三种微创手术治疗复杂性输尿管上段结石的临床疗效及安全性比较

Clinical efficiency and safety of 3 mini-invasive approaches for complex upper ureteral calculi

目的比较经尿道输尿管镜碎石取石术、微通道经皮肾穿刺碎石取石术及后腹腔镜输尿管切开取石术3种微创手术方式治疗复杂性输尿管上段结石的有效性及安全性。方法我科于2009年3月至2013年8月共收治复杂性输尿管上段结石患者82例，对其中2l例行经尿道输尿管镜碎石取石术（trans-urethralureteroseopelithotripsy，URL），28例患者行微通道经皮肾穿刺碎石取石术（minimallyinvasivepercutaneousnephrolithotomy，MPCNL）、33例患者行后腹腔镜输尿管切开取石术（relroperitoneoscopicureterolithotomy，RLU），对比分析3组患者手术时间、术中出血量、术后住院时间、住院费用、结石清除率及并发症等。结果3组患者之间年龄、性别、体重指数、结石大小等方面比较无显著差异（P〉0．05）。3组患者手术时间比较，RLU组明显长于URL组及MPCNL组（P〈0．05），URL组与MPCNL组比较无明显差异（P〉0．05）；术中出血量比较，MPCNL组明显高于URL组及RLU组（P〈0．05），URL组与RLU组比较无明显差异（P〉0．05）；术后住院时间3组患者之间比较无显著性差异（P〉0．05）；住院费用比较，RLU组明显少于URL组及MPCNL组（P〈0．05），而URL与MPCNL组比较无明显差异（P〉0．05）。URL组、MPCNL组、RLU组手术成功率分别为66．7％，100．0％，100．O％，术后1个月结石清除率分别为85．O％、96．4％、100％。3组比较，MPCNL组及RLU组手术成功率及术后1个月结石清除率明显优于URL组（P〈0．05），而MPCNL组与RLU组比较无明显差异（P〉0．05）；URL组、MPCNL组、RLU组术后并发症发生率为14．2％、21．4％、0．0％。3组比较，MPCNL组术后并发症明显高于URL组及RLU组，而RLU组与URL及MPCNL比较，术后并发症明显低于另两组，有显著性差异（P〈0．05）。术后随访时间6—27个月，无复发。结论URL对患者损伤小，但一次清除率低。MPCNL结石清除率高，但手术风险较大，而RLU具有创伤小、出血少、并发症少、一次性取石成功率高等优点，通常不需联合其他治疗手段，是复杂性输尿管上段结石比较理想的治疗方法。

Objective To evaluate clinical efficiency and safety of 3 different mini-invasive surgery approaches, trans-urethral ureteroscope lithotripsy （URL）, minimally invasive percutaneous nephrolithotomy （MPCNL） and retroperitoneoseopie ureterolithotomy（RLU） in the treatment of complex upper ureteral calculi. Methods A total of 82 patients with complex upper ureteral stones in our department from March 2009 to August 2013 were subjected in this study. Among them, 21 patients underwent URL, 28 MPCNL, and 33 RLU for removal of upper ureteral stones. Operation time, intra-operative blood loss, hospitalization costs, stone clearance and incidence of complications were retrospectively analyzed and compared for the 3 approaches. Results No significant difference was seen in the age, sex, BMI and stone size among the 3 groups （P 〉 0.05 ）. The operation time was significantly longer in RLU group than URL and MPCNL groups （ P 〈 0. 05 ） , with no difference between the later 2 groups （P 〉 0.05 ）. The intra-operative bleeding volume was statistically larger in MPCNL group than URL and RLU groups （ P 〈 0. 05 ）, but no significance was seen in the 2 later groups （ P 〉 0. 05 ）. There was no statistical difference in hospital staying time in the 3 groups （ P 〉 0. 05 ）. But for the hospitalization costs, that of RLU group was the least, and no difference was found between URL and MPCNL groups （ P 〉 0. 05 ）. The successful rate of the operations was 66.7%, 100.0%, and 100.0%, respectively in the URL, MPCNL and RLU groups, and the stone clearance in 1 month after operation was 85.0%, 96.4%, and 100.0%, respectively. So, the successful rate and stone clearance in 1 month after operation were better in MPCNL and RLU groups than URL group （P 〈 0. 05 ）, but there was no difference between the former 2 groups （P 〉 0. 05 ）. The incidence of complications was 14.2%, 21.4%, and 0.0%, respectively in the URL, MPCNL and RLU groups, with that of MPCNL group the highest, while that of RLU group the lowest （P 〈 0. 05 ）. No recurrent calculus was observed during the follow-up period of 6 to 27 months. Conclusion URL is of less damage for the patient, but with low stone clearance. MPCNL has advantages of high stone clearance, but is with high risk of operation. RLU is a safe and effective mini-invasive procedure with less blood loss, high stone clearance and fewer complications. It is an ideal approach for complex upper ureteral calculi, usually with no need of other treatment to combine with.