留置输尿管外支架的无管化经皮肾镜取石术的应用研究
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摘要
研究背景：
经皮肾镜取石术(PCNL)由于创伤小、效果确切、并发症少,成为治疗上尿路结石的主要手段。标准PCNL术后通常须放置肾造瘘管,肾造瘘管的作用是压迫瘘道起止血作用、避免尿液外渗及引流肾脏内尿液。但肾造瘘管可引起患者术后疼痛不适,或者造瘘管周围尿外渗,增加止痛药物的使用量,延长住院时间。为了提高患者术后舒适度,PCNL的发展有两种趋势：一是更微创化,即穿刺通道变细,对肾脏损伤也更小；二是无管化(tubeless PCNL),即经皮肾镜取石术后有选择性地对患者不留置肾造瘘管,可放置或不放置输尿管支架管引流,从而避免留置造瘘管给患者带来的疼痛不适。
Jackman等最早在1997年应用微通道经皮肾镜取石术治疗小儿上尿路结石。随后被多项研究应用此项技术治疗成人上尿路结石,他们报道微通道可减低PCNL出血的风险,但因细小的工作通道导致手术时间延长,因此其应用范围仅限于结石负荷相对较小,肾盏颈相对狭小的病例。在此基础上,李逊等进行了一系列的改进,包括选择后组肾中盏入路,通道缩小至16F至20F,并配备相应的肾镜,使用相应的灌注泵把结石冲洗出体外,大大缩短手术时间,提高了手术效率。而且钟文等通过实验证实,微通道经皮肾镜取石术中肾盂内压小于30mmHg(肾盂返流的阈值),提示微通道PCNL是安全。目前全世界已经有关微通道PCNL的报道已经超过1万例,其安全性和有效性不断被报道。而且,与标准通道相比,微通道因失血需要输血的发生率较低。因此,微通道经皮肾镜取石术具有较广阔的应用前景。
无管化的概念最早由Wickham于1984年提出,他报告了100例tubeless PCNL,患者术后既不留置肾造瘘管,也不留置输尿管内外支架管,可在24小时内安全出院。然而,1986年Vnfield报道2例患者在PCNL术后由于造瘘管未留置于正常位置而发生严重血尿和尿外渗,需要输血和重新放置内支架,导致住院时间延长,他推荐PCNL术后使用肾造瘘管引流24-48小时。大多数学者认为PCNL术后不留置造瘘管的手术风险较大,因此PCNL术后留置造瘘管成为常规。但近年由于PCNL技术的不断提高,留置肾造瘘管带来的不适感和较长的住院时间使无管化PCNL重新受到重视,国外关于无管化PCNL的报道渐渐增多,认为对经选择的患者行PCNL而不留置肾造瘘管是安全的,并不引起严重并发症,且能明显改善患者术后生活质量。国内对无管化PCNL术仅有零星的报道。
并不是所有的PCNL患者均适合无管化。目前仍无明确指征规定究竟哪些患者适合行无管化PCNL。一般认为,无管化PCNL的适应证为：①结石直径小于3cm；②通常为单一通道；③PCNL术后无明显结石残留；④无明显集合系统穿孔；⑤出血较少;⑥无须行二期手术；⑦不是合并重度肾积液。然而,近年来,无管化PCNL也成功应用于肾多发性结石、分枝型的复杂性结石、肾铸型结石、合并UPJ梗阻的上尿路结石、各种不同程度肾积水的上尿路结石,甚至肥胖患者、儿童患者,和既往有开放尿路结石手术的患者。
普遍认为过度出血、需行二期手术(肾盂积脓,有明显结石残留)、集合系统广泛损伤是绝对禁忌证。下列情况也应尽可能避免：活动性尿路感染,有肾手术或体外震波碎石史,存在先天性尿路异常,血肌酐水平上升和孤立肾患者,术中发生并发症(穿孔等并发症),手术时间较长(超过2h),存在明显尿路梗阻(如输尿管有结石或狭窄,重度前列腺增生影响排尿者),应用抗凝药物,超过2个通道者。
文献报告tubeless PCNL有多种形式。①完全无管化。即在PCNL术后不放置肾造瘘管和输尿管支架管引流,而依靠输尿管自然引流,患者没有肾造瘘管和输尿管支架管引起的不适,但是术后可能出现小血块、小结石,或输尿管水肿引起输尿管梗阻,须再次置管引流。因此完全无管化未被广泛接受,仅被少数医疗机构发表例数较少的病例报告。②留置双J管引流的tubeless PCNL。此法是较为常用的无管化PCNL的形式之一,PCNL术后留置一双J管,但不留置肾造瘘管。其优点是避免小结石或血块造成输尿管梗阻,尤其适合有结石残留需要辅助体外震波碎石术者,或存在结石以外的输尿管梗阻须留置支架引流者。其不足之处是可能双J管会造成膀胱刺激症、膀胱-输尿管返流、肾盂内压升高、尿外渗致肾周尿性囊肿、削弱了输尿管的蠕动,造成一定程度的输尿管梗阻,而且术后患者须用膀胱镜拔除双J管,增加经济负担以及手术操作引起的不适。③留置带绳的双J管。放置一条近端带绳的双J管,绳子经肾造瘘口引出,并固定于腹壁上,术后在病房拔除双J管。若须二期经皮肾手术,可把双J管近端拔出至皮肤外,向双J管的内腔插入导丝,重新经原瘘口建立肾造瘘通道。④留置输尿管外支架。把原来逆行插入的输尿管导管的头端调整至肾盂的中央,末端固定在尿管上。Mouracade认为采用输尿管外支架作引流可免于膀胱镜拔支架管,而且没有留置双J管的不适感,具有可行性。
输尿管外支架与双J管的引流机制可能存在较大的差异,Fine等通过同位素视踪证实,双J管的引流是由膀胱内尿液经过双J管的内腔返流至肾盂,由返流的尿液触发肾盂输尿管的蠕动,尿液经双J管与输尿管之间空隙引流至膀胱。由此推测,放置双J管的患者可能存在膀胱输尿管返流,存在肾盂内压增高情况。而留置输尿管外支架的末端连接至体外,膀胱输尿管返流可能相对较轻,肾盂内压可能相对较低,引流效果或许较双J管可靠,可能有利于tubeless PCNL。
微通道与无管化同时结合的经皮肾镜取石术,国内外较少报道。本课题包括一项回顾性研究主要探索留置输尿管外支架微通道tubeless PCNL的安全性与有效性,一项动物实验研究主要比较输尿管外支架引流与双J管引流对肾盂内压的影响,一项前瞻性对照研究主要比较微通道tubeless PCNL采用输尿管外支架引流与采用双J管引流的差异。
第一章留置输尿管外支架的微通道无管化经皮肾镜取石术的可行性研究
目的探讨留置输尿管外支架的微通道无管化经皮肾镜取石术(tubeless PCNL)的安全性和有效性。
