1、适应证适应证C.Trk,T.Knoll,A.Petrik,et al.Guidelines on Urolithiasis.European Association of Urology,2013.适应证适应证C.Trk,T.Knoll,A.Petrik,et al.Guidelines on Urolithiasis.European Association of Urology,2013.适应证适应证肾结石肾结石输尿管软镜PCNL适应证适应证坎贝尔-沃尔什泌尿外科学：第9版，1601.适应证适应证CAMPBELL-WALSH Urology.Tenth Edition,1364.非鹿角形结
2、石大于非鹿角形结石大于2cm，首选，首选PCNL适应证适应证CAMPBELL-WALSH Urology.Tenth Edition,1373.肾下极结石大于肾下极结石大于2cm，首选，首选PCNL适应证适应证vPNL,followed by either SWL or repeated PNL,should be used for most patients with struvite staghorn calculi,with PNL being the initial element of the combination therapy.v鹿角型肾结石应把PCNL作为综合治疗的第一步。小
3、结小结v直径2cm、复杂性、鹿角形肾结石应首选PCNLv输尿管软镜的局限性：手术时间长 分期处理 并发症多 取石困难定位方式定位方式C臂机臂机超声超声SonixGPS定位定位方式：方式：C臂臂机机v优点：显示图像直观 扩张过程实时监视 术后查看残石情况v缺点：二维平面图像 对医患存在放射性 不能显示穿刺路径周围器官Yang R M,Morgan T,Bellman G C.Radiation protection during percutaneous nephrolithotomy:a new urologic surgery radiation shieldJ.Journal of end
4、ourology,2002,16(10):727-731.定位定位方式：超声方式：超声v优点：无辐射 提供三维立体信息 显示集合系统、脉管系统及肾脏周围组织v缺点：不直观 需具备超声知识，经过特殊培训 需要“人工肾积水”无法明确观察残留结石Tzeng B C,Wang C J,Huang S W,et al.Doppler ultrasound-guided percutaneous nephrolithotomy:a prospective randomized studyJ.Urology,2011,78(3):535-539.定位定位方式：方式：SonixGPSv穿刺前可以预判和设计穿刺
5、路径及角度v可精确看到穿刺针在组织中的穿刺轨迹v显示探头切面与穿刺针的位置关系v缩短经皮肾穿刺的学习曲线小结小结联合应用联合应用准确定位准确定位穿刺通道穿刺通道超微通道（超微通道（ultra-mini-PCNL）微通道（微通道（mini-PCNL）标准通道（标准通道（standard PCNL）穿刺通道穿刺通道v标准通道（standard PCNL）2024 F 清石率高 并发症多穿刺通道穿刺通道v微通道（mini-PCNL）1420 F 并发症少 效率低穿刺通道穿刺通道v超微通道（ulrta-mini-PCNL）1113 F 6 F mini-肾镜+钬激光 直径2 cm肾结石 取石效率低 灌
6、注压力大 亦可行输尿管软镜或ESWL MPCNL的补充手段Desai J,Zeng G,Zhao Z,et al.A novel technique of ultra-mini-percutaneous nephrolithotomy:introduction and an initial experience for treatment of upper urinary calculi less than 2 cmJ.Biomed Res Int,2013,2013:490793.穿刺通道穿刺通道v超微通道（ulrta-mini-PCNL）Desai J,Zeng G,Zhao Z,et a
7、l.A novel technique of ultra-mini-percutaneous nephrolithotomy:introduction and an initial experience for treatment of upper urinary calculi less than 2 cmJ.Biomed Res Int,2013,2013:490793.金属工作鞘和封堵器管道、封堵器、导丝、激光纤维穿刺通道穿刺通道v超微通道（ulrta-mini-PCNL）Desai J,Zeng G,Zhao Z,et al.A novel technique of ultra-min
8、i-percutaneous nephrolithotomy:introduction and an initial experience for treatment of upper urinary calculi less than 2 cmJ.Biomed Res Int,2013,2013:490793.3.5 F的mini肾镜与6 F的镜鞘，灌注管与激光纤维小结小结v大通道清石效率高v适用于体积大、复杂性肾结石v小结石可选ESWL或输尿管软镜，不必MPCNL并发症并发症vEven for the most experienced urologist,major complications can still occur in up to 7%of patients undergoing PNL.vAnd minor complications may be encountered in up to 25%of patients.v出血、肾盂损伤、液体吸收、胸腔损伤、肠道穿孔、肝脾损伤、败血症等。CAMPBELL-WALSH Urology.Tenth Edition,1405.
