输尿管软镜治疗中上盏肾结石术后无管化的临床研究

Clinical study of flexible ureteroscope with tubeless in the treatment of middle or upper calyx renal calculi

目的 探讨输尿管软镜治疗中上盏肾结石术后无管化的可行性和安全性。 方法 回顾性分析2015年1月至2018年10月我院收治的107例肾结石患者的临床资料。男68例,女39例;年龄(32.1±5.2)岁(18~55岁)。结石均为初发、单发,位于肾上盏或肾中盏,结石直径<2.0 cm,结石CT值≤800 HU,患侧肾脏积水轻。所有患者术前均在膀胱镜下常规留置双J管2周,术中行输尿管软镜碎石取石术治疗,按术后是否常规留置双J管分为两组,其中50例术后无管化,为无管化组;57例术后常规置管,为置管组。无管化组年龄(30.4±5.9)岁;男33例,女17例;左侧结石28例,右侧结石22例;上盏结石24例,中盏结石26例;结石直径(1.3±0.5)cm。置管组年龄(31.3±5.4)岁;男35例,女22例;左侧结石26例,右侧结石31例;上盏结石27例,中盏结石30例;结石直径(1.4±0.4)cm。两组一般资料比较差异均无统计学意义(P>0.05)。 结果 107例术中均未见明显输尿管畸形、狭窄、息肉、肿瘤,软镜鞘置入顺利。无管化组手术时间[(48.2±9.7)min]显著低于置管组[(51.7±7.8)min, P<0.05]。无管化组和置管组术后第1天[92.0%(46/50) 与 91.2%(52/57)]、术后2周[96.0%(48/50)与 98.2%(56/57)]的结石清除率差异无统计学意义(P>0.05);术后1个月结石清除率均达100.0%。无管化组血尿发生率[24.0%(12/50)]显著低于置管组[54.4%(31/57),P=0.001];无管化组膀胱刺激征发生率[14.0%(7/50)]显著低于置管组[36.8%(21/57),P=0.007];无管化组术后1周、2周、1个月腰腹部疼痛发生率[32.0%(16/50)、8.0%(4/50)、2.0%(1/50)]均显著低于置管组[57.9%(33/57)、49.1%(28/57)、33.3%(19/57),P<0.05]。术后1 d腰腹部疼痛发生率两组差异无统计学意义[86.0%(43/50)与84.2%(48/57),P>0.05]。 结论 对于输尿管条件好(无明显畸形、狭窄、息肉、肿瘤)、无泌尿系结石病史、肾积水轻以及单发、直径<2.0 cm、CT值≤800 HU的中、上盏肾结石患者,输尿管软镜术后无管化并未显著影响结石清除率,且具有更低的并发症发生率,有较好的可行性和安全性。

Objective To explore the feasibility and safety of flexible ureteroscope with tubeless in the treatment of middle or upper calyx renal calculi.Methods The clinical data of 107 patients with renal calculi treated from January 2015 to October 2018 were analyzed retrospectively. Age ranged from 18 to 55 years, with mean of (32.1±5.2) years. Calculi was single, locating in the middle or upper calyx, with the diameter less than 2.0 cm, the CT value ≤800 HU, and mild renal hydronephrosis. All patients were routinely indwelling double-J tube using cystoscopy 2 weeks preoperatively, and ureteroscopic lithotripsy was performed. Fifty patients in group A were received tubeless treatment, and 57 patients in group B were given routinely indwelling double-J tube. The 50 patients in group A were (30.4±5.9) years of age, including 33 males and 17 females, 28 cases on the left and 22 cases on the right, 24 cases locating in the upper calyx and 26 cases locating in the middle calyx, and calculi diameter of (1.3±0.5) cm. The 57 patients in group B were (31.3±5.4) years of age, including 35 males and 22 females, 26 cases on the left and 31 cases on the right, 27 cases locating in the upper calyx and 30 cases locating in the middle calyx, and diameter of (1.4±0.4) cm. There were no significant difference in the demographics between the two groups (P>0.05).Results There were no obvious ureteral malformations, stenosis, polyps or tumors in the 107 cases intraoperatively, and the flexible ureteroscope sheath was placed smoothly. The operation time in group A [(48.2±9.7)min] was significantly lower than that in group B [(51.7±7.8)min, P<0.05]. There was no significant difference in the calculi clearance rate between the two groups on the first day [92.0%(46/50) vs. 91.2%(52/57)] and two weeks[96.0%(48/50) vs. 98.2%(56/57)] after operation(P>0.05), and the calculi clearance rate reached 100% at 1 month after operation. The incidence of hematuria in group A [24.0%(12/50)] was significantly lower than that in group B [54.4%(31/57), P=0.001]. The incidence of bladder irritative symptoms in group A [14.0%(7/50)] was significantly lower than that in group B [36.8%(21/57), P=0.007]. The incidence of lumbar and abdominal pain at 1 week, 2 weeks and 1 month after operation was significantly lower in group A [32.0%(16/50), 8.0%(4/50), 2.0%(1/50)] than that in group B [57.9%(33/57), 49.1%(28/57), 33.3%(19/57), P<0.05]. There was no significant difference between the two groups about the incidence of lumbar and abdominal pain at first day after operation [86.0%(43/50) vs. 84.2%(48/57), P>0.05]. Conclusions It was feasibility and safety to perform flexible ureteroscope with tubeless for the patients with renal primary and single calculi, ideal ureteral conditions (no malformations, stenosis, polyps or tumors), mild renal hydronephrosis, calculi, diameter <2.0 cm, CT value ≤800 HU, locating in the middle or upper calyx, and no history of urinary calculi. This procedure had not only similar calculi clearance rate compared with routinely indwelling double-J tube, but also has a lower incidence of complications (hematuria, bladder irritative symptoms, lumbar or abdominal pain).