Yadav Rajiv, Aron Monish, Gupta Narmada P, Hemal Ashok K, Seth Amlesh, Kolla Surendra B
Department of Urology, All India Institute of Medical Sciences, New Delhi, India.
Int J Urol. 2006 Oct;13(10):1267-70. doi: 10.1111/j.1442-2042.2006.01537.x.
Supracostal superior calyceal access has been shown to be the most suitable approach for staghorn calculi, calculi in the upper ureter and complex inferior calyceal calculi, as well as for antegrade endopyelotomy. However, many urologists hesitate in using this approach because of the potential for chest complications. The aim of this study was to analyze one institution's data regarding the safety and efficacy of this approach for percutaneous renal surgery.
A total of 890 renal units (762 patients) were treated with percutaneous renal surgery (849 percutaneous nephrolithotomy, 41 antegrade endopyelotomy) from July 1998 to July 2004. Supracostal access was obtained in 332 (37.3%) patients. The indications for a supracostal approach were ureteropelvic junction obstruction, staghorn and complex inferior calyceal calculi, and stones in the upper calyx or the upper ureter. All punctures were made by the urologist under C-arm fluoroscopic guidance in the prone position.
The interspace between 11th and 12th rib was used in all except four patients in whom the puncture was made above the 11th rib. Eleven patients (3.31%) had a pleural breach presenting with fluid in the chest. Insertion of a chest tube was required in seven patients, while other four were managed conservatively. No patient had injury to the lung or other viscera. Hospital stay was not significantly prolonged as a result of the pleural breach in any patient. Except for staghorn calculi where multiple tracts were a necessity for maximal clearance, a single supracostal superior or middle posterior calyceal access served the purpose in 86% (177/205) of patients who underwent percutaneous surgery for renal or upper ureteric calculi.
The supracostal superior calyceal approach was found to be effective as well as safe, with an acceptably low risk of chest complications.
肋上肾盏入路已被证明是治疗鹿角形结石、上段输尿管结石、复杂的下肾盏结石以及顺行性肾盂内切开术最合适的方法。然而，由于存在胸部并发症的可能性，许多泌尿外科医生在使用这种方法时犹豫不决。本研究的目的是分析一家机构关于这种经皮肾手术方法的安全性和有效性的数据。
1998年7月至2004年7月，共有890个肾单位（762例患者）接受了经皮肾手术（849例经皮肾镜取石术，41例顺行性肾盂内切开术）。332例（37.3%）患者采用肋上入路。肋上入路的适应证为输尿管肾盂连接处梗阻、鹿角形和复杂的下肾盏结石以及上肾盏或上段输尿管结石。所有穿刺均由泌尿外科医生在俯卧位C形臂荧光透视引导下进行。
除4例在第11肋上方穿刺的患者外，所有患者均采用第11肋和第12肋间隙。11例患者（3.31%）出现胸膜破裂，胸腔积液。7例患者需要插入胸管，其他4例采用保守治疗。没有患者出现肺或其他内脏损伤。任何患者均未因胸膜破裂而导致住院时间显著延长。除鹿角形结石需要多条通道以实现最大程度清除外，对于接受经皮肾或上段输尿管结石手术的患者，86%（177/205）采用单一的肋上肾盏上极或中后肾盏入路即可达到目的。
肋上肾盏上极入路被发现既有效又安全，胸部并发症风险低至可接受程度。
