术前预测输尿管嵌顿性结石的临床因素分析

Screening of clinical indicators for evaluation of incarcerated stone before operation

目的 探讨可用于术前预判输尿管嵌顿性结石的临床指标。 方法 回顾性分析2017年6—11月收治的96例输尿管结石患者的临床资料。男62例,女34例。年龄24~78岁,平均(54.5±12.7)岁。伴高血压病35例,糖尿病9例,肾盂积水85例。既往同侧结石病史24例。肾区叩击痛阳性11例、弱阳性64例、阴性21例。输尿管上段结石49例、中段结石19例、下段结石28例。结石横径为(7.75±2.68)mm;结石最大横截面积为(36.12±24.43)mm^2;结石体积为(304.06±303.39)mm3;结石CT值为(755.75±318.05)HU。CT检查测量结石处输尿管壁最大厚度(UWTmax)为(3.18±1.13)mm。96例均行输尿管镜钬激光碎石术。根据结石是否嵌顿将患者分为两组,比较两组各项临床数据的差异,对有差异的指标进行多因素logistic回归分析嵌顿性结石的独立预测因素。绘制ROC曲线并分析独立预测因素的最佳界值,分析该界值预测结石嵌顿的准确性和特异性,并根据该界值分组,比较组间相关指标的差异。 方法 本组96例手术均顺利完成,术后清石率为93.8%(90/96)。嵌顿组40例,男24例,女16例;年龄(53.4±12.3)岁;伴高血压病20例,糖尿病4例,肾积水40例;既往同侧结石病史14例;结石位于输尿管上段19例、中段9例、下段12例;UWTmax(4.15±0.94)mm;结石CT值(847.66±282.39)HU;结石横径(8.67±2.28)mm,结石最大横截面积(43.83±23.65)mm^2,结石体积(386.20±296.60)mm3;肾区叩击痛阳性8例、弱阳性27例、阴性5例。非嵌顿组56例,男38例,女18例;年龄(48.7±12.7)岁;伴高血压病15例,糖尿病5例,肾积水50例;既往同侧结石病史10例;结石位于输尿管上段30例、中段10例、下段16例;UWTmax(2.58±0.76)mm;结石CT值(698.65±325.50)HU;结石横径(7.17±2.75)mm,结石最大横截面积(31.14±23.64)mm^2,结石体积(253.04±296.29)mm3;肾区叩击痛阳性3例、弱阳性37例、阴性16例。单因素分析结果显示UWTmax、高血压病史、既往同侧结石病史、结石CT值、肾积水、结石横径、结石最大横截面积、结石体积、肾区叩击痛差异均有统计学意义(P<0.05)。多因素logistic回归分析结果显示UWTmax为术前输尿管嵌顿性结石的独立预测因素(OR=10.40,P<0.001)。ROC曲线预测输尿管嵌顿性结石的UWTmax界值为3.26 mm,其预测结石嵌顿的敏感性为82.5%,特异性为87.5%。根据UWTmax界值将患者分为厚壁组(≥3.26 mm)40例和非厚壁组(<3.26 mm)56例,两组输尿管发生水肿、息肉、狭窄的例数分别为31例和18例、12例和4例、15例和7例,术后结石清除率分别为87.5%(35/40)和98.2%(55/56),差异均有统计学意义(P<0.05)。 结论 结石处UWTmax可用于术前预测输尿管嵌顿性结石,且UWTmax≥3.26 mm的患者输尿管结石发生嵌顿,以及输尿管发生水肿、息肉、狭窄的概率更高,术后结石清除率更低。

