| Objective：1. To evaluate the safety and efficacy of an improved balloon dilation method in establishingthe tract for percutaneous nephrolithotomy under ultrasonography guidance.2. To evaluate the feasibility of the improved ultrasound-guided balloon dilation method inestablishing percutaneous channel for renal surgery using a porcine model withouthydronephrosis and disscuss the possibility of using the balloon dilator for hemostasis bycompressing the channel, as well as the least effective time.3. To compare the degree of porcine renal trauma and inflammatory reaction induced by theimproved balloon dilatation method and fascia dilatation method during percutaneousrenal surgery.Methods：1. A retrospective analysis was performed with86patients who underwent one-stagepercutaneous nephrolithotomy under ultrasound guidance between August2011andDecember2013at our institution.46patients in group1underwent improved balloondilation, while the other40patients in group2underwent fascial dilation. In group1,surgeons marking pen was used to record the penetration depth in surgery, a marked10Frfascial dilator with exterior sheath expanded the channel, subsequently a labeled6Frnephrostomy balloon dilator was indwelled and inflated with20atm for5minutes in thetract, then the balloon was removed and a tagged22Fr Amplatz sheath was left as thework sheath, the balloon dilator dilated the access again for at20atm for5minutes afterremoving stones. In group2, the fascial dilation was conducted according to the standardmethod：A10Fr fascial dilator was used to expand the tract, and then graduallyincremental dilators by2Fr up to22Fr were applied. Operation time, hemoglobinconcentration and hematocrit decline, serum creatinine fluctuation, length ofpostoperative hospital stay, stone-free rate and complications were recorded in the2groups.2. Sixteen kidneys from8male Bama miniature pigs were used in this experiment.According to the indwelling time of balloon dilators which were used to compress thecompleted channels for percutaneous renal surgery with the purpose of suppressinghemmorrhage, they were randomly divided into4groups: group A,1minute; group B,3minutes; group C,5minutes; group D,10minutes. The time of establishing the tract was recorded, hemoglobin concentration and hematocrit decline was also recorded. UsingSPSS18.0software for statistical analysis, the nonparametric Kruskall-Wallis H test wasused to evaluate the differences among groups, and post-hoc multiple comparisons wereassessed by Nemenyi test, p<0.05was considered to be statistically significant.3. Two male Bama mini pigs were enrolled in the study, the left kidney of each pigunderwent the advanced balloon dilation, while the right kidneys underwent the fascialdilation. The duration of balloon dilation at20atm was5minutes. The fascial dilationwas used according to the standard method: A10Fr fascial dilator was used to expand thetract, and then gradually incremental dilators by2Fr up to22Fr were applied. The pigswere killed separately at the third day and the seventh day after operation, the kidneyswere removed for gross and histologic examination.Results：1. Tracts in all patients were successfully established in the first attempt. Compared to group2, the time for establishing access, length of postoperative hospital stay, decline ofhemoglobin concentration and mean corpuscular volume were significantly reduced ingroup1（p<0.05）. No significant difference of operation time, serum creatinine andstone free rate was observed between the two groups （p>0.05）. One case with fever wasobserved in each group, which was cured after antibiotic treatment. No patient in group1needed transfusion while2patients in group2underwent transfusion. In both groupsthere were no other severe complications such as septic shock, pleural damage, organdamage, perforation and acute renal insufficiency.2. All the kidney tracts were successfully established in the first attempt, the mean time ofestablishing access was5.96±1.17minutes. There were significant differences amonggroups in hemoglobin concentration decline (p=0.009) and hematocrit decline (p=0.009)at48hours postoperatively. There were no significant differences （p>0.05）inhemoglobin concentration decline between group A and B, group C and D; there weresignificant differences （p<0.05）in hemoglobin concentration decline other post-hocmultiple comparisons. There were no significant differences （p>0.05）in hematocritdecline between group A and B, group C and D; there were significant differences（p<0.05）in hematocrit decline other post-hoc multiple comparisons.3. One percutaneous renal channel was failed to be established by the fascial dilationmethod in the first attempt and had to be re-established, the other three cases weresuccessfully performed. The wound of left kidney was found to be the form of fissure on the third postoperative day, while the wound of right kidney was hard to be observedclearly for apparent hematoma around it. The wound of left kidney were also found to bethe form of fissure on the seventh postoperative day, it seemed as if the wound waspacked with inflammatory granulation tissue. The right kidney showed two largehematomas, the cut was hard to be distinguished definitely. The varying degrees ofinflammatory reaction were observed in the wound tissues of both kidneys for HE stainon the third or seventh postoperative day.Conclusion:1. The improved balloon dilation method under ultrasound guidance used in percutaneousnephrolithotomy was safe and effective, which would reduce the time for establishingaccess, loss of blood and length of postoperative hospital stay. However, rich experiencein ultrasound technology was a guarantee.2. Establishing the channel for percutaneous renal surgery by the improved balloon dilationmethod under ultrasound guidance in a porcine model without hydronephrosis wasfeasible. Compressing the channel by the balloon (at20atm) more than5minutes couldsignificantly reduce hemorrhage in the surgery.3. Compared to the fascia dilation method, the improved balloon dilation method inestablishing the percutaneous channel in porcine kidney without hydronephrosis mighthave higher success rate and lighter acute kidney injury. However, the both dilationmethods could cause varying degrees of inflammatory reaction of the wound. |
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