腹腔镜与开放肾盂成形术比较治疗肾盂输尿管连接部梗阻有效性和安全性的系统评价

Efficacy and Safety of Laparoscopic Pyeloplasty versus Open Pyeloplasty for Ureterpelvic Junction Obstruction: A Systematic Review

目的系统评价腹腔镜肾盂成形术(laparoscopic pyeloplasty,LP)与开放肾盂成形术(open pyeloplasty,OP)比较治疗肾盂输尿管连接部梗阻(ureterpelvic junction obstruction,UPJO)的疗效与安全性。方法计算机检索PubMed、The Cochrane Library(2015年11期)、Sciverse、VIP、WanFang Data和CNKI数据库,搜集LP与OP两种术式治疗UPJO的相关随机对照试验(RCT)和非随机的临床对照试验(CCT),检索时限均从建库至2015年12月。由2位评价员独立筛选文献、提取资料并评价纳入研究的偏倚风险/方法学质量后,采用RevMan 5.3软件进行Meta分析。结果共纳入38个研究,包括8个RCT,30个CCT。对RCT的Meta分析结果显示:两组手术成功率[OR=0.50,95%CI(0.20,1.24),P=0.13]、术后并发症发生率[OR=1.19,95%CI(0.61,2.31),P=0.62]差异无统计学意义;OP组的手术时间明显短于LP组,且差异有统计学意义[MD=62.07,95%CI(3.94,120.19),P=0.04],但LP术经腹膜后途径手术时间与OP术式比较差异无统计学意义[MD=49.99,95%CI(–23.69,123.67),P=0.18];LP组术后患者住院时间短于OP术后,且差异有统计学意义[MD=–3.96,95%CI(–4.92,–2.99),P<0.000 1]。对CCT的Meta分析结果显示:两组手术成功率差异无统计学意义[OR=1.34,95%CI(0.84,2.16),P=0.22],经腹途径或腹膜后途径对成功率无影响。LP组术后并发症发生率[OR=0.51,95%CI(0.37,0.69),P<0.000 1]、术后住院时间短于OP组[MD=–3.87,95%CI(–4.90,–2.83),P<0.000 01],LP术经腹后途径患者术后住院时间明显短于OP术式,两组差异有统计学意义[MD=–4.08,95%CI(–5.21,–2.95),P<0.000 1]。OP组手术时间短于LP组,但差异没有统计学意义[MD=24.15,95%CI(–7.56,55.87),P=0.14]。结论现有证据表明,与OP术式比较,LP术式治疗UPJO的成功率与OP术式相当,但LP术式的并发症更少、住院天数更短。受纳入研究质量所限,上述结论尚需开展更多高质量研究予以验证。

Objective To systematically review the efficacy and safety of laparoscopic pyeloplasty（LP） versus open pyeloplasty（OP） for patients with ureterpelvic junction obstruction（UPJO）. Methods We electronically searched databases including PubMed, The Cochrane Library（Issue 11, 2015）, Sciverse, VIP, Wan Fang Data and CNKI from inception to Dec., 2015, to collect randomized controlled trials（RCTs） and non-randomized clinical controlled trials（CCTs） about LP versus OP for UPJO patients. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed using RevMan 5.3 software. Results A total of 38 studies including 8 RCTs and 30 CCTs were included. The results of meta-analysis based on RCTs showed that, there were no significant differences in successful operation rate（OR=0.50, 95%CI 0.20 to 1.24, P=0.13） and the incidence of postoperative complications（OR=1.19, 95%CI 0.61 to 2.31, P=0.62） between the OP group and the LP group; The operation time of the OP group was shorter than that of the LP group（MD=62.07, 95%CI 3.94 to 120.19, P=0.04）, but this difference was not found in subgroup analysis of retroperitoneal approach（MD=49.99, 95%CI –23.69 to 123.67, P=0.18）; The hospital stay of the LP group was shorter than that of the OP group（MD= –3.96, 95%CI –4.92 to –2.99, P〈0.000 1）. The results of meta-analysis based on CCTs showed that, there was no significant difference in successful operation rate between two groups（OR=1.34, 95%CI 0.84 to 2.16, P=0.22）, and similar results were found in subgroup analysis of transperitoneal or retroperitoneal approaches; The incidence of postoperative complications of the LP group was shorter than that of the OP group（OR=0.51, 95%CI 0.37 to 0.69, P〈0.000 1）; The hospital stay of the LP group was shorter than that of the OP group（MD= –3.87, 95%CI –4.90 to –2.83, P〈0.000 01） and similar result was found in subgroup analysis of transperitoneal approach（MD= –4.08, 95%CI –5.21 to –2.95, P〈0.000 1）; There was no significant difference between two groups in operation time（MD=24.15, 95%CI –7.56 to 55.87, P=0.14）. Conclusion Current evidence shows that, the successful operation rate between LP and OP operations is similar, but the LP operation has less incidence of postoperative complication and shorter hospital stay. Due to limited quality of the included studies, the above conclusion needs more high quality studies to verify.