局部麻醉超声引导下部分无管化经皮肾镜取石术治疗高危上尿路结石的疗效评价

Efficacy of local anesthesia partial tubeless percutaneous nephrolithotomy by ultrasound-guided for upper urinary tract calculus patients with high-risk factors

摘要:

目的 分析局部麻醉下超声引导行微通道（16 F）部分无管化经皮肾镜取石术（PCNL），治疗合并高危因素的肾和输尿管上段结石的安全性和有效性。方法 回顾性分析2021年5月－2024年3月该院收治的29例合并高危因素的肾和输尿管上段结石患者的临床资料。其中，合并心功能不全6例，肺功能不全10例，肾功能不全10例，高血压10例，糖尿病5例，喉癌术后困难气道1例，脑血管及神经病变7例。采用局部麻醉后，在超声引导下行16 F微通道PCNL，术后常规放置输尿管内支架管，不留置肾造瘘管，即：部分无管化PCNL。结果 所有患者均顺利完成手术，6例患者因感染和肾功能损害明显，先行局部麻醉下超微造瘘（F 6单J管）引流，病情稳定后行PCNL。手术时间为30～94 min，平均（55.8±16.7）min，术中疼痛视觉模拟评分法（VAS）3～6分，平均（4.2±0.9）分，术后血红蛋白下降1～26 g/L，平均（8.4±6.6）g/L，术后疼痛VAS 2～7分，平均（3.2±1.2）分，术后2至3天复查腹部CT，结石清除率为82.8%（24/29），1例术后3周行局部麻醉下输尿管软镜清石，2例行体外冲击波碎石排出，2例因多发小结石行药物排石治疗。1例术后因动静脉瘘行输血和肾动脉介入治疗，无中转开放病例，无胸膜损伤等并发症发生。结论 局部麻醉超声引导下行部分无管化PCNL，治疗高危肾和输尿管上段结石，具有麻醉风险低、并发症少和恢复快等优点，手术效果满意，值得临床推广。

Abstract:

Objective To explore the safety and efficacy of ultrasound-guided minimally invasive (16 F) partial tubeless percutaneous nephrolithotomy (PCNL) in the treatment of renal and ureteral upper calculus with high-risk factors.Methods 29 patients with renal or/and ureteral upper calculus with high-risk factors from May 2021 to Mar 2024 were retrospectively analyzed. Among them, there were 6 cases of cardiac insufficiency, 10 cases of pulmonary insufficiency, 10 cases of renal insufficiency, 10 cases of hypertension, 5 cases of diabetes, 1 case of postoperative difficult airway of laryngeal cancer, and 7 cases of cerebrovascular and neuropathy. All the patients underwent PCNL with 16 F microchannel under the ultrasound-guided after local anesthesia, and the ureteral stent was routinely placed after surgery without insetting nephrostomy tube, that was, partial tubeless PCNL.Results All the patients completed the operation, of which 6 patients due to infection and renal dysfunction, first under local anesthesia ultra-microstomy (F 6 single J tube) drainage. PCNL was performed after the condition was stabilized. The operative time was 30 ~ 94 min, with an average of (55.8 ± 16.7) min. The intraoperative visual analogue scale (VAS) was 3 ~ 6, with an average of (4.2 ± 0.9). The postoperative hemoglobin decreased by 1 ~ 26 g/L, with an average of (8.4 ± 6.6) g/L, and the postoperative VAS was 2~7, with an average of (3.2 ± 1.2). The stone-free rate was 82.8%(24/29) by abdominal CT examination 2 to 3 days after surgery. 1 case underwent flexible ureteroscopy under local anesthesia in 3 weeks, 2 cases underwent extracorporeal shock wave lithotripsy, and 2 cases underwent drug lithotripsy due to renal multiple small calculi. 1 case underwent blood transfusion and renal artery embolization due to arteriovenous fistula, no open surgery occurred, and no complications such as pleural injury.Conclusion Local anesthesia partial tubeless PCNL by ultrasound-guided for the treatment of high-risk renal or/and ureteral calculus has the advantages of low anesthesia risk, fewer complications, rapid recovery, and satisfactory surgical results, and can be used as a surgical method for such patients.