采用超声监控输尿管软镜钬激光碎石术的有效性及安全性

The solely ultrasonic guided retrograde intra-renal lithotripsy： evaluation of safety and efficacy

目的 探讨采用超声监控输尿管软镜碎石术的安全性及有效性.方法 回顾性分析2015年1月至2016年12月我院行输尿管软镜碎石术治疗的130例结石患者的临床资料,根据结石定位方式不同,分为B超组和X线组,每组65例.B超组男37例,女28例;平均年龄（47.7±21.3）岁;体重指数（22.1 ±4.7）kg/m2;结石大小（1.4±0.2）cm.X线组男22例,女43例;平均年龄（51.3±19.2）岁;体重指数（21.6±3.3） kg/m2;结石大小（1.6±0.1）cm.两组上述指标比较差异均无统计学意义（均P ＞0.05）.两组均在全麻下行输尿管软镜钬激光碎石术.B超组在患侧以超声探头自患者背侧及腹侧监测,可清楚地观察导丝、输尿管软镜送达鞘（ureteral access sheath,UAS）及软镜在集合系统内的操作过程,明确其与结石的位置,确保手术安全.比较两组的手术时间、结石清除率及围手术期并发症等资料.结果 两组手术均顺利完成.B超组和X线组的手术时间分别为（62.4±31.7） min和（80.4±42.1） min,两组比较差异有统计学意义（P＜0.01）.X线组射线暴露时间为（37.5±25.2）s.B超组和X线组的输尿管损伤发生率分别为20.0％（13/65）和18.5％（12/65）,其中输尿管黏膜损伤发生率分别为92.3％（12/13）与83.3％（10/12）,差异无统计学意义（P＞0.05）;浅肌层损伤分别为1例和2例,差异无统计学意义（P＞0.05）.B超组术后出现发热、疼痛、恶心或呕吐、持续性血尿分别为2、3、1、5例,X线组分别为1、2、3、7例,两组比较差异无统计学意义（P＞0.05）.两组均未出现≥ClavienⅣ级并发症.术后1个月B超组清石率为90.8％ （118/130）,X线组清石率为89.2％（116/130）,差异无统计学意义（P＞0.05）.结论 超声监控可引导输尿管软镜钬激光碎石术,该引导方式安全有效,可以有效替代传统的X线引导模式,实现无射线下的输尿管软镜手术.

Objective To evaluate the safety and efficacy of ultrasound guided flexible ureteroscopic lithotripsy.Methods From January 2015 to December 2016,a randomized clinical trial enlisted 130 patients,presenting symptomatic renal stones with 1.3-2.0 cm,in our center.Patients were randomly assigned to ultrasound or radical guided retrograde intrarenal surgery （RIRS） with flexible ureteroscope.There were 37 male and 28 female patients in ultrasound group.Their mean age,BMI index and stone size were （47.7 ± 21.3） years,（22.1 ± 4.7） kg/m2 and （1.4 ± 0.2） cm,respectively.In radical group,there were 22 male and 43 female patients.Their mean age,BMI index and stone size were （51.3 ± 19.2） years,（21.6 ± 3.3） kg/m2 and （1.6 ± 0.1） cm,respectively.There was no significant difference of those items between ultrasound and radical group.In ultrasound group,the transducer was placed at the dorsal and ventral to visualize the real time image of ipsilateral renal collecting system.The safety wire placing,ureteroscope passing through the uretheral access sheath and the lithotripsy detail could be easily monitored.We compared stone size,operative time,stone-free status and complication rates between the ultrasound and radical group.Results All patients accepted the operation successfully.Operative time was significantly shorter in the ultrasound group than that in radical group.[（62.4 ± 31.7） min vs.（80.4 ± 42.1）min,P 〈0.05].The average radical exposure during was （37.5 ± 25.2）seconds in radical group.Ureteral injury was seen in 20.0% （13/65）,18.5% （12/65） cases in ultrasound and radical group,respectively.The mucosal injury rate in each group was 92.3% （12/13） and 83.3% （10/12） （P 〉 0.05）,respectively.Muscle layer injury was recorded in 1 case of in ultrasound group and 2 cases in radical group.Clavien grade Ⅳ or higher grade complications was not observed in both groups.Fever,pain,nausea or vomiting,persistent hematuria in ultrasound group were 2 cases,3 cases,1 cases and 5 cases.In radical group,those complications were in 2 cases,3 cases,7 cases and 1 cases,respectively.There was no significant difference between the two groups （P 〉 0.05）.The ultrasound group showed no significant difference in the stone-free rate [90.8% （118/130）vs.89.2% （116/130）] or the complication rate compared to those in radical group（P 〉 0.05）.Conclusions The retrograde intra-renal lithotripsy guided solely by ultrasound can be carried out in the general population in an effective and safe fashion without ionizing radiation,which has the potential to replace radical guided in flexible ureteroseopy.