【EAU指南学习】经皮肾镜取石术（PCNL）

3.4.7.Percutaneous nephrolithotomy

经皮肾镜取石术

Percutaneous nephrolithotomy remains the standard procedure for large renal calculi. Different rigid and flexible endoscopes are available and the selection is mainly based on the surgeon's own preference. Standard access tracts are 24-30 F. Smaller access sheaths, < 18 F, were initially introduced for paediatric use, but are now increasingly utilised in the adult population.

经皮肾镜取石术仍然是大型肾结石的标准治疗方法。目前有不同的硬镜和软镜，选择哪种内镜主要是根据外科医生自己的偏好。标准通道为24-30F。较小的通道鞘（<18 F）最初是用于儿科，但现在也越来越多地用于成年患者。

Contraindications禁忌症

Patients receiving anti-coagulant therapy must be monitored carefully pre- and post-operatively. Anti-coagulant therapy must be discontinued before PNL.

必须对接受抗凝治疗的患者进行术前和术后仔细监测。PNL之前必须停止抗凝治疗。

Other important contraindications include:

·untreated UTI;

·tumour in the presumptive access tract area;

·potential malignant kidney tumour;

·pregnancy (Section 3.4.14.1).

其他重要的禁忌症包括：

·未经治疗的尿路感染（UTI）；

·计划建立的通道区域内存在肿瘤；

·潜在的恶性肾肿瘤；

·怀孕（见第3.4.14.1节）。

Best clinical practice最佳临床实践

Intracorporeal lithotripsy体内碎石

Several methods for intracorporeal lithotripsy during PNL are available. Ultrasonic and pneumatic systems are most commonly used for rigid nephroscopy, whilst laser is increasingly used for miniaturised instruments. Flexible endoscopes also require laser lithotripsy to maintain tip deflection, with the Ho:YAG laser having become the standard.

目前有多种PNL期间体内碎石的方法。对于硬性肾镜，最常用的是超声和气压弹道，而激光越来越多地用于小型设备。对于软镜，还需要激光碎石，保持尖端偏转，而Ho：YAG激光已成为标准。

Pre-operative imaging术前成像

Pre-procedural imaging evaluations are summarised in Section 3.3.1. In particular, US or CT of the kidney and the surrounding structures can provide information regarding interpositioned organs within the planned percutaneous path (e.g., spleen, liver, large bowel, pleura, and lung).

术前成像评估的总结见第3.3.1节。值得注意的是，肾脏或周围结构的US或CT可以提供有关经皮穿刺路径内相关器官的信息（例如，脾脏，肝脏，大肠，胸膜和肺）。

Positioning of the patient患者体位

Both prone and supine positions are equally safe, although the supine position confers some advantages, it depends on appropriate equipment being available to position the patient correctly, for example, X-ray devices and an operating table.

俯卧位和仰卧位的安全性相同，虽然仰卧位具有一些优点，但能否发挥优势取决于是否有适当的设备（例如X射线设备和手术台）可以使患者处于正确位置。

Most studies cannot demonstrate an advantage of supine PNL in terms of OR time. Prone position offers more options for puncture and is therefore preferred for upper pole or multiple accesses. On the other hand, supine position allows simultaneous retrograde access to the collecting system, using flexible ureteroscope.

大多数研究都不能证明仰卧位PNL在操作时间方面具有优势。俯卧位可以为穿刺提供更多选择，因此对于肾上极或多通道来说，首选俯卧位。而仰卧位有助于同时利用输尿管软镜逆行进入肾集合系统。

Puncture穿刺

Although fluoroscopy is the most common intra-operative imaging method, the (additional) use of US reduces radiation exposure.

尽管X光透视是最常见的术中成像方法，但（额外使用）US可减少放射线暴露。

Pre-operative CT or intra-operative US allows identification of the tissue between the skin and kidney and lowers the incidence of visceral injury. The calyceal puncture may be done under direct visualisation using simultaneous flexible URS.

术前CT或术中US有助于识别皮肤和肾脏之间的组织，并降低内脏损伤发生率。同时利用输尿管软镜，可以在直视下进行肾盏穿刺。

Dilatation扩张

Dilatation of the percutaneous access tract can be achieved using a metallic telescope, single (serial) dilators, or a balloon dilatator. Although there are papers demonstrating that single step dilation is equally effective as other methods, the difference in outcomes is most likely related to surgeon experience rather than to the technology used.

