Kaufmann Oskar Grau, Sountoulides Petros, Kaplan Adam, Louie Michael, McDougall Elspeth, Clayman Ralph
Department of Urology, University of California, Irvine, Orange, CA, USA.
J Endourol. 2009 Oct;23(10):1739-41. doi: 10.1089/end.2009.1544.
After percutaneous nephrolithotomy (PCNL), a nephrostomy tube has been routinely placed to ensure hemostasis, provide drainage, and maintain access to the collecting system should a second-look procedure be necessary. Recently, efforts have been expended to either reduce the size of the nephrostomy tube or eliminate it altogether. We describe the tubeless technique of closure and skin treatment after PCNL using FloSeal as a sealant for tubeless PCNL.
A 7F 11.5-mm occlusion balloon catheter is passed retrograde over the through-and-through guidewire. Next, under endoscopic guidance, with a rigid or flexible nephroscope, the 30F Amplatz sheath is pulled back to the torn edge of the calix through which the nephrostomy tract enters the kidney. Under endoscopic guidance, the balloon is inflated at the torn edge. Next, the long metal laparoscopic FloSeal applicator is passed through the 30F sheath until it encounters resistance from the occlusion balloon catheter. FloSeal is injected down the sheath as the sheath is slowly withdrawn simultaneously with the FloSeal applicator until both have cleared the nephrostomy incision. The through-and-through guidewire is pulled per the urethra under fluoroscopic control until its tip is in the renal pelvis. A 7F double pigtail stent is passed retrograde over the through-and-through guidewire. A bladder catheter is placed. A running subcuticular suture of 4-0 poliglecaprone is placed, and cyanoacrylate adhesive is used to close the skin. No dressing is applied.
For patients who have been rendered completely stone free during uncomplicated PCNL, administration of hemostatic gelatin matrix to the nephrostomy tract may achieve immediate hemostasis and eliminate the need for placement of a nephrostomy tube. Although there have not been any clinical reports of urinary obstruction caused by the application of hemostatic sealants in the PCNL tract, we recommend using an occlusion balloon and subsequent placement of an indwelling ureteral stent to ensure maximum safety.
经皮肾镜取石术（PCNL）后，通常会放置肾造瘘管以确保止血、提供引流，并在需要二次手术时保持进入集合系统的通道。最近，人们一直在努力减小肾造瘘管的尺寸或完全取消它。我们描述了使用FloSeal作为无管PCNL的密封剂进行PCNL后闭合和皮肤处理的无管技术。
将一根7F 11.5毫米的闭塞球囊导管逆行穿过贯穿导丝。接下来，在内镜引导下，使用刚性或柔性肾镜，将30F的安普瑞兹鞘管拉回到肾造瘘通道进入肾脏的肾盏撕裂边缘。在内镜引导下，在撕裂边缘处充盈球囊。接下来，将长金属腹腔镜FloSeal涂抹器穿过30F鞘管，直到遇到闭塞球囊导管的阻力。在缓慢拔出鞘管的同时，将FloSeal注入鞘管，同时将FloSeal涂抹器缓慢拔出，直到两者都离开肾造瘘切口。在荧光镜控制下，经尿道将贯穿导丝拔出，直到其尖端位于肾盂内。将一根7F双猪尾支架逆行穿过贯穿导丝。放置膀胱导管。用4-0聚乙醇酸进行皮下连续缝合，并用氰基丙烯酸酯粘合剂闭合皮肤。不应用敷料。
对于在无并发症的PCNL过程中已完全清除结石的患者，向肾造瘘通道施用止血明胶基质可实现即时止血，并消除放置肾造瘘管的必要性。尽管尚无关于在PCNL通道中应用止血密封剂导致尿路梗阻的临床报告，但我们建议使用闭塞球囊并随后放置输尿管内支架以确保最大安全性。
