冉启华 陈颖虎 廖小强

摘要：目的 探讨后腹腔镜肾盂切开采用“剥”、“撬”、“推”、“旋”四步法取石术治疗复杂性肾结石的技术要点及临床应用价值。方法 回顾分析2008年4月至2018年2月经后腹腔镜肾盂切开采用“四步法”取石术治疗的126例复杂性肾结石患者的基本资料、手术时间、术中出血量、术后住院时间、术后并发症、结石清除率、随访结果等情况。结果 126 例患者均顺利完成手术，其中8例同時行同侧肾实质切开取石。取出结石数量1-300枚，结石直径0.2-11cm，手术时间40-130min，术中出血量5-60ml，术后住院时间4-7天，一期清石率为95.2%，围手术期2例发热，1例尿漏，均经保守治疗痊愈。术后3-5天拔除尿管，无结石残留者术后4周拔除双J管。随访2-36个月，无结石复发及上尿路梗阻，肾积水较术前明显减轻或消失。结论 后腹腔镜肾盂切开“四步法”取石术是治疗复杂性肾结石简单、快速并能有效预防手术副损伤的操作方法。

关键词：后腹腔镜；复杂肾性结石；肾盂切开取石术

Abstract：Objective To introduce a four-step method，summarized as “peel，pry，push and rotate”，in retroperitoneoscopic pyelolithotomy for treatment of complex renal calculi，and discuss the skill points and the clinical value of this method.Methods We retrospectively analyzed 126 cases of complex renal calculi underwent the four-step retroperitoneoscopic pyelolithotomy between April 2008 and February 2018. The data included general information，operative time，blood loss，hospital stay after operation，stone-free rate and follow-up results. Results The operation was completed successfully for all the patients. Eight patients underwent lithotomy of renal parenchyma during the operation. The number of extracted stone was 1 to 300. The diameter of the stones was 0.2-11cm. The operative time was 40-130min.The blood loss was 5-60ml. The hospital stay after operation was 4-7 days. The stone-free rate was 95.2%. During the perioperative period，two patients had a fever，one had urine leakage，and all of them recovered after conservative treatment. The urethral catheter was removed 4 to 7 days after the operation. The double-J stent was removed 4 weeks after the operation for the stone-free patients. There was no stone recurrence and upper urinary tract obstruction，and the uronephrosis alleviated obviously or disappeared than before the operation after 2-36 months of follow-up.Conclusions This four-step method is a simple and fast procedure in retroperitoneoscopic pyelolithotomy for treatment of complex renal calculi. Moreover，it also could prevent the accessory injury of operation effectively.

Key words：retroperitoneoscopy；complex renal calculi；pyelolithotomy

复杂性肾结石包括鹿角形结石、直径大于3cm 结石、多发性肾结石、孤立肾结石[1]。复杂性肾结石一直是临床治疗的难点，尿石症诊断治疗指南推荐经皮肾镜取石术（percutaneousnephrolithotomy，PCNL）作为其首选方案[2]。但因其手术操作对肾组织损伤较大、围手术期易出现严重并发症、结石一次清除率不理想等不足，目前在临床上仍存在争议。我科自2008年4月至2018年2月实施后腹腔镜肾盂切开“四步法”取石术治疗复杂性肾结石126例，手术均获得成功，疗效满意，现报告如下。

1.资料与方法

1.1 临床资料