头端可弯负压吸引鞘辅助的输尿管软镜碎石术后无管化离院的可行性和安全性

Feasibility and safety of stentless discharge after flexible ureteroscopic lithotripsy assisted by flexible negative pressures heath

目的找探讨头端可弯负压吸引鞘辅助的输尿管软镜碎石术后无管化离院的可行性和安全性。方法回顾性分析2022年11月至2023年2月天津医科大学第二医院收治的72例上尿路结石患者的临床资料。所有患者均行头端可弯负压吸引鞘辅助输尿管软镜碎石术并无管化离院。男50例,女22例。年龄(54.7±12.1)岁。术前尿细菌培养阳性14例,尿细菌培养阴性但亚硝酸盐阳性3例,尿细菌培养和尿亚硝酸盐阴性但尿白细胞(+++)11例。肾结石29例,输尿管上段结石33例,输尿管上段结石合并肾结石10例。结石长径17.0(14.0,24.0)mm。结石CT值(1049.3±258.6)HU。24例术前携带输尿管支架。术中42例使用F11/13输尿管鞘,30例使用F12/14输尿管鞘。术中使用灌注泵提供足够的灌注压力,头端可弯负压吸引输尿管导引鞘的尾端外接负压吸引结石击碎后,利用软镜将鞘头端的可弯曲部分引导至目标肾盏,彻底吸出碎石颗粒和粉末。11例使用套石篮。手术结束后根据Traxer分级体系判断输尿管损伤程度,留置带线输尿管支架。术后第1天行CT检查评估残石情况,术后2~3d拔除尿管和输尿管支架后患者出院。术后随访30d,应用输尿管支架相关症状调查问卷(USSQ)评估拔管后的排尿症状和疼痛情况,记录止痛药使用和急诊返诊情况,术后第30天行CT检查评估无石率。结果本研究72例手术均顺利完成,术后均无管化出院。手术时间30.0(20.0,44.5)min。术中输尿管损伤程度分别为无损伤70例,1级损伤2例(轻微黏膜损伤)。3例术后72h内出现发热,无感染性休克病例,无拔管后发热病例。出院后8例报告腰腹部疼痛不适并口服止痛药,其中1例返回急诊科接受止痛治疗;5例报告排尿症状(排尿间隔、夜尿次数、尿急/尿失禁、尿灼热感、血尿情况、尿不尽感)的总体影响为中度以上(患者主观评价)。所有患者出院后即可正常工作和生活,无需要再次住院或进行额外手术操作的患者。术后第1天61例达到无石状态,术后第30天66例达到无石状态。结论头端可弯负压吸引鞘辅助的输尿管软镜碎石术后无管化离院安全、可行。

Objective To investigate the feasibility and safety of a treatment system for stentless discharge after flexible ureteroscopic lithotripsy assisted by flexible negative pressure sheath.Methods The clinical data of 72 patients with upper urinary calculi admitted to the Second Hospital of Tianjin Medical University from November 2022 to February 2023 were retrospectively analyzed.All patients achieved stentless discharge after flexible ureteroscopic lithotripsy assisted by flexible negative pressure sheath.There were 50 males and 22 females.The average age was(54.7±12.1)years.Preoperative urine culture was positive in 14 cases,negative in 3 cases(4.2%)with nitrite positive,and 11 cases were negative for urine culture and nitrites but positive of white blood cells(+++).There were 29 cases of renal calculi,33 cases of upper ureteral calculi,and 10 cases of upper ureteral calculi combined with renal calculi.The mean stone diameter was 17.0(14.0,24.0)mm.CT value was(1049.3±258.6)HU.Twenty-four patients carried ureteral stents before operation.A total of 42 cases used ureteral sheaths with diameters of F11/13,and 30 cases used sheaths with diameters of F12/14.During the operation,an infusion pump was used to provide sufficient irrigation pressure.The negative pressure suction was attached to the distal end of the sheath.The flexible head of the sheath was guided to the target renal calyx,to completely aspirate stone fragments.Stone baskets was used in ll cases during the procedure.The level of ureteral injury was assessed according to the Traxer grading system at the end of the operation.A ureteral stent with extraction string was retained.On the first day postoperatively,CT scanning was performed to evaluate the residual stone fragments.Patients were discharged on postoperative day 2-3 after the removal of the ureteral stent and catheter.Follow-up was conducted for 30 days postoperatively,during which the Ureteral Stent Symptom Questionnaire(USSQ)was used to assess voiding symptoms and pain.Painkiller usage and emergency revisit situations were recorded.CT scans were performed to evaluate the stone-free rate on postoperative day 30.Results The average operation time was 30.0(20.0,44.5)minutes.A total of 70 cases had no ureteral injuries,and 2 cases had Grade 1 ureteral injuries(minor mucosal damage).Three cases developed fever within 72 hours postoperatively,with no cases of septic shock or fever after stent removal.Eight patients reported waist and abdominal discomfort after discharge and took oral pain medication.Among them,one patient returned to the emergency department for pain treatment.Five patients reported moderate or severe genitourinary symptoms(including voiding frequency,nocturia,urgency/incontinence,dysuria,hematuria,and incomplete emptying)based on subjective evaluation.All patients could work and recovered a normal daily life after discharge and there was no readmission or additional surgical procedures.There were 61 patients achieved immediate stone-free status on the first day after surgery,and 66 patients achieved stone-free status during follow-up at 30 days postoperatively.Conclusions Stentless discharge after flexible ureteroscopic lithotripsy assisted by flexible negative pressure sheath is safe and feasible.