Yates D R, Safdar R K, Spencer P A, Parys B T
Department of Urology, Rotherham District General Hospital, Rotherham, UK.
Ann R Coll Surg Engl. 2009 Oct;91(7):570-7. doi: 10.1308/003588409X432437. Epub 2009 Aug 14.
Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. 'Tubeless' or 'nephrostomy-free' PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of 'nephrostomy-free' PCNLs compared to standard PCNL over a 4-year period.
Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive 'nephrostomy-free' PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications.
'Nephrostomy-free' PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted 'nephrostomy-free' PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the 'nephrostomy-free' group developed a delayed perirenal haematoma.
'Nephrostomy-free' percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.
经皮肾镜取石术（PCNL）是治疗大型复杂肾结石的一线治疗方法。英国公认的做法是在手术结束时插入一根肾造瘘管以引流肾脏并减少潜在并发症。在部分患者中提倡“无管”或“无肾造瘘”PCNL，因为据认为这可以缩短住院时间、减少镇痛需求以及减轻患者的疼痛感受。我们展示了在4年期间连续一系列（n = 101）“无肾造瘘”PCNL与标准PCNL相比的结果。
在2004年1月至2006年10月期间，我们进行了55例标准（带肾造瘘管）PCNL（第1组）。从2006年10月起，我们改变了技术，连续进行了46例“无肾造瘘”PCNL（插入输尿管双J支架），不受患者和结石因素影响（第2组）。我们比较了两组在住院时间（LOS）、镇痛需求、输血率、血红蛋白（Hb）下降情况以及即刻、早期和晚期并发症方面的差异。
“无肾造瘘”PCNL显著缩短了住院时间（2.8天对5.1天；P < 0.001）、基于吗啡的镇痛需求（23%无需吗啡对2.8%；P < 0.001）、输血率（2.5%对7%；P < 0.01）以及平均Hb下降幅度（1.89 g/dl对2.25 g/dl；P > 0.05）。总体而言，没有患者发生严重并发症。所有尝试的“无肾造瘘”PCNL均完成（结石清除率95%），且没有患者需要进行计划外的肾造瘘。第2组中只有5%的患者因疼痛需要比计划更早地取出输尿管双J支架。两组在即刻、早期和晚期并发症方面具有可比性，不过第1组有3例患者出现慢性腰痛，“无肾造瘘”组有1例患者出现延迟性肾周血肿。
“无肾造瘘”经皮肾镜取石术是一种安全、有效且可行的手术，不受患者和结石因素影响。它缩短了住院时间、减轻了疼痛感受以及基于吗啡的镇痛需求；我们认为它应该成为接受PCNL患者的护理标准。
