小于2cm单发性肾结石3种手术方法比较

Three treatment methods for single renal calculi less than 2cm

目的探讨超微通道经皮肾镜、输尿管软镜与4.8F可视穿刺经皮肾镜治疗小于2 cm单发性肾结石的疗效及安全性。方法选取本院2018年1月至2019年12月收治的123例小于2 cm单发性肾结石患者资料并进行回顾性分析,结石大小为1~2 cm,CT值241~1964 Hu。依据治疗方法不同分为3组:超微通道经皮肾镜组40例,其中男24例,女16例,年龄(53.7±9.8)岁,结石CT值(1099.8±297.81)Hu,行超微通道经皮肾镜碎石术,通道大小为F12~14,钬激光将结石碎片化,负压吸引将结石碎片从负压吸引鞘吸出,选择性留置双J管,不留置肾造瘘管;输尿管软镜组42例,其中男24例,女18例,年龄(53.3±11.7)岁,结石CT值(999.2±388.4)Hu,行输尿管软镜碎石术,钬激光将结石粉末化,留置双J管;4.8F可视肾镜组41例,其中男20例,女21例,年龄(55.8±11.3)岁,结石CT值(1001.7±345.3)Hu,行4.8F可视穿刺经皮肾镜碎石术,用4.8F的针直视下穿刺后直接碎石,以钬激光将结石粉末化并冲至肾盂,不留置双J管及肾造瘘管。比较3组患者的手术时间、术中出血量、术后住院时间、近期和远期结石清除率、术后24 h内体温、白细胞计数(WBC)、降钙素原(PCT)等炎性指标的发生率。结果手术时间输尿管软镜组[(69.6±28.5)min]显著长于超微通道经皮肾镜组[(36.9±13.6)min]与4.8F可视肾镜组[(39.0±19.7)min],差异均有统计学意义(均P<0.05);术后住院时间输尿管软镜组[(4.1±1.3)d]显著长于超微通道经皮肾镜组[(3.6±0.8)d]与4.8F可视肾镜组[(3.2±1.0)d],差异均有统计学意义(均P<0.05);术后血红蛋白(Hb)下降值超微通道经皮肾镜组最大,输尿管软镜组与可视肾镜组差异无统计学意义;术后第2天结石清除率超微通道经皮肾镜组(95.0%,38/40)最高,显著高于输尿管软镜组(59.5%,25/42)与4.8F可视肾镜组(70.7%,29/41),差异均有统计学意义(均P<0.05);术后1个月结石清除率超微通道经皮肾镜组(95.0%,38/40)和可视肾镜组(90.2%,37/41)最高,组间差异无统计学意义,输尿管软镜组(73.8%,31/42)最低;术后高热、WBC与PCT等炎性指标异常的发生率均以超微通道经皮肾镜组最高。结论3种手术方法均是治疗小于2 cm单发性肾结石安全、有效的方法。

Objective To evaluate the efficacies and safety of super-mini percutaneous nephrolithotomy,retrograde intrarenal surgery,and 4.8F visual percutaneous nephrolithotomy in the treatment of 1-2 cm single renal calculus.Methods The data of 123 patients with 1-2 cm single renal calculus treated at our hospital from January,2018 to December,2019 were retrospectively analyzed.Their calculi's CT value was 241-1964 Hu.The patients were divided into a super-mini percutaneous nephrolithotomy group(n=40),a retrograde intrarenal surgery group(n=42),and a 4.8F visual percutaneous nephrolithotomy(n=41).The super-mini percutaneous nephrolithotomy group had 24 males and 16 females and were(53.7±9.8)years old;their calculus'CT value of was(1099.8±297.81)Hu;they were treated by super-mini percutaneous nephrolithotomy through F12-14 channel;their calculus were cracked by holmium laser,and the fragments were sucked out through irrigation-suction sheath with negative pressure aspirator;double J stents were selectively indwelled;and all the patients had no renal fistula.The retrograde intrarenal surgery group had 24 males and 18 females and were(53.3±11.7)years old;their calculus'CT value was(999.2±388.4)Hu;they were treated by retrograde intrarenal surgery;their calculus were pulverizef by holmium laser;and double J stents were placed in all the patients.The 4.8F visual percutaneous nephrolithotomy group had 20 males and 21 females and were(55.8±11.3)years old;their calculus'CT value was(1001.7±345.3)Hu;they were treated by 4.8F visual percutaneous nephrolithotomy;after the 4.8F visual puncture needle was used for the puncture under full vision,the calculus were pulverized with holmium laser and flushed to their renal pelvises;and all the patients had no double J stents and no renal fistulas.The operative times,intraoperative bleeding volumes,postoperative hospital stay,short-and long-term stone-free rates,and inflammatory indicators,such as body temperature 24 h after the surgery,white blood cell count(WBC),and procalcitonin(PCT),were compared between the three groups.Results The operation time was longer in the retrograde intrarenal surgery group[(69.6±28.5)min]than in the super-mini percutaneous nephrolithotomy group[(36.9±13.6)min]and in the 4.8F visual percutaneous nephrolithotomy group[(39.0±19.7)min](both P<0.05).The postoperative hospital stay was longer in the retrograde intrarenal surgery group[(4.1±1.3)d]than in the super-mini percutaneous nephrolithotomy group[(3.6±0.8)d]and in the 4.8F visual percutaneous nephrolithotomy group[(3.2±1.0)d](both P<0.05).The postoperative Hb decreased the most in the super-mini percutaneous nephrolithotomy group;and there was no statistical difference in postoperative Hb between the retrograde intrarenal surgery group and the 4.8F visual percutaneous nephrolithotomy group.The stone-free rate on the second day after the surgery was higher in the super-mini percutaneous nephrolithotomy group(95.0%,38/40)than in the retrograde intrarenal surgery group(59.5%,25/42)and in the 4.8F visual percutaneous nephrolithotomy group(70.7%,29/41).The stone-free rate one month after the surgery was 95.0%(38/40)in the super-mini percutaneous nephrolithotomy group,90.2%(37/41)in the 4.8F visual percutaneous nephrolithotomy group,and 73.8%(31/42)in the retrograde intrarenal surgery group,with no statistical difference between the super-mini percutaneous nephrolithotomy group and the 4.8F visual percutaneous nephrolithotomy group.The incidences of abnormal postoperative fever,WBC,and PCT were the highest in the super-mini percutaneous nephrolithotomy group.Conclusion All the three surgical methods are safe and effective in the treatment of single renal calculi less than 2 cm.