超声联合内镜与联合X线引导经皮肾镜取石术治疗复杂性肾结石有效性的对比研究

Comparative study of ultrasound combined with endoscopy and ultrasound combined with X-ray guided PCNL in the treatment of complex renal calculi

目的比较超声联合内镜与联合X线引导经皮肾镜取石术(PCNL)治疗复杂性肾结石的有效性。方法回顾性分析2019年3月至2022年2月安徽医科大学第二附属医院收治的超声联合内镜和超声联合X线引导行PCNL治疗的119例复杂性肾结石患者的临床资料。根据引导方式不同分为超声联合内镜引导组(59例)和超声联合X线引导组(60例)。两组患者年龄[(53.9±14.2)岁与(55.6±13.5)岁]、性别[男/女:38/21例与30/30例]、体质量指数[(25.0±3.7)kg/m^(2)与(24.8±3.8)kg/m^(2)]、结石位置[左/右:34/25例与31/29例]、结石最大径[(31.9±8.3)mm与(33.9±13.5)mm]、结石最大横截面积[(601.5±242.5)mm^(2)与(632.6±278.9)mm^(2)]、累及肾盏数量[(3.5±0.9)个与(3.6±1.3)个]、结石S.T.O.N.E.评分[(9.4±1.0)分与(9.7±1.4)分]、Guy’s分级[Ⅲ级/Ⅳ级:45/14例与41/19例]、术前血红蛋白水平[(125.2±21.5)g/L与(125.6±18.4)g/L]、血肌酐水平[(89.1±33.8)μmol/L与(81.9±27.1)μmol/L]、术前尿路感染比例(43/59与47/60)及尿细菌培养阳性比例(12/59与11/60)差异均无统计学意义(P>0.05)。超声联合内镜引导组中患者取改良俯卧分腿位,输尿管软镜逆行进入肾盂,结合超声确定最佳穿刺肾盏,在超声和内镜引导下建立通道和清除结石。超声联合X线引导组中,患者先取截石位,将F5输尿管导管逆行置入患侧输尿管,后患者改俯卧位,在超声和X线联合引导下穿刺目标肾盏,通过顺行或逆行注入造影剂确定穿刺位置,在肾盏穹隆部中央进入。比较两组手术情况、术中及术后相关指标。结果超声联合内镜引导组手术时间显著短于超声联合X线引导组[(90.2±34.5)min与(129.4±43.0)min,P<0.001],两组初次通道建立成功率[94.0%(63/67)与87.7%(107/122),P=0.167]、单个通道建立时间[(7.7±1.9)min与(7.7±1.4)min,P=0.765]、术后第1天血肌酐[(89.3±33.6)μmol/L与(82.9±27.0)μmol/L,P=0.257]和术后住院时间[(5.3±1.6)d与(5.4±1.7)d,P=0.883]差异均无统计学意义。超声联合X线引导组较超声联合内镜引导组有较高的结石清除率[93.3%(56/60)与81.4%(48/59),P=0.049]和较低的再次手术率[3.3%(2/60)与15.3%(9/59),P=0.025];超声联合内镜引导组术后第1天血红蛋白下降值显著低于超声联合X线引导组[(8.7±6.3)g/L与(16.8±6.9)g/L,P<0.001],超声联合内镜引导组并发症发生率显著低于超声联合X线引导组[5.1%(3/59)与16.7%(10/60),P=0.043]。结论超声联合内镜引导PCNL治疗复杂性肾结石,患者无需换体位且穿刺通道少,故手术时间短和并发症发生率低,适用于孤立肾、易出血的患者;超声联合X线引导PCNL有利于多通道的建立,结石清除率较高,再次手术率低,适用于身体状况良好、结石累及肾盏较多的患者。对复杂性肾结石采用个体化治疗,可提高结石清除率和降低并发症发生率。

