肾盂低压并高效清石的增强版超微经皮肾镜技术

doi:10.3877/cma.j.issn.1674-3253.2021.02.005

目的

近年来超微经皮肾镜碎石取石术（SMP）技术飞速发展，逐步成熟，但14 F超微通道处理大负荷肾结石可能导致手术时间延长。我们在SMP基础上将灌注负压吸引鞘增大为18 F，以期提高碎石效率并保持肾盂内低压。本研究通过对比分析18 F增强版超微经皮肾镜碎石取石术（eSMP）与同为18 F通道的微创经皮肾镜碎石取石术（mPCNL）治疗2～5 cm肾结石的术中肾盂内压及取石效率等指标，验证eSMP技术的安全有效性。

方法

2017年1月至2019年12月，我院100例肾结石患者接受PCNL治疗，随机分入eSMP组和mPCNL组。建立18 F通道，eSMP组采用灌注吸引鞘，mPCNL组采用剥离鞘，分别用超微肾镜（11 F）和8/9.8 F输尿管镜，钬激光联合气压弹道碎石器碎石取石。术中监测肾盂内压，并记录手术时间、碎石时间、结石体积以及并发症等数据，进行统计学分析。

结果

mPCNL组与eSMP组取出结石体积差异无统计学意义，但mPCNL组碎石取石所耗时间显著长于eSMP组[（50.1±19.6）min vs （35.3±14.3）min，t=4.314，P<0.001]，因而单位时间内eSMP取石更多[（13.66±1.17）mm³/h vs （9.78±1.23）mm³/h，t=16.150，P<0.001]，且总的手术时间上mPCNL组相较eSMP组也显著延长[（67.3±19.5）min vs（52.1±14.4）min，t=4.429，P<0.001]。术中肾盂内压mPCNL组显著高于eSMP组[（17.88±3.28）mmHg vs（12.01±2.45）mmHg，t=10.140，P<0.001]，mPCNL组术中肾盂内压>30 mmHg累计时间显著长于eSMP组[（23.2±16.6） s vs （3.8±4.3） s，t=8.012，P<0.001]。术后血红蛋白下降量mPCNL组较eSMP组更显著[（17.1±6.8）g/L vs（14.0±7.5）g/L，t=2.182，P=0.032]。两组患者术后发热率、结石清除率的差异均无统计学意义，但mPCNL组住院时间显著长于eSMP组[（2.98±0.87）d vs （2.60±0.78）d，t=2.298，P<0.001]。

结论

增强版SMP（eSMP）借助于灌注负压吸引鞘，相较传统mPCNL，能够提高碎石取石效率，并保持术中较低的肾盂内压，治疗2～5 cm肾结石是安全有效的。

关键词: 肾结石, 经皮肾镜, 肾盂内压, 碎石效率, 前瞻性研究

Objective

In recent years, the super mini-PCNL (SMP) technique has developed rapidly and matured gradually. However, the operation time may be prolonged when manage the large burden renal calculi with 14 F tract. On the basis of SMP, the suction sheath was increased to 18 F, in the aim to improve the lithotripsy efficiency and keep a low renal pelvic pressure, which was called enhanced-SMP (eSMP). In the present study, eSMP and mini-PCNL was compared to analyze the intra-operative renal pelvic pressure and stone removal efficiency when managed the 2-5 cm renal calculi, and to verify the safety and efficiency of eSMP technique.

Methods

From January 2017 to December 2019, 100 patients with 2-5 cm renal calculi in our hospital were randomly divided into eSMP group and mPCNL group. 18 Fpercutaneous tract was established, suction sheath with 11 F mini nephroscope and peel-away sheath with 8/9.8 F ureteroscope was used in eSMP and mPCNL, respectively. Ho:YAG laser and pneumatic lithotriptor was used for lithotripsy. During the operation, renal pelvic pressure was measured, operation time, lithotripsy time, removed stone volume and complications were recorded and analyzed statistically.

