输尿管软镜治疗上尿路结石后全身炎症反应综合征的预测模型

A model for predicting the systemic inflammatory response syndrome after flexible ureteroscope lithotripsy for upper urinary tract calculi

目的 分析输尿管软镜钬激光碎石术治疗上尿路结石后发生全身炎症反应综合征（Systemic inflammatory response syndrome,SIRS）的相关因素,建立预测术后重症感染风险的列线图预测模型.方法 回顾性分析2014年1月至2016年5月我中心457例输尿管软镜治疗上尿路结石患者的临床资料.男302例,女155例.年龄20 ～76岁,平均49.9岁.最大结石直径12～22mm,平均（16.5±3.0）mm.51例（11.2％）术前出现结石相关感染性发热.根据术后是否发生SIRS将患者分为两组,通过单因素分析和多因素Logistic回归分析评价患者发生SIRS的围手术期独立危险因素,根据回归系数绘制相应的列线图预测模型.结果 本组457例中,27例（5.9％）术后发生SIRS,多变量Logistic回归分析结果显示,结石相关发热病史（OR=1.5569,P=0.009）、术前未置支架管（OR=1.4004,P=0.004）、导入鞘外径较小（F13～14）（OR=1.1120,P=0.016）、术中存在感染表现（OR=2.0176,P=0.000）,以及感染性结石（OR=1.0981,P=0.013）是术后SIRS发生的独立预测危险因素.列线图模型在建模样本中的一致系数为0.845,而在验证样本中的一致系数为0.79,并表现出较好的符合度.结论 术前结石相关发热病史、术中存在感染表现,以及感染性结石、术前未置支架管、导入鞘外径较小,可以显著增加输尿管软镜治疗上尿路结石术后的SIRS发生率.根据患者临床资料,应用列线图有助于预测术后SIRS风险.

Objective To analyze the risk factors that affect severe infection following flexible ureteroscope Holmium laser lithotripsy for upper urinary tract calculus,and to construct the regression model and nomogram for predicting the probability of postoperative SIRS.Methods We retrospectively analyzed the clinical data from 457 cases （male 302 and female 155） of upper urinary calculi treated by flexible ureteroscopy from January 2014 to May 2016,with mean age of 49.9 （ranged 20-76） years.The mean maximum size of stones was （16.5 ± 3.0） mm （ranged 12-22rmm）.There were 51 cases （11.2%） with a recent infectious febrile history related to stones.The patients were divided into two groups as patients developing SIRS or not.Univariate and multivariate statistical analyses were performed to determine factors affecting the development of postoperative SIRS,and then a nomogram was built based on regression coefficients.Results The incidence of SIRS after flexible ureteroscopic lithtripsy was 5.9% （27/457）.Multivariable logistic regression analysis identified febrile history related to urinary stones （OR =1.5569,P =0.009）,without preoperative placement of ureteral stent （OR =1.4004,P =0.004）,small-caliber （F 13-14） ureteral access sheath （OR =1.1120,P =0.016）,endoscopic signs of infection （OR =2.0176,P =0.000） and infectious stones （OR =1.0981,P =0.013） as independent risk factors for postoperative SIRS.The concordance index was 0.845 in the nomogram model sample and 0.79 in the validation sample.Conclusions Febrile history related to urinary stones,without preoperative placement of ureteral stent,small-caliber ureteral access sheath,endoscopic signs of infection and infectious stones would be independent risk factors to predict SIRS after flexible ureteroscope holmium laser lithtripsy.A nomogram based on perioperative clinical factors could be used to predict the risk of SIRS.