【摘要】：背景和目的經(jīng)皮腎鏡技術(shù)經(jīng)過半個(gè)多世紀(jì)的發(fā)展，在和傳統(tǒng)開放手術(shù)的競爭中，逐漸體現(xiàn)出獨(dú)特的優(yōu)勢，并成為了復(fù)雜性腎結(jié)石的首選治療方法。隨著科技的進(jìn)步，操作水平的提高，近年來不少科學(xué)家們逐漸意識到傳統(tǒng)經(jīng)皮腎鏡術(shù)后留置腎造瘺管給患者帶來的痛苦和諸多不便，進(jìn)而試圖淘汰這種落后的引流方式，并為此做了不少實(shí)驗(yàn)研究工作；但同樣也有不少學(xué)者不贊成這種觀點(diǎn)，認(rèn)為術(shù)后不放置腎造瘺管會(huì)引起嚴(yán)重并發(fā)癥，進(jìn)而給患者帶來更大的危害。帶著以上兩種觀點(diǎn)，并總結(jié)了之前學(xué)者們的工作經(jīng)驗(yàn)，我們開展了此次臨床對比研究，目的還是為了探討無管化經(jīng)皮腎鏡相對于傳統(tǒng)經(jīng)皮腎鏡處理上尿路結(jié)石的有效性和安全性，及在臨床工作中是否存在優(yōu)勢。 方法回顧性分析2011年1月-2013年10月期間，105例行經(jīng)皮腎鏡取石術(shù)（percutaneous nephrolithotomy，PCNL）的上尿路結(jié)石患者。其中39例行無管化經(jīng)皮腎鏡取石術(shù)（無管化組），另外66例行傳統(tǒng)經(jīng)皮腎鏡取石術(shù)（傳統(tǒng)組）。入選病例在性別、年齡、結(jié)石參數(shù)等指標(biāo)上均無明顯統(tǒng)計(jì)學(xué)差異（P＞0.05）。對兩組病例的手術(shù)時(shí)間、術(shù)后24h視覺模擬疼痛評分、鎮(zhèn)痛藥需求、感染發(fā)生情況、術(shù)后失血情況及輸血率、術(shù)后腸道功能恢復(fù)時(shí)間、腎周血腫及積液情況、術(shù)后住院時(shí)間、住院費(fèi)用等指標(biāo)進(jìn)行統(tǒng)計(jì)分析。 結(jié)果105例手術(shù)均成功完成，無中轉(zhuǎn)開放病例，無胸膜及腸管等周圍臟器損傷病例發(fā)生，無感染性休克病例發(fā)生。所有患者出院后均隨訪一月，無嚴(yán)重并發(fā)癥出現(xiàn)。無管化組與傳統(tǒng)組在手術(shù)時(shí)間（52.92±7.95min vs55.59±7.21min P＞0.05），，發(fā)熱發(fā)生率（9/39vs14/66P＞0.05），術(shù)后Hb下降值（8.00±4.03g/L vs8.62±4.33g/LP＞0.05），術(shù)后HCT下降值（4.29%±1.27%vs4.61%±1.36%P＞0.05），術(shù)后輸血率（0/39vs1/66P＞0.05），術(shù)后腸道功能恢復(fù)時(shí)間（15.55±5.59h vs16.74±6.58h P＞0.05），腎周血腫發(fā)生率（2/39vs7/66P＞0.05），腎周積液發(fā)生率（10/39vs28/66P＞0.05）及清石率（33/39vs58/66P＞0.05)方面無明顯統(tǒng)計(jì)學(xué)差異。而在術(shù)后24hVAS（2.41±1.32分vs4.54±1.65分P＜0.05），術(shù)后鎮(zhèn)痛藥的需求率（3/39vs15/66P＜0.05），術(shù)后恢復(fù)工作時(shí)間（14.97±4.73d vs20.18±5.25d P＜0.05），術(shù)后平均住院時(shí)間（5.82±1.00d vs7.76±1.45d P＜0.05），術(shù)后平均住院費(fèi)用（2805.41±385.63元vs4243.86±596.52元P＜0.05）方面均存在明顯統(tǒng)計(jì)學(xué)差異。 結(jié)論無管化經(jīng)皮腎鏡是對傳統(tǒng)經(jīng)皮腎鏡手術(shù)引流方式的改進(jìn)，通過臨床對比研究發(fā)現(xiàn)，在減少術(shù)后疼痛及鎮(zhèn)痛藥物需求，縮短住院時(shí)間、降低醫(yī)療費(fèi)用等方面具有優(yōu)勢。在經(jīng)嚴(yán)格篩選病例，熟練手術(shù)操作和術(shù)畢準(zhǔn)確判斷能否行無管化的基礎(chǔ)上，無管化經(jīng)皮腎鏡是一種效果可靠、安全、經(jīng)濟(jì)的方法，值得推廣應(yīng)用。
[Abstract]:Background and objective after more than half a century of development, percutaneous nephroscopy has gradually shown its unique advantages in the competition with traditional open surgery, and has become the first choice for the treatment of complex kidney stones. With the progress of science and technology and the improvement of operation level, in recent years, many scientists have gradually realized the pain and inconvenience caused by indwelling renostomy tube after traditional transcatheter renal endoscopy, and then tried to eliminate this backward drainage method, and have done a lot of experimental research work for this purpose. However, many scholars do not agree with this view, that the placement of renostomy tube after operation will cause serious complications, and then bring greater harm to patients. With the above two viewpoints and summing up the previous working experience of scholars, we have carried out this clinical comparative study in order to explore the effectiveness and safety of non-tubular percutaneous nephroscopy in the treatment of upper urinary calculi compared with traditional transcatheter nephroscopy, and whether there are advantages