Research And Clinical Application Of CT Three-dimensional Image Reconstruction Assistance And X-ray Guided Accurate Establishment Of Percutaneous Nephrolithotomy (PCNL) Channel

Objective:Explore the application of CT three-dimensional reconstruction aids to accurately establish an efficient and safe PCNL surgical channel and its clinical application value.Methods:For patients who were admitted to the hospital from January 2017 to May 2020 due to urinary tract stones and were diagnosed with renal stones and upper ureteral stones by PCNL surgery,patients were screened according to the inclusion and exclusion criteria.A total of 175 patients with load inclusion conditions were selected.All patients underwent CT chest and abdomen thin-layer scan and enhanced scan before operation.The CT scanned image is transmitted to the CT image post-processing workstation to reconstruct the image in three dimensions.By reconstructing the three-dimensional image of the stone and kidney collection system,the three-dimensional image of the stone and the kidney collection system and the upper ureter and the two-dimensional images of the cross-section,sagittal plane and coronal plane of the kidney and adjacent organs are obtained.In the back view of the three-dimensional imaging of the collection system,according to the relationship between the location of the stones and the kidney collection system,the posterior calyx that is the easiest to reach the stones or covers the largest range of stones is selected as the target renal calyx.Sagittal image analysis of the anatomical relationship between the target kidney calyces and adjacent organs.On the CT plane(transverse plane,sagittal plane,oblique plane)that passes through the center of the fornix of the target calyx and coincides with the axis of the target calyx,the surgical channel and puncture path are designed.Under the guidance of the C-arm X-ray,the determination of the target renal calyx,the design of the surgical channel and the puncture path are used in PCNL surgery to establish a safe and efficient surgical channel.After operation,the perioperative data of 175 patients were counted.According to the improved Clavien classification method,the establishment of surgical channels and clinical application were systematically evaluated.Results:175 cases of kidney stones and upper ureteral stones were assisted by CT stones and three-dimensional image reconstruction of the kidney collection system to plan the surgery before operation,and the accurate selection of the target kidney calyx and surgical path was completed.The operation was performed under the guidance of C-arm X-ray The precise puncture of the target kidney calyx and the safe establishment of the surgical channel are achieved.A total of 198 surgical channels were established,including 153 single-channel,21 double-channel and 1 triple-channel.The operation time was 24-190min,with an average of 87.6±38.8min,and the longest time for clearing the gravel was 120min.There were no cases of failed surgical channel establishment.There was no case of termination of operation or transfer operation due to intraoperative bleedingTotal PCNL stone-free rate(SFR)was 144 cases,accounting for 82.3%,of which the upper ureteral calculi had no calculi in one operation,and the renal pelvis stones had no calculi in 30 cases,accounting for 96.8%.There were 30 cases of secondary PCNL surgery,accounting for 17.1%,and the total stone-free rate was 159 cases,accounting for 90.9%in the three months after operation,including 17 cases of upper ureteral stones,100%of stone-free rate,69 cases of renal pelvis stones,100%of stone-free rate,There were 69 cases of renal calyx stones,with a total stone-free rate of 92.1%,partial staghorn stones in 28 cases,stone-free rate of 87.5%,complete staghorn stones in 14 cases,and stone-free rate of 73.7%Postoperative hemoglobin decreased by an average of 14.4±13.2g/L.There were 24 cases with body temperature>38℃ after operation,accounting for 13.7%,and 1 case with sepsis,accounting for 0.57%.No blood transfusion and arterial embolism required,no adjacent organ damage.Conclusions:By assisting the CT three-dimensional reconstruction of the stone and kidney collection system,it can help the operator fully understand the size and distribution of the stones and the anatomical structure of each kidney before PCNL operation,accurately select the target kidney and design a safe surgical path to complete the puncture Determination of the penetration point,puncture angle and puncture depth of the target kidney calyx skin.Combined with intraoperative C-arm X-ray guidance,the safe establishment of the surgical channel is achieved,PCNL’s clearing rate is maximized,and serious complications such as bleeding and damage to adjacent organs are avoided,effectively shortening the learning curve.