负压吸引鞘经皮肾镜取石术治疗感染性肾结石的有效性和安全性

The efficiency and safety of percutaneous nephrolithotomy with negative pressure suction sheath in the treatment of infectious renal calculus

目的比较负压吸引鞘和传统扩张鞘在经皮肾镜取石术治疗感染性肾结石中应用的有效性和安全性。方法回顾性分析2019年5月至2022年6月深圳市第二人民医院收治的70例感染性肾结石患者的病例资料,其中35例采用负压吸引鞘行经皮肾镜取石术(负压鞘组),通过倾向性评分匹配35例接受传统扩张鞘经皮肾镜取石术的患者(对照组)。两组的年龄[(45.5±6.8)岁与(44.9±7.3)岁,P=0.723]、性别(男/女:19/16例与21/14例,P=0.629)、体质量指数[(24.2±4.2)kg/m^(2)与(24.5±3.9)kg/m^(2),P=0.758]、美国麻醉医师协会分级(1/Ⅱ级:30/5例与29/6例,P=0.743)、结石侧别(左/右:18/17例与17/18例,P=0.811)、Guys结石评分(1/Ⅱ/Ⅲ级:3/25/7例与1/29/5例,P=0.443)、结石CT值[(629.2±98.8)HU与(608.5±105.1)HU,P=0.399]、尿白细胞(-/+/++:29/5/1例与28/5/2例,P=0.839)、合并高血压病(3例与5例,P=0.707)、合并糖尿病(2例与2例,P=1.000)差异均无统计学意义。两组术中患者先取截石位,留置患侧输尿管导管,然后改俯卧位,于患肾侧腋后线行超声引导下穿刺,建立穿刺通道后依次扩张至F20,置人碎石鞘建立碎石通道。与对照组的传统扩张鞘相比,负压鞘组的负压吸引鞘是在主干碎石通道基础上增加了侧支吸引通道并接持续负压吸引,负压值为40kPa。两组均采用气压弹道联合激光的混合碎石方式。术后1周复查腹部X线片显示无残石或≤4mm未引起尿路梗阻的临床无意义残石定义为结石清除。比较两组的手术时间、术后临床参数(血白细胞、降钙素原、C反应蛋白、血红蛋白、结石清除率)和围手术期并发症发生率。结果昊负压鞘组的手术时间短于对照组[(35.6±19.5)min与(45.4±20.2)min,P<0.05]。负压鞘组和对照组术后血白细胞、降钙素原、C反应蛋白升高的患者比例分别为25.7%(9/35)和54.3%(19/35)、42.9%(15/35)和68.6%(24/35)62.9%(22/35)和85.7%(30/35),差异均有统计学意义(P<0.05);术后血红蛋白下降的患者比例分别为2.9%(1/35)和8.6%(3/35),差异无统计学意义(P=0.607);结石清除率分别为97.1%(34/35)和94.3%(33/35),差异无统计学意义(P=1.000)。两组术后的结石成分分析结果均为以磷酸镁铵和磷酸磷灰石为主的感染性结石。负压鞘组的围手术期并发症发生率低于对照组[22.9%(8/35)与51.4%(18/35),P<0.05],其中负压鞘组术后发热(体温>37.5℃)的患者比例低于对照组[14.3%(5/35)与37.1%(13/35),P<0.05]。负压鞘组和对照组术后分别有2例和3例需升级抗生素治疗(P=1.000);两组术后出现因血块造成梗阻和肾绞痛的患者各1例(P=1.000);仅对照组1例术后发生尿源性脓毒血症(P=0.476)。结论与传统扩张鞘经皮肾镜取石术相比,负压吸引鞘经皮肾镜取石术可以缩短手术时间,能有效降低术后的感染发生率和围手术期并发症发生率,负压吸引鞘的安全性更高;二者的结石清除率无差异。

