融合肾锥体解剖在经皮肾通道建立中的临床意义
The anatomical structure of a fused renal pyramid and its clinical significance in the establishment of percutaneous renal access
林方优 1程帆 1余伟民 1叶芃 1饶婷 1阮远 1路井校 1夏煜琦1
作者信息
- 1. 430060 武汉大学人民医院泌尿外科
- 折叠
摘要
目的 探讨融合肾锥体解剖在经皮肾镜取石术通道建立中的临床意义.方法 2017年5月至2018年4月选取90个新鲜猪肾,其中10个行血管铸型后对肾动脉进行分级.余80个猪肾由同一名术者模拟行经皮肾穿刺扩张建立F24操作通道,分别采用经正常肾锥体(A组)、融合肾锥体一侧(B组)、融合肾锥体正中(C组)及正常肾柱(D组)4种路径穿刺,采用内镜观察及病理组织切片对比4种穿刺路径对肾血管的损伤情况.结果 肾血管铸型结果显示肾动脉分为6级,融合肾锥体内存在Ⅳ级支-叶间动脉分布.融合肾锥体内叶间动脉的平均血管直径为(0.442±0.012) mm,肾柱内叶间动脉为(0.778±0.037) mm,差异有统计学意义(P＜0.001).内镜观察及病理组织切片结果显示,A组穿刺通道基本无血管分布,肾柱结构与通道间有一定距离,6个标本损伤皮质层Ⅴ/Ⅵ级动脉,1个标本由于肾锥体体积小,穿刺定位不准确,损伤肾柱内Ⅳ级动脉;B组融合肾椎体内的Ⅳ级动脉与通道间有一定距离,但仍有4个标本出出现损伤,6个标本出现Ⅴ/Ⅵ级动脉损伤,1个标本由于肾锥体发生重度融合且锥体体积偏小,损伤肾柱内m级动脉末端和Ⅳ级动脉;C组穿刺通道沿途有白色条状结缔组织显露,14个标本损伤异位Ⅳ级动脉,7个标本损伤Ⅴ/Ⅵ级动脉;D组穿刺通道密布白色脂肪及结缔组织,沿途可见Ⅲ～Ⅵ级动脉均有损伤,Ⅲ、Ⅳ、Ⅴ/Ⅵ级动脉损伤个数分别为4、19、5个.A、B、C、D组动脉损伤程度的秩均值分别为17.0、30.1、33.5、41.5,总体差异有统计学意义(P=0.006),A、B组间差异无统计学意义(P=0.122),A、C组间差异有统计学意义(P=0.018),C、D组间差异无统计学意义(P=0.072).A、B、C组Ⅳ级动脉损伤的比例分别为5％ (1/20)、25％(5/20)和70％(14/20),A、C组间差异有统计学意义(P=0.029),A、B组间差异无统计学意义(P=0.316).4组穿刺损伤Ⅴ/Ⅵ级动脉的比例差异均无统计学意义(P=0.827).结论 建立经皮肾通道时,经融合肾锥体穿刺所致的血管损伤不可忽视,应仔细辨别并尽量避开融合肾锥体.如果无法避免,应采用经一侧肾锥体的中心线穿刺较安全.
Abstract
Objective To explore the clinical significance of fused renal pyramid (FRP) structure in the establishment of percutaneous renal access.Methods From May 2017 to April 2018,10 fresh porcine kidneys were selected to cast in blood vessels for grading the kidney artery.Then another 80 isolated porcine kidueys were used to simulate percutaneous renal pu ncture and dilatation to establish F24 operative access by the same surgeon.Under the endoscope and microscope,we compared the effects of four different puncture paths on the occurrence of renal vascular injury when respectively punctured through the normal renal pyramid (group A),the side of the FRP (group B),the centre of the FRP (group C) and the renal column (group D).Results The kidney arteries can be divided into six grades,there is grade Ⅳ branchinterlobar artery walking inside the FRP.The diameter of interlobar artery in the FRP was significantly smaller than that in the renal column (0.442 ±0.012) mm vs.(0.778 ±0.037) mm,(P ＜0.001).Endoscopic observation and pathological tissue section showed the following results.In group A,there was no injured blood vessel distributed along the access.There were six specimens with grade Ⅴ or Ⅵ arteries injury in the cortex.Owing to the small size of the renal pyramid and the inaccurate location of the puncture,there was also injury associated with a normal grade Ⅳ artery in the renal column.In group B,there was a certain distance between the tract and the grade Ⅳ artery that distributed in the FRP,injury was still noticed in four specimens.And six specimens have grade Ⅴ/Ⅵ arterial injury.As the distance between the tract and the renal column decreased,there was a case in which a simultaneously injury occurred to the extremity of a grade Ⅲ artery and a grade Ⅳ artery.In group C,there was a white thin strip of connective tissue exposed along the puncture tract.Ectopic grade Ⅳ artery injury occurred in fourteen specimens,and grade Ⅴ/Ⅵ artery injury occurred in seven specimens.In group D,there were grade Ⅲ to Ⅵ arteries distributed along the operational access,which was cowered with white fat and connective tissue.The number of arteryinjury in grades Ⅲ,Ⅳ,and Ⅴ/Ⅵ were4,19,and 5,respectively.The mean ranks of artery injury degree in groups A (17.0),B (30.1),C (33.5) and D (41.5) gradually increased,and the difference was significant (P =0.006).There was a significant difference between group A and C (P =0.018),while no significant difference between group A and B (P =0.122),groups C and D (P =0.072).The proportion of grade Ⅳ artery injury in group A,B,and C was 5％ (1/20),25％ (5/20),and 70％ (14/20),respectively.There was a significant difference between group A and C (P =0.029),while no significant difference between group A and B (P =0.316).There was no significant difference in the injury of grade Ⅴ and Ⅵ artery in four groups (P =0.827).Conclusions When establishing a percutaneous renal access,vascular injury caused bv puncturing through the FRP cannot be ignored.It is necessary to carefu lly identify and bypass the FRP when selecting the puncture path.If unavoidable,the puncture path shoull be on the centreline of one side pyramid of the FRP.
关键词
精准穿刺/融合肾锥体/经皮肾镜取石术/血管损伤Key words
Accurate puncture/Fused renal pyramid/Percutaneous nephrolithotomy/Vascular injury引用本文复制引用
出版年
2018
NETL
NSTL
维普
万方数据