A Clinical Study Of Mini-invasive Percutaneous Nephrolithotomy And Retrograde Intrarenal Surgery In The Treatment Of Complex Renal Calculi

Purpose:In the first part,to compare the efficacy of RIRS and mPCNL in lower pole renal stones 2-4cm in diameter.Next step,to investigate the effect of multiple endoscopic treatment for renal mutiple stones under oblique lithotomy position.In the third part,to investigate and observe the influence of mini invasive percutaneous nephrolithotomy and retrograde intrarenal surgery on the serum inflammatory stress indexes of patients witht renal stones.The last part,to compare the clinical effect of mini-insive percutaneous neprolithotomy and retrograde intrarenal sugery on renal function in the treatment of solitary renal calculi.Methods:First part,a total of 167 patients who underwent mPCNL or RIRS for lower pole stone 2-4cm in Diameter between June 2011 and June 2016,were retrospectively analyzed.Lower pole stone was diagnosed with CT scan.Stone size was assessed as the longest axis of the stone.All patients were informed about the advantages,disadvantagesand probable complications of both mPCNL and RIRS before the selection of the procedure.Patients decided the surgery type by themselves without being under any influences and written informed consent was obtained from all patients prior to the surgery.Patients were divided into two groups according to the patients’ preference of surgery type.Group 1 consisted of 98 patients who underwent mPCNL and Group 2 consisted of 69 patients treated with RIRS.Stone free statuses,postoperative complications,operative time and hospitalization time were compared in both groups.Second part,A total of 23 patients with renal mutiple stones were treated under tracheal intubation general anesthesia.Patients were all placed in the oblique lithotomy position.Two groups of surgical staffs operated percutaneous nephrolithotomy and flexble ureteroscopic lithotripsy respectively under supervisions of two monitors at the same time.Third part,100 patients with renal stones 2～4cm in Diameter in our hospital from June 2011 to June 2016 were selected as the research object,100 patients were divided into mPCNL group(52 cases)and RIRS group(48 cases),By assessing the serum inflammatory stress indexes tumor necrosis factor-alpha(TNF-alpha),interleukin-6(IL-6),C-reactive protein(CRP),and procalcitonin(PCT),at all sampling times in all patients.of two groups before operation(TO)and the end of anesthesia(T1),2 hours(T2),12 hours(T3),24 hours(T4)and 48 hours(T5)after the operation were compared.The last part,We analyzed 96 cases of calculi in solitary kidney from People’s Hospital of Xinjiang Uygur Autonomous Region between June 2011 and June 2016.Among them,52 cases underwent mPCNL,and 44 cases underwent RIRS.Blood samples of the two groups were analyzed for blood serum creatinine(SCr),serum neutrophils gelatinase-associated lipocalin(NGAL)and serum Cystatin C(Cys-C)including preoperative and postoperative.Results:First part,the mean operation time was(84.0±27.9)min vs(116.2±23.1)min(P<0.001);The mean hemoglobin drop value was(5.2± 1.6)g/1 vs(1.9±0.4)g/1(P<0.001);The postoperative hospital stay was 8.5±1.4d for MPCNL,which was longer than that of the RIRS group(3.8±1.2d,P<0.001).The respective complication rates were 14.3%(14/98)and 4.3%(3/69)(P=0.036).In mPCNL group,stone-free rate was 87.8%(86/98)at first session and 93.9%(92/98)after the additional procedure.In RIRS group,stone-free rate was 55.1%(38/69)at the first procedure and 91.3%(63/69)after the additional procedure.The final stone-free rates were similar in both groups(P=0.506).Second part,the surgeries were technically successful in all the 23 patients.No postoperative complications occurred.The operation time was 75-135min(mean,95min).The blood loss was 35-150mL(mean,65mL).Postoperative re-examinations of X-ray or CT at 3-5days after surgery found the stone-free rate of 86.95%(20/23)for renal calculus.Second phase flexble ureteroscopic lithotripsy was needed in 2 patients.Extracorporeal shock wave lithotripsy was conducted in 1 patients.Postoperative follow-up for 3～12months(mean,9 months)in 23 cases found no local recurrence.Third part,Two groups of IL-6 began to increase at T1,reached the peak at T2,then decreased gradually,close to T5 before the operation,but still higher than T0;T2,T3,T4 and TO were statistically significant difference(P<0.05),T1 and T5 had no significant difference compared with TO(P>0.05);the two group began to increase TNF-a in T1,T2 reached the highest peak,and then decreased,T3 is close to the level of TO,T5 continued to recover to the level of TO;T1,T2 and TO were statistically significant difference(P<0.05),T3,T4,T5 and TO showed no significant difference(P>0.05);the two group CRP began to increase at T2,T5 reached the highest,T3,T4,T5 and TO the differences were statistically significant(P<0.05),T1 and T2had no significant difference compared with TO(P>0.05);the two group PCT began to increase at T1,T4 reached the highest peak,and then decreased,T2,T3,T4,T5 and TO the differences were statistically significant(P<0.05),T1 and TO had no significant difference(P>0.05);preoperative level of the inflammatory markers between the two groups showed no significant difference(P>0.05);postoperative inflammation index at each time point between the two groups had no statistically significant difference(P>0.05).The last part,Serum NGAL began to increase at 2 hours after operation in two groups,and reached the peak in 12 hours postoperatively.Then it’s began to decline after the peak,but it is still higher at 72hours than preoperative level(P<0.05).Serum Cys-C increased obviously at 12 hours and lowed down after the peak that occurred at 24 hours after surgery in two groups.,It recovered to the baseline at 72 hours after surgery(P>0.05).The levels of SCr in two groups did not show significantchanges between preoperation and postoperation(P>0.05).In the comparisons of increasing amplitude of three biological indicators,the variation range of SCr and NGAL level in the two groups preoperative and after operation of 2h,12h,24h,48h,72h in two groups had no significant differences(P>0.05),but serum Cys-C at 24 and 48 hours after surgery were remarkably increased in RIRS group than in mPCNL group(P<0.05).Conclusions:The first part,mPCNL is an effective method for the treatment of lower pole stones 2-4cm in diameter.RIRS should be an effective treatment alternative to mPCNL in lower pole stones,especially in selected patients.Second part,Multiple endoscopic treatment for renal mutiple stones under oblique lithotomy position is an effective and safe treatment modality.Also,it can be a useful complement to traditionalminimally invasive sugery.The Third part,in the course of operation,both groups caused the change of the levels of inflammatory factors;PCT and IL-6 level rised early in the postoperative time,and maintain a high level in a period of time,it’s important significance for the prediction of infection after operation,TNF-levels had increased then down quickly in the early time,is not conducive to monitoring,it has certain restrictions on the early diagnosis of infection after operation,changes in the level of CRP is relatively slow,no obvious significance for early diagnosis of infection;the changes of inflammatory factors monitoring indicators prompt two kinds of operation were no different effect on a body.The last part,RIRS and mPCNL both can cause reversible damage to the renal function after surgery,but the damage is reversible.The damage of RIRS to the glomerular is longer,the probable mechanism is related to higher intrapelvic perfusion pressure that were produced during RIRS can damage renal function in treatment of renal calculi.