微创经皮输尿管镜与逆行输尿管镜治疗梗阻性输尿管上段结石的前瞻性随机对照研究

Treatment of Impacted Proximal Ureteral Stones: Randomized Comparison Study between Retrograde Ureterolithotripsy and Percutaneous Ureterolithotripsy

目的比较微创经皮输尿管镜与逆行输尿管镜治疗梗阻性输尿管上段结石的疗效和安全性。方法 91例梗阻性输尿管上段结石患者,随机分为两组,分别行微创经皮输尿管镜(44例)和逆行输尿管镜(47例)结合钬激光碎石治疗。结石横径均>1cm。纳入研究的梗阻性输尿管上段结石定义为结石位于肾盂输尿管连接部至第四腰椎横突下缘水平之间且静脉肾盂造影片中造影剂不能到达结石以下部位。分析比较术后次日和术后1个月的结石清除率、手术时间、住院时间、手术失败率以及术中、术后并发症。结果微创经皮输尿管镜组术后次日和术后1月的结石清除率均明显高于逆行输尿管镜组,分别为(95.3%和79.5%,P=0.027)以及(100%和86.4%,P=0.026)。微创经皮输尿管镜组平均手术时间[(75.4±11.8)和(30.6±7.8)分钟,P<0.001]、平均住院时间[(6.3±0.5)和(2.1±0.4)天,P<0.001]均明显高于逆行输尿管镜组。手术失败率和术中、术后并发症两组无统计学差异。结论对于结石横径>1cm的梗阻性输尿管上段结石,微创经皮尿管镜与逆行输尿管镜比较,前者更易取净结石,但手术时间和住院时间较长。

Objective We compared the safety and efficacy of percutaneous antegrade ureterolithotripsy and retrograde ureterolithotripsy for large impacted proximal ureter stones in a prospective randomized manner. Methods A total of 91 patients with large impacted proximal ureteral stones,defined as stones greater than 1 cm and located from the ureteropelvic junction to the lower border of the 4th lumbar vertebra,were prospectively randomized for antegrade (44)or retrograde(47)ureterolithotripsy. The failure rate of intend procedure intraop-erative and postoperative morbidity,operative time,hospital stay,stone clearance at discharge home and follow-up were analyzed in each group. Results Main complication was bleeding (2. 3%,1 of 43)for antegrade pro-cedure and ureter injury (2. 3%,1 of 44)for retrograde procedure. Percutaneous antegrade ureterolithotripsy was associated with longer operative time [(75. 4 ± 11. 8)vs (30. 6 ± 7. 8)minutes,P<0. 001],longer hospi-tal stay [(6. 3 ± 0. 5)vs (2. 1 ± 0. 4)days,P <0. 001]and longer interval to return to normal activities[(7. 8 ± 0. 7)vs (2. 7 ± 0. 6)days,P <0. 001]. Nevertheless percutaneous antegrade procedure had higher stone-free rate both at discharge home (95 . 3% vs 79 . 5%,P=0 . 027 )and 1 month after the procedure (100% vs 86 . 4%,P=0 . 026 ). Conclusions Percutaneous antegrade ureterolithotripsy is a valuable treatment modality for impacted proximal ureteral calculi larger than 1 cm and achieves higher stone-free rate than that of retrograde ureteroscopy with holmium:YAG laser lithotripsy. The drawbacks of antegrade procedure are longer operative time and hospital stay.