Ganpule Arvind P, Mishra Shashikant, Desai Mahesh R
Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India.
J Endourol. 2009 Oct;23(10):1675-8. doi: 10.1089/end.2009.1535.
Several techniques have been described for percutaneous access and stone removal. The method of choice depends on the available instrumentation, stone burden in given caliceal anatomy, and the surgeon's preference, depending on his or her level of training. The argument for multiple strategic tracts vs single-tract percutaneous nephrolithotomy (PCNL) with or without flexible instrumentation for complete clearance of the stones is ongoing. The "multiperc" or multiple tract approach offers clearance of stones without the added cost of sophisticated instrumentation; further, a surgeon who can achieve a primary tract can easily create secondary tracts. This does not require a learning curve to be overcome. The argument against the multiperc approach is a potential for increased bleeding, which has not been substantiated in any published series. The single-tract approach without need for flexible instrumentation, currently published, is for small burden and partial staghorn stone where multiple tracts are not really necessary. Use of single-tract PCNL with flexible instrumentation, such as ureteroscopy and nephroscopy, ideally needs a supracostal approach with its attendant morbidity. The success of this procedure depends on the collecting system anatomy. Few studies published to date report suboptimal stone clearance rates with the advantages of shorter hospital stay and less blood loss. The currently available literature is not sufficient because of mostly retrospective studies, fewer patient accrual, and paucity of staghorn cases. Proper prospective studies with head-on comparisons are needed to prove or disprove the advantages and disadvantages of either approach.
已经描述了几种经皮入路和结石清除的技术。选择的方法取决于可用的器械、给定肾盏解剖结构中的结石负荷以及外科医生的偏好，这取决于他或她的培训水平。关于采用多个策略通道与单通道经皮肾镜取石术（PCNL）（无论有无软性器械）以完全清除结石的争论仍在继续。“多通道”或多通道方法可在不增加复杂器械成本的情况下清除结石；此外，能够建立初始通道的外科医生可以轻松创建辅助通道。这不需要克服学习曲线。反对多通道方法的观点是可能增加出血，但在任何已发表的系列研究中都没有得到证实。目前发表的无需软性器械的单通道方法适用于结石负荷小和部分鹿角形结石，此时多通道并非真正必要。使用带有软性器械（如输尿管镜和肾镜）的单通道PCNL，理想情况下需要采用肋上入路及其相关的发病率。该手术的成功取决于集合系统的解剖结构。迄今为止发表的少数研究报告了结石清除率不理想，但具有住院时间短和失血少的优点。由于大多是回顾性研究、患者纳入较少以及鹿角形结石病例较少，目前可用的文献并不充分。需要进行适当的前瞻性研究并进行直接比较，以证明或反驳任何一种方法的优缺点。
