Multiple, antler-shaped, hoof-shaped kidneys, isolated kidneys and kidney stones larger than 2.5 cm are all complex kidney stones, and traditional open surgery is more traumatic and prone to renal parenchymal atrophy. With the continuous improvement of percutaneous nephrolithotomy and the introduction of new lithotripsy equipment, percutaneous nephrolithotomy has become a mature procedure for the treatment of complicated kidney stones, and has the advantages of high lithotripsy rate, less trauma and faster recovery.
From December 2008 to September 2010, 60 cases (67 sides) of complicated renal stones were treated with B-ultrasound-guided percutaneous nephrolithotomy combined with pneumatic ballistic ultrasound lithotripsy system (EMS III generation) in our hospital, and the results were satisfactory.
1. Information and methods.
1.1 Clinical data.
The group of 60 cases (67 sides), 39 cases (44 sides) male and 21 cases (23 sides) female, age 17-68 years old, average age 38 years old, including 18 cases of antler-shaped stones, 42 cases of multiple kidney stones, stone diameter 2.6-3.7 cm, 12 cases of elevated blood creatinine, up to 302umol/L; urinary routine examination WBC>10/uL 45 cases, middle urinary There were 37 cases of bacterial growth in the culture, and 6 cases of stone obstructive abscess kidney. There were 10 cases with previous history of kidney stone surgery, 7 cases with history of ESWL, 7 cases with combined diabetes mellitus, 15 cases with hypertension. 39 cases with moderate to severe hydronephrosis and cortical thinning in the kidneys, and 28 cases with mild hydronephrosis in the kidneys as indicated by ultrasound or CT.
1.2 Treatment method.
General anesthesia, firstly, take a lithotomy position, and retrograde placement of F6 ureteral catheter in the affected renal pelvis under cystoscopy or ureteroscopy, reserved for renal puncture or pushing saline (for mild hydronephrosis) during expansion, and pushing methylene blue (to clarify the entry of the puncture needle into the collecting system) if necessary.
After successful puncture with an 18G needle, a nephrostomy guidewire was placed into the renal pelvis, the needle sheath was removed, the guidewire was fixed, a small skin incision was made at the center of the guidewire, and a fascial dilator was used along the guidewire to dilate to The F8/9.8 ureteroscope was placed along the guidewire into the calyces and a 0.035 zebra guidewire was placed as a safety guidewire after confirmation;
It is best if the stone can be bypassed and placed directly into the ureter. The Amplatz dilator was then used to dilate the fistula guidewire to F24, and the F22-24 sheath was placed and operated with the EMS III pneumatic ballistic ultrasound combination lithotripsy system. The pneumatic ballistic energy was set at 80%-100%, the frequency was 5-12Hz, the ultrasound energy was 70%, and the duty cycle was 70%. For hard and large stones, the stones can be broken into larger pieces in a short time by using pneumatic ballistic lithotripsy, and then the stones can be further crushed and removed by using an ultrasound probe;
For smaller or less hard stones, the ultrasound probe can be used directly to crush the stones and aspirate them out of the body; for infected stones, ultrasound can be used continuously to aspirate the pus and pus moss on the surface of the stones and reduce the pelvic pressure before lithotripsy. After lithotripsy, each renal calyx and the ureteral junction of the renal pelvis were checked for residual stones, and a double J-tube of F6 was placed in line, and an F16 nephrostomy tube was placed to end the procedure.
Preoperatively, antibiotics were administered according to the urinary routine and median urine drug sensitivity results. After surgery, the nephrostomy tube was clamped for 24 h. After 3 d, the X-ray plain film was rechecked, and the treatment was successful if there was no stone residue or stone <4 mm. If there is a single stone remnant >10mm or multiple smaller stones located in the lower calyces of the kidney where stone removal is expected to be difficult, stage II percutaneous nephrolithotomy (PCNL) is performed on postoperative day 7-10. eswl is performed 4-6 weeks postoperatively for residual stones <10mm, and the double j-tube is removed 4-10 weeks postoperatively. < p="">
2. Results
Percutaneous renal channels were successfully established in 60 patients (67 sides), 2 percutaneous renal channels were established in 5 patients with multiple stones, 5 patients with bilateral renal stones underwent bilateral PCNL at the same time, and the remaining 50 cases were single-channel stone extraction. The bleeding stopped after postoperative symptomatic treatment, and the operation was changed to phase II after 7-10 days, and there were no cases of late postoperative hemorrhage.
The average operation time was 64(51-107) min, and the average stone treatment time was 35(23-59) min. 8 kidneys with residual stones were treated with stage II PCNL after 7-10 days or ESWL after 4-6 weeks. 88.1%(59/67) of stones were removed in stage I and 100%(8/8) of stones were removed in stage II lithotripsy. All patients had no serious complications such as infectious shock and peripheral organ injury during and after surgery, and there were no cases of renal artery embolism or nephrectomy. The duration of hospitalization ranged from 8 to 26 d, with an average of 14 d. At 1-6 months of follow-up, the secretory excretory function of the affected kidney was good, and the effusion improved significantly in those with moderate to severe effusion, and no significant infection was seen in the urinary routine.