经皮通道的扩张可以通过金属套叠扩张、单次（顺序逐根）扩张或气囊扩张来实现。尽管有研究证明一步扩张法与其他方法同样有效，但扩张效果的差异与所使用的扩张技术无关，很有可能与外科医生的经验有关。

Choice of instruments设备的选择

The Urolithiasis Panel performed a systematic review assessing the outcomes of PNL using smaller tract sizes (< 22 F, mini-PNL) for removing renal calculi.

尿石症专家小组进行了一项系统性回顾，评估了较小通道PNL（<22 F，mini-PNL）移除肾结石的结局。

Stone-free rates were comparable in miniaturised and standard PNL procedures. Procedures performed with small instruments tend to be associated with significantly lower blood loss, but the duration of procedure tends to be significantly longer. There were no significant differences in any other complications.

微通道PNL和标准PNL的结石清除率相当。使用小型设备进行取石时，失血量通常更少，但是操作时间通常更长。其他并发症方面无明显差异。

However, the quality of the evidence was poor with only two RCTs and the majority of the remaining studies were single-arm case series only. Furthermore, the tract sizes used, and types of stones treated, were heterogeneous; therefore, the risk of bias and confounding were high.

但是，相关证据质量较低，目前只有两项RCT，其余大多数研究都是单臂病例系列研究。此外，通道尺寸和所治疗的结石类型具有异质性；因此，存在很高的偏倚和混杂风险。

Nephrostomy and stents肾造瘘管和支架

The decision on whether, or not, to place a nephrostomy tube at the conclusion of the PNL procedure depends on several factors, including:

·presence of residual stones;

·likelihood of a second-look procedure;

·significant intra-operative blood loss;

·urine extravasation;

·ureteral obstruction;

·potential persistent bacteriuria due to infected stones;

·solitary kidney;

·bleeding diathesis;

·planned percutaneous chemolitholysis.

PNL结束时是否留置肾造瘘管取决于多个因素，包括：

·结石残留；

·二期手术的可能性；

·术中大量失血；

·尿外渗；

·输尿管梗阻；

·由于感染性结石可能存在持续性细菌尿；

·孤立肾；

·出血体质；

·计划进行经皮化学溶石。

Small-bore nephrostomies seem to have advantages in terms of post-operative pain. Tubeless PNL is performed without a nephrostomy tube. When neither a nephrostomy tube nor a ureteral stent is introduced, the procedure is known as totally tubeless PNL. In uncomplicated cases, the latter procedure results in a shorter hospital stay, with no disadvantages reported.

小口径的肾造瘘在术后疼痛方面似乎具有优势。无管化PNL无需留置肾造瘘管。当既不留置肾造瘘管，也不留置输尿管支架时，就称为完全无管化PNL。有研究表示，对于不复杂的病例，完全无管化PNL的住院时间更短，且无不良反应。

Complications of percutaneous nephrolithotomy

经皮肾镜取石术的并发症

A systematic review of almost 12,000 patients shows the incidence of complications associated with PNL; fever 10.8%, transfusion 7%, thoracic complication 1.5%, sepsis 0.5%, organ injury 0.4%, embolisation 0.4%, urinoma 0.2%, and death 0.05%.

一项纳入12,000例患者的系统性回顾显示了PNL相关并发症的发生率：发热10.8％，输血7％，胸腔并发症1.5％，败血症0.5％，器官损伤0.4％，栓塞0.4％，尿性囊肿0.2％，死亡0.05％。

Peri-operative fever can occur, even with a sterile pre-operative urinary culture and peri-operative antibiotic prophylaxis, because the renal stones themselves may be a source of infection. Intra-operative renal stone culture may therefore help to select post-operative antibiotics.

即使术前尿培养阴性，且进行了围手术期抗生素预防，围手术期发热也可能发生，因为肾结石本身就可能是感染源。因此，术中肾结石培养可能有助于选择术后抗生素。

Intra-operative irrigation pressure < 30 mmHg and unobstructed post-operative urinary drainage may be important factors in preventing post-operative sepsis. Bleeding after PNL may be treated by briefly clamping of the nephrostomy tube. Super-selective embolic occlusion of the arterial branch may become necessary in the case of severe bleeding.

术中灌注压力<30 mmHg和术后尿液引流通畅可能是预防术后败血症的重要因素。PNL术后出血可通过短暂夹闭肾造瘘管进行治疗。在严重出血的情况下，可能有必要进行超选择性动脉栓塞治疗。

Summary of evidence and guidelines for endourology techniques for renal stone removal

肾结石移除的腔道泌尿外科技术证据概述和指南建议