方法回顾性分析101例留置输尿管外支架的微通道tubeless PCNL治疗肾或输尿管上段结石的患者资料。男53例,女48例。年龄(47.5±14.7)岁。右侧54例,左侧46例,双侧1例。其中肾脏或输尿管上段单发结石67例(65.7%),多发性结石34例(34.3%)。结石最大径为(25.4±12.8)mm。合并患肾轻度积液41例,中度积液42例,重度积液18例。术前合并泌尿道感染21例(20.8%)。
联合B超和C臂X线定位,用穿刺针穿刺成功后退出针芯,置入0.028-inch斑马导丝,用筋膜扩张器从8F扩张到18-20F,并留置相应Peel-away鞘,采用气压弹道碎石器在微创肾镜直视下将结石击碎,通过MMC液压灌注泵冲洗出,或用5F取石钳夹出。
在经皮肾镜取石术结束时,通过B超和C臂X线证实结石已经完全清除,然后把逆行插入的输尿管导管的头端调整至肾盂的中央,让扩张鞘退至肾造瘘通道以外,证实瘘道无活动性出血,最后拔除扩张鞘,并用丝线缝合皮肤伤口。
结果101例患者,共建立100例个通道,其中采取单一通道取石者93例(91.2%),采用两个通道取石者7例,采用三个通道取石者1例；采用四个通道取石1例。95例患者(94.1%)术后结石被完全清除,6例为无意义残留结石。手术时间(54.1±13.7)min。手术引起血红蛋白下降(7.6±8.9)g/L。术后第1d视觉疼痛评分为(2.0±1.6)分。术后拔除输尿管外支架拔除时间为(2.3±1.6)d。术后住院天数(3.4±1.9)d。并发症：1例出现进行性肾出血,须行选择性肾动脉造影+栓塞术；2例手术当天出现急迫性尿失禁,予以拔除尿管和输尿管外支架后好转；1例出现肾周血肿,大小为23mm×68mm,未作特殊处理；10例出现术后发热,术后第3-5d拔除输尿管外支架和尿管,加强抗炎治疗治愈；2例术后出现持续性血尿,予保守治疗治愈；轻度尿外渗2例,予以对症处理好转。术后3个月随访,均无出现严重出血、发热和邻近器官损伤等并发症,没有因为输尿管阻须再次置管引流或肾造瘘引流。4例残留结石自行排出,另2例残留结石无变化。
结论在严格掌握手术适应证的前提下,留置输尿管外支架的微通道tubeless PCNL是安全和有效的,可以减少止痛药的使用,缩短住院时间,减少治疗费用。
第二章输尿管外支架管与双J管对实验大白兔肾盂内压的影响
目的比较留置输尿管外支架与留置双J管在实验大白兔肾盂内压的差异。
方法选取新西兰大白兔15只,平卧固定于手术台上,经尿管注入生理盐水,使膀胱膨胀。取下腹部正中切口,暴露膀胱和尿道、分离双侧肾脏及双侧输尿管,根据双侧输尿管的走行寻找双侧输尿管开口,经尿道向双侧输尿管开口方向插入2F硬膜外导管,双侧均插向肾盂中央,左侧作为外支架组,右侧把硬膜外导管剪断,末端送入膀胱,作为内支架组,再次调整左右支架的位置,让双侧支架的头端均位于肾盂的中央,左侧外支架的末端在尿道口,右侧内支架的末端位于膀胱中央。
经尿道插入专用的膀胱测压管,用丝线把测压管捆绑于尿道,连接专用灌注管。膀胱测压管连接压力传感器。
采用专用测压穿刺套针,经双侧肾脏中部向肾盂向穿刺,穿中后拔除针芯,并把针的末端调整至肾盂中央,并连接压力传感器。
比较左右两侧肾盂内压的差异。
结果右侧肾盂内压(内支架)为(14.08±1.74)mmHg,左侧肾盂内压(外支架)为(9.68±2.24)mmHg,两者比较有显著统计学差异。
结论放置输尿管外支架的肾盂内压低于放置双J管。
第三章留置输尿管外支架微通道无管化经皮肾镜取石术的前瞻性对照研究
目的采用前瞻性研究的方法比较留置输尿管外支架和留置双J管无管化经皮肾镜取石术的治疗效果。
方法2011年12月至2013年1月对符合无管化PCNL的病人采用随机数字表进行前瞻性分组。随机分成两组,一组留置输尿管导管(56例),另一组留置双J管(53例),共计109例。入选标准：①年龄在18周岁(含)至70周岁(含)之间；②术前无泌尿系统感染；③结石最大径≦4cm；④仅限于建立一个工作通道；⑤术中没有活动性出血；⑥术中没有肾脏集合系统及输尿管损伤；⑦C臂X线透视和尿路造影显示无结石残留或无意义残留结石(<4mm)。
通过比较两组病人的年龄、性别构成、体重指数、肾积水程度、结石大小等术前资料,分析手术时间、手术出血、VAS疼痛评分、止痛剂需求、住院天数、住院费用等方面有无差异。
结果两组病人各项术前资料、术后指标均无统计学差异。然而留置双J管组患者术后需要返院通过膀胱镜拔管,增加了额外的费用,且所有病人均合并有不同程度的支架管不适。
结论留置输尿管外支架的经皮肾镜取石术在治疗上尿路结石是安全可行的,和留置双J管的经皮肾镜取石术相比有同等的疗效,可以替代双J管,且显示了其独特的优异性。
Background
Based on its excellent outcomes and acceptable low morbidity, Percutaneous nephrolithotomy(PCNL) is considered the treatment of choice for complex renal or impacted upper ureteral calculi over the last30years, since Fernstro'm and Johansson first described it in1976. Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. Previously it was thought that nephrostomy tubes provide hemostasis along the tract, avoid urinary extravasation, and maintain adequate drainage of the kidney. Placement of nephrostomy tubes may increase postoperative pain, analgesia requirement, and hospital stay. In recent years,'Mini percutaneous nephrolithotomy'('mini-perc') and Tubeless PCNL' have been introduced with the aim to decrease the morbidity of this already established procedure.
