復(fù)雜性腎結(jié)石腎實(shí)質(zhì)切開(kāi)取石術(shù)不同術(shù)式探討

1、復(fù)雜性腎結(jié)石腎實(shí)質(zhì)切開(kāi)取石術(shù)不同術(shù)式探討    【摘要】  目的  通過(guò)不同術(shù)式的比較以提高復(fù)雜性腎結(jié)石的手術(shù)療效，降低結(jié)石的殘留率及術(shù)后腎功能的恢復(fù)。  回顧，35例復(fù)雜性腎結(jié)石不同術(shù)式手術(shù)的臨床資料。結(jié)果  低溫阻斷腎動(dòng)脈腎實(shí)質(zhì)切開(kāi)取石術(shù)組18例動(dòng)脈阻斷時(shí)間2565min，出血量80400ml，手術(shù)時(shí)間90170min。間斷性不完全性腎蒂阻斷行腎實(shí)質(zhì)切開(kāi)取石組17例手術(shù)病人, 12例手術(shù)病人出血少于200ml均未輸血,有2例患者術(shù)中出血稍多輸血400ml,手術(shù)取石時(shí)間(從上腎蒂鉗到腎實(shí)質(zhì)縫合完畢后取腎蒂鉗)15

2、 25min,平均17.5min。手術(shù)取石時(shí)間短,平均13.2min,術(shù)后患腎功能均正常。結(jié)論  對(duì)腎竇內(nèi)腎盂鑄型腎結(jié)石開(kāi)放手術(shù)治療需要根據(jù)結(jié)石的大小、形態(tài)、手術(shù)所需的時(shí)間及難易程度確定術(shù)式。低溫阻斷腎動(dòng)脈腎實(shí)質(zhì)切開(kāi)取石術(shù)具有出血少、顯露充分、術(shù)野清晰、結(jié)石取凈率高等優(yōu)點(diǎn)。間斷不完全性腎蒂阻斷下行腎實(shí)質(zhì)切開(kāi)取石術(shù)具有簡(jiǎn)單、快捷、腎功能損傷小、恢復(fù)快等優(yōu)點(diǎn)。     【關(guān)鍵詞】  腎結(jié)石;外科手術(shù)       exploration of various nephrotomy of re

3、moval the stones for the complex nephrolithiasis    【Abstract】  Objective  To the purpose of promote the surgical operating effect about complex kidney stone from the comparison of different surgical decrease the remain a rate of kidney stone and the recover the kidney funct

4、ion.  Methods   Review and analyze the clinic data of 35 cases of the complex kidney stone from different surgical operation method. Results   There are 18 examples at operation to cut open the kidney and take stone in the environment to stop kidney artery takes 2565min. The

5、 bleeding  quantity is 80400ml,it is 90170min to operation.There are 17 examples to cut open the kidney paren chyma and take stone in a environment to interrupted and imperfectly stop the kidney pedicel,there are 12 patients to bleeding of 200ml，not yet blood transfusion.There are 2 patients of

6、 blood transfusion 400ml,because of bleeding much,the time of taking the stone (from take the kidney pedicle forceps to get it and sew up the kidney paren chyma is 1525min)is 17.5min,the time of taking stone from kidney substance is short,the average is 13.2 min，the renal function of the trouble kid

7、ney is normal of operation.Conclusion  It is to decide the operation that the kidney stone and pelvis type  on the basis of the side and shape of kidney stone and the requirement of operation time,the quality of rate a kidney stone from cut open kidney in a low temperature is full reveal a

8、nd the operation field is clear,the rate of take the stone is high,there is a quality of simple shortcut and short of function damage and recover quickly in the operation method of take the kidney stone from cut open the kidney substance in a environment of stop the renal pedicle interruption. 

9、   【Key words】  kidney stone；surgical operation    腎結(jié)石是泌尿外科的常見(jiàn)疾病，其治療方法主要有中藥排石、溶石法、體外震波碎石法、彈道碎石及外科手術(shù)治療。其中外科手術(shù)治療又有多種，本文通過(guò)對(duì)復(fù)雜性腎結(jié)石術(shù)后結(jié)石取出率、術(shù)后腎功能恢復(fù)得比較，探討不同術(shù)式治療復(fù)雜性腎結(jié)石的優(yōu)劣性。    1  資料與方法    1.1  一般資料  低溫阻斷腎動(dòng)脈腎實(shí)質(zhì)切開(kāi)取石術(shù)組18例均為腎內(nèi)型腎盂腎結(jié)石患者，男1

