输尿管硬镜与软镜治疗10～20 mm输尿管上段结石的比较

Comparison of Rigid and Flexible Ureteroscopy for the Treatment of Upper Ureteral Stones Sized 10-20 mm

目的比较输尿管硬镜(rigid ureteroscopy,R-URS)和输尿管软镜(flexible ureteroscopy,F-URS)治疗输尿管上段结石的疗效和安全性。方法回顾性比较我院2014年12月~2016年12月输尿管上段结石(直径10~20 mm)53例,其中R-URS治疗25例(R-URS组),F-URS治疗28例(R-URS组),比较2组手术时间、一次碎石成功率、结石清除率、手术并发症、术后住院时间和住院费用等。结果 53例均能顺利入镜,F-URS组一次碎石成功率96.4%(27/28),显著高于R-URS组72.0%(18/25)(χ~2=4.391,P=0.036);术后2周结石清除率92.9%(26/28),显著高于R-URS组64.0%(16/25)(χ2=6.687,P=0.010);残余结石行体外冲击波碎石(extracorporeal shock wave lithotripsy,ESWL)后4周结石清除率分别为88.0%(22/25)、96.4%(27/28),无显著性差异(χ2=0.408,P=0.523);随访半年结石清除率分别为92.0%(23/25)、96.4%(27/28),无显著性差异(χ2=0.010,P=0.919)。2组均无严重手术并发症,R-URS组输尿管黏膜挫伤发生率36.0%(9/25),显著高于F-URS组7.1%(2/28)(χ2=6.687,P=0.010);R-URS组血红蛋白丢失量中位数9.0 g/L(-1.0~23.0 g/L),明显高于F-URS组0.5 g/L(-14.0~15.0 g/L)(Z=-3.685,P=0.000),但均无一例输血治疗。F-URS组住院费用(25 579.2±4324.3)元,显著高于R-URS组(14 309.9±2932.6)元(t=-10.967,P=0.000)。结论对于10~20 mm输尿管上段结石的治疗,F-URS和R-URS均安全可行,F-URS结石清除率高,并发症少,可作为首选治疗方式,但费用较高;R-URS费用相对较低,术后往往需要结合ESWL治疗才能有较好的疗效。

Objective To compare the effect and feasibility between rigid ureteroscopy（ R-URS） and flexible ureteroscopy（ F-URS） in the management of upper ureteral stones. Methods A total of 53 patients withupper ureteral stones（ sized 10-20 mm） in our hospital from December 2014 to December 2016 were retrospectively investigated. Of them,25 cases received R-URS and28 underwent F-URS,respectively. The two groups were compared and analyzed statistically in terms of operation time,success rate of stone fragmentation,stone-free rate,surgical-related complications,postoperative hospital stay and total hospital cost. Results Successful access was achieved in all the patients. The success rate of stone fragmentation was 96. 4%（ 27/28） in the F-URS group and 72. 0%（ 18/25） in the R-URS group,with significant difference（ χ^2= 4. 391,P = 0. 036）. In the F-URS group,the initial stonefree rate in 2 weeks achieved 92. 9%（ 26/28）,which was significantly higher than 64. 0%（ 16/25） in the R-URS group（ χ^2= 6. 687,P = 0. 010）. However,with the aid of ESWL for residual stone fragments,there was no statistically significant difference in terms of overall stone free rate in 4 weeks [88. 0%（ 22/25） vs. 96. 4%（ 27/28）,χ^2= 0. 408,P = 0. 523] and 6 months [92. 0%（ 23/25）vs. 96. 4%（ 27/28）,χ^2= 0. 010,P = 0. 919] between the two groups,respectively. No major complications were encountered.Ureteral mucosal injury was observed in 36. 0%（ 9/25） patients in the R-URS group and 7. 1%（ 2/28） patients in the F-URS group,respectively,with significant difference（ χ^2= 6. 687,P = 0. 010）. As compared to the F-URS group,the R-URS group was associated with much more loss of hemoglobin [median： 9. 0 g/L（ range,-1. 0-23. 0 g/L） vs. 0. 5 g/L（ range,-14. 0-15. 0 g/L）,Z =-3. 685,P = 0. 000）. Nevertheless,no patients required blood transfusion. In addition,significant difference was found between the R-URS and F-URS group in regard to hospitalization cost [（ 14 309. 9 ± 2932. 6） yuan vs.（ 25 579. 2 ± 4324. 3） yuan,t =-10. 967,P = 0. 000]. Conclusions Both R-URS and F-URS are safe and feasible for patients with upper ureteral stones in size of10-20 mm. Regardless of high cost,F-URS can be the first choice with higher stone free rate and less complications. R-URS achieves low stone free rate for upper ureteral stones unless it is combined with ESWL.