Micro-channel percutaneous nephrolithotomy (mPCNL) was first described by Jackman and associates for the application of PCNL to infants. Its use in adults has been subsequently described by several groups. They reported that the small tract significantly decreased the bleeding risk of traditional PCNL, but its indication was limited since the small percutaneous working sheath may increase the operating time. On this basis, Li X et al. modified the technique through a variety of ways,including preferring mainly posterior middle calyx access to inferior calyx access, using a specially designed nephroscope via the16F to20F tract,and using a pulse perfusion pump to flush out the stone fragments helped to shorten the operative time. Zhong W et al. also confirmed that intrapelvic pressure was lower than the level needed for a backflow(30mmHg) during mPCNL procedures. During the last10years, more than10,000mPCNL procedures performed to manage all kinds of upper urinary tract calculi were reported. The safety and efficacy of mPCNL have also been confirmed by recent reports. Furthermore, mPCNL has significantly lower incidence of bleeding necessitating transfusion in comparison with the standard PCNL
It may be interesting to note that the idea of 'tubeless' existed even in the early years of evolution of PCNL. In1984, Wickham published the results of100patients in which no internal or external drainage tubes were used at the conclusion of case. Authors stated that with this approach, patients could leave the hospital within24h and the procedure was safe and efficient with a shorter hospital stay. However, subsequently Winfield et al. reported two patients with complications of premature nephrostomy-tube removal after the extraction of simple upper-tract calculi, who experienced serious hemorrhage and marked urinary extravasation necessitating transfusion, internal stenting, and prolonged hospitalization. They recommended that nephrostomy tube drainage should be provided during the first24to48h after percutaneous stone extraction, which subsequently became the standard practice for PCNL worldwide. However, in recent years, the procedure has been modified to what has been called 'tubeless' PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. More and more cases of tubeless PCNL were reported.
Not all cases are suitable for being performed tubeless PCNL.There are no widely acknowledged selection criteria for tubeless PCNL. In general, the selection criteria for tubeless PCNL include stone burden<3cm, a single access tract, no significant residual stones, no significant perforations, minimal bleeding, and no requirement for a secondary percutaneous procedure. However, in recent years, the tubeless technique has been applied for the treatment of multiple stones, branching and complex stones, staghorn stones, concurrent UPJ obstruction, and collecting systems with various degrees of hydronephrosis. The technique has been successful in obese patients, children, and patients with recurrent stones after open surgery.
The general consensus is that the tubeless approach is feasible only in a selected population that generally excludes cases of significant intraoperative bleeding, or situations with a likelihood of residual stone fragments,or situations with intensive renal pelvic or calyx injuries. Some cases is not indicated for tubeless PCNL, such as uncontrolled urinary infection, with histories of open urinary calculi operations or ESWL, concurrent congenital urinary tract anomaly, renal insufficiency, solitary kidney, intraoperative complications (perforation or bleeding), operating time more than2hours, severe urinary obstruction (ureteral stenosis or severe benign prostatic hyperplasia), oral anticoagulating agents, and multiple tracts.
Literature has reported many types of tubeless PCNL. In the literature, tubeless PCNL studies are reported but only a few are totally tubeless PCNL. There are no discomforts of tubes and stents in those cases. These studies favor the suggestion that the best available drainage of the kidney is the normal peristalting ureter. However, this approach has not formed universal acceptability due to the concerns relating to the obstruction of ureter due to clots or stone fragments. Most authors seem to favor some kind of internal drainage in tubeless procedures. The most common type is tubeless PCNL with a double-J stent. It is suitable for those cases with residual stones after PCNL or upper urinary tract obstruction. One major disadvantage of tubeless PCNL with double-J stent is the need for postoperative cystoscopy to remove the stent. Another type is tubeless PCNL with a Tether. Bellman et al. suggested the placing of a7F/3F tailed stent with an attached string exiting the urethral meatus, which can be used to pull the stent out afterward in office setting to avoid the need of cystoscopy. However this procedure has the disadvantage that some patients may remove their stents prematurely by inadvertently pulling on the tether. Additional variations of the tubeless procedures have been described. Mouracade et al. prospectively analyzed the outcomes of tubeless PCNLs using two different stenting techniques, externalized ureteral catheter versus double-J stent placement. They concluded that externalized ureteral catheter is as feasible as a double-J stent. Moreover, stent-related discomfort and the need for postoperative cystoscopy to remove the double-J stent can be avoided with an externalized ureteral catheter. However, they suggested that in patients who are not completely stone-free at the end of the procedure, use of a double-J stent may be more beneficial as it may help in spontaneous passage of small residual fragments.
The mechanisms between the externalized ureteral stent and the double-J stent may be different. Fine et al. reported fluoroscopic observations and drainage mechanisms of double-J stent. The urine from the bladder refluxed from the inner chamber of the stent to the renal pelvic. The refluxed urine in the renal pelvis triggered the peristalsis of the ureter. The vesicoureteric reflux and elevated renal pelvic pressure existed in the patients with double-J stent. Hower, the end of the external ureteral stent is in vitro. The vesicoureteric reflux may be slight and the renal pelvic pressure may be low in the patients with externalized ureteral stent.
Only a few literature compared tubeless PCNL with standard PCNL.So far, there are no literature to study micro-channel tubeless PCNL.
