软镜碎石术中负压吸引鞘的临床应用评估与术后SIRS发生因素分析

发布时间：2018-04-16 18:26

本文选题：输尿管软镜碎石术 + 肾结石　；参考：《昆明医科大学》2017年硕士论文

【摘要】：[目的]评估输尿管软镜碎石术(flexible Ureteroscopic Lithotripsy,f-URL)中使用负压吸引输尿管软镜引导鞘(Ureteral Access Sheath,UAS)治疗肾结石的临床效果,比较该鞘与普通UAS两者间的应用差异。同时探讨f-URL术后发生全身炎症反应综合征(Systemic Inflammatory Response Syndrome,SIRS)的危险因素,研究负压吸引鞘的应用在预防及降低f-URL术后SIRS发生的影响。[方法]收集解放军昆明总医院于2015年12月-2017年3月收治的诊断明确且拟行手术治疗的肾结石患者111例。所有患者均由同一位临床经验丰富的医生完成f-URL手术治疗,术中按软镜鞘使用分为观察组和对照组,观察组患者使用新型的带负压测压吸引功能的UAS,对照组则使用普通UAS联合软镜手术治疗。术后分别比较两组患者的手术时间、术后清石率(Stone Free Rate,SFR)、术后并发症及术后平均住院日等指标的差异。并进一步将所有患者碎石术后按是否发生SIRS进行分组,采用单因素和多因素回归分析f-URL术后发生SIRS的危险因素。[结果]111例肾结石患者行软镜碎石术后结石清除率为88.3%,患者术后SIRS发生率为8.1%。术后SIRS患者中有1例进展为尿脓毒血症,经积极抗感染等治疗后好转出院。术中均无肾包膜下血肿、输尿管粘膜撕脱、输尿管穿孔等严重并发症发生。观察组手术时间为30.31±8.22min,较对照组(33.66±7.58 min)手术时间缩短,差异有统计学意义(P0.05);观察组SFR 93.7%,较对照组81.8%更高,差异有统计学意义(P0.05);观察组术后SIRS发生率6.3%,较对照组10.4%降低,差异无统计学差异(P0.05);观察组术后平均住院日3.01±1.20 d,较对照组(3.79±1.93 d)住院时间更短,差异有统计学意义(P0.05)。对SIRS发生因变量行单因素分析结果表明:术前发热、尿硝酸盐阳性、手术时间延长与软镜碎石术后SIRS发生相关。多因素分析提示尿培养阳性是输尿管软镜碎石术后SIRS发生的危险因素。[结论]输尿管软镜碎石术治疗小于2cm肾结石安全、有效。术中使用负压吸引输尿管软镜鞘配合软镜碎石较普通鞘能更有效的提升术后清石效果,而新型软镜鞘降低术后SIRS的发生有待进一步研究。尿培养阳性是软镜术后SIRS发生的独立风险因素,对于术前合并尿培养阳性、发热、尿硝酸盐阳性等患者,给予积极、有效的抗感染治疗,以及术中控制手术时间,尽快完成手术,有助于降低术后SIRS发生。
[Abstract]:[objective] to evaluate the clinical effect of ureteroscopic guided ureteral Access guided ureteroscopy (Ureteral Access UASS) in the treatment of renal calculi with flexible Ureteroscopic lithotripsy (UAS), and to compare the difference between the ureteroscopic lithotripsy and the common ureteroscopic lithotripsy (UAS).At the same time, the risk factors of systemic Inflammatory Response syndromes after f-URL were discussed, and the effect of negative pressure suction sheath on the prevention and reduction of SIRS after f-URL was studied.[methods] 111 patients with renal calculi who were admitted to Kunming General Hospital of PLA from December 2015 to March 2017 were collected.All the patients were treated with f-URL by the same experienced doctor. The patients were divided into the observation group and the control group according to the use of soft microscope sheath during the operation.The patients in the observation group were treated with a new type of UAS with suction function of negative pressure and the control group were treated with conventional UAS combined with soft endoscopy.The operative time, stone Free rate, postoperative complications and average hospital stay were compared between the two groups.All patients were further divided according to whether SIRS occurred after lithotripsy. Univariate and multivariate regression analysis was used to analyze the risk factors of SIRS after f-URL.[results] the stone clearance rate was 88.3 in 111 patients with renal calculi and the incidence of SIRS was 8.1 in patients with renal calculi after soft endoscope lithotripsy.One patient with SIRS developed urinary sepsis and was discharged from hospital after active anti-infection therapy.There were no severe complications such as renal subcapsular hematoma, ureteral mucosal avulsion and ureteral perforation.The operative time in the observation group was 30.31 卤8.22 min, which was shorter than that in the control group (33.66 卤7.58 min), the difference was statistically significant (P 0.05), the SFR in the observation group was higher than that in the control group (81.8%), the difference was statistically significant, the incidence of SIRS in the observation group was 6.3%, which was lower than that in the control group (10.4%).There was no significant difference between the two groups (P 0.05), and the average hospitalization time of the observation group was 3.01 卤1.20 days, which was shorter than that of the control group (3.79 卤1.93 days), and the difference was statistically significant (P 0.05).The results of univariate analysis on the dependent variables of SIRS showed that fever, positive urine nitrate and prolonged operation time were correlated with SIRS after soft endoscope lithotripsy.Multivariate analysis showed that positive urine culture was a risk factor for SIRS after ureteral soft lithotripsy.[conclusion] Ureteroscopic lithotripsy is less safe and effective than 2cm in the treatment of renal calculi.The negative pressure suction ureteral soft sheath combined with soft lithotripsy was more effective than the common sheath in improving the effect of postoperative lithotripsy, but the new soft sheath could reduce the incidence of postoperative SIRS.Positive urine culture is an independent risk factor for the occurrence of SIRS after soft endoscopy. For patients with positive urinary culture, fever and urinary nitrate positive before operation, we should give active and effective anti-infection therapy, and control the operative time during operation.To complete the operation as soon as possible is helpful to reduce the incidence of postoperative SIRS.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699

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