[Abstract] Objective To investigate the method and efficacy of percutaneous nephrolithotomy in the horizontal position for the treatment of renal stones. Methods: After minimally invasive percutaneous nephropuncture with X-ray positioning, ureteroscopy and pneumatic ballast machine were used for lithotripsy and stone extraction. Results: All 17 cases were successful in establishing PCN channels in one stage, no puncture failure or conversion to open surgery, 13 cases of stage I stones were removed, and 4 cases of residual stones (3 cases of stones were removed in stage II surgery, and 1 case was cured by ESWL after refusal of surgery). Conclusion The treatment of renal stones by PCNL surgery in the horizontal position is less invasive and has a faster recovery. The patient’s comfortable position facilitates intraoperative anesthesia monitoring, improves surgical safety, and helps intraoperative stone discharge with good results. Wang Chuansheng, Department of Urology, Lu’an Hospital of Traditional Chinese Medicine
[Keywords] Kidney stone, minimally invasive percutaneous nephrolithotomy, posture
Percutaneous nephrolithotomy (PCNL) has now become the main surgical method for the treatment of renal stones (>=3 cm in diameter). In order to overcome the above-mentioned shortcomings, we performed PCNL on 17 patients with renal stones in the prone position from November 2005 to June 2007 with good results, as reported below.
Subjects and methods
(I) Clinical data
There were 17 cases in this group, 12 males and 5 females, aged 42 to 73 years old, with an average of 56 years old. Among them, there were 6 cases of solitary renal pelvis and calyx stones, 11 cases of deerstalker stones, the largest stone diameter reached 8 cm, 5 cases had ESWL or open surgery, 1 case combined with chronic obstructive pulmonary disease. Preoperatively, ultrasound, KUB, IVU and CT 3D imaging were performed to determine the stone sites and sizes.
(B) Methods
Epidural anesthesia + lumbar anesthesia was used. The patient was first placed in the lithotomy position, and the ureter on the affected side was retrograde inserted into the F5-6 ureteral catheter to the renal pelvis to receive saline irrigation, and the catheter was left in place and changed to the horizontal position. The affected side of the lumbar rib area is padded with a water bag (choose a different size water bag according to the body shape). It is tilted upward at 40° to 45°, and the ipsilateral arm is fixed to the surgical brace above the neck, paying attention to reveal the posterior axillary line and the subscapular angle line. Under the C-arm X-ray positioning, the gap and puncture point are selected according to the preoperative KUB and CT analysis of stone distribution and location, often using the subcostal and posterior axillary lines as the puncture point, which can be appropriately varied according to the actual situation, with the direction of needle entry tilted upward by 10° to 25° on the horizontal plane and 10° to 45° on the coronal plane to the cephalad side. Usually, the needle is inserted rapidly at the end of the patient’s inspiration momentarily, and the needle core is withdrawn to see urine flow, and the zebra wire is placed. after withdrawing the needle sheath, the skin is cut about 0.5 cm to 0.7 cm along the guide wire to expand the channel with a fascial dilator and expand to 16 F. Intermittent X-ray fluoroscopic monitoring is performed to ensure accurate puncture expansion, and the thin 16 F plastic sheath is left in place to establish percutaneous renal access. wolfF8～9.8 ureteroscope in perfusion pump Under intermittent low pressure perfusion, the stone is located in the renal pelvis or calyces through the PCN channel. The stones are crushed with the EMS pneumatic ballast machine, small stones can be flushed by the hydraulic perfusion pump, and slightly larger stones are removed with the epidural forceps. After the stone is removed, a double J tube is placed through the PCN channel in a downstream direction, and a 16F silicone tube is left in place for nephrostomy drainage.
(C) Results
In this group, 17 cases of PCNL were carried out in a horizontal position, and all of them were successful, no puncture failure or intermediate open surgery, and all of them were successful in establishing PCNL channels in the first stage, among which 2 cases were given blood transfusion with more bleeding. In this group, 13 cases of stage I stone extraction were completed (76.4% of stage I removal rate), 4 cases of residual stones, among which 3 cases were completed during stage II surgery and 1 case was cured by ESWL, with a stone removal rate of 94.1%. There were no serious complications such as intestinal perforation in this group, and all patients were discharged from the hospital with an average hospital stay of 6 days. The nephrostomy tube was removed 3 to 5 days after surgery, and the double J tube was left in place and removed 2 to 4 weeks after surgery.
DISCUSSION
PCNL is usually performed in the prone position, but there are some disadvantages in the prone position. (1) the prone position puts pressure on the chest, which may lead to poor breathing during the operation; (2) the prone position does not facilitate the anesthesiologist to observe the patient’s condition in time; (3) when intraoperative airway obstruction occurs, the prone position cannot be rescued in time. In recent years, scholars at home and abroad have begun to explore the feasibility and safety of using PCNL in the prone position. The key to the success of this procedure is the selection of the puncture site, and the insertion of ureteral catheter and water injection before puncture to cause artificial “hydronephrosis” is also very important to the success of the puncture. The design of the puncture site should focus on the proximity to the kidney and the proximity to the stone, and the shortest distance to the kidney and the stone should be chosen as the puncture expansion path. Usually, the puncture is performed under X-ray guidance in a safe area between the posterior axillary line of the 12th rib and the subscapular angle line, entering from the posterior row of the middle renal calyces, which can avoid hemorrhage. It also facilitates ureteroscopic exploration from the middle calyces to the supra- and infrarenal calyces and distal ureteral oscillations.
This method has the following advantages: (1) the skin, subcutaneous fat, muscles and perirenal tissues are less traumatized, and the patient recovers quickly after surgery; (2) the patient is in a comfortable position, and no special practice is needed before surgery; (3) complications of colonic injury are less likely to occur than in the prone position, and the position does not have a significant impact on blood circulation and respiration. (6) The angle between the PCN channel and the horizontal plane is small when lying down, so the lithotripsy can be easily flushed out during the operation. In the process of lithotripsy, the renal pelvis or ureteral pedicle is lifted first, and the zebra wire is passed through the stone, which can prevent the stone or blood clot from blocking the ureter. If the stone is too large to be taken out at one time or there is much bleeding during the operation, a nephrostomy tube can be left in place, and the stone is taken out in the second stage after 5-7 days.
The results of this group show that the treatment of kidney stones by PCNL in the horizontal position is less traumatic, comfortable for the patient, conducive to intraoperative anesthesia monitoring, improves surgical safety, and helps intraoperative stone expulsion with good results.
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