In order to investigate the the safety and efficacy of micro-channel tubeless PCNL with a externalized ureteral catheter, we initiated this projects. This projects include a retrospective study, a prospective study and a experimental research. The retrospective study will investigate the effectiveness and safety of micro-channel tubeless PCNL with an externalized ureteral catheter. The prospective study will investigate the differences between an externalized ureteral catheter and and double-J stent in micro-channel tubeless PCNl. The experimental research will investigate the differences of renal pelvic pressure in experimental white rabbits between indwelling a externalized ureteral catheter and a double-J stent.
Section Ⅰ Safty and efficacy of micro-channel tubeless percutaneous nephrolithotomy with a externalized ureteral catheter:a retrospective study
Objective To review the safety and efficacy of micro-channel tubeless percutaneous nephrolithotomy (tubeless PCNL) with a externalized ureteral catheter.
Methods From May2010to Dec2012,101patients (53males and48femals,mean age of47.5years) of renal or proximal ureteral calculi treated by micro-channel tubeless PCNL with a ureteral catheter were reviewed. The calculi were in right side in54patients, in the left side in46, and in the bilateral sides in one pantient. Single renal or upper ureteral stone was found in34(34.3%) patients, and multiple calculi in67(65.7%) patients. The stone burden was (25.4±12.8) mm. Of101cases, mild hydronephrosis was found in41cases, moderate hydronephrosis in42cases,and severe hydronephrosis in18cases.
The kidney was punctured under ultrasonagraphic or/and fluoroscopic guidance. Once the pelvicalyceal system (PCS) was entered, a0.028-inch hydrophilic Zebra guidewire was manipulated down the ureter if possible, or coiled in a distant calyx. The track was dilated using a fascial dilator (Cook Urological, Spencer,IN) from8F to16F or20F. The corresponding peel-away sheath (Cook Urological, Spencer, IN) was placed as the percutaneous access port. Subsequently, a8.5F/11.5F nephroscope (Lixun Nephroscope, Richard Wolf, Knittlingen, Germany) was inserted to inspect the collecting system. Under direct vision, the stone was fragmented by pneumatic lithotripsy(Richard Wolf, Knittlingen, Germany).Most of the fragments(<0.3cm) were mainly pushed out with an endoscopic pulsed perfusion pump (MMC Yiyong, Guangzhou, China)and the big fragments (0.3cm-0.5cm) were extracted with a5F forceps (Richard Wolf, Knittlingen, Germany).
At the end of the procedure of PCNL, the calculi were cleared under the monitoring of C-armed fluoroscopy and B-ultrasound. The head end of the ureteral catheter was adjusted in the center of renal pelvis. The peel-away sheath was removed when no active bleeding was confirmed.
Results Of101patients,110tracts were established. Of110tracts, single tract was established in93(91.2%)cases, double tracts in7cases, three tracts and four tracts in one case respectively. Stone-free was found in95(94.1%) patients, and insignificant residual stone in6patients.The average operative time was (54.1± 13.7) min. The mean hemoglobin drop was (7.6±8.9) g/L. The visual analogue score on the first postoperative day was (2.0±1.6). The average time of ureteral catheter removal was (2.3±1.6) d. The average postoperative hospital stay was (3.4±1.9) days. The complications included one servere renal hemorrhage requiring selective renal arterial radiography and embolism,one urge incontinence, one perirenal hematoma, ten postoperative fever, two persistent macrohematuria, and two mild urinary extravasation.
Conclusions Under the premise of strict surgical indications, micro-channel tubeless PCNL with a ureteral catheter was safe and effective for the treatment of upper urinary calculi. It can reduce hospitalization time and analgesic requirement, and promotes quality of life in selected patients.
Section Ⅱ The differences of renal pelvic pressure in experimental white rabbits indwelling between a externalized ureteral catheter and a double-J stent
Objective:To investigate the differences of renal pelvic pressure in experimental white rabbits between indwelling a externalized ureteral catheter and indwelling a double-J stent.
Methods:Fifteen experimental white rabbits were chosen in the experiment. A externalized ureteral catheter was indwelled in the right upper urinary tract of white rabbits, and a double-J stent was in the left side. The renal pelvic pressure was messured by a baroreceptor. Compared the differences of of renal pelvic pressure in experimental white rabbits indwelling a externalized ureteral catheter with a double-J stent.
Results:The renal pelvic pressure was (14.08±1.74) mmHg and (9.68 ±2.24) mmHg in the externalized ureteral catheter group and in the double-J stent group respectively. There are significant statistic differences between the two groups between the two groups.
Conclusion:The renal pelvic pressure in the experimental white rabbit indwelling a externalized ureter catheter was lower than indwelling a double-J stent.
Section Ⅲ Effectiveness of micro-channel tubeless percutaneous nephrolithotomy with a externalized ureteral catheter in selected patients:a prospective randomized study
Objective:We prospectively analysis the outcome of micro-channel tubeless percutaneous nephrolithotomy using two different stenting techniques (i.e., a externalized ureteral catheter compared with Double-J placement).
Methods:109patients who were undergoing tubeless PCNL between December2011and January2013in our hospital were randomized to two groups:tubeless PCNL with ureteral catheter and tubeless PCNL with Double-J placement, respectively56cases and53cases.
Inclusion criteria for the study were the stone burden less than4cm, no urinary infection,no serious bleeding or perforation in the collecting system during the operation, stone free or clinically insignificant residual fragments (CIRF<4mm), and no more than one access.
The two groups were comparable with regard to age, sex, BMI, stone size, hydronephrosis. Factors evaluated included operative time, postoperative hemorrhage, visual analogue pain scale (VAS), analgesic requirement, hospitalization stay, hospitalization expenses and stent-related symptoms.
Results:There were not statistically significance in the preoperative data and postoperative indexes. However, the patients with double-J stent need for postoperative cystoscopy to remove the Double-J stent, adds additional fees, and all patients were disturbed varying degrees stent-related discomfort.
Conclusion:Tubeless PCNL with ureteral catheter is safe, as feasible as Double-J stent.,can replace the Double-J stent with ureteral catheter. And shows its unique superior.