Results

There was no significant difference in the stone volume removed between mPCNL group and eSMP group, but the lithotripsy time in mPCNL was significantly longer than eSMP group [(50.1±19.6) min vs (35.3±14.3)min, t=4.314, P<0.001], thus the stone removal effectiveness was higher in eSMP group [(13.66±1.17) mm³/h vs (9.78±1.23) mm³/h, t=16.150, P<0.001], and the total operation time in mPCNL group was longer than eSMP group [(67.3±19.5) min vs (52.1±14.4) min, t=4.429, P<0.001]. The intra-operative renal pelvic pressure in mPCNL group was higher than eSMP group [(17.88±3.28) mmHg vs (12.01±2.45) mmHg, t=10.140, P<0.001], and also the accumulated time of renal pelvic pressure >30 mmHg in mPCNL group was longer than eSMP group [(23.2±16.6) s vs (3.8±4.3) s, t=8.012, P<0.001]. The postoperative decreased hemoglobin in mPCNL group was more than eSMP group [(17.1±6.8) g/L vs (14.0±7.5) g/L, t=2.182, P=0.032]. There was no significant difference in the postoperative fever rate and stone clearance rate, while the hospital stay in mPCNL group was longer than eSMP group [(2.98±0.87) d vs (2.60±0.78) d, t=2.298, P<0.001].

Conclusion

Enhanced SMP (eSMP) was safe and effective in the management of 2-5 cm renal calculi. On the basis of irrigation-suction sheath, eSMP can keep a lower renal pelvic pressure and higher lithotripsy efficiency when compared to traditional mPCNL.

Key words: Renal calculi, PCNL, Renal pelvic pressure, Lithotripsy efficiency, Prospective study

表1 mPCNL对比eSMP治疗2～5 cm肾结石患者一般资料

组别	例数	性别(例)		年龄[岁，(±s)]	BMI[kg/m²，(±s)]	糖尿病[例，(%)]	高血压[例，(%)]	尿路感染[例，(%)]	结石最大径[cm，(±s)]	结石CT值[Hu，(±s)]	血肌酐[μmol/L，(±s)]	血红蛋白[g/L，(±s)]
组别	例数	男	女	年龄[岁，(±s)]	BMI[kg/m²，(±s)]	糖尿病[例，(%)]	高血压[例，(%)]	尿路感染[例，(%)]	结石最大径[cm，(±s)]	结石CT值[Hu，(±s)]	血肌酐[μmol/L，(±s)]	血红蛋白[g/L，(±s)]
mPCN组	50	34	16	50±10	23.3±2.2	3(6)	7(14)	10(20)	3.30±0.93	1130±250	117±68	138±14
eSMP组	50	32	18	50±9	23.4±2.4	3(6)	6(12)	10(20)	3.30±0.87	1118±240	118±81	136±13
统计值		χ²=0.178		t=0.182	t=0.367	χ²=0.000	χ²=0.088	χ²=0.000	t=0.044	t=0.241	t=0.055	t=0.506
P值		0.673		0.856	0.714	1.000	0.766	1.000	0.965	0.810	0.956	0.614

表1 mPCNL对比eSMP治疗2～5 cm肾结石患者一般资料

组别	例数	性别(例)		年龄[岁，(±s)]	BMI[kg/m²，(±s)]	糖尿病[例，(%)]	高血压[例，(%)]	尿路感染[例，(%)]	结石最大径[cm，(±s)]	结石CT值[Hu，(±s)]	血肌酐[μmol/L，(±s)]	血红蛋白[g/L，(±s)]
组别	例数	男	女	年龄[岁，(±s)]	BMI[kg/m²，(±s)]	糖尿病[例，(%)]	高血压[例，(%)]	尿路感染[例，(%)]	结石最大径[cm，(±s)]	结石CT值[Hu，(±s)]	血肌酐[μmol/L，(±s)]	血红蛋白[g/L，(±s)]
mPCN组	50	34	16	50±10	23.3±2.2	3(6)	7(14)	10(20)	3.30±0.93	1130±250	117±68	138±14
eSMP组	50	32	18	50±9	23.4±2.4	3(6)	6(12)	10(20)	3.30±0.87	1118±240	118±81	136±13
统计值		χ²=0.178		t=0.182	t=0.367	χ²=0.000	χ²=0.088	χ²=0.000	t=0.044	t=0.241	t=0.055	t=0.506
P值		0.673		0.856	0.714	1.000	0.766	1.000	0.965	0.810	0.956	0.614

