经尿道输尿管软镜碎石术前留置双J管预扩张输尿管时间的临床分析

Clinical analysis of the time of preoperative double J stent indwelling in transurethral flexible ureteroscopic lithotripsy

目的:分析不同的术前留置双J管预扩张输尿管时间,行经尿道输尿管软镜碎石术(flexible ureteroscopic lithotripsy,FURL)的有效性和安全性。方法:收集2018年1月—2021年4月北京积水潭医院泌尿外科CT确诊为肾或输尿管上段结石,结石最大直径≤2 cm,行FURL的患者315例。根据术前双J管留置时间分为A组(未留置组,40例),既往有排石史,或留置双J管史且入院前1个月已拔除;B组(58例):术前留置5 d;C组(120例):术前留置7 d;D组(50例):术前留置14 d;E组(47例):术前留置28 d及以上。收集有效和安全性相关数据并分析。结果:一期带导引鞘软镜置入成功率比较,A组:97.50%,B组:94.83%,C组:99.17%,D组:100.00%,E组:100.00%,各组间差异均无统计学意义(P>0.05)。手术时间比较,A组:(91.79±41.13)min,B组:(81.36±28.18)min,C组:(80.31±27.63)min,D组:(83.30±31.70)min,E组:(78.51±26.64)min,各组间差异均无统计学意义(P>0.05)。出血量比较,A组:(4.15±3.38)mL,B组:(5.64±4.86)mL,C组:(4.60±3.57)mL,D组:(7.50±10.50)mL,E组:(5.81±5.27)mL,其中C组较D组出血量少2.9 mL(P<0.05),其余A与C,B与C、C与E组间比较差异均无统计学意义(P>0.05)。术后1个月清石率比较,A组:95.00%,B组:93.10%,C组:98.33%,D组:98.00%,E组:95.74%,各组间差异均无统计学意义(P>0.05)。术后并发症发生率ClavienⅠ级比较,A组:62.50%,B组:67.24%,C组:60.83%,D组:56.00%,E组:61.70%,各组间差异均无统计学意义(P>0.05);ClavienⅡ级比较,A组:5.00%,B组:3.45%,C组:4.17%,D组:4.00%,E组:17.02%,E组较C组发生率高(P<0.05),其余A与C,B与C,C与D组间比较差异均无统计学意义(P>0.05)。术后住院天数比较,A组:(3.13±1.99)d,B组:(2.20±1.37)d,C组:(2.80±1.82)d,D组:(2.88±1.94)d,E组:(3.57±2.22)d,各组间比较差异均无统计学意义(P>0.05)。结论:经尿道输尿管软镜碎石术治疗肾结石和输尿管上段结石,术前留置双J管预扩张输尿管的时间,留置7 d可使得手术有效和安全,输尿管狭窄患者需延长至14 d,有经验的医师和医院可缩短至5 d,有确切上尿路自然排石史和留置双J管病史的患者术前可不留置,因上尿路感染和肾后性肾功能不全而留置双J管的患者可留置28 d以上,需警惕术后尿源性感染。

Objective:To evaluate the efficacy and safety of different durations of preoperative double J stent indwelling in transurethral flexible ureteroscopic lithotripsy(FURL).Methods:From January 2018 to April 2021,315 cases were diagnosed as intrarenal and proximal ureteral stones by CT and treated by transurethral FURL in Beijing Jishuitan Hospital.The stone diameters were 2 cm or less.According to the indwelling duration,40 cases in group A:no indwelling;58 cases in group B:5 days;120 cases in Group C:7 days;50 cases in Group D:14 days;47 cases in group E:28 days or more.Data were collected and analyzed.Results:First-time success rates of indwelling flexible ureteroscopic channel sheath was A:97.50%,B:94.83%,C:99.17%,D:100.00%,E:100.00%,P>0.05.Operation time A:(91.79±41.13)min,B:(81.36±28.18)min,C:(80.31±27.63)min,D:(83.30±31.70)min,E:(78.51±26.64)min,P>0.05.The blood loss A:(4.15±3.38)mL,B:(5.64±4.86)mL,C:(4.60±3.57)mL,D:(7.50±10.50)mL,E:(5.81±5.27)mL,only group C was 2.9 mL less than group D,P<0.05,others P>0.05.One month after surgery,the stone removal rate A:95.00%,B:93.10%,C:98.33%,D:98.00%,E:95.74%and P>0.05.The incidence of postoperative complications of ClavienⅠ,A:62.50%,B:67.24%,C:60.83%,D:56.00%,E:61.70%,P>0.05.ClavienⅡ,A:5.00%,B:3.45%,C:4.17%,D:4.00%,E:17.02%,between groups E and C,P<0.05,others P>0.05.Postoperative hospitalization time A:(3.13±1.99)day,B:(2.20±1.37)day,C:(2.80±1.82)day,D:(2.88±1.94)day,E:(3.57±2.22)day,P>0.05.Conclusion:Double J stent indwelling duration of 7 days before transurethral flexible ureteroscopic lithotripsy on the treatment of intrarenal and proximal ureteral stones can make surgery effective and safe.Patients with ureteral stricture should be prolonged to 14 days.However,experienced doctors and hospitals can reduce to 5 days.Patients with an exact history of upper urinary tract stone discharged or indwelling double J stent can be free of indwelling.Patients with the upper urinary tract infection or postrenal insufficiency can be indwelt double J stent for more than 28 days,but postoperative urinary infection should be minded.