Clinical Analysis Of Mini-Percutaneous Nephrolithtomy With Holmium Laser In The Treatment Of Upper Urinary Tract Stone

Urinary calculi is one of the most common diseases of Urology. The number of patients which are in hospital in urology department is on the top of the list. In China, the incidence of urinary tract stones is 1% -5%, which is the highest of 10% in south of China. As one of the countries which has the highest incidence of urinary tract stones in the world, China has a rising incidence of urinary stones in recent years. It is divided into upper urinary tract and lower urinary tract stones depends on the site of stones. The treatment of upper urinary calculi is always a big problem for the urologic surgeons. The treatment principle is to effectively remove the stones, to remove the obstruction and protecting the kidney from damaging the large blood vessels of kidney, and to save renal function. Currently there are a lot of methods to treat the upper urinary calculi. The strong shock wave of ESWL can damage the renal function, and it usually needs fractionated treatments. It is not effective bacause of the complications such as postoperative renal colic, fever, and stone street. PCNL with pneumatic lithotripsy is commonly used in treating kidney stones. The time of the operation is short, and it is effective in treating large blocks of stones. but the PL can only break stones by mechanical energy, it is not useful in deal with little stones. The fragments of stones can easily move and form stone street in the ureter, and then cause obstruction. In addition, PL demands a larger aperture nephrostomic channel, increasing the risk of the damage of the large kidney blood vessels, which can easily lead to uncontrolled intraoperative bleeding, postoperative bleeding and increase the risk of infection. Compared with the standard PCNL, the mini-PCNL with holmium laser use F18 dilator to establish the channel, which is smaller and more safe because it can reduce the risk of intraoperative and postoperative bleeding. There are several opinions about the effect of mini-PCNL with holmium laser reported by the scientists both in China and in broad. This article describes the effect of mini-PCNL with holmium laser in treating upper urinary stones in our hospital.In this group, there are totally 201 cases,120 male and 81 female. The age is from 13 to 72 years old, the mean age is 48.2.169 cases have lumbodynia and 32 cases have no pain.71 cases in the left kidney,62 cases in the right kidney. And 62 cases of double kidney stones, in which there are 22 cases combined with upper ureteral calculi.6 cases of pure upper ureteral calculi. The average diameter of the stones is 2.5cm, in which there are 46 cases of complete staghorn calculi and 118 cases of incomplete staghorn calculi.125 ceses combined with varying degrees of hydronephrosis.All the cases are under general anesthesia. Firstly, the patient take the lithotomy position, receive the cystoscopy by F21OLYPMUS cystoscope. Putting the F6 ureteral catheter and the F18 balloon catheter in the ballder, then fixing the two things together. Then let the patient prone on the operating table, padded belly. Scan to know the position of the kidney, the collection system and the location of the stones in the scope from the shoulder to posterior axillary line under 12 or 11 intercostal rib margin according to B ultrasound guiding. Establish the to the percutaneous gastrostomy channel according to the position of the stone. If there is no hydronephrosis, we should inject water from the ureteral catheter to make hydronephrosis. When there are urine overflowing, put in Zebra urological guidewire and record the puncture depth, then establish the percutaneous gastrostomy channel by the renal sheath dilator of F8-F16, detain the Peel -away sheath. Place the F9.8OLYPMUS ureteroscope through this channel, connect the perfusion system and the surveillance system. Surgery carried out under 0.9% saline infusion. The holmium laser fiber will be placed beside the stone and break it. It usually break the stones while move the ureteroscope to the stones. To break all the stones seen and to flood the stone fragments out of the body from the channel. If there are not stones have been seen, we can find the ureteral catheter in the renal pelvis, and then put the F5 double-J guide wire tube into the ureteral. Withdrawal of the ureteroscope, detain the F20 balloon catheter from this channel. this channel indwelling colostomy. The nephrostomy tube should be detain for 3 to 9 days and the double J tube should be detain for 4 to 6 weeks. After surgery, patients should be taken KUB or CT scan to check if there are residual stones. No residual stones or residual stones with less than 0.5cm in diameter can be thought as a stone clearance.The result shows that the number of successful one-stage surgery is 198.There are 22 caces receive the surgery again after one week just because of the too much operative time, no good exposition of the stones case, excessive bleeding and other reasons in the first time of the surgery. So we have done the mini-PNL for 220 times totally.3 case is failed on puncture and then conversed to open surgery. The success rate of the one-stage operation is 98.5%. Among the successful one staged 198 cases, there are 43 cases with residual stones, the clearance is 78.3%, there are 22 cases undered the second stage operatiom,21 cases undered ESWL or treated by drugs. The clearance of the second stage surgery is 95.5%. The clearance of the former 110 cases is 74.5% and 85.5% of the laster 110 cases(P<0.05). The clearance of the cases with complete staghorn calculi is 50%(23/46) while the number of the ones with incomplete staghorn calculi is 91.5%(108/118) (P<0.05).2 cases have pleural effusion after the surgery.1 case has water and electrolyte imbalance. There are 49 cases with fever (postoperative body temperature is higher than 38.5℃), in which 2 cases have eptic shock. There are 2 cases with operative bleeding,1 case received the renal artery embolization, another received a routine kidney Resection.The conclusion is that:(1) Mini-PCNL with holmium laser is an effective and safe method in treating upper urinary calculi which has few complications and is worth spreading. (2) To puncturatio with ultrasound guidness can effectively reduce the risk of the complications and it is a good puncturatio method to PCNL. (3) To master the skill of mini-PCNL and the puncture exactly and adeptly is important to improve the clearance and reduce the comlications.