在無腎造瘻管的經皮腎造瘻取石術時肋間與肋下穿刺所產生的併發症比較

Complications Associated With Tubeless Percutaneous Nephrolithotomy:Supra-Versus Subcostal Approach

嚴孟意(Meng-Yi Yan)

指導教授 ： 藍守仁

亞洲大學/健康學院/健康管理研究所/碩士(2012年)

摘要

Purpose
A higher complication of supracostal approach is noted in standard PCNL (percutaneous nephrolithotomy). We prospectively evaluate the morbidity associated with supracostal and subcostal access during our tubeless PCNL series.

Materials and methods
From January 2002 to December 2007, 118 patients underwent one-stage fluoroscopic-guide percutaneous nephrolithotomy for complex renal and upper ureteral stone by one experienced surgeon at our medical center. Surgical indications were renal staghorn stones, large renal calculi (larger diameter ＞2.5cm), large upper ureteral stone (transverse diameter ＞1.5cm) or mixed. It was not a randomized trial, whether to place a nephrostomy tube (standard PCNL) or double-J stent only (tubeless PCNL); the decision was made at the end of the procedure. Our exclusion criteria included: significant postoperative bleeding, significant perforation of the collecting system, much residue stone burden, more than one percutaneous tracts and obstructive renal anatomy. There were 86 patients received tubeless percutaneous nephrolithotomy totally.
In 56 patients, a supracostal puncture, above the 12th rib (between 11-12th rib) was performed. In the other 30 patients, a subcostal tract, below the 12th rib was established. Morbidity, 0peration time, analgesia requirement, length of hospital stay, stone- free rate, was analyzed.

Results
A total of 86 patients (56 patients in supracostal group and 30 patients in subcostal group) were included in this study. The mean age, operation side, stone locations were similar. The male: female ratio is higher in supracostal group (39/17) than in subcostal group (13/17) (p=0.0174). Large renal stones and staghorn stones occupied most of the stone cases (supracostal group: subcostal group= 75%: 80%). Whenever possible, an upper pole access was chosen when operation. The operative puncture calyx was most located over post middle or upper calyx in both groups. The stone–free rate of supracostal group was 59% (33/56) and in subcostal group was 50 % (15/30) (p=0.4274). Our initial total stone-free rate was 56% (p=0.4274). Post ancillary procedure (SWL or URSL) 3 months later, the total stone-free rate was increasing to 90%. Upper ureteral stone group had the highest initial stone-free rate (10/11) and the staghorn stone group owned the lowest (3/25) (p＜0.0001). The mean operation time is 100±23 minutes in supracostal group and 110±27 minutes in subcostal group. The staghorn stone group spent more operation time than the other 3 groups. Length of stay is around the same 4 days in both groups. There was no statistically significant difference in pethidine requirements (supracostal: subcostal =25.76mg: 33.92mg) and Hct change (supracostal: subcostal=3.5%: 3.3%). The overall complication rate is 6% (supracostal group: 2 % (1/56) and subcostal group: 13 %( 4/30)) (p=0.0292). Most complications were renal infection. They got recovery eventually. No hemothorax or pneumothorax happened.

Conclusions
Supracostal puncture within 11th -12th rib intercostal space by an experienced urologist during tubeless PCNL is a safe and effective procedure. It does not cause a higher incidence of hemothorax or pneumothorax.

Key word: calculi; renal, upper ureter, nephrostomy, percutaneous; endoscopy, Double- stent

關鍵字

結石 ； 腎臟 ； 上輸尿管 ； 腎造瘻管 ； 經皮 ； 內視鏡 ； 雙J導管

並列摘要

Purpose
A higher complication of supracostal approach is noted in standard PCNL (percutaneous nephrolithotomy). We prospectively evaluate the morbidity associated with supracostal and subcostal access during our tubeless PCNL series.

