无管化MPCNL治疗上尿路结石的有效性和安全性研究

发布时间：2018-04-24 06:42

本文选题：上尿路结石 + 微创经皮肾镜取石术　；参考：《广州医科大学》2017年硕士论文

【摘要】：背景目前,经皮肾镜取石术(percutaneous nephrolithotomy,PCNL)是处理直径大于2cm上尿路结石,尤其是治疗复杂性上尿路结石的首选方法。我国吴开俊、李逊教授等著名泌尿外科专家结合我国实际情况提出微创经皮肾镜取石术(minimally invasive percutaneous nephrolithotomy,MPCNL)。PCNL如今有两种发展趋势,第一是微创化,使经皮肾穿刺通道较前进一步变细,从上世纪80年代的F30-F36发展到现在常用的F14-F18,使术后并发症的发生与肾实质损伤大大地减少;微创理念的基本要求是在尽可能少或小创伤的基础上,令患者达到和保持最佳的内环境状态[1]。第二是无管化,即PCNL术后选择性不放置肾造瘘管,甚至有部分同时也不放置D-J管,以实现完全无管化,从而减轻病人的痛苦及术后带来的诸多不便。虽然PCNL已发展成为一种设计且改造精良的手术方式,但它仍然存在并发症。EAU指南(2015年版)指出术后出血、发热、尿外渗等是PCNL术后常见并发症;在这其中,术后出血是临床医生非常关注的,Seitz等[2]综合了2001年至2011年文献综述指出,PCNL术后出血可通过采用夹闭肾造瘘管、应用气囊肾造瘘管,压迫肾实质等方法来阻止静脉出血,严重的动脉出血则需行选择性肾动脉栓塞术。但是PCNL术后留置肾造瘘管会增加患者术后不适,甚至疼痛,影响患者生活质量和住院满意度。目前国内外学者虽然已先后对无管化PCNL的安全性和可行性做了相关的临床研究,但对患者术后不适和生活质量方面的关注较少,国外已有学者用SF-36健康调查量表来评价PCNL术后患者的生活质量,在国内关于这方面的报道仍较少。故本试验在研究无管化(不留置肾造瘘管,仅留置D-J管)MPCNL治疗上尿路结石的有效性和安全性的同时,也应用SF-36健康调查量表来评价MPCNL术后患者的生活质量。目的探讨无管化MPCNL治疗上尿路结石的有效性和安全性。SF-36健康调查量表在MPCNL术后患者生活质量评估中的应用。方法此研究选取2016年7月至2017年2月期间在本中心广州医科大学附属第一医院海印分院泌尿外科符合试验纳入标准并行微创经皮肾镜取石术治疗上尿路结石的患者共计129例,可分为两组,即留置肾造瘘管组和不留置肾造瘘管组。分析两组的手术时间、术后血红蛋白下降值、术后血肌酐变化值、术后住院时间、术后并发症发生情况、术后不同时间点的疼痛视觉模拟评分(Visual Analogue score,VAS)、术后止痛药使用情况、不同时间点SF-36健康调查量表评分等相关指标。结果129例患者中不留置肾造瘘管组因术后发现残余结石及失访者共10例,留置肾造瘘管组因术后发现残余结石、出血需介入及失访者共11例,予以排除出组,最终入选108例。108例患者术前一般资料如性别、年龄、BMI、术前合并症、既往患侧手术史、肾积水程度、结石部位及类型、结石表面积等均无统计学差异。两组患者在手术时间、术后血红蛋白下降值、术后血肌酐变化值等方面的比较上,差异均无统计学意义(p0.05);而两组患者术后住院时间、术后疼痛的发生率的比较均有统计学差异(p0.05);术后6h、术后24h、术后48h的VAS评分不留置肾造瘘管组均低于留置肾造瘘管组,结果具有统计学意义(p0.05);无论是非甾体类药物还是阿片类药物的术后使用量,留置肾造瘘管组均多于不留置肾造瘘管组。两组间并发症Clavien分级有显著统计学差异(p0.001),Clavien I级(p0.001)两组间比较有统计学差异,而Clavien II级(p=1.000)、III级(p=0.985)两组间比较均无统计学差异。两组患者均未发生ClavienⅣ和ClavienⅤ级的并发症;SF-36健康调查量表评分术后第一天PF生理功能的得分分别为69.2±8.4、79.2±8.5,BP躯体疼痛这一维度的得分分别为46.2±16.9、71.2±16.5,差异有明显统计学意义(p0.001)。其他维度上同一时间点的得分均无统计学意义(p0.05)。结论无管化MPCNL能减少患者术后疼痛及止痛药的使用,缩短住院时间,提高住院期间生活质量,且不增加术后并发症的发生。SF-36健康调查量表在MPCNL术后患者生活质量的评估上有临床价值,值得推广。
[Abstract]:Background, percutaneous nephrolithotomy (percutaneous nephrolithotomy, PCNL) is the first choice for the treatment of urinary calculi with a diameter larger than 2cm, especially in the treatment of complicated upper urinary calculi. Wu Kaijun, Professor Li Xun and other famous experts in our country have proposed a minimally invasive percutaneous nephrolithotomy (minimally invasive per) combined with the actual situation in our country. Cutaneous nephrolithotomy, MPCNL).PCNL now has two development trends. The first is minimally invasive, which makes the percutaneous renal puncture passage further thinner. From the F30-F36 of the 80s of last century to the commonly used F14-F18, the postoperative complications and renal parenchyma damage are greatly reduced; the basic requirements of the minimally invasive concept are as few as possible. On the basis of the small trauma, the patients reach and maintain the best internal environment, [1]. second is no tube, that is, the selective absence of nephrostomy after PCNL, or even part of the D-J tube at the same time, in order to achieve complete incannatization, thus alleviating the patient's pain and a lot of inconvenience after the operation. Although PCNL has developed into a kind of establishment. The.EAU Guide (2015 Edition) indicates that postoperative bleeding, fever, and extravasation of urine are common complications after PCNL; in which, postoperative bleeding is a great concern for clinicians, and Seitz and [2] combined from 2001 to 2011 that hemorrhage after PCNL can be used with clipping. Nephrostomy tube, air bag nephrostomy tube, compression of renal parenchyma and other methods to prevent venous bleeding, severe arterial bleeding requires selective renal artery embolization. However, after PCNL, indwelling renal fistulas will increase postoperative discomfort and even pain, affecting patients' quality of life and hospitalization satisfaction. The clinical study of the safety and feasibility of unmanaged PCNL