3. Discussion
3.1 Establishment of percutaneous renal access
3.1.1 B-ultrasound-guided renal puncture
Establishing an ideal working channel is the key step for successful lithotripsy and stone retrieval. The puncture approach is considered to be the closest to the kidney and to the stone, and to reach each renal calyx and the ureteral junction of the renal pelvis as far as possible, in order to facilitate the maximum extraction of the stone and the placement of the double J-tube in a downstream direction. According to this principle, the most commonly used puncture target calyces are the posterior middle calyces, and the working channel established through the posterior middle calyces access allows for a wider swing up and down to reach more calyces, and allows for treatment of pelvic-ureteral junction obstruction and favorable placement of the double J tube.
However, sometimes it is necessary to choose to puncture the upper calyces or lower calyces according to the location of the stone, and the puncture of the upper calyces may cause pneumothorax by puncturing the pleura, so it is necessary to choose a good puncture point under B-ultrasound positioning and grasp the angle and depth of puncture, usually the direction of needle and the horizontal angle of 30°～60°. If the punctured kidney has no fluid or mild fluid accumulation, methylene blue solution can be injected into the ureteral catheter, and when the position of the puncture needle is appropriately adjusted under B-ultrasound guidance and blue fluid is overflowed, it indicates successful puncture.
Cao Guocan et al. found that the rate of residual stones in B-ultrasound-guided surgery was higher than that in X-ray localization by comparing four puncture methods to establish percutaneous renal access, which may be due to the difficulty of using ultrasound for intraoperative follow-up of residual stones. However, the advantages of ultrasound localization are self-evident, as it can clearly display the thickness of the renal parenchyma, monitor the route of the puncture needle, and even detect large renal vessels so as to avoid them and prevent hemorrhage during the puncture.
Li Jianxing et al. successfully treated two patients with diverticulum stones located ventrally in the renal calyces by determining the puncture path through ultrasound. The group used positioning were successful in one-time channel construction without complications such as perirenal organ damage.
3.1.2 Precautions for channel expansion
The smooth establishment of the lithotripsy channel directly affects the effect of lithotripsy and stone removal, so the expansion of the channel along the guidewire is also a crucial step. The operator understands that the guidewire should be straight when expanding the channel, the right hand rotates the fascial dilator, the left hand fixes its lower end to control the expansion speed and depth, following the principle of “preferring shallow to deep”.
Two patients in this group had bleeding during dilatation, and the effect was not good after using soft sheath compression, so a fistula was placed and left for the phase II surgery.
3.2 Experience of combined pneumatic ballistic ultrasound lithotripsy
The clinical study [3] found that the combined pneumatic ballistic ultrasound lithotripsy was faster than ultrasound alone, and the combined group also had certain advantages in terms of stone clearance rate and reduction of complications.The EMS combined pneumatic ballistic ultrasound lithotripsy machine combined with a large channel nephrolithoscope can aspirate the lithotripsy out of the body while crushing the stones, avoiding the process of repeatedly clamping or flushing out the stones, reducing the possible adverse consequences of multiple operations, and reducing the patients’ surgical exposure time. The operation time was 64(51-107) min in this group of cases.
The use of combined pneumatic ballistic ultrasound lithotripsy achieved good lithotripsy and stone clearing results, reduced the number of intraoperative lithotripsy forcepses used, and reduced the incidence of complications. It is worth mentioning that 6 patients in this group were found to have stone obstructed pus kidney, and they were operated with ultrasonic probe as much as possible, and the flushing pressure was controlled to lithotripsy and lithotripsy under low pressure condition, and one case had fever after the operation, and the body temperature returned to normal after 3 days of antibiotics according to the drug sensitivity results.
Therefore, we believe that performing stage I PCNL in some patients with stone abscess kidney with strict intraoperative control of operation time and flushing pressure is also a treatment method that can be tried.
The common complications of PCNL surgery include bleeding, infection, upper urinary tract obstruction and renal colic, among which peripheral organ damage is often associated with channel establishment, and its incidence is low under ultrasound guidance.Osman [5] reported that in 300 patients with PCNL, 32.1% had elevated body temperature secondary to surgery and one case died of sepsis. We have learned during the treatment that the complications that need to be prevented are infection and bleeding, among which the control of infection is the most important, and the consequences of severe infection are more serious.
Operators routinely use antibiotics for 3-5 days before surgery according to drug sensitivity or experience, and carry sensitive antibiotics for 30 minutes intravenously at the beginning of anesthesia during surgery. This can effectively prevent the occurrence of postoperative infection. Intraoperative bleeding is commonly caused by bleeding from the renal parenchyma during channel establishment and mucosal tears caused by swinging of the mirror during intraoperative operation, which can often be treated symptomatically by pushing hemostatic drugs and temporarily placing fascial dilators for compression.
In conclusion, percutaneous nephrolithotomy with pneumatic ballistic ultrasound combined with lithotripsy is a safe and effective surgical treatment for complex renal stones, with minimally invasive, high lithotripsy clearance rate, safe and reliable, and worthy of further clinical promotion.