经皮肾镜取石术(PCNL)由于创伤小、效果确切、并发症少,成为治疗上尿路结石的主要手段。标准PCNL术后通常须放置肾造瘘管,肾造瘘管的作用是压迫瘘道起止血作用、避免尿液外渗及引流肾脏内尿液。但肾造瘘管可引起患者术后疼痛不适,或者造瘘管周围尿外渗,增加止痛药物的使用量,延长住院时间。为了提高患者术后舒适度,PCNL的发展有两种趋势：一是更微创化,即穿刺通道变细,对肾脏损伤也更小；二是无管化(tubeless PCNL),即经皮肾镜取石术后有选择性地对患者不留置肾造瘘管,可放置或不放置输尿管支架管引流,从而避免留置造瘘管给患者带来的疼痛不适。
Jackman等最早在1997年应用微通道经皮肾镜取石术治疗小儿上尿路结石。随后被多项研究应用此项技术治疗成人上尿路结石,他们报道微通道可减低PCNL出血的风险,但因细小的工作通道导致手术时间延长,因此其应用范围仅限于结石负荷相对较小,肾盏颈相对狭小的病例。在此基础上,李逊等进行了一系列的改进,包括选择后组肾中盏入路,通道缩小至16F至20F,并配备相应的肾镜,使用相应的灌注泵把结石冲洗出体外,大大缩短手术时间,提高了手术效率。而且钟文等通过实验证实,微通道经皮肾镜取石术中肾盂内压小于30mmHg(肾盂返流的阈值),提示微通道PCNL是安全。目前全世界已经有关微通道PCNL的报道已经超过1万例,其安全性和有效性不断被报道。而且,与标准通道相比,微通道因失血需要输血的发生率较低。因此,微通道经皮肾镜取石术具有较广阔的应用前景。
无管化的概念最早由Wickham于1984年提出,他报告了100例tubeless PCNL,患者术后既不留置肾造瘘管,也不留置输尿管内外支架管,可在24小时内安全出院。然而,1986年Vnfield报道2例患者在PCNL术后由于造瘘管未留置于正常位置而发生严重血尿和尿外渗,需要输血和重新放置内支架,导致住院时间延长,他推荐PCNL术后使用肾造瘘管引流24-48小时。大多数学者认为PCNL术后不留置造瘘管的手术风险较大,因此PCNL术后留置造瘘管成为常规。但近年由于PCNL技术的不断提高,留置肾造瘘管带来的不适感和较长的住院时间使无管化PCNL重新受到重视,国外关于无管化PCNL的报道渐渐增多,认为对经选择的患者行PCNL而不留置肾造瘘管是安全的,并不引起严重并发症,且能明显改善患者术后生活质量。国内对无管化PCNL术仅有零星的报道。
并不是所有的PCNL患者均适合无管化。目前仍无明确指征规定究竟哪些患者适合行无管化PCNL。一般认为,无管化PCNL的适应证为：①结石直径小于3cm；②通常为单一通道；③PCNL术后无明显结石残留；④无明显集合系统穿孔；⑤出血较少;⑥无须行二期手术；⑦不是合并重度肾积液。然而,近年来,无管化PCNL也成功应用于肾多发性结石、分枝型的复杂性结石、肾铸型结石、合并UPJ梗阻的上尿路结石、各种不同程度肾积水的上尿路结石,甚至肥胖患者、儿童患者,和既往有开放尿路结石手术的患者。
普遍认为过度出血、需行二期手术(肾盂积脓,有明显结石残留)、集合系统广泛损伤是绝对禁忌证。下列情况也应尽可能避免：活动性尿路感染,有肾手术或体外震波碎石史,存在先天性尿路异常,血肌酐水平上升和孤立肾患者,术中发生并发症(穿孔等并发症),手术时间较长(超过2h),存在明显尿路梗阻(如输尿管有结石或狭窄,重度前列腺增生影响排尿者),应用抗凝药物,超过2个通道者。
文献报告tubeless PCNL有多种形式。①完全无管化。即在PCNL术后不放置肾造瘘管和输尿管支架管引流,而依靠输尿管自然引流,患者没有肾造瘘管和输尿管支架管引起的不适,但是术后可能出现小血块、小结石,或输尿管水肿引起输尿管梗阻,须再次置管引流。因此完全无管化未被广泛接受,仅被少数医疗机构发表例数较少的病例报告。②留置双J管引流的tubeless PCNL。此法是较为常用的无管化PCNL的形式之一,PCNL术后留置一双J管,但不留置肾造瘘管。其优点是避免小结石或血块造成输尿管梗阻,尤其适合有结石残留需要辅助体外震波碎石术者,或存在结石以外的输尿管梗阻须留置支架引流者。其不足之处是可能双J管会造成膀胱刺激症、膀胱-输尿管返流、肾盂内压升高、尿外渗致肾周尿性囊肿、削弱了输尿管的蠕动,造成一定程度的输尿管梗阻,而且术后患者须用膀胱镜拔除双J管,增加经济负担以及手术操作引起的不适。③留置带绳的双J管。放置一条近端带绳的双J管,绳子经肾造瘘口引出,并固定于腹壁上,术后在病房拔除双J管。若须二期经皮肾手术,可把双J管近端拔出至皮肤外,向双J管的内腔插入导丝,重新经原瘘口建立肾造瘘通道。④留置输尿管外支架。把原来逆行插入的输尿管导管的头端调整至肾盂的中央,末端固定在尿管上。Mouracade认为采用输尿管外支架作引流可免于膀胱镜拔支架管,而且没有留置双J管的不适感,具有可行性。
输尿管外支架与双J管的引流机制可能存在较大的差异,Fine等通过同位素视踪证实,双J管的引流是由膀胱内尿液经过双J管的内腔返流至肾盂,由返流的尿液触发肾盂输尿管的蠕动,尿液经双J管与输尿管之间空隙引流至膀胱。由此推测,放置双J管的患者可能存在膀胱输尿管返流,存在肾盂内压增高情况。而留置输尿管外支架的末端连接至体外,膀胱输尿管返流可能相对较轻,肾盂内压可能相对较低,引流效果或许较双J管可靠,可能有利于tubeless PCNL。
微通道与无管化同时结合的经皮肾镜取石术,国内外较少报道。本课题包括一项回顾性研究主要探索留置输尿管外支架微通道tubeless PCNL的安全性与有效性,一项动物实验研究主要比较输尿管外支架引流与双J管引流对肾盂内压的影响,一项前瞻性对照研究主要比较微通道tubeless PCNL采用输尿管外支架引流与采用双J管引流的差异。
第一章留置输尿管外支架的微通道无管化经皮肾镜取石术的可行性研究
目的探讨留置输尿管外支架的微通道无管化经皮肾镜取石术(tubeless PCNL)的安全性和有效性。
方法回顾性分析101例留置输尿管外支架的微通道tubeless PCNL治疗肾或输尿管上段结石的患者资料。男53例,女48例。年龄(47.5±14.7)岁。右侧54例,左侧46例,双侧1例。其中肾脏或输尿管上段单发结石67例(65.7%),多发性结石34例(34.3%)。结石最大径为(25.4±12.8)mm。合并患肾轻度积液41例,中度积液42例,重度积液18例。术前合并泌尿道感染21例(20.8%)。