10、1例，女7例，年齡3365歲，平均45歲，左腎結(jié)石10例，右腎結(jié)石8例，結(jié)石最大直徑4.2cm。間斷性不完全性腎蒂阻斷行腎實(shí)質(zhì)切開(kāi)取石組17例也均為腎內(nèi)型腎盂腎結(jié)石患者，其中男10例,女7例,年齡2672歲,平均46歲,左腎結(jié)石9例,右腎結(jié)石8例，有1例為體外沖擊波碎石治療失敗而改為開(kāi)放性手術(shù)的。以上病例術(shù)前均經(jīng)B超、KUB、IVP、CT及逆行腎盂造影等影像學(xué)檢查而明確診斷。    1.2  手術(shù)方法  低溫阻斷腎動(dòng)脈腎實(shí)質(zhì)切開(kāi)取石術(shù)組取第十二肋床斜切口，切除十二肋切開(kāi)腎周筋膜，充分顯露腎臟，游離腎臟及腎蒂，仔細(xì)分離出腎動(dòng)脈，此時(shí)快速靜脈注射肌

11、苷2g和20%甘露醇250ml后，用無(wú)損傷鉗夾動(dòng)脈，腎周加入碎冰冷卻15min。腎臟變軟、變白。沿腎背側(cè)外緣相對(duì)無(wú)血管區(qū)（Brodel）線切開(kāi)腎實(shí)質(zhì)腎盞取石，結(jié)石取凈后插入雙“J”管。用4-0可吸收線貫穿縫合相鄰腎盞切緣。間斷縫合腎盂切口兩端，連續(xù)貫穿縫合，完成腎盂關(guān)閉。用2-0可吸收線貫穿間斷縫合腎包膜。    間斷不完全性腎蒂阻斷下行腎實(shí)質(zhì)切開(kāi)取石術(shù)患者取硬膜外麻醉，側(cè)臥位在分離暴露腎臟后,根據(jù)X線片、手探查、針刺確定結(jié)石位置,游離腎蒂,用帶皮套的腎蒂鉗鉗夾腎蒂,只上一個(gè)鉗齒,觀察腎臟顏色變淡紅或稍變暗,但未變灰暗或蒼白,迅速用小尖刀在距結(jié)石最近距離或較近距離

12、相對(duì)較薄的腎實(shí)質(zhì)表面刺達(dá)結(jié)石,用止血鉗或取石鉗分離結(jié)石后夾出結(jié)石。如取石時(shí)間較長(zhǎng),可每隔5min松開(kāi)腎蒂鉗3min,松開(kāi)腎蒂鉗時(shí),用紗布或大腹紗壓迫腎實(shí)質(zhì)切口。取完結(jié)石,從切口插管沖洗腎盂,沖洗時(shí)如發(fā)現(xiàn)腎盂積血較多,且不易沖洗干凈,可在原切口留置腎盂造瘺引流管,用較粗的220, 120, 0號(hào)或1號(hào)腸線間斷縫合腎實(shí)質(zhì)切口,腸線中間夾帶腎周脂肪做墊襯。    2  結(jié)果    采用原位低溫腎動(dòng)脈阻斷腎實(shí)質(zhì)切開(kāi)取石術(shù)組：左側(cè)10例次，右側(cè)8例次。腎實(shí)質(zhì)切口35cm，血流阻斷時(shí)間2565min，出血量80400ml（有2例輸血20

13、0ml）。最多取石130余顆，最大結(jié)石4.2cm×3.5cm×3cm，最小如沙粒狀。手術(shù)時(shí)間90170min，術(shù)后血尿2例27天。術(shù)后近期檢查，發(fā)現(xiàn)結(jié)石殘留3例，經(jīng)ESWL治愈。腎萎縮1例。10例獲6個(gè)月1年隨訪，行IVP檢查，患者腎功能恢復(fù)良好，腎盂、腎盞顯影良好。    間斷性不完全性腎蒂阻斷行腎實(shí)質(zhì)切開(kāi)取石組17例腎結(jié)石均一次取出, 12例手術(shù)病人出血少于200ml均未輸血,有2例患者術(shù)中出血稍多，輸血400ml,最大結(jié)石3cm×2.5cm×1.5cm，術(shù)后3例患者出現(xiàn)肉眼血尿,用止血藥3天內(nèi)尿色均轉(zhuǎn)清亮。手術(shù)取石時(shí)間

