【摘要】：背景復雜性腎結石[1]是指鹿角形腎結石、多發(fā)性腎結石,伴有腎盞頸狹窄和腎盞擴張以及并發(fā)腎盞解剖異常的結石,如馬蹄形腎結石、海綿腎結石等。復雜性腎結石治療一直是泌尿外科較為棘手的問題,保持長期的無石率,降低結石復發(fā)率和感染率,積極保護腎功能是其治療目的。隨著泌尿外科微創(chuàng)技術的快速發(fā)展,經(jīng)皮腎鏡碎石術(Percutaneous nephroscope lithotripsy,PCNL)成為復雜性腎結石首選的治療方案,尤其是在處理多發(fā)結石與大型結石方面具有顯著成效,標準通道經(jīng)皮腎鏡碎石效果高,但標準通道較粗,擺動時容易出血盞頸撕裂,導致出血。在此基礎上出現(xiàn)了微創(chuàng)經(jīng)皮腎鏡碎石術(Minimally invasive percutaneous nephroscope lithotripsy,MPCNL)。單通道MPCNL氣壓彈道碎石術往往無法完全發(fā)現(xiàn)或徹底清除結石。多通道取石術可獲得較高的結石清除率,但易損傷腎實質(zhì),增加并發(fā)癥。故如何減少手術創(chuàng)傷,提高結石清除率成為臨床關注的焦點。目的探討單通道微創(chuàng)經(jīng)皮腎鏡氣壓彈道碎石聯(lián)合輸尿管軟鏡鈥激光碎石治療復雜性腎結石的臨床療效和安全性。方法將2015年3月至2016年7月我院收治的96例復雜性腎結石患者隨機分為兩組,每組各48例。對照組單用單通道MPCNL氣壓彈道碎石治療,觀察組單通道MPCNL氣壓彈道碎石聯(lián)合輸尿管軟鏡鈥激光碎石治療。所有患者術前均行泌尿系平片、泌尿系彩超檢查、靜脈泌尿系造影或CTU。兩組患者年齡、性別、結石大小、尿常規(guī)白細胞陽性率、尿培養(yǎng)陽性率無統(tǒng)計學差異。統(tǒng)計分析兩組患者結石清除率、手術時間、術后血紅蛋白變化、術后感染率、術后尿液轉(zhuǎn)清時間、并發(fā)癥發(fā)生率以及住院時間、住院費用等資料。結果觀察組結石取凈率93.75%(45/48)明顯高于對照組77.10%(37/48),差異顯著(P0.05);觀察組手術時間(58.1±25.2min)較對照組手術時間(46.8±20.5min)延長,具有統(tǒng)計學意義(P0.05);觀察組與對照組相比術中出血、術后感染、術后尿液轉(zhuǎn)清時間均無統(tǒng)計學意義(P0.05)。術后30min血白細胞較術前無明顯統(tǒng)計學意義,術后1h、2h較術前白細胞升高(P0.05)。術前尿常規(guī)白細胞異常術后感染發(fā)生率高,具有統(tǒng)計學意義(P0.05)。觀察組與對照組相關住院費用增加(P0.05),但住院時間無明顯延長(P0.05)。結論單通道MPCNL氣壓彈道碎石聯(lián)合腎造瘺輸尿管軟鏡鈥激光碎石治療復雜性腎結石療效確切,明顯提高結石清除效果。
[Abstract]:Background complex renal calculi [1] are staghorn kidney stones, multiple kidney stones, accompanied by renal calyceal neck stricture and renal calyceal dilatation, and complicated with renal calyceal anatomical abnormalities, such as horseshoe-shaped kidney stones, cavernous kidney stones, and so on. The treatment of complex renal calculi has always been a thorny problem in urology. To maintain a long-term stone-free rate, reduce the recurrence rate and infection rate of calculi, and actively protect renal function are the purposes of its treatment. With the rapid development of urological minimally invasive technique, percutaneous nephrolithotripsy (Percutaneous nephroscope lithotripsy,PCNL) has become the first choice for the treatment of complex renal calculi, especially in the treatment of multiple and large stones. The standard passageway has high effect of percutaneous nephrolithotripsy, but the standard channel is thicker, so it is easy to bleed breviscapus when swinging, which leads to bleeding. On this basis, minimally invasive percutaneous nephrolithotripsy (Minimally invasive percutaneous nephroscope lithotripsy,MPCNL) appeared. Single-channel MPCNL pneumatic lithotripsy often fails to completely detect or remove stones. Multi-channel lithotomy can obtain high stone clearance rate, but it is easy to injure renal parenchyma and increase complications. Therefore, how to reduce surgical trauma and improve stone clearance rate has become the focus of clinical attention. Objective to evaluate the clinical efficacy and safety of single-channel minimally invasive percutaneous nephrolithotripsy combined with ureteroscopic holmium: YAG laser lithotripsy in the treatment of complicated renal calculi. Methods from March 2015 to July 2016, 96 patients with complicated renal calculi were randomly divided into two groups with 48 cases in each group. The control group was treated with single-channel MPCNL pneumatic lithotripsy, and the observation group was treated with single-channel MPCNL pneumatic lithotripsy combined with holmium: YAG laser lithotripsy. All patients underwent plain urography, color Doppler urography, intravenous urography or CTU. before operation. There was no significant difference in age, sex, stone size, urine routine leukocyte positive rate and urine culture positive rate between the two groups. The data of stone clearance rate, operation time, postoperative hemoglobin change, postoperative infection rate, postoperative urine clearance time, complication rate, hospitalization time, hospitalization cost and so on in the two groups were statistically analyzed. Results the stone removal rate was 93.75% (45 / 48) in the observation group and 77.10% (37 / 48) in the control group, the difference was significant (P0.05). The operative time in the observation group (58.1 鹵25.2min) was longer than that in the control group (46.8 鹵20.5min) (P0.05). Compared with the control group, there was no significant difference in bleeding, postoperative infection and urine clearance time between the observation group and the control group (P0.05). There was no significant difference between the two groups before and after 30min, but at 1 h and 2 h after operation, the WBC levels were significantly higher than those before operation (P0.05). Preoperative urine routine leucocyte abnormality postoperative infection rate was high, with statistical significance (P0.05). The hospitalization cost of observation group and control group was increased (P0.05), but the length of hospitalization was not significantly prolonged (P0.05). Conclusion single-channel MPCNL pneumatic lithotripsy combined with ureterostomy ureteroscopic holmium: YAG laser lithotripsy is effective in the treatment of complicated renal calculi.
【學位授予單位】：新鄉(xiāng)醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R699.2

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