联合B超和C臂X线定位,用穿刺针穿刺成功后退出针芯,置入0.028-inch斑马导丝,用筋膜扩张器从8F扩张到18-20F,并留置相应Peel-away鞘,采用气压弹道碎石器在微创肾镜直视下将结石击碎,通过MMC液压灌注泵冲洗出,或用5F取石钳夹出。
在经皮肾镜取石术结束时,通过B超和C臂X线证实结石已经完全清除,然后把逆行插入的输尿管导管的头端调整至肾盂的中央,让扩张鞘退至肾造瘘通道以外,证实瘘道无活动性出血,最后拔除扩张鞘,并用丝线缝合皮肤伤口。
结果101例患者,共建立100例个通道,其中采取单一通道取石者93例(91.2%),采用两个通道取石者7例,采用三个通道取石者1例；采用四个通道取石1例。95例患者(94.1%)术后结石被完全清除,6例为无意义残留结石。手术时间(54.1±13.7)min。手术引起血红蛋白下降(7.6±8.9)g/L。术后第1d视觉疼痛评分为(2.0±1.6)分。术后拔除输尿管外支架拔除时间为(2.3±1.6)d。术后住院天数(3.4±1.9)d。并发症：1例出现进行性肾出血,须行选择性肾动脉造影+栓塞术；2例手术当天出现急迫性尿失禁,予以拔除尿管和输尿管外支架后好转；1例出现肾周血肿,大小为23mm×68mm,未作特殊处理；10例出现术后发热,术后第3-5d拔除输尿管外支架和尿管,加强抗炎治疗治愈；2例术后出现持续性血尿,予保守治疗治愈；轻度尿外渗2例,予以对症处理好转。术后3个月随访,均无出现严重出血、发热和邻近器官损伤等并发症,没有因为输尿管阻须再次置管引流或肾造瘘引流。4例残留结石自行排出,另2例残留结石无变化。
结论在严格掌握手术适应证的前提下,留置输尿管外支架的微通道tubeless PCNL是安全和有效的,可以减少止痛药的使用,缩短住院时间,减少治疗费用。
第二章输尿管外支架管与双J管对实验大白兔肾盂内压的影响
目的比较留置输尿管外支架与留置双J管在实验大白兔肾盂内压的差异。
方法选取新西兰大白兔15只,平卧固定于手术台上,经尿管注入生理盐水,使膀胱膨胀。取下腹部正中切口,暴露膀胱和尿道、分离双侧肾脏及双侧输尿管,根据双侧输尿管的走行寻找双侧输尿管开口,经尿道向双侧输尿管开口方向插入2F硬膜外导管,双侧均插向肾盂中央,左侧作为外支架组,右侧把硬膜外导管剪断,末端送入膀胱,作为内支架组,再次调整左右支架的位置,让双侧支架的头端均位于肾盂的中央,左侧外支架的末端在尿道口,右侧内支架的末端位于膀胱中央。
经尿道插入专用的膀胱测压管,用丝线把测压管捆绑于尿道,连接专用灌注管。膀胱测压管连接压力传感器。
采用专用测压穿刺套针,经双侧肾脏中部向肾盂向穿刺,穿中后拔除针芯,并把针的末端调整至肾盂中央,并连接压力传感器。
比较左右两侧肾盂内压的差异。
结果右侧肾盂内压(内支架)为(14.08±1.74)mmHg,左侧肾盂内压(外支架)为(9.68±2.24)mmHg,两者比较有显著统计学差异。
结论放置输尿管外支架的肾盂内压低于放置双J管。
第三章留置输尿管外支架微通道无管化经皮肾镜取石术的前瞻性对照研究
目的采用前瞻性研究的方法比较留置输尿管外支架和留置双J管无管化经皮肾镜取石术的治疗效果。
方法2011年12月至2013年1月对符合无管化PCNL的病人采用随机数字表进行前瞻性分组。随机分成两组,一组留置输尿管导管(56例),另一组留置双J管(53例),共计109例。入选标准：①年龄在18周岁(含)至70周岁(含)之间；②术前无泌尿系统感染；③结石最大径≦4cm；④仅限于建立一个工作通道；⑤术中没有活动性出血；⑥术中没有肾脏集合系统及输尿管损伤；⑦C臂X线透视和尿路造影显示无结石残留或无意义残留结石(<4mm)。
通过比较两组病人的年龄、性别构成、体重指数、肾积水程度、结石大小等术前资料,分析手术时间、手术出血、VAS疼痛评分、止痛剂需求、住院天数、住院费用等方面有无差异。
结果两组病人各项术前资料、术后指标均无统计学差异。然而留置双J管组患者术后需要返院通过膀胱镜拔管,增加了额外的费用,且所有病人均合并有不同程度的支架管不适。
结论留置输尿管外支架的经皮肾镜取石术在治疗上尿路结石是安全可行的,和留置双J管的经皮肾镜取石术相比有同等的疗效,可以替代双J管,且显示了其独特的优异性。
Background
Based on its excellent outcomes and acceptable low morbidity, Percutaneous nephrolithotomy(PCNL) is considered the treatment of choice for complex renal or impacted upper ureteral calculi over the last30years, since Fernstro'm and Johansson first described it in1976. Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. Previously it was thought that nephrostomy tubes provide hemostasis along the tract, avoid urinary extravasation, and maintain adequate drainage of the kidney. Placement of nephrostomy tubes may increase postoperative pain, analgesia requirement, and hospital stay. In recent years,'Mini percutaneous nephrolithotomy'('mini-perc') and Tubeless PCNL' have been introduced with the aim to decrease the morbidity of this already established procedure.
