B超引导下经皮肾镜碎石取石术治疗肾结石并发症影响因素与对策

发布时间：2018-08-23 13:24

【摘要】：目的：自1976年Femstram经皮肾镜取石术(PCNL)成功后PCNL开始广泛应用于治疗肾结石，国内从1998年提出中国特点的B超引导下经皮肾镜取石术，其后PCNL逐步推广应用至全国，使经皮肾镜取石技术的应用领域逐步扩大。虽然PCNL的安全性得到了广泛的验证，并发症明显较开放手术少且严重程度低。但作为一种有创操作，PCNL术中及术后所带来的并发症亦不容忽视，了解并发症的原因，是预防和减少其发生的重要前提；而如何及时处理并解决已经发生的并发症至关重要。本课题通过回顾性分析的方法对B超引导下经皮肾镜碎石取石术治疗肾结石并发症影响因素与对策进行探讨。方法：使用Excel软件制成表格，记录本院119例患者的各项临床资料：年龄、性别、平均住院时间、结石大小、结石位置、单侧/双侧结石、基础病、术前尿路感染、中段尿细菌培养、术前肾功能、肾积水量、术中出血量、手术时间、使用单/双/多通道完成手术、I期结石清除率、是否存在残石及残石大小、术后肾功能、造瘘时间、术后KUB结果、术中、术后并发症、术后结石成分分析结果，并计算出相应并发症发生率。使用Excel软件将欧洲泌尿外科杂志2007年发表大样本PCNL手术并发症发生率数据绘制成表。使用统计学分析对上述两者进行比较并得出结论。对本院119例患者的各项临床资料：年龄、术前尿路感染、尿细菌培养阳性、结石大小、鹿角型结石、糖尿病、手术时间超过90分钟、性别、是否存在肾积水、双肾结石、开放手术病史进行统计，并对术中、术后出现并发症进行统计，使用SPSS16.0软件采用χ2检验，P＜0.05表示结果具有统计学意义。结果：我院出现严重并发症与欧洲泌尿外科杂志发表大样本PCNL手术并发症百分率基本相符。我院119例接受经皮肾镜超声碎石取石术患者，手术均成功，I期清除率为87.39%（104/119），平均手术时间为58.67±29.2分钟，术中平均出血量为70.23±46.77ml。共发生严重并发症8例,所有严重并发症均出现于I期完成结石清除患者，发生率为6.72%（8/119）：分别为严重出血2例；胸膜损伤2例，灌注液外渗1例；术后延迟出血1例；术后重度感染2例。术后出现发热（体温＞38℃）35例,占29.41%,其中38-39℃之间21例,比例为17.64%（21/119）。12例在39-40℃之间，比例为10.08%（12/119）。2例大于40℃，比例为1.68%（2/119）。且发热以混合型结石者合并术前尿培养阳性者居多。输血7例，比例为5.88%（7/119）。无中转开放手术病例，未发生肾贯通伤、肠管及腹腔脏器损伤等严重并发症。就产生发热影响因素进行统计分析，结果表明年龄、术前尿路感染、尿细菌培养阳性者、结石大小、鹿角型结石、糖尿病、手术时间超过90分钟具有统计学意义（P0.05，a=0.05）。而性别、是否存在肾积水、双肾结石、开放手术病史无统计学意义（P0.05）。可以看出影响PCNL出现并发症的危险因素为年龄、术前尿路感染、尿细菌培养阳性者、结石大小、鹿角型结石、糖尿病、手术时间超过90分钟。结论：肾结石的治疗目前首选PCNL，且其具备对周围脏器损伤小、术后恢复快、可多次手术等优点，，并且术后残石的治疗可以选择通过ESWL或输尿管镜进行后续治疗。但是PCNL仍存在出血、损伤周围脏器、发热、感染等并发症，只有通过对各种并发症做出预防和正确的处理，才能使手术更加顺利，安全的开展。泌尿外科医师更加熟练的运用B超定位，并且结合CT、X线进行合理的穿刺通道选择，可以减少出血；而优秀的超声碎石清石系统（EMS），可以将碎石与吸出结石同步完成，并且能通过负压吸引取出视野外及掉落到输尿管中的碎石渣，可以极大的缩短术中处理结石时间，提高手术效率；围手术期抗生素的合理应用可以有效预防感染，尤其是根据药敏试验合理用药可以明显降低术后发热等并发症的出现。严格掌握手术适应症是减少并发症的前提，另外遵循学习曲线规律，提高术者的微创水平是减少并发症的关键保证。
[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.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692.4

【参考文献】