输尿管软镜碎石术治疗累计直径>2 cm上尿路结石一期清石率影响因素及预测模型建立

Influence factors and prediction model of one stage stone free rate in patients with flexible ureteroscopic lithotripsy in treatment of upper urinary calculi of cumulative diameter>2 cm

目的探讨输尿管软镜碎石术治疗累计直径>2 cm上尿路结石一期清石率的影响因素及建立清石预测模型。方法收集2016年1月至2021年7月采用输尿管软镜联合钬激光碎石术治疗的182例累计直径>2 cm上尿路结石患者的临床资料,包括术前资料、结石CT值、结石位置、结石累计直径、肾盂肾下盏漏斗夹角、手术时间、住院时间、术后并发症及一期清石率,分析影响清石率的独立因素并建立联合预测模型。结果182例患者全部完成手术,多因素回归分析得出的独立危险因素有:尿路感染、结石位置(肾下盏结石)、肾盂肾下盏漏斗夹角<30°、结石累计直径,得出联合预测因子公式:L=尿路感染+1.263×结石位置(肾下盏结石)+1.290×肾盂肾下盏漏斗夹角<30°+5.611×结石累计直径。比较联合预测因子与各独立影响因素预测术后结石残余阳性的ROC曲线下面积分别为:联合预测因子(0.898)>结石累计直径(0.811)>结石位于下盏(0.650)>尿路感染(0.608)>肾盂输尿管与肾下盏夹角<30°(0.588);约登指数最大值为0.660,对应敏感度为0.813,特异度为0.847,最大约登指数对应的联合预测因子是13.21,为临界值,大于此值则预测术后将出现结石残余阳性。结论输尿管软镜联合钬激光碎石术是治疗累计直径>2 cm上尿路结石的安全、可行的方式。综合各独立因素得出联合预测因子公式,并得出最大约登指数对应的联合预测因子为13.21,大于此值将预示术后结石残余阳性。

Objective To investigate the influencing factors of one-stage stone-free rate of flexible ureteroscopic lithotripsy in the treatment of upper urinary tract calculi of cumulative diameter>2 cm and establish a stone-free prediction model.Methods From January 2016 to July 2021,the clinic data of the 182 cases of upper urinary tract calculi of cumulative diameter>2 cm were collected,including preoperative data,CT value,stones location,cumulative diameter,pelvis and lower calyceal funnel angle<30°,operation time,hospital stay,postoperative complications and one-stage stone-free rate.The independent factors affecting the stone-free rate were analyzed and a combined prediction model was established.Results All 182 patients completed the operations.Multivariate regression analysis showed that the independent risk factors were urinary tract infection,stone location(subrenal calyx calculi),pelvis and lower calyceal funnel angle<30°,stone cumulative diameter.The formula of combined predictors was as follows:L=urinary tract infection+1.263×stone location(lower calyceal stone)+1.290×angle between renal pelvis and lower calyceal funnel<30°+5.611×cumulative stone diameter.The area under the ROC curve of the combined predictor and each independent influencing factor in predicting positive for postoperative stone residue was as follows:combined predictor(0.898)>cumulative stone diameter(0.811)>stones location(subrenal calyx calculi)(0.650)>urinary tract infection(0.608)>pelvis and lower calyx funnel angle<30°(0.588).The maximum value of Youden index was 0.660,the corresponding sensitivity was 0.813,and the specificity was 0.847.The maximum Youden index was assosciated with a combined predictor of 13.21,a cut off value above which postoperative prediction was made and residual stones will be positive.Conclusions Flexible ureteroscopy lithotripsy is a safe and feasible method for the treatment of upper urinary tract calculi of cumulative diameter>2 cm.The formula of combined predictors was obtained by combining the independent factors and the combined predictors higher than the critical value of 13.21 would indicate residual positive postoperative stones.