输尿管镜、钬激光联合筋膜扩张治疗复发性尿道狭窄的临床研究

Clinical study on ureteroscope, holmium laser combined with fascial dilator in the treatment of recurrent urethral stricture

目的探讨输尿管镜下钬激光尿道内切开术联合筋膜扩张器尿道扩张术治疗复发性尿道狭窄的临床效果。方法回顾性分析大同市第三人民医院2016年10月至2018年9月收治的复发性尿道狭窄患者62例的临床资料,依据治疗方法分为两组,对照组(n=28)行输尿管下钬激光尿道内切开术,联合组(n=34)行输尿管镜下钬激光尿道内切开术联合筋膜扩张器尿道扩张术。比较两组患者术前、术后6个月尿动力学指标[最大尿流率(Qmax)、残余尿量(RUV)、Abrams-Griffiths(AG)值]、下尿路症状[国际前列腺症状评分(IPSS)]、勃起功能[国际勃起功能问卷-5(IIEF-5)评分]、性生活质量[性生活质量问卷(SLQQ)评分]的变化,分析两组患者围术期相关指标及术后6个月内并发症发生率、尿道狭窄复发率。结果术后6个月,对照组Qmax、IIEF-5评分、SLQQ评分分别为(19.18±4.67)mL/s、(15.23±3.94)分、(55.69±16.97)分,联合组分别为(22.41±4.82)mL/s、(17.54±3.72)分、(64.31±15.80)分,两组均较术前显著提高,联合组均明显高于对照组(t=2.406、2.135、2.208,均P<0.05);对照组RUV、AG值、IPSS评分分别为(11.75±3.24)mL、(36.09±7.86)、(13.80±4.18)分,联合组分别为(9.46±2.89)mL、(30.58±7.27)、(11.34±3.65)分,两组均较术前显著下降,联合组均明显低于对照组(t=2.637、2.573、2.216,均P<0.05)。联合组手术时间、术中出血量、肉眼血尿持续时间、住院时间、导管留置时间分别为(35.10±10.26)min、(12.15±2.06)mL、(18.61±5.19)h、(4.72±1.25)d、(14.46±3.20)d,均短于、少于对照组的(44.12±11.95)min、(13.64±2.80)mL、(22.62±5.76)h、(5.81±1.43)d、(27.93±4.48)d(t=2.863、2.143、2.586、2.869、3.151,均P<0.05)。联合组局部血肿[2.94%(1/34)]、直肠损伤[0.00%(0/34)]发生率及尿道狭窄复发率[5.88%(2/34)]均明显低于对照组的25.00%(7/28)、21.43%(6/28)、28.57%(8/28)(χ^2=4.830、5.801、4.286,均P<0.05)。结论输尿管镜下钬激光尿道内切开术联合筋膜扩张器尿道扩张术能有效改善复发性尿道狭窄患者下尿路症状,术后并发症少,复发率低,并可改善患者的性生活质量。

Objective To explore the clinical effects of ureteroscopic holmium laser urethrotomy combined with fascial dilator urethral dilatation in the treatment of recurrent urethral stricture.Methods The clinical data of 62 patients with recurrent urethral stricture in the Third People′s Hospital of Datong from October 2016 to September 2018 were retrospectively analyzed.The patients were divided into two groups according to the treatment method.The control group(n=28)underwent ureteroscopic holmium laser urethrotomy,and the combined group(n=34)underwent ureteroscopic holmium laser urethrotomy combined with fascial dilator urethral dilatation.The urodynamic parameters[maximum urinary flow rate(Qmax),residual urine volume(RUV),Abrams-Griffiths(AG)value],lower urinary tract symptoms[International Prostate Symptom Score(IPSS)],erectile function[International Index of Erectile Function-5(IIEF-5)]and sexual life quality[Sexual Life Quality Questionnaire(SLQQ)]were compared between the two groups before surgery and at 6 months after surgery.The perioperative basic indicators and incidence rate of complications and recurrence rate of urethral stricture within 6 months after surgery were analyzed in the two groups.Results At 6 months after surgery,the Qmax,scores of IIEF-5 and SLQQ in the control group were(19.18±4.67)mL/s,(15.23±3.94)points and(55.69±16.97)points,respectively,which in the combined group were(22.41±4.82)mL/s,(17.54±3.72)points and(64.31±15.80)points,respectively,and the indicators in the two groups were significantly increased compared with before surgery,and the indicators in the combined group were significantly higher than those in the control group(t=2.406,2.135,2.208,all P<0.05).The RUV,AG value and IPSS score in the control group were(11.75±3.24)mL,(36.09±7.86)and(13.80±4.18)points,respectively,which in the combined group were(9.46±2.89)mL,(30.58±7.27)and(11.34±3.65)points,respectively,and the indicators in the two groups were significantly decreased compared with before surgery,the indicators in combined group were significantly lower than those in control group(t=2.637,2.573,2.216,all P<0.05).The operative time,intraoperative blood loss,gross hematuria duration,hospital stay and catheter indwelling time in the combined group were(35.10±10.26)min,(12.15±2.06)mL,(18.61±5.19)h,(4.72±1.25)d and(14.46±3.20)d,respectively,which were significantly shorter or lower than those in the control group[(44.12±11.95)min,(13.64±2.80)mL,(22.62±5.76)h,(5.81±1.43)d and(27.93±4.48)d](t=2.863,2.143,2.586,2.869,3.151,all P<0.05).Within 6 months after surgery,the incidences of local hematoma,rectal injury and recurrence rate of urethral stricture in the combined group were 2.94%(1/34),0.00%(0/34)and 5.88%(2/34),respectively,which were significantly lower than those in the control group[25.00%(7/28),21.43%(6/28)and 28.57%(8/28)](χ^2=4.830,5.801,4.286,all P<0.05).Conclusion Ureteroscopic holmium laser urethrotomy combined with fascial dilator urethral dilatation can effectively improve the lower urinary tract symptoms in patients with recurrent urethral stricture.And it has few complications and low recurrence rate,and can improve sexual life quality of patients.