has been made, but less attention has been paid to postoperative discomfort and quality of life. Foreign scholars abroad have used SF-36 health survey to evaluate the quality of life of patients after PCNL, and there are few reports in this area. The effectiveness and safety of MPCNL in the treatment of upper urinary calculi and the use of SF-36 health inventory to evaluate the quality of life of patients after MPCNL. Objective to explore the effectiveness and safety of the non tube MPCNL for the treatment of upper urinary calculi, and to evaluate the quality of life of the patients after MPCNL after the MPCNL operation. Methods a total of 129 patients were selected from July 2016 to February 2017 in the Department of Urology, the First Affiliated First Hospital of Guangzhou Medical University, the first hospital of the first hospital, the Department of Urology, the standard parallel minimally invasive percutaneous nephrolithotomy for the treatment of upper urinary calculi, which could be divided into two groups, that is, the indwelling nephrostomy tube group and the non indwelling nephrostomy tube group. Analysis of the two groups of operation time, postoperative hemoglobin decreased value, postoperative blood creatinine change value, postoperative hospitalization time, postoperative complications, postoperative pain visual analog score (Visual Analogue score, VAS), postoperative analgesics use, not the same time point SF-36 health survey scale scores and other related indicators. Results 1 In the 29 cases, there were 10 cases of residual stones and lost visitors in the group of non indwelling nephrostomy tubes. The residual stones were found in the group of renal fistulas after operation. 11 cases of bleeding need to intervene and lose the visitors. The group was excluded, and the general data of 108.108 patients were selected, such as sex, age, BMI, preoperative complication, and history of side surgery. There was no significant difference in the degree of hydronephrosis, the place and type of stone, and the surface area of the stone. There was no significant difference between the two groups in the operation time, the decrease of hemoglobin and the change of blood creatinine after operation (P0.05), but the rate of postoperative hospital residence time and postoperative pain was statistically significant in the two groups. Difference (P0.05); postoperative 6h, postoperative 24h, and VAS score of 48h after operation were lower than that of the left renal fistulae group, and the results were statistically significant (P0.05); the amount of postoperative use of non steroid or opioids was more than that of the non indwelling nephrostomy tube group. The complications of the two groups were classified as Clavien classification. There were significant statistical differences (p0.001), Clavien I grade (p0.001) two groups had statistical differences, but Clavien II (p=1.000), III class (p=0.985) two groups were not statistically significant differences. Two groups of patients did not have Clavien IV and Clavien grade complications; SF-36 Health Questionnaire score score on the first day after the score points of physiological function score points The score was 69.2 + 8.4,79.2 + 8.5, and the score of BP body pain was 46.2 + 16.9,71.2 + 16.5 respectively. The difference was statistically significant (p0.001). There was no statistical significance in the same time point on other dimensions (P0.05). Conclusion no tube MPCNL can reduce the pain and use of painkillers after operation, shorten the time of hospitalization and improve hospitalization. The quality of life, without the increase of postoperative complications, is of clinical value in the assessment of the quality of life of the patients after MPCNL, which is worthy of promotion.

【学位授予单位】：广州医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699

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