Objective To investigate the clinical indicators which could be used to differentiate incarcerated stones from unincarcerated stones by comparing clinical characteristics of patients.Methods 96 patients who were diagnosed as ureteral stones treated by ureteroscopic lithotripsy (URSL) from June 2017 to November 2017 were selected in the study. Clinical characteristics of patients were collected. The total study consisted of 62 male and 34 female patients. The patients’ age ranged from 24 to 78 years old and average age was (54.5±12.7) years old. There were 35 patients were diagnosed as ureteral stones with hypertension, 9 patients with diabetes, 85 patients with hydronephrosis, respectively. The number of patients, whose stone located in upper ureters, middle ureters and lower ureters were 49, 19, 28, respectively. The average of maximum stone diameter, maximum cross-sectional area of the stone, stone volume, hounsfield units of stone and maximum ureteral wall thickness (UWTmax) at the stone site were(7.75±2.68)mm, (36.12±24.43)mm2, (304.06±303.39)mm3, (755.75±318.05) HU, and (3.18±1.13)mm, respectively. Percussion tenderness over kidney region were positive in 11 cases, weak positive in 64 cases and negative in 21 cases, respectively. Stone-free rate after operation were 93.8%. Patients were divided into two groups, incarcerated or unincarcerated, and statistical differences between clinical characteristics of the two groups were analyzed by univariate analysis. The differences were further compared by multivariate logistic regression analysis to find independent predictors of impacted stones. The ROC curve was used to find the optimal UWTmax for diagnosis of impacted stone. The accuracy of this value was evaluated and patients were grouped by this value to compare the differences between groups.Results The operation and follow-up were successfully performed in all patients. Univariate analysis showed there were no statistical significance differences in gender[(24 males and 16 females)vs. (38 males and 18 females)], age [(53.4±12.3) years vs.(48.7±12.7) years], previous history of diabetes (4 cases vs. 5 cases) and stone location[(19 upper stones, 9 middle stones, 12 lower stones) vs. (30 upper stones, 10 middle stones, 16 lower stones)], between the two groups(P>0.05). Among the clinical characteristics of patients in incarcerated and unincarcerated groups, UWTmax were (4.15±0.94)mm and (2.58±0.76)mm, previous history of hypertension were 20 cases and 15 cases, ipsilateral URSL history were 14 cases and 10 cases, hounsfield units of stone were (847.66±282.39)HU and (698.65±325.50) HU, hydronephrosis were 40 cases and 50 cases, maximum stone diameter were (8.67±2.28)mm and (7.17±2.75)mm, maximum cross-sectional area of the stone were (43.83±23.65)mm2 and (31.14±23.64)mm2, stone volume were (386.20±296.60)mm3 and (253.04±296.29)mm3, percussion tenderness over kidney region were positive in 8 cases(20.0%), weak positive in 27 cases, negative in 5 cases and positive in 3 cases, weak positive in 37 cases, negative in 16 cases, respectively. The difference was statistically significant(P<0.05). Multivariate logistic regression analysis showed UWTmax (OR=10.40, P<0.001) at the stone site was significantly correlated with impacted ureteral stones and it was an independent predictor of impacted stones. ROC curve analysis showed that the optimal cut-off value of UWTmax was 3.26 mm. The sensitivity of the value to predict impacted stone is 82.5% and the specificity is 87.5%. Depending on the cut off value of 3.26 mm, cases were divided into two groups, 40 cases were in high UWTmax(≥3.26 mm)group and 56 cases were in low UWTmax(<3.26 mm)group. Higher UWTmax was accompanied with a higher incidence of ureteral edema[77.5%(31/40) vs. 32.1%(18/56)], polyps[30.0%(12/40)vs. 7.1%(4/56)], strictures[37.5%(15/40)vs. 12.5%(7/56)] and a lower stone-free rate[87.5%(35/40)vs. 98.2%(55/56)]. The difference was statistically significant(P<0.05).Conclusions UWTmax can be used to differentiate impacted stones from unimpacted stones before surgery. The patients with Higher UWTmax(≥3.26 mm) was accompanied with a higher incidence of stone impacted, ureteral edema, polyps, and strictures, and a lower rate of stone clearance.