Doré Bertrand, Conort Pierre, Irani Jacques, Amiel J, Ferrière Jean-Marie, Glémain Pascal, Hubert Jacques, Lechevallier Eric, Meria Paul, Saussine Christian, Traxer Olivier
Service d'Urologie, Hôpital La Milétrie, Poitiers, France.
Prog Urol. 2004 Dec;14(6):1140-5.
Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70 is considered to be associated with a higher risk than extracorporeal shock-wave lithotripsy (ESWL). However this technique is sometimes necessary for very large or complex stones in patients with several comorbidities.
To evaluate the predictive factors of success and operative risks likely to influence the results of PCNL in a population of patients over the age of 70.
Retrospective study of 203 patients (110 males, 97 females) over the age of 70, in whom a total of 210 PCNL were performed over a 12-year period in ten referral centres for the treatment of stones. 68.5% of cases presented a comorbidity and the median ASA score was 2. The median stone dimensions were 24 x 15 mm. There were 67 solitary pelvic stones, 7 infrapelvic ureteric stones, 31 solitary inferior caliceal stones, 40 complex stones and 13 staghorn calculi. A standard one-stage operative technique was performed in 92% of cases; the nephrostomy tract was easily performed by the urologists themselves in 71.8% of cases.
The overall stone-free (SF) rate was 70.8%. The patient's weight and height (p=0.03 and p=0.01), stone dimensions and their solitary nature were significant factors of success (p<0.00001 and p=0.01) with SF rates of 81.1% for pelvic stones and 90.3%for solitary inferior caliceal stones (p<0.003); the SF rate for complete staghorn calculi was only 30.8%. A history of stones (p=0.04) and diabetes (p=0.03) influenced the stone-free rate, but the other comorbidities, body mass index, and age did not influence the stone-free rate. There were two deaths (0.9% and haemostasis nephrectomy was performed in 2 ASA 3 subjects in renal failure. In the other patients, there was no difference between preoperative and postoperative serum creatinine and haemoglobin levels. The ease of nephrostomy, the rapidity of PCNL, the day of removal of the drainage nephrostomy, the mean hospital stay (median stay: 6 days), sterility of postoperative urine and at the 1-month visit were significantly correlated with the SF rate.
PCNL in subjects over the age of 70 years is a safe and reliable technique that achieved a stone-free rate of 70.8% for all types of stones combined. The best results were obtained for solitary stones larger than 20 mm in the renal pelvis or inferior calyx. Apart from diabetes, which remains a risk factor, well controlled comorbidities do not increase the operative risk. PCNL did not affect haemodynamic parameters or renal function.
70岁以上患者的经皮肾镜取石术（PCNL）被认为比体外冲击波碎石术（ESWL）风险更高。然而，对于患有多种合并症的患者，若结石非常大或复杂，有时该技术是必要的。
评估可能影响70岁以上患者PCNL治疗结果的成功预测因素和手术风险。
对10个转诊中心12年间共203例（110例男性，97例女性）70岁以上患者进行回顾性研究，这些患者共接受了210次PCNL治疗结石。68.5%的病例存在合并症，美国麻醉医师协会（ASA）评分中位数为2。结石尺寸中位数为24×15毫米。有67例孤立性肾盂结石、7例肾盂下输尿管结石、31例孤立性下盏结石、40例复杂性结石和13例鹿角形结石。92%的病例采用标准一期手术技术；71.8%的病例中，泌尿外科医生自己能轻松建立肾造瘘通道。
总体无结石（SF）率为70.8%。患者的体重和身高（p=0.03和p=0.01）、结石尺寸及其孤立性是成功的显著因素（p<0.00001和p=0.01），肾盂结石的SF率为81.1%，孤立性下盏结石的SF率为90.3%（p<0.003）；完全鹿角形结石的SF率仅为30.8%。结石病史（p=0.04）和糖尿病（p=0.03）影响无结石率，但其他合并症、体重指数和年龄不影响无结石率。有2例死亡（0.9%），2例ASA 3级肾衰竭患者进行了止血性肾切除术。在其他患者中，术前和术后血清肌酐及血红蛋白水平无差异。肾造瘘的难易程度、PCNL的速度、肾造瘘引流管拔除日、平均住院时间（中位住院时间：6天）、术后尿液无菌情况及术后1个月复查情况与SF率显著相关。
70岁以上患者的PCNL是一种安全可靠的技术，所有类型结石合并的无结石率达70.8%。肾盂或下盏大于20毫米的孤立性结石效果最佳。除糖尿病仍是危险因素外，控制良好的合并症不会增加手术风险。PCNL不影响血流动力学参数或肾功能。
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