Materials and methods
From January 2002 to December 2007, 118 patients underwent one-stage fluoroscopic-guide percutaneous nephrolithotomy for complex renal and upper ureteral stone by one experienced surgeon at our medical center. Surgical indications were renal staghorn stones, large renal calculi (larger diameter ＞2.5cm), large upper ureteral stone (transverse diameter ＞1.5cm) or mixed. It was not a randomized trial, whether to place a nephrostomy tube (standard PCNL) or double-J stent only (tubeless PCNL); the decision was made at the end of the procedure. Our exclusion criteria included: significant postoperative bleeding, significant perforation of the collecting system, much residue stone burden, more than one percutaneous tracts and obstructive renal anatomy. There were 86 patients received tubeless percutaneous nephrolithotomy totally.
In 56 patients, a supracostal puncture, above the 12th rib (between 11-12th rib) was performed. In the other 30 patients, a subcostal tract, below the 12th rib was established. Morbidity, 0peration time, analgesia requirement, length of hospital stay, stone- free rate, was analyzed.

Results
A total of 86 patients (56 patients in supracostal group and 30 patients in subcostal group) were included in this study. The mean age, operation side, stone locations were similar. The male: female ratio is higher in supracostal group (39/17) than in subcostal group (13/17) (p=0.0174). Large renal stones and staghorn stones occupied most of the stone cases (supracostal group: subcostal group= 75%: 80%). Whenever possible, an upper pole access was chosen when operation. The operative puncture calyx was most located over post middle or upper calyx in both groups. The stone–free rate of supracostal group was 59% (33/56) and in subcostal group was 50 % (15/30) (p=0.4274). Our initial total stone-free rate was 56% (p=0.4274). Post ancillary procedure (SWL or URSL) 3 months later, the total stone-free rate was increasing to 90%. Upper ureteral stone group had the highest initial stone-free rate (10/11) and the staghorn stone group owned the lowest (3/25) (p＜0.0001). The mean operation time is 100±23 minutes in supracostal group and 110±27 minutes in subcostal group. The staghorn stone group spent more operation time than the other 3 groups. Length of stay is around the same 4 days in both groups. There was no statistically significant difference in pethidine requirements (supracostal: subcostal =25.76mg: 33.92mg) and Hct change (supracostal: subcostal=3.5%: 3.3%). The overall complication rate is 6% (supracostal group: 2 % (1/56) and subcostal group: 13 %( 4/30)) (p=0.0292). Most complications were renal infection. They got recovery eventually. No hemothorax or pneumothorax happened.

Conclusions
Supracostal puncture within 11th -12th rib intercostal space by an experienced urologist during tubeless PCNL is a safe and effective procedure. It does not cause a higher incidence of hemothorax or pneumothorax.

Key word: calculi; renal, upper ureter, nephrostomy, percutaneous; endoscopy, Double- stent

並列關鍵字

calculi ； renal ； upper ureter ； nephrostomy ； percutaneous ； endoscopy ； Double- stent

參考文獻

Aghamir, S. M., Khazaeli, M. H., & Meisami, A. (2006). Use of Surgicel for sealing nephrostomy tract after totally tubeless percutaneous nephrolithotomy. J Endourol, 20(5), 293-295.

Agrawal, M. S., Agrawal, M., Gupta, A., Bansal, S., Yadav, A., & Goyal, J. (2008). A randomized comparison of tubeless and standard

percutaneous nephrolithotomy. J Endourol, 22(3), 439-442.

Aron, M., Goel, R., Kesarwani, P. K., & Gupta, N. P. (2004). Hemostasis in tubeless PNL: point of technique. Urol Int, 73(3), 244-247.

Falahatkar, S., Khosropanah, I., Roshani, A., Neiroomand, H., Nikpour, S., Nadjafi-Semnani, M., et al. (2008). Tubeless percutaneous nephrolithotomy for staghorn stones. J Endourol, 22(7), 1447-1451.