| Objective:To explore the operative method and clinical value of accurate selection of target renal calyx and scientific design of surgical plan by using the three-dimensional CT images before operation,and to guide the safe establishment of supracostal approach for percutaneous nephrolithotomy(PCNL)during operation.Methods:A total of 41 patients with kidney stones and upper ureteral calculi who admitted to the Third Ward of Urology Department of the Second Affiliated Hospital of Kunming Medical University from May 2018 to February 2021 were screened according to the inclusion criteria and exclusion criteria.Before operation,the patients were scanned with CT thin scan+enhanced scanning,and than the original image data were transferred to workstation image processing system and 3D reconstruction was performed.On the three-dimensional reconstruction images of collective system CT,the adjacent relationship between the target renal calyces and adjacent organs will be focused according to the spatial distribution characteristic of stones in the kidney collecting system and the surrounding anatomic distribution of organs,so as to select the posterior calyces or posterolateral calyces that can cover the largest range of kidney stones as the target renal calyces.After that,according to the principle of coaxial entry into the central point of the target calyces fornix and safe avoidance of damage to adjacent organs,the correct supracostal surgical approach was designed to determine the skin needle entry point,needle entry Angle and depth.During the operation,under the guidance of C-arm X-ray,the central point of the target calix fornix was accurately punctured according to the preoperative plan to establish the supracostal PCNL working approach.After operation,chest X-ray and KUB examination were performed to understand the pleural effusion,pneumatosis and stone clearance.Th en,the contrast-enhanced CT scan of the surgical channel was performed to evaluate the consistency of the surgical channel.Finally,the clinical data of 41 patients in pre-,intra-and post-operative were retrospectively analyzed,so as to systematically evaluate the efficacy and safety of the operation.Results:All the 41 patients in this group were successfully established supracostal PCNL approach under the guidance of C-arm X-ray,and there was no failure.A total of 41 supracostal approachs were established,including 40 intercostal approachs(97.6%)in 11 cases and 1 intercostal approach(2.4%)in 10 cases.Supracostal approachs were established in 3 cases of staghorn and 2 cases of multiple calistones.The operation time ranged from 40 to 150min,with an average of 96.5±30.3min.No loss of approach or severe bleeding occurred during the operation.The total incidence of complications was 17,1%(7/41),including 2 patients(4.9%)with postoperative fever,3 patients(7.3%)requiring drug analgesia,and 2 patients(4.9%)with postoperative hematuria with clear urine after conservative treatment.No postoperative complications such as chest pain,dyspnea,bleeding,sepsis and intestinal fistula occurred in all patients.On the first day after surgery,the Hb decreased 0～28g/L,with an average of 8.5±5.4g/L.No blood transfusion or vascular interventional therapy was needed.The postoperative hospital stay ranged from 3 to 7 days,with an average of 3.9±1.1 days.The stone-free rate after one PCNL operation was 87.8%(36/41),including 100%(6/6)of upper ureteral calculi,100%(3/3)of renal pelvic calculi,100%(7/7)of single calyx calculi,84.6%(11/13)of multiple calyx calculi,and 75.0%(9/12)of stag-antler calculi.During 1-3 months of follow-up,the total stone-free rate of the 41 patients was 97.6%(40/41),and the multiple calculi were completely removed,and the stone-free rate was 100%(13/13).The total stone-free rate of 12 patients with antler calculi was 91.7%(11/12),and the clearance rate of partial stone-free calculi was 100%(8/8),and that of complete stone-free calculi was 75.0%(3/4).Conclusions:1.CT three-dimensional imaging can accurately provide the position,size,renal collection system and anatomical structure of the upper segment of the ureter,visually display the anatomical relationship between the renal calyces and the adjacent pleural and related organs,and lay an anatomical foundation for the correct selection of the target renal calyces and the safe design of the surgical approach.2.CT 3D imaging is used to measure the needle insertion point,needle insertion depth and angle,which can help the operator to achieve accurate puncture of the target calyces during the operation.3.In this study,the improved supracostal approach PCNL can effectively improve the stone-free rate of surgery,minimize surgical complications and shorten the learning curve of surgery. |
