Portis Andrew J, Laliberte Mark A, Drake Stephanie, Holtz Cindy, Rosenberg Michael S, Bretzke Carl A
Metropolitan Urologic Specialists P. A., St. Paul, Minnesota, USA.
J Urol. 2006 Jan;175(1):162-5; discussion 165-6. doi: 10.1016/S0022-5347(05)00052-2.
Percutaneous nephrolithotomy effectively treats large volume renal calculi but relies on postoperative imaging to judge success. We evaluated the effectiveness of maximizing intraoperative imaging through combined high resolution fluoroscopy and flexible nephroscopy.
Percutaneous nephrolithotomy was performed cooperatively with a radiologist in an interventional radiology suite equipped with a ceiling mounted, high resolution C-arm. Aggressive rigid and flexible nephroscopy was performed. At the conclusion patients were prospectively classified as radiologically and/or endoscopically stone-free. Postoperative noncontrast CT allowed fragment classification as stone-free, 2 mm or less, 2 to 4 mm and greater than 4 mm.
The average stone dimension +/- SEM was 579 +/- 77 mm(2) in 25 consecutive renal units. CT demonstrated that 15 renal units (60%) were stone-free after the primary procedure, while 2 (8%), 5 (20%) and 3 (12%) had fragments 2 or less, 2 to 4 and greater than 4 mm, respectively. Of 21 renal units considered endoscopically and fluoroscopically stone-free postoperative CT demonstrated that 6 had residual fragments, of which all were less than 4 mm. All 4 renal units not considered radiologically and endoscopically stone-free had fragments on CT. Intraoperative fluoroscopy after nephroscopy demonstrated fragments in 36% of renal units, of which after further nephroscopy 78% were stone-free on CT. The sensitivity of intraoperative imaging with reference to the gold standard of postoperative CT was 40%, 38% and 100% at thresholds of 0, 2 and 4 mm, respectively. Specificity was 100%, 94% and 95%, respectively.
Flexible nephroscopy combined with high magnification rotational fluoroscopy allows sensitive and specific intraoperative detection of residual fragments, enabling immediate removal or the planning of necessary second look nephroscopy.
经皮肾镜取石术能有效治疗大量肾结石，但依赖术后影像学检查来判断手术是否成功。我们评估了通过联合高分辨率荧光透视和软性肾镜检查使术中影像最大化的有效性。
在配备有天花板安装式高分辨率C形臂的介入放射科手术室中，由一名放射科医生配合进行经皮肾镜取石术。实施积极的硬性和软性肾镜检查。在手术结束时，对患者进行前瞻性分类，分为放射学和/或内镜下无结石。术后非增强CT可将结石碎片分类为无结石、2毫米及以下、2至4毫米和大于4毫米。
连续25个肾单位的平均结石尺寸±标准误为579±77毫米²。CT显示，15个肾单位（60%）在初次手术后无结石，而2个（8%）、5个（20%）和3个（12%）分别有2毫米及以下、2至4毫米和大于4毫米的结石碎片。在21个被认为术后内镜和荧光透视下无结石的肾单位中，CT显示6个有残留碎片，所有残留碎片均小于4毫米。所有4个未被认为放射学和内镜下无结石的肾单位在CT上均有结石碎片。肾镜检查后的术中荧光透视显示36%的肾单位有结石碎片，其中在进一步肾镜检查后，78%在CT上无结石。术中影像相对于术后CT金标准的敏感性在阈值为0、2和4毫米时分别为40%、38%和100%。特异性分别为100%、94%和95%。
软性肾镜检查联合高倍旋转荧光透视能够敏感且特异性地在术中检测到残留碎片，从而能够立即取出或规划必要的二次肾镜检查。
