复杂肾结石的最优解决方案.pptx

,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Company Logo,#,单击此处编辑母版标题样式,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,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,C,臂机,超声,联合应用,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 F,6 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,ESWL,MPCNL,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 complications,may be encountered in up to,25%,of patients.,出血、肾盂损伤、液体吸收、胸腔损伤、肠道穿孔、肝脾损伤、败血症等。,CAMPBELL-WALSH Urology.Tenth Edition,1405.,谢谢！,