Micro-channel percutaneous nephrolithotomy (mPCNL) was first described by Jackman and associates for the application of PCNL to infants. Its use in adults has been subsequently described by several groups. They reported that the small tract significantly decreased the bleeding risk of traditional PCNL, but its indication was limited since the small percutaneous working sheath may increase the operating time. On this basis, Li X et al. modified the technique through a variety of ways,including preferring mainly posterior middle calyx access to inferior calyx access, using a specially designed nephroscope via the16F to20F tract,and using a pulse perfusion pump to flush out the stone fragments helped to shorten the operative time. Zhong W et al. also confirmed that intrapelvic pressure was lower than the level needed for a backflow(30mmHg) during mPCNL procedures. During the last10years, more than10,000mPCNL procedures performed to manage all kinds of upper urinary tract calculi were reported. The safety and efficacy of mPCNL have also been confirmed by recent reports. Furthermore, mPCNL has significantly lower incidence of bleeding necessitating transfusion in comparison with the standard PCNL
It may be interesting to note that the idea of 'tubeless' existed even in the early years of evolution of PCNL. In1984, Wickham published the results of100patients in which no internal or external drainage tubes were used at the conclusion of case. Authors stated that with this approach, patients could leave the hospital within24h and the procedure was safe and efficient with a shorter hospital stay. However, subsequently Winfield et al. reported two patients with complications of premature nephrostomy-tube removal after the extraction of simple upper-tract calculi, who experienced serious hemorrhage and marked urinary extravasation necessitating transfusion, internal stenting, and prolonged hospitalization. They recommended that nephrostomy tube drainage should be provided during the first24to48h after percutaneous stone extraction, which subsequently became the standard practice for PCNL worldwide. However, in recent years, the procedure has been modified to what has been called 'tubeless' PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. More and more cases of tubeless PCNL were reported.
Not all cases are suitable for being performed tubeless PCNL.There are no widely acknowledged selection criteria for tubeless PCNL. In general, the selection criteria for tubeless PCNL include stone burden<3cm, a single access tract, no significant residual stones, no significant perforations, minimal bleeding, and no requirement for a secondary percutaneous procedure. However, in recent years, the tubeless technique has been applied for the treatment of multiple stones, branching and complex stones, staghorn stones, concurrent UPJ obstruction, and collecting systems with various degrees of hydronephrosis. The technique has been successful in obese patients, children, and patients with recurrent stones after open surgery.
The general consensus is that the tubeless approach is feasible only in a selected population that generally excludes cases of significant intraoperative bleeding, or situations with a likelihood of residual stone fragments,or situations with intensive renal pelvic or calyx injuries. Some cases is not indicated for tubeless PCNL, such as uncontrolled urinary infection, with histories of open urinary calculi operations or ESWL, concurrent congenital urinary tract anomaly, renal insufficiency, solitary kidney, intraoperative complications (perforation or bleeding), operating time more than2hours, severe urinary obstruction (ureteral stenosis or severe benign prostatic hyperplasia), oral anticoagulating agents, and multiple tracts.
Literature has reported many types of tubeless PCNL. In the literature, tubeless PCNL studies are reported but only a few are totally tubeless PCNL. There are no discomforts of tubes and stents in those cases. These studies favor the suggestion that the best available drainage of the kidney is the normal peristalting ureter. However, this approach has not formed universal acceptability due to the concerns relating to the obstruction of ureter due to clots or stone fragments. Most authors seem to favor some kind of internal drainage in tubeless procedures. The most common type is tubeless PCNL with a double-J stent. It is suitable for those cases with residual stones after PCNL or upper urinary tract obstruction. One major disadvantage of tubeless PCNL with double-J stent is the need for postoperative cystoscopy to remove the stent. Another type is tubeless PCNL with a Tether. Bellman et al. suggested the placing of a7F/3F tailed stent with an attached string exiting the urethral meatus, which can be used to pull the stent out afterward in office setting to avoid the need of cystoscopy. However this procedure has the disadvantage that some patients may remove their stents prematurely by inadvertently pulling on the tether. Additional variations of the tubeless procedures have been described. Mouracade et al. prospectively analyzed the outcomes of tubeless PCNLs using two different stenting techniques, externalized ureteral catheter versus double-J stent placement. They concluded that externalized ureteral catheter is as feasible as a double-J stent. Moreover, stent-related discomfort and the need for postoperative cystoscopy to remove the double-J stent can be avoided with an externalized ureteral catheter. However, they suggested that in patients who are not completely stone-free at the end of the procedure, use of a double-J stent may be more beneficial as it may help in spontaneous passage of small residual fragments.
The mechanisms between the externalized ureteral stent and the double-J stent may be different. Fine et al. reported fluoroscopic observations and drainage mechanisms of double-J stent. The urine from the bladder refluxed from the inner chamber of the stent to the renal pelvic. The refluxed urine in the renal pelvis triggered the peristalsis of the ureter. The vesicoureteric reflux and elevated renal pelvic pressure existed in the patients with double-J stent. Hower, the end of the external ureteral stent is in vitro. The vesicoureteric reflux may be slight and the renal pelvic pressure may be low in the patients with externalized ureteral stent.
Only a few literature compared tubeless PCNL with standard PCNL.So far, there are no literature to study micro-channel tubeless PCNL.
