Khargi Raymond, Serna Juan S, Gupta Kavita, Yaghoubian Alan J, Connors Christopher, Gupta Kasmira R, Ricapito Anna, Atallah William M, Gupta Mantu
Icahn School of Medicine at Mount Sinai, Department of Urology, New York, New York, USA.
University of Foggia, Department of Urology, Foggia, Italy.
J Endourol. 2025 Mar;39(3):214-221. doi: 10.1089/end.2024.0390. Epub 2025 Feb 3.
Intrarenal pressure (IRP) generated during percutaneous nephrolithotomy (PCNL) may have the potential to cause renal damage and/or sepsis. It has been suggested that mini-PCNL (mPCNL) can further increase IRP but that a suctioning sheath may mitigate this elevation. We sought to measure IRP throughout the PCNL process, randomizing patients getting mPCNL to receiving two different mPCNL sheaths, one suctioning and the other nonsuctioning, and then comparing them with patients undergoing standard PCNL (sPCNL) using a 24F sheath. Twenty patients meeting the eligibility criteria for mPCNL were randomized into two groups: suctioning mPCNL (s-mPCNL) with a single-step dilator and continuous suction sheath (ClearPetra™, 18F, = 10) and nonsuctioning mPCNL (ns-mPCNL) with a metallic dilator and sheath (Storz MIP-M™, 17.5F, = 10). A group of 10 patients undergoing sPCNL using a balloon dilator with a Polytetrafluoroethylene (PTFE) sheath (NephroMax™, 24F, = 10) were included as a control. IRP was measured with a 0.014″ COMET™ II Pressure guidewire retrogradely positioned in the renal pelvis. Gravity irrigation was utilized. Pressure data captured include baseline IRPs, retrograde pyelogram (RPG), needle entry, fascial dilation, tract dilation, sheath insertion, nephroscopy, and lithotripsy. The primary outcome was differences in mean and peak IRP during each stage. Categorical data were compared using chi-square or Fisher's exact tests. Continuous variables were analyzed using one-way analysis of variance. Peak and mean IRPs (millimeters of mercury or mm Hg) were similar at baseline and during RPG, needle insertion, and fascial dilation in the two experimental groups and in the control group. During tract dilation and sheath placement, both the mPCNL sheaths generated much higher peak IRP compared with the 24F balloon dilation control group but similar to each other (dilation: 36.6 and 38.6 vs 6.9, < 0.001; sheath placement: 36.6 and 35.3 vs 13.8, = 0.039). During nephroscopy, ns-mPCNL generated greater peak IRP compared with s-mPCNL and the control group (41.8 vs 19.09 and 24.15; = 0.019). The highest peak IRP for each group occurred during RPG and when a nephroscope was placed through a narrow infundibulum. Compared with balloon dilation, coaxial dilation with mPCNL sheaths generates significantly higher IRP. During nephroscopy, ns-mPCNL sheaths generate higher IRP compared with standard and suctioning sheaths. Highest IRPs are generated during RPG and when a nephroscope goes through a narrow infundibulum. These findings can inform improved sheath and nephroscope design. Further research assessing the effect of high IRP on postoperative pain, sepsis, and renal injury is needed.
经皮肾镜取石术（PCNL）过程中产生的肾内压（IRP）可能有导致肾损伤和/或脓毒症的风险。有人提出，迷你PCNL（mPCNL）会进一步升高IRP，但使用抽吸鞘可能会减轻这种升高。我们试图在整个PCNL过程中测量IRP，将接受mPCNL的患者随机分为两组，分别使用两种不同的mPCNL鞘，一种是抽吸鞘，另一种是非抽吸鞘，然后将它们与使用24F鞘进行标准PCNL（sPCNL）的患者进行比较。20名符合mPCNL入选标准的患者被随机分为两组：使用单步扩张器和连续抽吸鞘（ClearPetra™，18F，n = 10）的抽吸mPCNL（s - mPCNL）组和使用金属扩张器和鞘（Storz MIP - M™，17.5F，n = 10）的非抽吸mPCNL（ns - mPCNL）组。另外选取10名使用带聚四氟乙烯（PTFE）鞘的球囊扩张器进行sPCNL的患者（NephroMax™，24F，n = 10）作为对照组。使用0.014英寸的COMET™ II压力导丝逆行置于肾盂中测量IRP。采用重力灌注。采集的压力数据包括基线IRP、逆行肾盂造影（RPG）、穿刺针进入、筋膜扩张、通道扩张、鞘插入、肾镜检查和碎石术期间的压力。主要结局是各阶段平均和峰值IRP的差异。分类数据采用卡方检验或Fisher精确检验进行比较。连续变量采用单因素方差分析。两个试验组和对照组在基线、RPG、穿刺针插入和筋膜扩张期间的峰值和平均IRP（毫米汞柱或mmHg）相似。在通道扩张和鞘置入期间，与24F球囊扩张对照组相比，两种mPCNL鞘产生的峰值IRP均高得多，但两组之间相似（扩张：36.6和38.6 vs 6.9，P < 0.001；鞘置入：36.6和35.3 vs 13.8，P = 0.039）。在肾镜检查期间，ns - mPCNL产生的峰值IRP高于s - mPCNL组和对照组（41.8 vs 19.09和24.15；P = 0.019）。每组的最高峰值IRP出现在RPG期间以及肾镜通过狭窄肾盂漏斗部时。与球囊扩张相比，使用mPCNL鞘进行同轴扩张会产生明显更高的IRP。在肾镜检查期间，ns - mPCNL鞘产生的IRP高于标准鞘和抽吸鞘。最高IRP出现在RPG期间以及肾镜通过狭窄肾盂漏斗部时。这些发现可为改进鞘和肾镜设计提供参考。需要进一步研究评估高IRP对术后疼痛、脓毒症和肾损伤的影响。
