Kidney stone is a common disease in urology. Percutaneous nephrolithoscopic pneumatic ballast lithotripsy is a new technique of intracavitary lithotripsy in urology, which was applied in the early 1990s. Percutaneous nephrolithotomy requires the artificial creation of a 0.7 cm diameter skin-to-pelvis channel in the patient’s affected lumbar region. The principle of lithotripsy is to use compressed gas to push the lithotripsy probe to break up the stone. The impact amplitude of the probe is small, no heat is generated, and the damage to the mucosa is slight and brief.
I. Indications for percutaneous nephrolithotomy pneumatic ballistic lithotripsy.
All kinds of kidney and ureteral stones are indications for percutaneous nephrolithoscopy
1. Kidney stones larger than 2 or 5 cm including multiple, cast, and antler-shaped stones.
2.Complex kidney stones, symptomatic diverticular stones, stones with intrarenal type pelvic joint stenosis, etc.
3.Cystine stones, calcium oxalate stones that ESWL is ineffective.
4.Stone street or residual stones in the kidney after ESWL, multiple kidney stones or antler-shaped stones, especially recurrent stones after open surgery.
5, various obstructions and unexplained hydronephrosis
6, postoperative upper urinary tract obstruction, infection and pus accumulation
Contraindications to percutaneous nephrolithoscopic pneumatic ballistic lithotripsy.
1. Absolute contraindication is uncontrollable coagulation dysfunction. Those taking anticoagulant drugs such as aspirin and warfarin should stop taking the drugs for more than 2-4 weeks and recheck the coagulation function before the procedure can be performed.
2.Severe heart disease and pulmonary insufficiency, unable to withstand surgery.
3. Uncorrected severe diabetes mellitus and hypertension.
4.Stone combined with ipsilateral kidney tumor.
5.Acute infection or renal tuberculosis is not suitable for PCNL.
6.Severe chronic hepatic and renal insufficiency should be noted for bleeding tendency.
Establishing percutaneous nephrological access technique.
Percutaneous nephrological access is the core of the whole percutaneous nephrological pneumatic ballistic lithotripsy technique. It requires the surgeon to be proficient in B-ultrasound, X-ray, CT, and MRI techniques, to have a better understanding of the three-dimensional space of human organs, organ blood circulation, anatomy, and surrounding organ relationships, and to accumulate certain clinical experience in open surgery. He should have a good understanding of the depth and angle of the puncture needle, the avoidance of the calyx interval, blood vessels, surrounding organs, the percentage of surgical operations to be completed after the establishment of the channel, and the possibility of residual stone removal.
IV. Points to note after percutaneous nephrolithotomy.
Any kind of advanced technology has its possible complications. Careful observation of the patient’s recovery after surgery, timely detection of possible problems and early treatment will help the patient’s postoperative recovery a lot.
1, infection (including bacteriuria, fever, sepsis, etc.): strict aseptic operation. Apply antibiotic treatment after surgery.
2, haemorrhage (in serious cases, there is a possibility of kidney cutting): try to choose the puncture “non-vascular area”, if necessary, renal artery embolization or surgical exploration, if necessary, renal parenchymal repair or vascular repair.
3, renal pelvis perforation, urinary fistula, urinary extravasation: the puncture point should be shallow rather than deep, and avoiding violent operation is the main method of prevention.
4, intestinal injury (intestinal obstruction, fecal fistula, urinary fistula) injury to the pleura, abdominal organs: familiar with the anatomical relationship around the kidney, strictly under the ultrasound or x-ray guidance of careful operation, can generally be avoided
5, blockage and dislodgement of nephrostomy tube: observe the patient at all times, carefully fix the drainage tube and maintain unobstructed drainage.
6, double J tube displacement can not be removed from the bladder: intraoperative bladder injection of melanoma fluid to confirm the double J tube into the bladder. Ureteroscopy was performed to remove it.
7, perirenal urine accumulation: the nephrostomy tube is not completely placed in the combined system, and its lateral holes are outside the renal envelope, so that some urine accumulates in the retroperitoneal space; obstruction caused by small stones or edema falling into the ureter is also a cause of perirenal urine accumulation. The diagnosis of perirenal urine accumulation can be confirmed by ultrasound examination. If the perirenal urine accumulation is too much, it should be punctured and drained, and the depth of the nephrostomy tube should be adjusted at the same time.
8. Stone residual: Stone residual is one of the common complications of percutaneous nephrological surgery. If there are large residual stones, postoperative extracorporeal shock wave lithotripsy (ESWL) is a better way to remedy them.
Complications include retroperitoneal hematoma, contrast reaction, pelvic ureteral junction stenosis, pleural effusion and pneumatization, foreign body, stone residue, nephrostomy tube prolapse, and loss of renal access.
In conclusion, the advantages of percutaneous nephrolithotomy are: avoiding the pain of open surgery, fast postoperative recovery, short hospital stay, fewer complications, less medication, and significantly lower cost compared to open surgery. Percutaneous nephrolithotomy is an ideal method for the treatment of complex kidney stones.