Objective To compare the efficacy of ultrasound combined with endoscopy and ultrasound combined with X-ray guided percutaneous nephrolithotomy(PCNL)in the treatment of complex renal calculi.Methods The clinical data of 119 patients with complex kidney stones treated by ultrasound combined with endoscopy or ultrasound combined with X-ray guided PCNL in the Second Affiliated Hospital of Anhui Medical University from March 2019 to February 2022 were analyzed retrospectively.According to different guidance methods,they were divided into ultrasound combined with endoscopic guidance group and ultrasound combined with X-ray guidance group.There was no significant difference in age[(53.9±14.2)years vs.(55.6±13.5)years],gender(male/female:38/21 vs.30/30),body mass index[(25.0±3.7)kg/m^(2)vs.(24.8±3.8)kg/m^(2)],stone location(left/right:34/25 vs.31/29),maximum diameter of renal stones[(31.9±8.3)mm vs.(33.9±13.5)mm],kidney stones maximum cross-sectional area[(601.5±242.5)mm^(2)vs.(632.6±278.9)mm^(2)],number of renal calices involved(3.5±0.9 vs.3.6±1.3),S.T.O.N.E.scores(9.4±1.0 vs.9.7±1.4),Guy's grade(Ⅲ/Ⅳ:45/14 vs.41/19),preoperative hemoglobin[(125.2±21.5)g/L vs.(125.6±18.4)g/L],serum creatinine[(89.1±33.8)μmol/L vs.(81.9±27.1)μmol/L],urinary tract infection(43/59 vs.47/60)and positive urinary bacterial culture(12/59 vs.11/60)between the two groups(all P>0.05).The patients in the ultrasound combined with endoscopic guidance group were placed in the modified prone split-leg position.Flexible ureteroscope retrograde into the renal pelvis,combined with ultrasound to determine the best puncture calices.The channels were established and stones were removed under the guidance of ultrasound and endoscopy.In the ultrasound combined with X-ray guidance group,the F5 ureteral catheter was placed retrogradely into the operative side ureter under the lithotomy position.Then the patient changed to prone position and the target calices were punctured under the guidance of ultrasound and X-ray.Through anterograde or retrograde injection of contrast medium,the puncture position was determined to enter in the center of the calicean dome,and the channel establishment process and stone removal are monitored.The operative results and postoperative data were recorded.Results The average operation time in the ultrasound combined with endoscopic guidance group was significantly shorter than that in the ultrasound combined with X-ray guidance group[(90.2±34.5)min vs.(129.4±43.0)min,P<0.001].There was no significant difference in the success rates of initial channel establishment[94.0%(63/67)vs.87.7%(107/122),P=0.167],the time of single channel establishment[(7.7±1.9)min vs.(7.7±1.4)min,P=0.765],serum creatinine on the first day after operation[(89.3±33.6)μmol/L vs.(82.9±27.0)μmol/L,P=0.257]and postoperative hospital stay[(5.3±1.6)d vs.(5.4±1.7)d,P=0.883].In contrast,patients in ultrasound combined with X-ray guidance group had higher stone free rate[93.3%(56/60)vs.81.4%(48/59),P=0.049]and lower reoperation rate[3.3%(2/60)vs.15.3%(9/59),P=0.025].The mean hemoglobin decrease value of ultrasound combined with endoscopic guidance group was significantly lower than ultrasound combined with X-ray guidance group on the first day after operation[(8.7±6.3)g/L vs.(16.8±6.9)g/L,P<0.001].The complication rate of ultrasound combined with endoscopic guidance group was significantly lower than that of ultrasound combined with X-ray guidance group[5.1%(3/59)vs.16.7%(10/60),P=0.043].Conclusions Ultrasound combined with endoscopic guidance PCNL does not need to change body position during operation and has fewer puncture channels,thus saving operation time and reducing complications.It is more suitable for patients with isolated kidney or easy bleeding.Ultrasound combined with X-ray guidance is conducive to the establishment of multi-channel,the stone clearance rate is high and the reoperation rate is low,which is suitable for patients with good health and more renal calices involved with stones.