后腹腔镜肾实质切开取石术治疗肾脏铸形结石（附23例报告）

摘要： 摘要：目的??探讨后腹腔镜技术处理肾脏铸形结石的手术要点与临床应用价值。方法?2013年8月-2017年10月，对23例不适合经皮肾镜取石术（PCNL）的患者给予后腹腔镜肾实质切开取石，结石均为单侧，至少占据一个肾盏和全部肾盂，平均直径2.8（2.3～3.8）cm。术中阻断肾动脉后，经吸引器注入冰水给予肾表面降温，沿Brodel线切开肾实质取出结石，根据肾实质厚度以QuillTM双向倒刺线进行全层或分层连续缝合关闭创缘。结果?23例手术均获成功。手术时间75~135?min，中位数95?min；肾脏热缺血时间17~35?min，中位数25?min；术中估计失血量25~350?ml，中位数105?ml，术中术后均未输血。术后5例出现血尿，均在3.0?d后消失；另有3例出现漏尿，于术后3.0~5.0?d消失。术后复查无明显残石。术后平均随访10（2~18）个月，静脉尿路造影（IVU）显示患肾梗阻程度明显减轻。结论?后腹腔镜肾实质切开取石术是一种安全、有效的微创手术方法，对于不适合行PCNL的患者，有望作为PCNL的替代治疗措施，但需进一步增加例数并观察远期疗效。
Abstract: Abstract: Objective?To explore the key technical points and clinical value of retroperitoneal laparoscopic nephrolithotomy in the treatment of renal staghorn calculi.?Methods?From August 2013 to October 2017, 23 patients with unilateral staghorn calculi (occupying the whole pelvis and at least one caliceal group), who were unsuitable for percutaneous nephrolithotomy (PCNL), underwent retroperitoneal laparoscopic nephrolithotomy. The mean stone size was 2.8 cm (2.3?~?3.8?cm). After the blocking of renal artery, ice-cold saline was infused to reduce the kidney temperature via the suction. An incision on the Brodel line was made and the stone was removed, then the renal collecting system and parenchyma were closed by using bidirectional suture line (QuillTM SRS suture) for single-layer or two-layer stitching according to the different thickness of the renal parenchyma.?Results?All the cases were successfully operated. There were no major intraoperative and postoperative complications. Median operative time was 95?min (75?~?135?min). Median warm ischemia time was 25 min (17?~?35 min). Median estimated blood loss was 105?ml (25?~?350?ml), no blood transfusion was needed during or after surgery. Gross hematuria occurred in 5 patients and disappeared three days later. Urine leakage occurred in 3 patients and disappeared three to five days later. No bleeding and residual stone occurred. Mean follow-up was 10 months (2 ~ 18), radiographic assessment by intravenous urography after surgery showed all renal units were completely functional, with significant relief of obstruction in all patients.?Conclusion?Retroperitoneal laparoscopic nephrolithotomy is a safe and effective procedure which could act as a promising alternative in treating staghorn renal calculi unsuitable for PCNL. Further investigation with a larger population group and longer follow up period are needed before this is suggested as the preferred method in selected patients in the future.