复杂肾结石的最优解决方案

,复杂肾结石的最优解决方案,郭剑明复旦大学附属中山医院泌尿外科,适应证,C. Trk, T. Knoll, A. Petrik, et al. Guidelines on Urolithiasis. European Association of Urology, 2013.,适应证,C. Trk, T. Knoll, A. Petrik, et al. Guidelines on Urolithiasis. European Association of Urology, 2013.,适应证,肾结石,中国泌尿外科疾病诊断治疗指南（2011年版）:218-220.,输尿管软镜,PCNL,适应证,坎贝尔-沃尔什泌尿外科学：第9版，1601.,适应证,CAMPBELL-WALSH Urology. Tenth Edition, 1364.,非鹿角形结石大于2cm，首选PCNL,适应证,CAMPBELL-WALSH Urology. Tenth Edition, 1373.,肾下极结石大于2cm，首选PCNL,适应证,PNL, followed by either SWL or repeated PNL, should be used for most patients with struvite staghorn calculi, with PNL being the initial element of the combination therapy.鹿角型肾结石应把PCNL作为综合治疗的第一步。,CAMPBELL-WALSH Urology. Tenth Edition, 1365.,小结,直径2cm、复杂性、鹿角形肾结石应首选PCNL输尿管软镜的局限性：手术时间长分期处理并发症多取石困难,定位方式,C臂机,超声,SonixGPS,定位方式：C臂机,优点：显示图像直观扩张过程实时监视术后查看残石情况缺点：二维平面图像对医患存在放射性不能显示穿刺路径周围器官,Yang R M, Morgan T, Bellman G C. Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shieldJ. Journal of endourology, 2002, 16(10): 727-731.,定位方式：超声,优点：无辐射提供三维立体信息显示集合系统、脉管系统及肾脏周围组织缺点：不直观需具备超声知识，经过特殊培训需要“人工肾积水”无法明确观察残留结石,Tzeng B C, Wang C J, Huang S W, et al. Doppler ultrasound-guided percutaneous nephrolithotomy: a prospective randomized studyJ. Urology, 2011, 78(3): 535-539.,定位方式：SonixGPS,穿刺前可以预判和设计穿刺路径及角度可精确看到穿刺针在组织中的穿刺轨迹显示探头切面与穿刺针的位置关系缩短经皮肾穿刺的学习曲线,小结,准确定位,穿刺通道,超微通道（ultra-mini-PCNL）,微通道（mini-PCNL）,标准通道（standard PCNL）,穿刺通道,标准通道（standard PCNL）2024 F清石率高并发症多,穿刺通道,微通道（mini-PCNL）1420 F并发症少效率低,穿刺通道,超微通道（ulrta-mini-PCNL）1113 F6 F mini-肾镜+钬激光直径2 cm肾结石取石效率低灌注压力大亦可行输尿管软镜或ESWLMPCNL的补充手段,Desai J, Zeng G, Zhao Z, et al. A novel technique of ultra-mini-percutaneous nephrolithotomy: introduction and an initial experience for treatment of upper urinary calculi less than 2 cmJ. Biomed Res Int,2013,2013:490793.,穿刺通道,超微通道（ulrta-mini-PCNL）,Desai J, Zeng G, Zhao Z, et al. A novel technique of ultra-mini-percutaneous nephrolithotomy: introduction and an initial experience for treatment of upper urinary calculi less than 2 cmJ. Biomed Res Int,2013,2013:490793.,金属工作鞘和封堵器,管道、封堵器、导丝、激光纤维,穿刺通道,超微通道（ulrta-mini-PCNL）,Desai J, Zeng G, Zhao Z, et al. A novel technique of ultra-mini-percutaneous nephrolithotomy: introduction and an initial experience for treatment of upper urinary calculi less than 2 cmJ. Biomed Res Int,2013,2013:490793.,3.5 F的mini肾镜与6 F的镜鞘，灌注管与激光纤维,小结,大通道清石效率高适用于体积大、复杂性肾结石小结石可选ESWL或输尿管软镜，不必MPCNL,并发症,Even for the most experienced urologist, major complications can still occur in up to 7% of patients undergoing PNL.And minor complica