14、(從上腎蒂鉗到腎實(shí)質(zhì)縫合完畢后取腎蒂鉗)15 25min,平均17. 5min。術(shù)后腎功能均正常。15例患者從術(shù)后1個(gè)月2年獲得隨訪,或復(fù)查B超,或復(fù)查同位素腎圖或行靜脈腎盂造影，手術(shù)側(cè)腎臟形態(tài)、功能與術(shù)前相比無(wú)明顯減退。    3  討論    復(fù)雜性鹿角狀腎結(jié)石的治療一直是較為棘手的,雖有采用經(jīng)皮腎鏡取石術(shù)(PCNL)及體外震波碎石術(shù)(ESWL)或PCNL+ESW治療取得成功的報(bào)道1,但開(kāi)放手術(shù)治療復(fù)雜性鹿角狀腎結(jié)石仍占重要地位2,3，隨著ESWL和氣壓彈道碎石技術(shù)的和普遍開(kāi)展，腎結(jié)石患者需行開(kāi)放性手術(shù)的已明顯減少4。當(dāng)

15、然微創(chuàng)概念是不可阻擋的趨勢(shì),腎切開(kāi)取石術(shù)本身也在向微創(chuàng)方向5。對(duì)復(fù)雜性腎結(jié)石仍多以開(kāi)放性手術(shù)為主要治療手段，如腎臟為腎內(nèi)型腎盂,結(jié)石巨大或?yàn)槁菇菢咏Y(jié)石或腎盂多發(fā)結(jié)石或腎盂腎盞多發(fā)結(jié)石,且梗阻較輕或梗阻早期,腎實(shí)質(zhì)無(wú)萎縮或萎縮較輕,要切開(kāi)腎實(shí)質(zhì)取石,出血多,手術(shù)操作困難,腎臟損傷大,腎功能損害嚴(yán)重。所以,腎內(nèi)型腎盂無(wú)萎縮腎臟腎實(shí)質(zhì)切開(kāi)取石手術(shù)一直是泌尿外科的難題之一69。一般中小鹿角狀腎結(jié)石采用腎盂或腎竇內(nèi)腎盂切開(kāi)取石術(shù)即可達(dá)到理想的取石效果,而復(fù)雜性巨大鹿角狀腎結(jié)石的手術(shù)治療較為困難,既要取盡結(jié)石,又要盡可能使腎功能免遭損害10。  腎實(shí)質(zhì)切開(kāi)取石術(shù),術(shù)中術(shù)后出血較多,作好術(shù)前各種檢

16、查和準(zhǔn)備,正確選擇合理術(shù)式,在減少出血的同時(shí)保護(hù)好腎功能,促進(jìn)術(shù)后恢復(fù)是手術(shù)成功的關(guān)鍵。對(duì)于巨大鹿角型結(jié)石或鑄型結(jié)石,應(yīng)采用局部低溫阻斷腎蒂情況下行腎實(shí)質(zhì)切開(kāi)取石。常溫下施行腎實(shí)質(zhì)切開(kāi)取石，腎血流阻斷時(shí)間超過(guò)30min會(huì)造成腎實(shí)質(zhì)不可逆損害，因此可能會(huì)因時(shí)間所限而不易取凈結(jié)石和止血不徹底，導(dǎo)致結(jié)石殘留、繼發(fā)出血、尿漏等，而有時(shí)為了取凈結(jié)石，其取石時(shí)間往往很難預(yù)料，采用原位低溫手術(shù)復(fù)雜性腎結(jié)石可彌補(bǔ)上述缺點(diǎn)。腎臟血運(yùn)豐富，對(duì)熱缺血非常敏感，常溫下腎缺血20min，腎功能將減退40%50%，需要67天才能恢復(fù)功能;缺血30min，腎功能減退60%70%，需要29天才能恢復(fù);腎缺血120min，腎功