In order to investigate the the safety and efficacy of micro-channel tubeless PCNL with a externalized ureteral catheter, we initiated this projects. This projects include a retrospective study, a prospective study and a experimental research. The retrospective study will investigate the effectiveness and safety of micro-channel tubeless PCNL with an externalized ureteral catheter. The prospective study will investigate the differences between an externalized ureteral catheter and and double-J stent in micro-channel tubeless PCNl. The experimental research will investigate the differences of renal pelvic pressure in experimental white rabbits between indwelling a externalized ureteral catheter and a double-J stent.
Section Ⅰ Safty and efficacy of micro-channel tubeless percutaneous nephrolithotomy with a externalized ureteral catheter:a retrospective study
Objective To review the safety and efficacy of micro-channel tubeless percutaneous nephrolithotomy (tubeless PCNL) with a externalized ureteral catheter.
Methods From May2010to Dec2012,101patients (53males and48femals,mean age of47.5years) of renal or proximal ureteral calculi treated by micro-channel tubeless PCNL with a ureteral catheter were reviewed. The calculi were in right side in54patients, in the left side in46, and in the bilateral sides in one pantient. Single renal or upper ureteral stone was found in34(34.3%) patients, and multiple calculi in67(65.7%) patients. The stone burden was (25.4±12.8) mm. Of101cases, mild hydronephrosis was found in41cases, moderate hydronephrosis in42cases,and severe hydronephrosis in18cases.
The kidney was punctured under ultrasonagraphic or/and fluoroscopic guidance. Once the pelvicalyceal system (PCS) was entered, a0.028-inch hydrophilic Zebra guidewire was manipulated down the ureter if possible, or coiled in a distant calyx. The track was dilated using a fascial dilator (Cook Urological, Spencer,IN) from8F to16F or20F. The corresponding peel-away sheath (Cook Urological, Spencer, IN) was placed as the percutaneous access port. Subsequently, a8.5F/11.5F nephroscope (Lixun Nephroscope, Richard Wolf, Knittlingen, Germany) was inserted to inspect the collecting system. Under direct vision, the stone was fragmented by pneumatic lithotripsy(Richard Wolf, Knittlingen, Germany).Most of the fragments(<0.3cm) were mainly pushed out with an endoscopic pulsed perfusion pump (MMC Yiyong, Guangzhou, China)and the big fragments (0.3cm-0.5cm) were extracted with a5F forceps (Richard Wolf, Knittlingen, Germany).
At the end of the procedure of PCNL, the calculi were cleared under the monitoring of C-armed fluoroscopy and B-ultrasound. The head end of the ureteral catheter was adjusted in the center of renal pelvis. The peel-away sheath was removed when no active bleeding was confirmed.
Results Of101patients,110tracts were established. Of110tracts, single tract was established in93(91.2%)cases, double tracts in7cases, three tracts and four tracts in one case respectively. Stone-free was found in95(94.1%) patients, and insignificant residual stone in6patients.The average operative time was (54.1± 13.7) min. The mean hemoglobin drop was (7.6±8.9) g/L. The visual analogue score on the first postoperative day was (2.0±1.6). The average time of ureteral catheter removal was (2.3±1.6) d. The average postoperative hospital stay was (3.4±1.9) days. The complications included one servere renal hemorrhage requiring selective renal arterial radiography and embolism,one urge incontinence, one perirenal hematoma, ten postoperative fever, two persistent macrohematuria, and two mild urinary extravasation.
Conclusions Under the premise of strict surgical indications, micro-channel tubeless PCNL with a ureteral catheter was safe and effective for the treatment of upper urinary calculi. It can reduce hospitalization time and analgesic requirement, and promotes quality of life in selected patients.
Section Ⅱ The differences of renal pelvic pressure in experimental white rabbits indwelling between a externalized ureteral catheter and a double-J stent
Objective:To investigate the differences of renal pelvic pressure in experimental white rabbits between indwelling a externalized ureteral catheter and indwelling a double-J stent.
Methods:Fifteen experimental white rabbits were chosen in the experiment. A externalized ureteral catheter was indwelled in the right upper urinary tract of white rabbits, and a double-J stent was in the left side. The renal pelvic pressure was messured by a baroreceptor. Compared the differences of of renal pelvic pressure in experimental white rabbits indwelling a externalized ureteral catheter with a double-J stent.
Results:The renal pelvic pressure was (14.08±1.74) mmHg and (9.68 ±2.24) mmHg in the externalized ureteral catheter group and in the double-J stent group respectively. There are significant statistic differences between the two groups between the two groups.
Conclusion:The renal pelvic pressure in the experimental white rabbit indwelling a externalized ureter catheter was lower than indwelling a double-J stent.
Section Ⅲ Effectiveness of micro-channel tubeless percutaneous nephrolithotomy with a externalized ureteral catheter in selected patients:a prospective randomized study
Objective:We prospectively analysis the outcome of micro-channel tubeless percutaneous nephrolithotomy using two different stenting techniques (i.e., a externalized ureteral catheter compared with Double-J placement).
Methods:109patients who were undergoing tubeless PCNL between December2011and January2013in our hospital were randomized to two groups:tubeless PCNL with ureteral catheter and tubeless PCNL with Double-J placement, respectively56cases and53cases.
Inclusion criteria for the study were the stone burden less than4cm, no urinary infection,no serious bleeding or perforation in the collecting system during the operation, stone free or clinically insignificant residual fragments (CIRF<4mm), and no more than one access.
The two groups were comparable with regard to age, sex, BMI, stone size, hydronephrosis. Factors evaluated included operative time, postoperative hemorrhage, visual analogue pain scale (VAS), analgesic requirement, hospitalization stay, hospitalization expenses and stent-related symptoms.
Results:There were not statistically significance in the preoperative data and postoperative indexes. However, the patients with double-J stent need for postoperative cystoscopy to remove the Double-J stent, adds additional fees, and all patients were disturbed varying degrees stent-related discomfort.
Conclusion:Tubeless PCNL with ureteral catheter is safe, as feasible as Double-J stent.,can replace the Double-J stent with ureteral catheter. And shows its unique superior.
引文
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