不同结石评分法预测输尿管软镜碎石术后结石清除率的准确性比较

Comparison of different stone scoring systems in predicting the stone-free rate after RIRS for upper urinary tract lithiasis

目的比较不同结石评分法预测输尿管软镜碎石术(RIRS)后结石清除率的准确性。方法回顾性分析2017年6月至2020年12月南京医科大学附属明基医院和青岛阜外医院收治的227例行RIRS肾结石患者的临床资料。男152例,女75例;年龄(53.0±10.4)岁;结石位于左侧133例,右侧94例;体质量指数(26.9±2.1)kg/m^(2);无或轻度肾积水163例,中度肾积水40例,重度肾积水24例。结石最大径(22.7±12.8)mm;结石位于上段输尿管、肾上盏或肾盂44例,肾中盏23例,肾下盏157例,位于肾盏憩室3例。结石CT值(778.3±350.4)HU。美国麻醉医师协会(ASA)分级Ⅰ级86例,Ⅱ级129例,Ⅲ级12例。根据不同结石评分法的评分标准,利用术前泌尿系CT+三维重建结果分别对患者术前结石特征进行评分。比较结石清除组和结石残留组临床特征的差异。采用logistic回归模型分析改良S.T.O.N.E.、RUSS、改良S-ReSC、R.I.R.S.、SHA.LIN、Ito列线图、S.O.L.V.E.、清石指数评分与结石清除率的相关性。绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC),分析各评分系统预测RIRS术后结石清除率的敏感性和特异性。结果本研究227例结石清除率为83.0%(189/227)。手术时间(55.1±24.6)min。总住院时间(10.2±5.2)d;术后住院时间(6.2±3.6)d。结石清除组与结石残留组改良S.T.O.N.E.[(10.5±1.9)分与(12.7±1.8)分]、RUSS[1(0,4)分与3(0,6)分]、改良S-ReSC[(8.2±5.6)分与(11.8±6.0)分]、R.I.R.S.[(6.2±1.4)分与(8.1±1.2)分]、SHA.LIN[(9.9±2.4)分与(13.0±2.1)分]、Ito列线图[(12.1±5.8)分与(4.3±3.3)分]、S.O.L.V.E.[(6.8±1.6)分与(8.7±1.2)分]、清石指数评分[(7.9±1.1)分与(6.3±0.9)分]差异均有统计学意义(P<0.05)。logistic回归模型分析上述各评分与结石清除率均存在相关性(P<0.05)。改良S.T.O.N.E.、RUSS、改良S-ReSC、R.I.R.S.、SHA.LIN、Ito列线图、S.O.L.V.E.、清石指数评分ROC曲线的AUC分别为0.797、0.818、0.700、0.828、0.837、0.868、0.838、0.872。改良S-ReSC评分与其他评分的AUC两两比较差异均有统计学意义(P<0.05),其他评分AUC两两比较差异均无统计学意义(P>0.05)。当SHA.LIN评分、清石指数评分、R.I.R.S.评分的界值分别为10、6、6分时,其预测结石清除率的特异性分别为94.7%、92.6%、89.5%。结论改良S.T.O.N.E.、RUSS、改良S-ReSC、R.I.R.S.、SHA.LIN、Ito列线图、S.O.L.V.E.、清石指数评分均可预测RIRS的术后结石清除率。在特定评分界值的情况下,SHA.LIN评分、清石指数评分和R.I.R.S.评分预测RIRS术后结石清除率的准确性较高,改良S-ReSC预测RIRS术后结石清除率的准确性较其他评分系统略差。

Objective To compare the accuracy of different stone scoring systems for predicting the stone-free rate(SFR)after retrograde intrarenal surgery(RIRS).Methods The clinical data of 227 patients with lithiasis undergoing RIRS from June 2017 to December 2020 in Affiliated Benq Hospital of Nanjing Medical University and Qingdao Fuwai Hospital were retrospectively analyzed.There were 152 males and 75 females.The average age was(53.0±10.4)years old.The average body mass index was(26.9±2.1)kg/m^(2).The maximum diameter of the stone was(22.7±12.8)mm.The stone is located in left side in 133 cases and in right side in 94 cases.The stones of 44 cases were located in upper ureter,upper calyceal or renal pelvis,that of 23 cases were in medium calyceal,157 cases in lower calyceal,and 3 cases in calyceal diverticulum.The average CT value of stone was(778.3±350.4)HU.American Society of Anesthesiology(ASA)scores:86 cases of gradeⅠ,129 cases of gradeⅡ,12 cases of gradeⅢ.Preoperative non-contrast CT was conducted and three-dimensional data were constructed.A single observer reviewed and entered the modified S.T.O.N.E.,RUSS,modified S-ReSC,R.I.R.S.,SHA.LIN,Ito nomogram,S.O.L.V.E.,stone free index(SFI)scores.Logistic analysis were performed between every score and SFR.Receiver operating characteristic(ROC)curve was drawn to detect sensitivity and specificity of every score in predicting the SFR.The predictive accuracies of all scores were compared.Results The SFR was 83.0%(189/227).There were statistically significant differences in modified S.T.O.N.E.(10.5±1.9 vs.12.7±1.8),RUSS[1(0,4)vs.3(0,6)],modified S-ReSC(8.2±5.6 vs.11.8±6.0),R.I.R.S.(6.2±1.4 vs.8.1±1.2),SHA.LIN(9.9±2.4 vs.13.0±2.1),Ito nomogram(12.1±5.8 vs.4.3±3.3),S.O.L.V.E.(6.8±1.6 vs.8.7±1.2),SFI score(7.9±1.1 vs.6.3±0.9)between the stone-free group and the stone remaining group(P<0.05).Logistic regression revealed that modified S.T.O.N.E.,RUSS,modified S-ReSC,R.I.R.S.,SHA.LIN,Ito nomogram,S.O.L.V.E.and SFI score were significantly associated with SFR(P<0.05).There were no significant differences in the area under the curve(AUC)between the modified S.T.O.N.E.,RUSS,R.I.R.S.,SHA.LIN,Ito nomogram,S.O.L.V.E.and SFI score(P>0.05),but there were significant differences in the AUC between modified S-ReSC score and other score(P<0.05).When the cutoff of SHA.LIN,SFI and R.I.R.S.score was determined as 10,6 and 6 scores,the specificity of SHA.LIN,SFI and R.I.R.S.score was 94.7%,92.6%and 89.5%,respectively.Conclusions All score could predict the postoperative SFR of RIRS,while the SHA.LIN,SFI and R.I.R.S.score were more accurate than the other scores.The accuracy of the modified S-ReSC in predicting SFR after RIRS was slightly worse than other scores.