目的 探讨免穿刺架超声引导下微创经皮肾镜钬激光碎石术治疗肾、输尿管上段结石的可行性. 方法 2009年7月～2011年8月,采用免穿刺架超声引导下微创经皮肾镜钬激光碎石术治疗36例上尿路结石.肾结石26例,输尿管上段结石6例,肾结石合并同侧输尿管上段结石4例.输尿管上段结石0.8～2.5 cm,平均1.7 cm；肾结石1.5 ～4.0 cm,平均2.2 cm.在肩胛下角线与腋后线第11肋间或第12肋下区域,用无穿刺架的超声探头纵切横切十字交叉检查肾脏,确定目标肾盏、穿刺点以及穿刺角度和深度.依据经皮肾通道入路要求,选择在探头下方沿探头面纵轴线或探头内侧中线处穿刺.一手持探头,一手持穿刺针,在超声引导下将18G穿刺针先穿刺到肾包膜外,再调整角度穿刺目标肾盏,建立F16或F18碎石通道.F8/9.8输尿管镜下钬激光粉碎结石. 结果 所有患者成功建立F16～F18通道并进行钬激光碎石取石,均为单通道.手术时间45 ～195 min,平均84.8 min,出血20 ～400 ml,平均50.2 ml.34例一期碎石成功,2例因术中出血和肾周积液,于术后5～7d行二期碎石.术后4周复查KUB、超声,结石排净率88.9％(32/36).未出现严重出血、液气胸、腹腔脏器损伤等并发症. 结论 免穿刺架超声引导下微创经皮肾镜钬激光碎石术治疗肾、输尿管上段结石可行,安全、有效,定位准确.%Objective To discuss the feasibility of ultrasound-guided minimally invasive percutaneous nephrolithotomy (PCNL) without using a puncture needle holder for renal and upper ureteral stones. Methods From July 2009 to August 2011, we performed PCNL under the guidance by ultrasonography without a puncture needle holder on 36 patients with upper urinary calculi. Among the cases, 26 patients had renal stones, 6 patients had upper ureteral stones, and 4 had renal stones complicated with ipsilateral upper ureteral stones. The size of the upper ureteral stones ranged from 0. 8 to 2. 5 cm with a mean of 1. 7 cm in diameter, and that of the renal stones ranged from 1. 5 to 4. 0 cm with a mean of 2. 2 cm. To determine the target renal calices, and site, angle and depth of puncture, between the infrascapular and posterior axillary lines, at the 11th intercostal region or below the 12th rib, we crisscrossedly detected the kidney with an ultrasound probe. With the probe in one hand and a puncture needle in the other hand, under the guidance by ultrasonography, we inserted an 18-G puncture needle to the renal capsule, and then, after adjusting the angle, into the target renal calices, so that to build a F16 or F18 channel. Afterwards, holmium laser lithotripsy was carried out under a F8/9.8 ureteroscope. Results Single F16 or F18 Channel was established in all the patients, and holmium laser lithotripsy was completed within a mean of 84.8 minutes (ranged from 45 to 195 minutes). The mean intraoperative blood loss was 50.2 ml (ranged from 20 to 400 ml). The lithotripsy was succeeded in 34 of the patients in one session, and the other two received a second lithotripsy in 5 to 7 days after the first session because of intraoperative hemorrhage or perirenal effusion. Postoperative examination by KUB and ultrasonography showed that the stone clearance rate was 88.9% (32/36). No patients had massive hemorrhage, hydropneumothorax or injuries to the abdominal organs. Conclusions It is feasible, effective and safe to perfrom PCNL under ultrasound guidance without using puncture needle holder. The approach is accurate in positioning upper urinary stones.
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