不同微创方法治疗输尿管上段结石的比较分析

Comparative study of different minimally invasive methods for the treatment of upper ureter calculi

目的总结比较不同微创方法治疗输尿管上段结石的效果。方法分析不同微创方法治疗488例输尿管上段结石的临床资料。其中输尿管镜气压弹道碎石组129例,后腹腔镜输尿管切开取石组25例,输尿管镜钬激光碎石组91例,微创经皮肾镜取石(MPCNL)243例。各组年龄、性别、结石大小和结石停留时间无统计学差异。分析各组手术时间、血红蛋白下降值、住院天数、碎石成功率、结石排尽率和并发症发生率等指标。结果各组手术时间有统计学差异(P=0.000),后腹腔镜组手术时间84.76±11.32min最长,气压弹道碎石组28.45±8.96min和钬激光碎石组30.80±7.80min较短,两组间无统计学差异(P=0.095);住院天数后腹腔镜组7.81±1.36d和MPCNL组7.67±1.26d均显著长于气压弹道组3.44±0.99d(P=0.000,P=0.000)与钬激光组3.58±1.15d(P=0.000,P=0.000),后腹腔镜组与MPCNL组间(P=0.473)、气压弹道组与钬激光组间(P=0.275)无统计学差异;术后血红蛋白下降值后腹腔镜组显著高于其他三组(P=0.000,P=0.000,P=0.000),气压弹道组和钬激光组间无统计学差异(P=0.352)。后腹腔镜组、mPCNL组碎石成功率和术后结石排尽率均为100%。气压弹道组手术成功率和结石排尽率分别为93.79%(121/129)和92.24%(119/129),均显著低于钬激光组(P=0.041,P=0.037)。后腹腔镜组并发症发生率为16.00%(4/25),显著高于气压弹道碎石组(5.42%)(P=0.027)和钬激光组(4.39%)(P=0.044)。MPCNL组并发症发生率(11.10%)与后腹腔镜组16.00%无显著性差异(P=0.463),但显著高于气压弹道碎石组(P=0.045)和钬激光组(P=0.046),气压弹道碎石组与钬激光碎石组间无统计学差异(P=0.733)。结论对于输尿管上段较大结石、结石停留时间较长者宜首选MPCNL;如采用输尿管镜下碎石,钬激光碎石效果优于气压弹道碎石;对于MPCNL和输尿管镜下碎石失败的病例可采用后腹腔镜下输尿管切开取石。

Objetctive To summarize the clinical experience of upper ureter calculi treated by dif- ferent minimally invasive methods. Methods The clinical data of 488 cases of upper ureter calculi from June 1999 to June 2009 was analyzed, including 129 cases underwent ureteroscopic pneumatic lithotripsy （UPL）, 25 cases underwent retroperitoneal laparoscopic ureterolithotriosy （RLU）, 91 cases underwent ureteroscopic Holmium laser lithotripsy （UHL） and 243 cases of minimally invasive percutaneous nephrolithotomy （MPCNL） There were no significantly differences in age, sex and diameter of stone among the four groups. Data on the operative time, value of hemoglobin decreasement, hospitalization time, success rate of primary lithotripsy, stonefree rate and complication rate were analyzed. Results There were significantly difference on the operating time among the four groups （P=0.000）, and the RLU group had the longest operating time （84.76±11.32 min）, while the operating time group of UPL group and UHL group were （28.45±8.96 min） and （30.80±7.80 min）, respectively （P=0.095）. There were no significantly difference on hospitalization time between the RLU （7.81±1.36 d） and mPCNL group （7.67±1.26 d, P=0.473）, and be tween the UPL3.44±0.99 d and UHL group 3.58±1.15 d （P=0.275）. That of RLU group was significantly higher than that of UPL （P=0.000） and UHL group （P=0.000）, and that of MPCNL group was also signifi- cantly higher than that of UPL （P=0.000） and UHL group （P=0.000）. The value of hemoglobin decrease in RLU group was significantly higher than the other three groups （P=0.000, P=0.000, P=0.000）, and there were no significantly difference between the UPL and UHL group （P=0.352）. The success rate of primary lithotripsy and stonefree rate of UPL group were significantly higher than those of UHL group （P=0.041, P=-0.037）. The complication rate of MPCNL group was significantly higher than those of UPL（P=0.045） and UHL group （P=0.046）, while there were no significantly difference between MPCNL and RLU group （P=- 0.463）, and between UPL and UHL group （P=0.733）. Conclusions MPCNL is the first choice for the upper ureter calculi with bigger volume and longer residence time. For the method of ureteroseope lithotripsy, holmium laser lithotripsy has better treatment effect than pneumatic lithotripsy. RLU should be applied for the unsuccessful treatment cases by methods of MPCNL and ureteroscope lithotripsy.