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目的探讨合并心肺功能障碍和/或上尿路感染的高危老年肾结石患者手术治疗方式的选择及其安全有效性。方法回顾性总结2006年1月至2008年3月我科治疗的12例患者的临床资料。12例患者术前检查均有通气功能障碍或混合性呼吸功能障碍,7例合并高血压,3例合并心功能不全,4例合并糖尿病,6例合并上尿路感染。术前ASA分级均≥3级。手术均分期进行。一期在1%利多卡因局麻下B超引导经皮肾穿刺,皮肾通道扩张至14F,放置12F造瘘管。5～7 d后局麻下经原皮肾通道行经皮肾镜取石术。应用视觉模拟评分法(visual analogue scale,VAS)评估患者耐受程度。结果12例手术两期均顺利完成。一期手术时间15～25 min,平均21 min。二期手术时间20～45 min,平均35 min。一期手术VAS评分2.1～6.2 mm,平均3.9 mm,二期手术VAS评分1.5～6.4 mm,平均3.5 mm,患者均能良好耐受,无需更改麻醉方式。12例术后均无继发性大出血,无继发肺部感染、电解质异常及心脏并发症。1例术前有明显上尿路感染者一期术后发热2 d,经广谱抗生素治疗后缓解。二期术后复查KUB,仅1例下盏残留结石4 mm。随访6～18个月,均无结石复发,无继发上尿路感染。结论对于选择性的合并心肺功能障碍和/或伴有上尿路感染等高危因素的肾结石患者,采用局麻下分期经皮肾取石术(percutaneous nephrolithotomy,PCNL)的方法疗效确切,同时明显降低了手术风险,是一种可选择的方法。
Objective To investigate the surgical treatment options and safety and efficacy of high-risk senile nephrolithiasis with cardiopulmonary dysfunction and / or upper urinary tract infection. Methods The clinical data of 12 patients treated in our department from January 2006 to March 2008 were retrospectively reviewed. All 12 patients had ventilatory or mixed respiratory dysfunction, 7 had hypertension, 3 had heart failure, 4 had diabetes mellitus, and 6 had upper urinary tract infection. Preoperative ASA grade ≥ 3 grade. Surgery were staged. A 1% lidocaine in 1% under local anesthesia guided percutaneous renal biopsy, renal tubular expansion to 14F, placed 12F fistula. 5 ~ 7 d after local anesthesia underwent primary renal percutaneous nephrolithotomy lithotomy. The degree of patient tolerance was assessed using a visual analogue scale (VAS). Results 12 cases of surgery were completed successfully. The first operation time 15 ~ 25 min, an average of 21 min. Second surgery time 20 ~ 45 min, an average of 35 min. The VAS score of the first surgery ranged from 2.1 to 6.2 mm, with an average of 3.9 mm. The VAS score of the second phase surgery ranged from 1.5 to 6.4 mm with an average of 3.5 mm. All patients were well tolerated without changing the anesthetic mode. No postoperative hemorrhage was found in 12 cases. No secondary pulmonary infection, electrolyte abnormalities and cardiac complications were found. One case of preoperative obvious upper urinary tract infection in one postoperative fever 2 d, after a broad-spectrum antibiotic treatment ease. Two postoperative review KUB, only 1 case of residual light stones 4 mm. Follow-up 6 to 18 months, no recurrence of stones, no secondary upper urinary tract infection. Conclusion The method of percutaneous nephrolithotomy (PCNL) under local anesthesia has definite curative effect and obvious reduction for patients with kidney stones who are selectively treated with high risk factors such as cardiopulmonary dysfunction and / or upper urinary tract infection Surgical risk is an alternative method.