目的:PCNL术中对比超声引导穿刺影像和逆行肾盂造影影像,明确PCNL术中超声引导肾盏穿刺的有效性和安全性。方法:2016年1~6月,顺序进入协和医院泌尿外科准备接受PCNL手术的42例患者被纳入本研究。所有患者均在穿刺前行患侧输尿管逆行插管。结合术前KUB和CT影像,依据术中超声影像确定穿刺目标肾盏。首先在超声影像下确定穿刺路径:目标肾盏的穹窿核心点、盏颈中点及皮肤穿刺点(前两点连线在皮肤的投影点);取穿刺针分两段沿已确定的穿刺路径分别穿刺肾外段(固定段)和肾内段(活动段)进入集合系统,即“三点一线和两段穿刺法”。超声引导穿刺成功后,置入超硬导丝,行术中逆行肾盂造影,对比超声影像和逆行肾盂造影影像所显示的穿刺针走行路径。采用一步扩张法建立取石通道,行碎石取石手术。手术结束前,将工作鞘逐步旋转后撤至肾脏实质取石通道边缘,肾镜直视下观察取石通道是否经肾盏乳头建立。分析取石通道建立成功率、通道建立时间、集合系统穿孔率、术前术后血红蛋白值和血清肌酐浓度值、一次手术结石清除率和并发症的发生率。结果:所有42例患者均成功在超声引导下完成目标肾盏穿刺,采用术中逆行肾盂造影进行对比,证实所有患者超声引导穿刺均成功经目标肾盏穹窿核心点进入集合系统。术中肾镜直视通道观察进一步证实工作鞘是经肾盏乳头中心区域扩张进入集合系统。术后血红蛋白下降值为(0.46±0.72)g/dl,术后平均住院日为(3.3±1.7)d,术中无肾脏周围组织器官损伤。结论:术中逆行肾盂造影和肾镜直视通道观察证实,“三点一线和两段穿刺法”超声引导下目标肾盏穿刺安全有效。 OBJECTIVE: To compare the effectiveness of ultrasound-guided puncture and retrograde pyelography in PCNL during operation to determine the effectiveness and safety of ultrasound-guided renal calyceal puncture in PCNL. METHODS: From January to June 2016, 42 consecutive patients admitted to Union Hospital urology for PCNL surgery were enrolled in this study. All patients underwent retrograde intubation of ipsilateral ureter before puncturing. Combined with preoperative KUB and CT images, according to intraoperative ultrasound images to determine the puncture target calyx. First determine the puncture path under the ultrasound image: the culm core of the target calyceal center, the center of the lamp neck and the puncture point of the skin (the first two points are connected to the projection point of the skin); take the puncture needle in two steps along the defined puncture path Respectively puncture the outer segment of the kidney (fixed segment) and the renal segment (active segment) into the collection system, that is, “three-point line and two puncture method.” Ultrasound-guided puncture success, the super-hard guide wire implantation, intraoperative retrograde pyelography, contrast ultrasound and retrograde pyelography imaging shows the path of the puncture needle. A step expansion method to establish stone access, gravel stone surgery. Before surgery, the working sheath is gradually rotated and withdrawn to the edge of the renal access to the real stone passage. The renal access to the stone passage is observed under the direct vision of the renal calluses. The successful rate of stone access, the time of channel establishment, perforation rate of collection system, preoperative and postoperative hemoglobin and serum creatinine concentration, the rate of primary stone removal and the incidence of complications were analyzed. Results: All 42 patients successfully completed the target renal calyce puncture under the guidance of ultrasound. The retrograde pyelography was used to compare all the patients. All the patients were successfully guided into the collecting system through the core of the target calyceal culdocentesis. Intraoperative nephrolithotomy observation further confirmed that the working sheath is expanded through the central area of ​​the calyx and into the collection system. The postoperative hemoglobin value was (0.46 ± 0.72) g / dl, and the average postoperative hospital stay was (3.3 ± 1.7) days. There was no renal tissue damage during operation. Conclusion: Intraoperative retrograde pyelography and direct observation of nephrolithiasis confirm that the target renal celi puncture is safe and effective under the guidance of “three-point and two-point puncture” ultrasound guidance.