表2 mPCNL对比eSMP治疗2～5 cm肾结石结果

组别	例数	通道数量[例，(%)]			碎石时间[min，(±s)]	结石体积[mm³，(±s)]	取石速度[mm³/h，(±s)]	手术时间[min，(±s)]	术后血肌酐[μmol/L，(±s)]
组别	例数	单通道	双通道	三通道及以上	碎石时间[min，(±s)]	结石体积[mm³，(±s)]	取石速度[mm³/h，(±s)]	手术时间[min，(±s)]	术后血肌酐[μmol/L，(±s)]
mPCNL组	50	35(70.0)	9(18.0)	6(12.0)	50±20	8.12±3.32	9.78±1.23	67±19	126±667
eSMP组	50	40(80.0)	6(12.0)	4(8.0)	35±14	7.95±3.11	13.66±1.17	52±14	122±69
统计值		χ²=1.333			4.314	0.271	16.150	4.429	0.295
P值		0.513			<0.001	0.787	<0.001	<0.001	0.768
组别	术后血红蛋白[g/L，(±s)]	血红蛋白下降[g/L，(±s)]	基础肾盂内压[mmHg，(±s)]	术中肾盂内压[mmHg，(±s)]	肾盂内压升高[mmHg，(±s)]	肾盂内压>30 mmHg时间[s，(±s)]	结石清除率(%)	术后住院时间[d，(±s)]
mPCNL组	120.5±16.7	17.1±6.8	9.10±1.43	17.88±3.28	8.78±3.20	23.2±16.6	43(86%)	2.98±0.87
eSMP组	122.2±15.8	14.0±7.5	9.06±1.62	12.01±2.45	3.23±3.42	3.8±4.3	45(90%)	2.60±0.78
统计值	t=0.529	t=2.182	t=0.131	t=10.140	t=8.389	t=8.012	χ²=0.379	t=2.298
P值	0.598	0.032	0.896	<0.001	<0.001	<0.001	0.538	<0.001
组别	并发症[例，(%)]			结石成分[例，(%)]
组别	发热	脓毒症	输血	草酸钙	磷酸镁铵	碳酸磷灰石	尿酸	胱氨酸
mPCNL组	6(12)	3(6)	1(2)	34(68)	1(2)	7(14)	7(14)	1(2)
eSMP组	3(6)	1(2)	1(2)	32(64)	2(4)	7(14)	9(18)	0(0)
统计值	χ²=1.099	χ²=1.042	χ²=0.000	χ²=1.644
P值	0.295	0.307	1.000	0.801

表2 mPCNL对比eSMP治疗2～5 cm肾结石结果

组别	例数	通道数量[例，(%)]			碎石时间[min，(±s)]	结石体积[mm³，(±s)]	取石速度[mm³/h，(±s)]	手术时间[min，(±s)]	术后血肌酐[μmol/L，(±s)]
组别	例数	单通道	双通道	三通道及以上	碎石时间[min，(±s)]	结石体积[mm³，(±s)]	取石速度[mm³/h，(±s)]	手术时间[min，(±s)]	术后血肌酐[μmol/L，(±s)]
mPCNL组	50	35(70.0)	9(18.0)	6(12.0)	50±20	8.12±3.32	9.78±1.23	67±19	126±667
eSMP组	50	40(80.0)	6(12.0)	4(8.0)	35±14	7.95±3.11	13.66±1.17	52±14	122±69
统计值		χ²=1.333			4.314	0.271	16.150	4.429	0.295
P值		0.513			<0.001	0.787	<0.001	<0.001	0.768
组别	术后血红蛋白[g/L，(±s)]	血红蛋白下降[g/L，(±s)]	基础肾盂内压[mmHg，(±s)]	术中肾盂内压[mmHg，(±s)]	肾盂内压升高[mmHg，(±s)]	肾盂内压>30 mmHg时间[s，(±s)]	结石清除率(%)	术后住院时间[d，(±s)]
mPCNL组	120.5±16.7	17.1±6.8	9.10±1.43	17.88±3.28	8.78±3.20	23.2±16.6	43(86%)	2.98±0.87
eSMP组	122.2±15.8	14.0±7.5	9.06±1.62	12.01±2.45	3.23±3.42	3.8±4.3	45(90%)	2.60±0.78
统计值	t=0.529	t=2.182	t=0.131	t=10.140	t=8.389	t=8.012	χ²=0.379	t=2.298
P值	0.598	0.032	0.896	<0.001	<0.001	<0.001	0.538	<0.001
组别	并发症[例，(%)]			结石成分[例，(%)]
组别	发热	脓毒症	输血	草酸钙	磷酸镁铵	碳酸磷灰石	尿酸	胱氨酸
mPCNL组	6(12)	3(6)	1(2)	34(68)	1(2)	7(14)	7(14)	1(2)
eSMP组	3(6)	1(2)	1(2)	32(64)	2(4)	7(14)	9(18)	0(0)
统计值	χ²=1.099	χ²=1.042	χ²=0.000	χ²=1.644
P值	0.295	0.307	1.000	0.801

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Enhanced SMP (eSMP) technique: low renal pelvic pressure and high lithotripsy efficiency

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Enhanced SMP (eSMP) technique: low renal pelvic pressure and high lithotripsy efficiency