输尿管软镜碎石术治疗上尿路结石的疗效和安全性

Clinical efficacy and safety analysis of retrograde intrarenal stone surgery for treatment of upper urinary calculi

目的探讨输尿管软镜碎石术(retrograde intrarenal stone surgery,RIRS)治疗上尿路结石的疗效和安全性。方法回顾性分析2016年4月至2019年1月武汉大学人民医院行RIRS的640例上尿路结石患者的临床资料。男424例,女216例。年龄(46.2±12.8)岁。结石最大径(1.4±0.7)cm。肾下盏结石126例,非肾下盏结石514例。单侧输尿管上段结石196例,单侧输尿管上段结石合并肾结石118例,单侧肾结石236例,双肾结石90例。104例术前留置双J管。马蹄肾8例,孤立肾合并肾功能不全30例,盆腔异位肾合并旋转不良4例,先天性输尿管畸形6例,海绵肾2例。术前血红蛋白(133.2±5.6)g/L,血清肌酐(84.4±12.2)μmol/L。手术均采用全麻,患者取截石位。采用输尿管软镜联合钬激光碎石,软镜顺利进入肾盂后首先观察肾盂及各肾盏并寻及结石。使用200μm光纤碎石,钬激光功率为12~45 W(0.5~1.5 J/10~30 Hz),根据实际情况辅助取石网篮套取结石。术中检查各肾盂、肾盏,确保结石已完全粉末化(结石最大径<0.3 cm),留置双J管和尿管。手术均由同等资历的术者完成。结果所有手术均顺利完成,手术时间(45.6±14.6)min。术后第1天复查血清肌酐(76.0±10.6)μmol/L,与术前比较差异有统计学意义(t=64.76,P<0.05);血红蛋白(126.4±9.6)g/L,与术前比较差异无统计学意义(t=2.02,P=0.064)。术后住院时间(4.8±1.5)d。术后3例(0.9%)发生严重并发症,分别为2例脓毒血症,1例包膜下血肿。术后3个月596例获得随访,其中552例达到结石清除标准,结石清除率(stone-free rate,SFR)为92.6%;余44例未达到结石清除标准者采用体外冲击波碎石、再次输尿管软镜手术或拔除双J管后观察。结石大小(χ^2=29.569,P<0.05)和位置(χ^2=44.949,P<0.05)是SFR的影响因素。多因素回归分析结果显示结石大小不是影响SFR的独立危险因素(P=0.639),结石位置是影响SFR的独立危险因素(P=0.013)。结论RIRS对于上尿路中小结石患者是一种可靠的治疗方式,疗效确切,并发症少,安全性高。但对于大结石及肾下盏结石的治疗还存在一定的局限性。肾下盏结石是影响RIRS疗效的独立危险因素。

Objective To evaluate efficacy and safety of retrograde intrarenal stone surgery for treatment of upper urinary calculi.Methods The clinical data of 640 patients with upper urinary tract calculi treated by retrograde intrarenal stone surgery(RIRS)in Renmin Hospital of Wuhan University from April 2016 to January 2019 were retrospectively analyzed.There were 424 males and 216 females.The awerage age was(46.2±12.8)years old,ranging 18 to 76 years old.The maximum diameter of the stone is(1.4±0.7)cm,ranging 0.6-3.2 cm.There were 126 cases with inferior calculi and 514 cases with non-lurgical calculi.There were 196 cases with unilateral ureteral calculi,118 unilateral ureteral calculi cases with renal calculi,236 cases with unilateral renal stones,and 90 cases with double kidney stones.104 cases were placed with double J tube before operation and 496 cases were not placed before operation.There were 8 cases of horseshoe kidney,30 cases of isolated kidney with renal insufficiency,4 cases of pelvic ectopic kidney with dysplasia,6 cases of congenital ureteral malformation and 2 cases of sponge kidney.Preoperative average hemoglobin was(133.2±5.6)g/L,ranging 126-188 g/L.And average serum creatinine was(84.4±12.2)μmol/L,ranging 74-242μmol/L before operation.All patients were treated with general anesthesia under the lithotomy position.The ureteroscopy combined with holmium laser lithotripsy was performed.The 200μm fiber was used,which the parameters were set as 12-45 W(0.5-1.5 J/10-30 Hz).The stone baskets were used to take stones according to actual conditions.The operation was performed by doctors of the same qualifications.Results All patients underwent successful operation.The mean operation time was(45.6±14.6)min.The average postoperative hospitalization was(4.8±1.5)d.The postoperative serious complication rate was 0.9%,including(2 cases of sepsis and 1 case of subcapsular hematoma.Of the 640 patients,596 were admitted to the hospital for a double J tube and 44 were lost of follow-up.552 patients met the stone removal criteria,44 patients did not meet the stone removal criteria for other treatments,such as extracorporeal shock wave lithotripsy,ureteroscopy or observed regularly.The stone-free rate(SFR)was 92.6%(552/596)after 1-3 months.On the first postoperative day,serum creatinine was(76.0±10.6)(58-156)μmol/L,and postoperative hemoglobin was(126.4±9.6)(120-176)g/L.There was no significant difference in preoperative and postoperative hemoglobin(t=2.02,P=0.064).Preoperative and postoperative creatinine(t=64.76,P<0.05)was statistically significant.Meanwhile,the stone size(χ^2=29.569,P<0.05)and position(χ^2=44.949,P<0.05)versus SFR the impact was statistically significant.Multivariate regression analysis showed that stone size was not an independent risk factor for stone clearance(P=0.639).The stone position was an independent risk factor for stone clearance(P=0.013).Conclusions RIRS is a reliable treatment for small and medium calculi patients of the upper urinary tract.The curative effect of stone removal is clear,the complications are few,the safety is high.However,there are certain limitations to the efficacy in the treatment of large stones and lower calculi.Lower calculi is the independent risk factor for the treatment of efficacy.