(A) Indications for surgery.
1. Renal pelvis size above 2 cm or stone in the lower renal calyces above 1.5 cm.
2. Partial renal antler-shaped stones with hydronephrosis in the renal calyces.
3, Large stones in the ureteropelvic junction (UPJ).
4.Ureteral stone in the upper part of the ureter.
5. Complete renal antler-shaped stones.
(B) Preoperative preparation.
1.Apply antibacterial drugs to control infection.
2.Prepare 300~600ml of blood.
3.Exclude hematological diseases and bleeding tendency.
4. For stage I surgery, it is best to perform CT examination before surgery.
(C) Anesthesia.
Epidural anesthesia.
(iv) Position prone.
1.The affected side is padded 25°~30°
2. The chest and iliac region should be elevated, and the abdomen should be lowered.
(E) Surgical steps: 1.
1, first percutaneous renal puncture, the puncture channel should be designed before surgery, the fistula channel must be established on the calyces of stone extraction. Twelve subcostal and eleven intercostal perforator approaches are more commonly used at present, and occasional upper renal calyx stones can be accessed from the ten intercostal approach. However, care should be taken to avoid pleural injury. Complete deerstalker stones may require multiple accesses from the lower, middle, and upper calyces. Stones in the ureteral junction of the renal pelvis or upper ureter are best approached from the middle calyx. For partial renal deerstalker stones, the approach is from the lower or middle calyces.
The former is performed immediately after percutaneous nephrostomy, while the latter is performed after percutaneous nephrostomy and then a few days or a week later.
2.Stage I standard percutaneous nephrolithotomy.
Percutaneous renal access is dilated using an Amplaz dilator tube. After the puncture needle enters the kidney according to the preoperative designed approach, the guidewire is fed into the kidney along the puncture needle canal and sent as far as possible into the ureter or into the superior calyx rolled up and dilated along the guidewire using a fascial dilatation tube F6 to F10. Using guiding vascular catheter F7, enter the kidney along the metal guidewire, and under C-arm X-ray fluoroscopic surveillance, manipulate the guiding vascular catheter and metal guidewire by hand to introduce the guidewire into the ureter or, if it fails, into the superior calyx. The metal guidewire entering the ureter is called a safety guidewire. The F8 catheter is pushed in along the guidewire. Then, the Amplaz dilatation tube is pushed along the F8 catheter from F12 to F22. From F24 to F30, the dilatation tube with the corresponding rigid sheath is pushed in. At this point, the F24 dilatation tube with the rigid sheath is pushed into the kidney along the F8 catheter. The dilatation tube and F8 catheter are withdrawn, leaving the metal guidewire and the rigid sheath in place.
The operation with the nephroscope into the dural sheath usually starts with a large number of blood clots, which are first removed with a lithotripter so that there is a clearer view (and the stone is easier to see). If the stone is less than 1 cm, the stone can be removed with duckbill forceps. If the stone is about 1 cm in size, a three-jawed forceps can be used to remove the stone. If the stone is larger, it should be broken by ballistic lithotripter, holmium laser lithotripter or ballistic lithotripter with ultrasonic lithotripter. After lithotripsy, the stone is retrieved with a lithotripter. After the stone is removed, a nephrostomy tube is left in place to drain the stone.
3.Stage II standard percutaneous nephrolithotomy method.
A percutaneous nephrostomy is performed first, as described in the previous section. The F14 or F16 nephrostomy tube is left in place. For second-stage stone extraction ( a few days later), a metal guidewire is placed along the F14 or F16 nephrostomy tube to the kidney, and then an F9.5 ureteroscope is used to follow the guidewire and enter the kidney via the fistula channel under direct vision. The stone location is observed and the guidewire is placed into the ureter or suprarenal calyces. The remaining steps are performed as in the first-stage percutaneous nephrolithotomy.
(F) Postoperative treatment
1.Observe whether the nephrostomy tube drainage fluid is clear and whether the urine color becomes clear.
2.Take abdominal plain film 2d after surgery to see if the stone is clear. If the stone is clear, the tube can be clamped when the drainage fluid becomes clear in 3 d after surgery, and the tube can be removed after 2 d if the patient does not feel distended in the lower back and there is no urine leakage.
3. Use antibacterial drugs to prevent and control infection.