经皮肾穿刺通道的选择

经皮肾穿刺穿刺点的选择和皮肾工作通道的建立是保证经皮肾镜技术（PCNL）成功的前提条件。2010年6月～2011年8月，我们使用B超引导行经皮肾穿刺术并扩张建立皮肾工作通道69例，全部成功，无严重并发症，效果满意，现报道如下。

1临床资料

1.1一般资料肾结石患者69例,男36例，女33例；年龄35～66岁，平均51.6岁；术前B超、KUB、IVU、CT显示单发肾结石21例，多发肾结石13例，鹿角型结石10例，输尿管上段结石15例，肾和输尿管上段多发结石9例。左侧31例，右侧29例，双侧9例。重度肾积水10例，中度肾积水28例，轻度肾积水22例，无肾积水9例。术前均排除严重心肺疾患、脑血管病变及全身出血性疾病。

1.2方法患者采用连续硬脊膜外阻滞麻醉或者全身麻醉，首先取膀胱截石位膀胱镜下逆行输尿管插管，插入6F输尿管导管至肾盂，导管远端连接生理盐水持续加压泵加压滴注，制造人工肾积水。接着变换体位为俯卧位。腹部垫软枕使腰背部呈弧形突起，穿刺点选第11肋间、12肋缘下，腋后线与肩胛线之间，避开肋骨和肋间血管。18G穿刺针从穿刺部位皮肤处进针，进入肾被膜此时可根据超声图像中目标肾盏和穿刺针尖的影像，再一次调整穿刺针方向，再进1.5～

2.0cm，穿刺进入目标肾盏，有尿液溢出或用注射器抽出尿液证实穿刺成功后引入导丝，退出穿刺针，筋膜扩张器扩张至16F，置入薄皮鞘，用输尿管镜观察，确定位置后，置入天线套叠式金属扩张器顺导丝逐号扩入至18～21F，再推入21F镜鞘，置入肾镜，寻找结石，采用气压弹道联合超声取石清石系统将结石清除。最后顺行置入双J管，退出肾镜，置入肾造瘘管并退出镜鞘。术后3～5d复查B 超或KUB，显示无大块结石残余后拔出肾造瘘管，若有残余结石直径>2cm者行2次经皮肾镜取石术，<2 cm的残留结石辅以体外冲击波碎石治疗。

doi:10.3969/j.issn.1008-4118.2012.03.05

经皮肾穿刺通道的选择

夏连营,闫成智

(天津市宝坻区人民医院,天津宝坻301800)

摘要：目的探讨经皮肾穿刺取石术穿刺通道的选择碎石、取石成功率的影响。方法根据结石的位置、大小、形态选择确定目标肾盏、体表穿刺点、穿刺角度和深度，用穿刺针经皮肾穿刺至肾盏，并逐级扩张建立工作通道。结果肾穿刺69例穿刺均成功，单通道63例，2通道4例，3通道2例。穿刺无大出血及周围脏器损伤，术后发现16例患者结石大于0.5cm的残石，接受2期经皮肾镜或体外震波碎石治疗，残石率23.2%。其中1例出现高灌注综合征，穿刺通道丢失1例，肾盂穿孔3例，但没有出现其他严重并发症。结论经皮肾穿刺取石术中准确合理选择穿刺通道是手术成功的关键，能够减少出血、降低残石率。

关键词：穿刺通道；肾穿刺；经皮肾镜碎石术；肾结石/治疗

中图分类号：R446.9文献标识码：A文章编号：1008-4118（2012）03-0009-02

Choice of Percutaneous Access of Puncture Percutaneous Nephrolithotripsy for Treatment of Renal Stone

Xia Lianying,Yan Chengzhi

（Tianjin Baodi District People's hosptial,Baodi301800,Tianjin)

Abstract：Objective To evaluate the effect of stone clearance of management of renal stone by percutaneous nephrolithotrip⁃sy（PCNL）by choice of percutaneous access.Methods According to the site,size and shape of renal stone determine target calyx, skin puncture site,angle and depth of puncture，percutaneous access from skin to calyx was constructed by percutaneous puncture nee⁃dle and was gradually expand.Results The percutaneous kidney access was successfully established in whole the patients，single channel was performed on63cases two channel on4cases three channel on cases.Stones were cleared in53out of69cases（76.8.1%）during immediate phase lithotripsy，residual stone fragment was found in16cases（＞0.5cm）who received second PCNL or adjuvant extracorporeal shock wave lithotripsy.1case had perfusate absorbing sydrome，1case lost the tract of puncture，3case had renal pel⁃vic perforation，but no other severe complications occured during nephrolithotripsy.Conclusion It that percutaneous renal access was select of accurately and reasonable is key of success。It has adventages of diminished residual stone and hemorrhage.

Key words：percutaneous renal access；kidney puncture；percutaneous nephrolithotripsy;kidney stone/therapy

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