侧卧位输尿管镜碎石术在输尿管上段结石治疗中的临床应用价值

The application of lateral decubitus position in ureteroscopic lithotripsy for the treatment of upper ureteral calculi

目的:探讨侧卧位输尿管镜碎石术在输尿管上段结石治疗中的可行性及临床应用价值。方法:回顾性分析2015年1月～2017年7月两家医院治疗输尿管上段结石及部分肾结石患者资料,分别采用侧卧体位下经尿道硬质输尿管镜碎石术、仰卧截石位硬质输尿管镜碎石术。对比两组在碎石成功率、手术时间、并发症发生率及术后平均住院时间方面的差异,重点分析侧卧体位显著提高输尿管镜碎石成功率的原因。结果:侧卧位组一次碎石成功率为89.28%(250/280),总碎石成功率为92.14%(258/280),仰卧截石位组一次碎石成功率为67.92%(144/212),总碎石成功率为78.77%(167/212),两组相比差异有统计学意义(P<0.001)。两组在平均手术时间、术后平均住院时间及并发症发生率方面相比差异无统计学意义(P>0.05)。仰卧截石位组失败因素主要是57.78%(26/45)结石逃逸,而侧卧位组结石逃逸率仅为18.18%(4/22);两组碎石失败的另一重要因素是输尿管狭窄。失败病例进一步采用PCNL、开放手术或ESWL等治疗。两组患者均无严重并发症。结论:侧卧体位下行输尿管镜碎石术在治疗输尿管上段结石时,与仰卧截石位相比,能有效防止结石上移进入肾盏,有助于保持结石在手术所及视野范围内、增加碎石成功率,可避免开放手术,减轻患者经济负担,为输尿管上段结石的治疗提供了一个安全可行的新方法。

Objective:To investigate the feasibility and clinical value of lateral decubitus position in ureteroscopic lithotripsy for the treatment of upper ureteral calculi.Methods:We retrospectively reviewed the data of patients with upper ureteral calculi,including 280 cases treated by lateral decubitus position and 212 cases treated by supine lithotripsy from January 2015 to July 2017 in two hospitals.The achievement ratio of lithotripsy,the time of operation,the incidence of complications and the average hospitalization time after operation were compared between the two groups.The reasons why lateral position significantly improved the success rate of ureteroscopic lithotripsy were analyzed.Results:The achievement ratio in one operation was 89.28%(250/280)and total achievement ratio was 92.14%(258/280)in lateral position group,and that was 67.92%(144/212)and 78.77%(167/212)respectively in supine lithotripsy group.The difference between the two groups was significant(P<0.001).There was no significant difference between the two groups in the mean operation time,postoperative hospitalization time and the incidence of complications(P >0.05).The main failure factor was stone escape[57.78%(26/45)]in supine lithotripsy group,and the failure rate was only 18.18%(4/22)in lateral position group.Ureteral stenosis was another failure factor in both groups.Failure cases were further treated by percutaneous nephrolithotomy,extracorporeal shock wave lithotripsy,open surgery,etc.Conclusions:Compared with supine lithotripsy,ureteroscopic lithotripsy in lateral decubitus position can more effectively prevent the upper ureteral stones from moving into the renal calyx,which can help keep the stone in the range of visual field,increase the success rate of lithotripsy,and avoid conversion to open operation.It can treat bilateral calculi at the same time and reduce the economic burden of patients.It provides a feasible new method for the treatment of upper ureteral calculi.