输尿管镜钬激光、经皮肾镜、后腹腔镜下输尿管切开三种取石术治疗复杂性输尿管上段结石的对照研究

Comparative study of ureteroscopic holmium laser lithotripsy, percutaneous nephrolithotomy and retroperitoneal laparoscopic ureterolithotomy for the treatment of complex upper ureteral calculi

目的 比较输尿管镜钬激光、经皮肾镜、后腹腔镜下输尿管切开三种取石术治疗复杂性输尿管上段结石的效果和安全性.方法 选取2014年1月至2017年1月在本院接受治疗的195例复杂性输尿管上段结石患者为研究对象.随机分为三组,每组65例,分别行输尿管镜钬激光碎石取石术（ureteroscopic holmium laser lithotripsy,USL）,经皮肾镜碎石取石术（percutaneous nephrolithotomy,PCNL）,后腹腔镜下输尿管切开取石术（retroperitoneal laparoscopic ureterolithotomy,RLU）.观察三组患者手术时间、术中出血量、住院时间、手术成功率、术后并发症发生情况和结石清除率.结果 RLU组手术时间长于USL组和PCNL组（P＜0.05）,USL组长于PCNL组（P＜0.05）.PCNL组术中出血量和住院时间大于USL组和RLU组（P＞0.05）,而USL组和RLU组比较差异无统计学意义（P＞0.05）.PCNL组、RLU组和USL组手术成功率分别为100.0％、100.0％和72.3％（47/65）,结石清除率分别为95.4％（62/65）、100.0％和83.0％（39/47）,PCNL组和RLU组手术成功率和结石清除率均优于USL组（P＜0.05）,而PCNL组和RLU组比较差异无统计学意义（P＞0.05）.PCNL组、RLU组和USL组术后并发症分别为20.0％ （13/65）、1.5％ （1/65）和10.6％ （5/47）,PCNL组术后并发症发生率高于RLU组和USL组（P＜0.05）,USL组又高于RLU组（P＜0.05）.结论 PCNL组手术时间短,手术成功率和结石清除率高,但术中出血量和术后并发症多;URL手术风险较低,但是手术成功率和结石清除率低;RLU手术时间短,术中出血少,术后并发症少,而且手术成功率和结石清除率高.RLU是治疗复杂性输尿管上段结石的理想术式.

Objective To compare the clinical effect and safety of ureteroscopic holmium laser lithotripsy （USL）,percutaneous nephrolithotomy （PCNL） and retroperitoneal laparoscopic ureterolithotomy （RLU） for the treatment of complex upper ureteral calculi.Methods A total of 195 patients with complex upper ureteral calculi treated in our hospital from January 2014 to January 2017 were selected as research subjects.All of the patients were randomly divided into three groups with 65 patients in each group.Patients in the three groups were treated with USL,PCNL and RLU,respectively.The operation time,intra-operative blood loss,hospitalization time,operation success rate,postoperative complications and stone clearance rate of the three groups were compared.Results The operation time was significantly longer in RLU group than USL and PCNL groups （P ＜ 0.05）,and the USL group was longer than PCNL group （P ＜ 0.05）.The intra-operative bleeding volume was statistically larger in PCNL group than USL and RLU groups （P ＜ 0.05）,but no significance was found in the two later groups （P ＞ 0.05）.The hospitalization time was statistically longer in PCNL group than USL and RLU groups （P ＜ 0.05）,with no difference between the later two groups （P ＞ 0.05）.The successful rate of the operations was 100.0％,100.0％ and 72.3％ （47/65） in PCNL,RLU and USL groups,and the stone clearance was 95.4％ （62/65）,100.0％ and 83.0％ （39/47）,respectively.The successful rate and the stone clearance rate of PCNL and RLU groups were better than USL group （P ＜ 0.05）,but there was no difference between the former two groups （P ＞ 0.05）.The incident of postoperative complications rate was 20.0％ （13/65）,1.5％ （1/65） and 10.6％ （5/47） in PCNL,RLU and USL groups,with that of PCNL group the highest,while that of RLU group the lowest （P ＜ 0.05）.Conclusions PCNL has advantages of short operation time,high stone clearance,but the intra-operative bleeding volume and postoperative complications are high.USL has less risk,but with low stone clearance.RLU is a safe and effective procedure with short operation time,less blood loss,fewer complications and high stone clearance rate.RLU is an ideal approach for the treatment of complex upper ureteral calculi.