17、能僅部分可恢復(fù)，甚至不能恢復(fù)。阻斷腎血管的同時(shí)，若將腎臟溫度降至1520，則至少可在3h內(nèi)對(duì)腎功能無(wú)損害。術(shù)中采用局部低溫,能最大限度使腎臟在缺血時(shí)減少氧耗,抑制能量代謝,保護(hù)腎臟。對(duì)于中小鹿角狀結(jié)石,術(shù)式應(yīng)首選腎竇內(nèi)腎盂加腎后基段間區(qū)聯(lián)合切口,在不阻斷腎蒂情況下取石。此類(lèi)患者雖然可采用或腎盂、腎竇內(nèi)腎盂、腎竇后唇切開(kāi)取石,但對(duì)于小腎盂并發(fā)大結(jié)石時(shí),上述均較困難。強(qiáng)行取石則有可能損傷腎竇內(nèi)大血管。根據(jù)解剖學(xué)特點(diǎn),腎段間區(qū)為少血管區(qū),切開(kāi)時(shí)不會(huì)損傷腎后段及基段動(dòng)脈,對(duì)腎血供小,損傷小。腎后基段間腎實(shí)質(zhì)相對(duì)較薄,且腎實(shí)質(zhì)切口兩側(cè)已行“”形鏈扣式逢扎,切開(kāi)時(shí)出血少,視野清楚。腎門(mén)腎實(shí)質(zhì)切開(kāi)后,腎內(nèi)腎

18、盂切口寬暢,即使結(jié)石稍大也能取出,并可在直視下探查有無(wú)腎內(nèi)殘石。術(shù)后1周開(kāi)始鼓勵(lì)患者多飲水,口服氫氯噻嗪利尿,促進(jìn)細(xì)小結(jié)石、血塊及壞死組織排出。    腎動(dòng)脈阻斷后，腎臟處于缺血狀態(tài)，體積縮小，實(shí)質(zhì)變軟，手術(shù)視野清晰，便于結(jié)石的觸摸和手術(shù)操作，利于取凈結(jié)石。腎實(shí)質(zhì)切口縫合時(shí)我們采用腎包膜、腎實(shí)質(zhì)、腎盂全層縫合，打結(jié)時(shí)以不切割腎組織為度，血流恢復(fù)后腎體積均勻膨大，對(duì)切口均勻擠壓，起到壓迫止血作用，本組病例，腎臟血流恢復(fù)后均未發(fā)生嚴(yán)重出血。復(fù)雜性腎結(jié)石治療復(fù)雜，很難以一種術(shù)式去解決所有的病例，我們認(rèn)為原位低溫腎動(dòng)脈阻斷腎實(shí)質(zhì)切開(kāi)取石術(shù)治療復(fù)雜性腎結(jié)石具有安全、顯露充分

19、、術(shù)野清晰，結(jié)石取凈率高，并能較好地保護(hù)腎功能等優(yōu)點(diǎn)，是治療復(fù)雜性腎結(jié)石理想的手術(shù)方法之一。    傳統(tǒng)的無(wú)萎縮腎切開(kāi)取石是沿Brodel線切開(kāi),腎動(dòng)脈前后支的末梢在腎弓形緣中部靠背側(cè)面約1cm距離處形成相對(duì)無(wú)血管的前后段間線,稱Brodel線,沿此線切開(kāi)腎實(shí)質(zhì)取石,認(rèn)為可減少出血量及避免腎缺血萎縮。但前后段間線因人而異,彎曲走行,多不在一條直線上,常不能根據(jù)表面的固定解剖標(biāo)志劃出其準(zhǔn)確位置3 。且由于段間線有時(shí)距結(jié)石較遠(yuǎn),而沿段間線切開(kāi),切口相對(duì)固定,有時(shí)切口與結(jié)石不在一條軸線上,這樣往往取石比較困難,增加了手術(shù)的路徑,增大了手術(shù)對(duì)腎臟的創(chuàng)傷。我們對(duì)腎內(nèi)型腎盂的無(wú)萎縮腎臟行腎實(shí)質(zhì)切開(kāi)取石時(shí),對(duì)腎蒂不完全阻斷,也就是把腎蒂鉗只扣一個(gè)齒,不扣死,且間隔5min松開(kāi)腎蒂鉗3min,延長(zhǎng)不損傷腎臟功能的手術(shù)操作時(shí)間,最大限度地減少腎蒂阻斷對(duì)腎功能的損害。手術(shù)對(duì)腎功能的影響一個(gè)是阻斷血供的時(shí)間長(zhǎng)短,另一個(gè)因素則是對(duì)腎實(shí)質(zhì)切開(kāi)的破壞。我們體會(huì)到:從最近距離腎實(shí)質(zhì)切開(kāi)抵達(dá)結(jié)石或從較近距離較薄處切開(kāi)腎實(shí)質(zhì)抵達(dá)結(jié)石,路徑最短或較短,腎實(shí)質(zhì)的損傷較小,且較容易取出結(jié)石,也縮短了腎蒂的阻斷時(shí)間。