Stening S G, Bourne S
Urology Department, Royal Brisbane Hospital, Herston, Queensland, Australia.
J Endourol. 1998 Aug;12(4):359-62. doi: 10.1089/end.1998.12.359.
The incidence of upper pole calculi is 15% of all caliceal calculi. The management of such calculi has been simplified since the advent of extracorporeal shockwave lithotripsy (SWL). In our experience, however, there is a subset of upper pole caliceal calculi wherein certain features can render SWL less than adequate treatment, namely diameter >1.5 cm, narrowing of the caliceal infundibulum, either singly or combined, and morbid obesity. In such instances, percutaneous nephrolithotomy (PCNL) is indicated. Percutaneous access to an upper pole calix can be difficult by a subcostal track. The supracostal 12th rib approach provides direct and efficient access to an upper pole calix and is ideally suited for upper pole calculi. Twenty-one patients with large or complex upper pole calculi were treated by supracostal PCNL. The maximum diameter of the calculi ranged from 7 to 40 mm. Eight were branched (staghorn). There was one horseshoe kidney, and calculi were bilaterally represented in another patient. Two patients were morbidly obese. All procedures were performed in one stage under general anesthesia. Following cystoscopy and ureteral catheterization, the upper pole calix was accessed directly with the aid of C-arm fluoroscopy and retrograde ureteral contrast injection. The percutaneous tract was dilated to a maximum of 26 F, a working sheath was inserted, and the calculi were extracted after ultrasonic or pneumatic fragmentation. One patient required secondary SWL for residual fragments. There were no intrathoracic complications, and blood loss was minimal. Large or complex upper pole caliceal calculi, particularly in the morbidly obese, can be treated effectively by PCNL using supracostal percutaneous access.
上极结石的发病率占所有肾盏结石的15%。自体外冲击波碎石术（SWL）出现以来，此类结石的治疗已得到简化。然而，根据我们的经验，有一部分上极肾盏结石，其某些特征会使SWL治疗效果欠佳，这些特征包括结石直径>1.5 cm、肾盏漏斗部狭窄（单独存在或合并存在）以及病态肥胖。在这种情况下，应采用经皮肾镜取石术（PCNL）。经肋下途径经皮进入上极肾盏可能会有困难。经肋上第12肋途径可直接、有效地进入上极肾盏，非常适合治疗上极结石。21例患有大的或复杂的上极结石的患者接受了经肋上PCNL治疗。结石的最大直径为7至40 mm。8例为分支状（鹿角形）结石。有1例马蹄肾，另1例患者双侧均有结石。2例患者为病态肥胖。所有手术均在全身麻醉下一期完成。在膀胱镜检查和输尿管插管后，借助C形臂荧光透视和逆行输尿管造影剂注射直接进入上极肾盏。经皮通道最大扩张至26F，插入工作鞘，超声或气压碎石后取出结石。1例患者因残留结石碎片需要二期SWL治疗。无胸腔内并发症，失血极少。大的或复杂的上极肾盏结石，尤其是病态肥胖患者，采用经肋上经皮途径的PCNL可有效治疗。
