calculi complicated with positive urine culture before operation. 7 cases (5.88%) had no conversion to open surgery, no penetrating renal injury, intestinal and abdominal organ injury, etc. Serious complications.
The results showed that age, preoperative urinary tract infection, positive urinary bacteria culture, stone size, staghorn calculi, diabetes mellitus, operation time more than 90 minutes were statistically significant (P 0.05, a = 0.05). However, gender, the presence of hydronephrosis, double kidney stones, open surgery history was not statistically significant (P 0.05). It can be seen that the risk factors of PCNL complications are age, preoperative urinary tract infection, positive urinary bacterial culture, stone size, staghorn calculi, diabetes mellitus, the operation time is more than 90 minutes.
CONCLUSION: PCNL is the first choice for the treatment of renal calculi, and it has the advantages of less damage to the surrounding organs, quick recovery and multiple operations. ESWL or ureteroscope can be used for the follow-up treatment of residual calculi. Complications can be prevented and correctly handled so that the operation can be carried out smoothly and safely. Urological surgeons are more skilled in the use of B-ultrasound positioning, and combined with CT, X-ray puncture reasonable channel selection, can reduce bleeding; and excellent ultrasonic lithotripsy system (EMS), can be completed with stone aspiration, and It can greatly shorten the time of lithotripsy and improve the efficiency of operation by sucking out the lithotripsy residue out of visual field and dropping into ureter through negative pressure suction. The rational use of antibiotics during perioperative period can effectively prevent infection, especially the rational use of antibiotics according to drug sensitivity test can significantly reduce the occurrence of postoperative fever and other complications. Mastering surgical indications is the premise of reducing complications, and following the law of learning curve, improving the level of minimally invasive surgery is the key to reduce complications.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R692.4

【參考文獻】

相關(guān)期刊論文 前10條

1 李遜,曾國華,袁堅,吳開俊,單熾昌,郭彬,梁志雄;經(jīng)皮腎穿刺取石術(shù)治療上尿路結(jié)石(20年經(jīng)驗)[J];北京大學(xué)學(xué)報(醫(yī)學(xué)版);2004年02期

2 熊六林;黃曉波;葉雄俊;李建興;楊波;許清泉;馬凱;陳亮;王曉峰;高健;金龍;陳雷;;經(jīng)皮腎鏡術(shù)后腎臟嚴(yán)重出血特點及選擇性介入栓塞的時機選擇(附13例報告)[J];北京大學(xué)學(xué)報(醫(yī)學(xué)版);2010年04期

3 郭志宏,楊建軍;腹腔鏡泌尿外科手術(shù)并發(fā)癥[J];國外醫(yī)學(xué).泌尿系統(tǒng)分冊;2005年05期

4 李遜,何朝輝,曾國華,陳文忠,吳開俊,單熾昌,袁堅;上尿路結(jié)石的現(xiàn)代治療方法的探討(附5178例報告)[J];臨床泌尿外科雜志;2004年06期

5 鄧耀良;;復(fù)雜性腎結(jié)石的外科治療[J];臨床泌尿外科雜志;2006年02期

6 魏武;葛京平;馬宏青;張征宇;周文泉;周水根;王冬;高建平;;經(jīng)皮腎鏡鈥激光碎石術(shù)全身炎癥反應(yīng)綜合征發(fā)生的相關(guān)因素[J];臨床泌尿外科雜志;2007年04期

7 李凱;鐘明;唐順利;黃順壇;袁國奇;張勝林;;復(fù)雜性上尿路結(jié)石微創(chuàng)綜合治療的臨床應(yīng)用研究[J];臨床泌尿外科雜志;2010年01期

8 趙磊;張忠云;甘露;段啟林;黃桂曉;曾靜;黃樹聲;李偉東;;微創(chuàng)經(jīng)皮腎鏡取石術(shù)治療結(jié)石性膿腎的探討(附21例報告)[J];臨床泌尿外科雜志;2011年03期

9 陳興發(fā);;泌尿系結(jié)石診療指南解讀[J];現(xiàn)代泌尿外科雜志;2010年06期

10 張曉春;錢慶鵬;;經(jīng)皮腎鏡取石術(shù)的并發(fā)癥及其處理[J];現(xiàn)代實用醫(yī)學(xué);2007年04期

本文編號：2199205