in clinical work. Methods from January 2011 to October 2013, 105 patients with upper urinary tract stones treated with percutaneous nephrolithotomy,PCNL were analyzed retrospectively. the results were as follows: (1) from January 2011 to October 2013, 105 patients with upper urinary calculi were analyzed. Among them, 39 cases were treated with non-catheterization and 66 cases with traditional percutaneous nephrolithotomy (traditional group), while 39 cases were treated with endoscophenoscopic lithotomy (non-tubular group) and 66 cases by traditional nephrolithotomy (traditional group), and the other 66 cases were treated with traditional nephrolithotomy. There was no significant difference in sex, age and stone parameters (P > 0.05). The operation time, visual simulated pain score 24 hours after operation, analgesic demand, infection occurrence, postoperative blood loss and transfusion rate, postoperative intestinal function recovery time, perirenal hematomas and fluid accumulation, postoperative hospitalization time and hospitalization expenses were statistically analyzed. Results 105 cases of operation were successfully completed, no cases of conversion to open, no cases of pleura and intestinal tract injury, no cases of septic shock occurred. All patients were followed up for one month after discharge, and no serious complications occurred. The time of operation (52.92 鹵7.95min vs55.59 鹵7.21min P > 0.05), the incidence of fever (9/39vs14/66P > 0.05), the decrease of Hb (8.00 鹵4.03g/L vs8.62 鹵4.33g/LP > 0.05), the decrease of HCT (4.29% 鹵1.27% vs 4.61% 鹵1.36% P > 0.05), the postoperative transfusion rate (0/39vs1/66P > 0.05). There was no significant difference in the recovery time of intestinal function (15.55 鹵5.59h vs16.74 鹵6.58h P > 0.05), the incidence of perirenal hematomas (2/39vs7/66P > 0.05), the incidence of perirenal fluid accumulation (10/39vs28/66P > 0.05) and the rate of stone clearance (33/39vs58/66P > 0.05). The postoperative 24hVAS (2.41 鹵1.32 vs4.54 鹵1.65, P < 0.05), the demand rate of postoperative painkillers (3/39vs15/66P < 0.05), the recovery time (14.97 鹵4.73 d vs20.18 鹵5.25 d P < 0.05), and the average postoperative hospital stay (5.82 鹵1.00 d vs7.76 鹵1.45 d P < 0.05), the postoperative recovery time (14.97 鹵4.73 d vs20.18 鹵5.25 d P < 0.05), the average postoperative hospital stay (5.82 鹵1.00 d vs7.76 鹵1.45 d P < 0.05). There were significant differences in the average postoperative hospitalization expenses (2805.41 鹵385.63 yuan vs4243.86 鹵596.52 yuan, P < 0.05). Conclusion Catheter is an improvement of traditional endoscopic drainage. Through clinical comparative study, it is found that it has advantages in reducing postoperative pain and analgesic drug demand, shortening hospitalization time and reducing medical expenses. On the basis of strict screening of cases, skillful operation and accurate judgment of tracheization at the end of operation, tubular percutaneous nephroscopy is a reliable, safe and economical method, which is worth popularizing and applying.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R699.2

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