输尿管软镜碎石术后肾周血肿形成的危险因素

Risk factors for perirenal hematoma formation after ureteroscopy

目的探讨输尿管软镜碎石术后肾周血肿形成的危险因素。方法收集郑州大学第一附属医院泌尿外科2015年9月至2019年5月实施输尿管软镜碎石术的患者1856例,根据术后是否形成肾周血肿,分为两组,其中发生肾周血肿患者19例,未发生肾周血肿1837例。收集两组患者临床相关资料进行分析,主要包括患者性别、年龄、体重指数(BMI)、术前是否合并尿路感染(以多次尿培养结果阳性为尿路感染诊断标准)、术侧、术侧术前积水程度、术侧结石大小、是否为多发肾结石、手术时间。对各因素首先采取单因素分析,然后将筛选出的有意义的变量进行多因素Logistic回归分析。结果1856例患者行输尿管软镜碎石,术后发生肾周血肿者19例,其中8例自行吸收缓解,9例行穿刺引流,2例再次行血肿清除术。单因素分析表明,合并尿路感染(χ^2=23.922,P<0.01)、术侧肾中重度积水(χ^2=4.865、0.027)、术侧结石大(t=5.471,P<0.01)及手术时间长(t=3.092,P<0.01)与术后肾周血肿的形成相关。多因素分析表明,合并尿路感染[比值比(OR)=4.705,95%CI:1.725~12.833,P<0.01]、术侧肾中重度积水(OR=4.951,95%CI:1.781~13.767,P<0.01)、术侧结石较大(OR=3.931,95%CI:1.504~10.268,P<0.01)及手术时间长(OR=1.111,95%CI:1.053~1.173,P<0.01)为输尿管软镜术后肾周血肿形成的独立危险因素。结论为预防输尿管软镜术后血肿的形成,术前应注意控制尿路感染,对于术前中重度肾积水患者可考虑提前留置输尿管支架管或者经皮肾穿刺造瘘以缓解肾盂内压力;术中不能一味地追求清石率,应特别注意肾盂内灌注压力,及时终止手术,必要时可分期碎石;术后积极抗感染,保证引流通畅,加强监护。

Objective To explore the risk factors of perirenal hematoma formation after ureteroscopy.Methods A retrospective analysis was performed on 1856 patients with ureteroscopic lithotripsy in our hospital,Patients,including 19 patients with perirenal hematoma and 1837 patients with no perirenal hematoma,were divided into two groups.The clinical data of the two groups were collected for statistical analysis,including the patient’s gender,age,body mass index(BMI),preoperative urinary tract infection(multiple urine culture results were positive for urinary tract infection diagnostic criteria),surgery side,the degree of water accumulation before surgery,the size of the stones on the side of the operation,multiple kidney stones,and the operation time.A single factor analysis was first performed on each factor,and then the selected variables were subjected to multivariate Logistic regression analysis.Results 1856 patients underwent lithotripsy with ureteroscopy,and 19 patients had perirenal hematoma after surgery.Among them,8 patients relieved themselves,9 patients were punctured,and 2 patients had hematoma removal.Univariate analysis showed that postoperative perirenal hematoma formation was associated with urinary tract infection(χ^2=23.922,P<0.01),severe renal hydronephrosis(χ^2=4.865,P<0.01),large surgical stones(t=5.471,P<0.01),and long operative time(t=3.092,P<0.01).Multivariate analysis showed that urinary tract infection[odds ratio(OR)=4.705,95%confidence interval(CI):1.725-12.833,P<0.01],severe renal hydronephrosis(OR=4.951,95%CI:1.781-13.767,P<0.01),larger calculus(OR=3.931,95%CI:1.504-10.268,P<0.01)and long operation time(OR=1.111,95%CI:1.053-1.173,P<0.01)were independent risk factors of perirenal hematoma after ureteroscopy.Conclusion In order to prevent the formation of hematoma after ureteroscopy,the urinary tract infection should be controlled before operation.For patients with moderate to severe hydronephrosis,preoperative indwelling ureteral stent or percutaneous nephrolithotomy should be considered to relieve the pressure in the renal pelvis;the surgeons can not blindly pursue the rate of clear stone intraoperatively,and should pay special attention to the perfusion pressure in the renal pelvis,timely termination of surgery,if necessary,staging the gravel;active anti-infection is given after surgery to ensure smooth circulation and strengthen supervision.