超声引导下输尿管软镜与单纯输尿管软镜治疗内生型肾囊肿的疗效对比

The efficacy and safety of single flexible ureteroscope vs.flexible ureteroscope combined with intraoperative ultrasonography guided in the endogenous renal cyst incision and drainage

目的探讨超声引导下输尿管软镜与单纯输尿管软镜治疗内生型肾囊肿的疗效及安全性。方法回顾性分析2015年1月至2017年12月收治的64例内生型肾囊肿患者的病例资料,男38例,女26例。患者术前行增强CT尿路造影及超声检查。肾囊肿Bosniak分级Ⅰ级59例,Ⅱ级5例。32例行单纯输尿管软镜手术(A组),男20例,女12例;平均年龄(54.2±6.6)岁;单侧囊肿19例,双侧囊肿13例;单发囊肿24例,多发囊肿8例;囊肿最大径为(5.4±1.3)cm;合并肾结石8例,肾积水7例;既往行腹腔镜肾囊肿减压术1例,经皮肾囊肿穿刺引流术1例。32例行超声引导下输尿管软镜手术(B组),平均年龄(52.3±9.3)岁;单侧囊肿21例,双侧囊肿11例;单发囊肿25例,多发囊肿7例;囊肿最大径为(5.3±1.2)cm;合并肾结石9例,合并肾积水8例;既往行腹腔镜肾囊肿减压术2例,经皮肾囊肿穿刺引流术1例。64例均行输尿管软镜下钬激光内切开引流术,术前均预置双J管2周。手术采用电子输尿管软镜,200μm钬激光光纤,激光能量0.8J、频率20Hz。B组术中采用超声实时监测软镜镜头在肾集合系统中的方向及与囊肿的最近距离。钬激光切开囊壁时超声影像显示囊腔内呈明显"炊烟状",且软镜进入囊腔内定义为切开成功。术后复查CT测量囊肿最大径缩小≥80%或残留囊肿最大径<1cm为治愈,缩小50%~79%为好转,缩小30%~49%为一般,缩小<30%或囊肿未切开为无效。总有效率=(治愈+好转)病例数/总病例数×100%。比较两组的手术时间、手术效果、手术安全性及并发症。结果A组和B组的手术时间分别为(33.4±6.7)min和(35.1±8.6)min,差异无统计学意义(P>0.05)。A组和B组的囊肿切开例数分别为24例和30例,差异有统计学意义(P<0.05)。64例术后随访8~30个月,平均(14.6±4.5)个月,A组和B组的总有效率分别为62.5%(20/32)和87.5%(28/32),差异有统计学意义(P<0.05)。A组发生并发症8例(25%),分别为出血3例、泌尿系感染3例、肾周积液2例、肾功能损害1例,B组仅1例发生出血并发症,两组比较差异有统计学意义(P<0.05)。结论在治疗内生型肾囊肿时,与单纯输尿管软镜手术比较,术中联合超声引导可提高手术成功率,手术更安全,术后疗效好。

Objective To evaluate the efficacy and safety of single flexible ureteroscope vs.flexible ureteroscope combined with intraoperative ultrasonography guided in the endogenous renal cyst incision and drainage.Methods Retrospective analysis of case data of 64 patients with endogenous renal cysts admitted from January 2015 to December 2017.All the patients undrwent contrast-enhanced CT,urinary tract imaging,ultrasound B to confirm bosniak classificationⅠandⅡrenal cyst.The patients(38 males,26 females)were divided into single flexible ureteroscope group[group A,32 cases of patients,average age(54.2±6.6)years,unilateral or bilateral cystic patients:19 cases/13cases,simple cyst of kidney or polycystic kidney:24 cases/8 cases,average maximum diameter of the renal cyst(5.4±1.3)cm,combined with renal calculus:8 cases,combined with hydronephrosis:7 cases,1 case who had the history of laparoscopic renal cyst decapitation,1 case who had the history of percutaneous renal cyst puncture]and flexible ureteroscope group combined with intraoperative ultrasonography guided[group B,32 cases of patients,average age(52.3±9.3)years,unilateral or bilateral cystic patients:21 cases/11 cases,simple cyst of kidney or polycystic kidney:25 cases/7 cases.Average maximum diameter of the renal cyst(5.3±1.2)cm,combined with renal calculus:9 cases,combined with hydronephrosis:8 cases,2 case who had the history of laparoscopic renal cyst decapitation,1 case who had the history of percutaneous renal cyst puncture].The double J stent was placed two weeks before the surgery into the body of patients.During the operation,the surgical procedure were used by the electronic flexible ureteroscope and holmium laser(0.8 J,20 Hz),combined with ultrasound B in the monitoring,to find the suitable incision position.It would be defined as the successful result if we could put the head of flexible ureteroscope into the inside of renal cyst and see the image of mist in the screen of ultrasound B.According to the standard,the result of operation wound be defined compared to before operation(success:shrink more than 80%or maximum diameter was smaller than 1 cm;improvement:shrink about 50%-79%;ordinary result:shrink about 30%-49%;failure:shrink smaller than 30%).Effective rate=(success cases+improvement cases)/total cases.We compared the differences of two groups in the time,efficacy,safety and complication of surgery.Results Compared the results of single flexible ureteroscope groups vs flexible ureteroscope group combined with intraoperative ultrasonography guided in the success cases of surgery,after 8-30 months following-up,total operative complication rate was[8 cases(25%)vs.1 case(3.1%)],success rate of operation in 6 month later[(20 cases(62.5%)vs.28 cases(87.5%)].Flexible ureteroscope group combined with intraoperative ultrasonography guided had advantages statistically(P<0.05).However,there was no statistical difference for the two groups in the time of operation[(33.4±6.7)min vs.(35.1±8.6)min],single operative complication(intraoperative wounding bleeding:3 cases vs.1 case,postoperative urinary infection:3 cases vs.0 case,perinephric space effusion:2 cases vs.0 case,renal function impairment:1 case vs.0 case)(P>0.05).Conclusions Flexible ureteroscope combined with intraoperative ultrasonography guided can help the urologist can improve the success rate of surgery and reduce the chance of surgical injury intraoperatively.