Objective To compare the efficacy and safety of percutaneous nephrolithotomy(PCNL)with negative pressure suction sheath and PCNL with traditional expanded sheath in the treatment of infectious renal calculus.Methods From May 2019 to June 2022 in our department,35 patients with infectious renal calculus who received PCNL with negative pressure suction sheath(negative pressure sheath group,NPS group)and another 35 patients with infectious renal calculus who received PCNL with traditional expanded sheath(control group)were determined in our research.Propensity score matching(PSM)was conducted.Preoperative clinical data of the 2 groups was similar and there were no statistical differences between the 2 groups in the age[(45.5±6.8)vs.(44.9±7.3)years old,P=0.723],gender(man/woman 19/16 cases vs.21/14 cases,P=0.629),body mass index(BMI)[(24.2±4.2)kg/m^(2)vs.(24.5±3.9)kg/m^(2),P=0.758],American Society of Anesthesiologists risk score(ASA)(grade 1/grade 2:30/5 cases vs.29/6 cases,P=0.743),sides of calculus(lef/right:18/17 cases vs.left 17/18 cases,P=0.811),Guy's stone score(grade I/II/II:3/25/7 cases vs.1/29/5 cases,P=0.443),CT value of calculus[(629.2±98.8)HU vs.(608.5±105.1)HU,P=0.399],urinary leucocyte(-/+/++:29/5/1 cases vs.28/5/2 cases,P=0.839),hypertension(3 cases vs.5 cases,P=0.707),diabetes(2 cases vs.2 cases,P=1.000).The ureteral catheter on the affected side was indwelled in the lithotomy position,and ultrasound guided positioning puncture was performed on the affected renal side of the posterior axillary line in the prone position.The puncture channel was established and then expanded to F20 successively,and the lithotriptic sheath was placed to establish the lithotriptic channel.Compared with the traditional expanded sheath,the negative pressure suction sheath was different in that the collateral suction channel was added on the main gravel channel and connected with continuous negative pressure suction.The negative pressure was 40 kPa.All patients were treated with pneumatic ballistic lithotripsy combined with holmium laser.KUB was performed within 1 week after surgery.We defined stone removal as either no residual stones or clinically insignificant residual stones(≤4 mm)which did not cause urinary obstruction.The intraoperative duration of operation and postoperative clinical parameters[white blood cell(WBC),procalcitonin(PCT),C-reactive protein(CRP),hemoglobin(Hb),stone clearance rate]and incidence of perioperative complications were compared between the 2 groups.Results The operation time of NPS group was lower than that in control group[(35.6±19.5)min vs.(45.4±20.2)min,P<0.05].The proportion of patients with increased WBC,PCT and CRP in blood after operation in NPS group was lower than that in control group,and there were(WBC:25.7%vs.54.3%,P<0.05),(PCT:42.9%vs.68.6%,P<0.05)and(CRP:62.9%vs.85.7%,P<0.05)respectively.There was no significant difference in the proportion of patients with decreased Hb postoperatively between the 2 groups(2.9%vs.8.6%,P=0.607).There was no significant difference in calculus clearance rate postoperatively between the 2 groups(97.1%vs.94.3%,P=1.000).Postoperative calculus component analysis of the 2 groups suggested that all patients had infected calculus dominated by ammonium magnesium phosphate and phosphate apatite.The incidence of perioperative complications in NPS group was lower than that in control group(22.9%vs.51.4%,P<0.05).The proportion of patients with fever(body temperature>37.5℃)postoperatively in NPS group was lower than that in control group(14.3%vs.37.1%,P<0.05).There were 2 and 3 patients respectively required upgraded antibiotic therapy after operation in the 2 groups(P=1.000).There was one patient respectively with urinary tract obstruction and renal colic due to blood clots postoperatively in each group(P=1.000).There was one patient with urinary sepsis in control group after operation(P=0.476).Conclusions Compared with PCNL with traditional expanded sheath,PCNL with negative pressure suction sheath can save operation time for infectious renal calculus,and reduce the incidence of postoperative infection and perioperative complications.Therefore,the safety of negative pressure suction sheath is higher.However,there is no difference in stone clearance rate between them.