输尿管结石的微创治疗：Meta分析与随机对照临床研究

发布时间：2018-05-07 16:25

本文选题：输尿管结石 + 体外冲击波碎石术　；参考：《第三军医大学》2014年硕士论文

【摘要】：背景与目的目前输尿管结石的微创治疗方式主要有体外冲击波碎石术（ESWL）、经尿道输尿管镜碎石术（URL）、经皮肾镜碎石取石术（PCNL）、后腹腔镜下输尿管切开取石术（RPLU）等，不同的治疗方式对不同位置的输尿管结石的治疗各有优劣。2007年Cochrane协作网与美国泌尿外科协会肾结石治疗指南先后对输尿管结石的治疗进行了系统评价。Cochrane协作网表明URL较ESWL有较高的结石清除率，但其在并发症和住院日方面同样较高，并且未说明结石所在的位置；美国泌尿外科协会肾结石治疗指南同样认为URL能获得较高的结石清除率，且在下段输尿管结石更为显著，但对于上段输尿管结石并未指出有明确优势的治疗方法。因此，国内外对于不同位置的输尿管结石的治疗方式的选择仍存在争议。本研究拟对不同位置的输尿管结石的微创治疗进行循证医学研究(系统评价与Meta分析)，为输尿管结石的微创治疗的选择提供循证医学依据，同时通过随机对照临床试验，比较PCNL与输尿管软镜（F-URS）对输尿管上段结石的治疗效果与安全性，为输尿管上段结石的治疗提供进一步的循证医学证据。材料和方法检索MEDLINE、EMBASE、Cochrane图书馆随机对照试验注册数据库(CochraneCentral Register of Controlled Trails, CENTRAL)和中国生物医学文摘数据库(CBMDisc)等文摘数据库，以及PUBMED、相关期刊论文(CNKI)、维普中文期刊数据库(CQVIP)等全文数据库，时间限制为1995年1月-2012年12月。纳入文献均为对比不同微创方式治疗输尿管结石的随机对照试验研究。提取的结局观测指标数据包括初始结石清除率、整体结石清除率、重复治疗率、平均手术时间、术后并发症、平均住院日、术后第一天VAS疼痛评分等，数据采用RevMan5.1软件进行Meta分析。随机对照临床试验共纳入受试者120例，随机分为软镜组（F-URS）和微创经皮肾镜组（MPCNL），每组各60例，两组在年龄、性别、结石大小等方面无显著差别。收集受试者的一般特征及手术时间、术后住院日、术后第一日视觉模拟疼痛评分（VAS）、术后Hb下降量、结石清除率、并发症发生率等各项指标数据。统计分析采用SPSS16.0软件，以χ2检验比较计数资料；以两组独立样本的t检验比较计量资料；以Wilcoxon秩和检验比较偏态分布数据；P＜0.05考虑为有统计学差异。结果检索共获得文献612篇，，全面阅读题目、摘要及全文，根据事先拟定的文献纳入及排除标准，筛选纳入本次Meta分析的文献共有15篇文献。其中，6篇文献描述针对输尿管下段结石，ESWL与URL治疗疗效的对比；2篇文献描述对输尿管全段结石，ESWL与URL治疗的疗效对比，文中对某些观测指标如结石清除率分为上段结石和下段结石分别描述；3篇文献描述针对输尿管上段结石，ESWL与URL治疗的疗效对比；4篇文献描述针对输尿管上段结石，URL与PCNL的疗效对比。分析显示，对于输尿管下段结石，ESWL组较URL组有较低的结石清除率及较高的重复治疗率(P0.01)，而二者在术后并发症及手术时间方面无显著差异(P＞0.05)；对于输尿管上段结石，ESWL组与URL组在结石清除率、术后并发症及重复治疗率方面均无显著差异(P＞0.05)，而在平均治疗时间方面ESWL组较URL组短(P0.01)；URL组与PCNL组治疗上段结石的对比分析显示PCNL组在结石清除率方面较URL组高(P0.01)，两组在术后并发症、平均手术时间及重复治疗方面无显著差异(P＞0.05)。输尿管软镜（F-URS）与微创经皮肾镜（MPCNL）治疗输尿管上段结石的随机对照临床研究结果显示，F-URS组与MPCNL组初始结石清除率分别为68.33%和95.00%，两组差异有统计学意义（P＜0.05），3月后结石清除率分别为96.67%和98.33%，两组差异无统计学意义（P＞0.05）；F-URS组和MPCNL组手术时间分别为（35.33±11.57）min和（53.75±17.31）min，术后住院日分别为（3.05±0.62）d和（5.43±1.84）d，术后第1天VAS分别为（1.70±1.37）分和（3.68±1.57）分，两组患者比较差异均有统计学意义（P＜0.05）；两组患者术后血红蛋白（Hb）下降量及并发症发生率比较，差异无统计学意义（P＞0.05）。结论通过对输尿管结石微创治疗的系统评价我们认为对于输尿管下段结石的治疗，与ESWL相比，URL具有结石清除率高及重复治疗率低等优点，值得推荐；而随机对照试验研究结果则表明，对于输尿管上段结石，在结石清除率方面F-URS与MPCNL疗效相当，且F-URS与MPCNL相比安全性更高、术后住院日更短，在有条件开展F-URS的科室应列为首选治疗方法。
[Abstract]:Background and Purpose

Ureteroscopic lithotripsy ( URL ) , percutaneous nephrolithotripsy ( PCNL ) and retroperitoneal laparoscopic ureterotomy ( RPLU ) were used to evaluate the treatment of ureteral calculi .
In the same time , there is still a dispute about the treatment of ureteral calculi at different locations .

Materials and Methods

All - text databases , including initial stone clearance , total stone clearance , repeat treatment rate , average operation time , postoperative complications , mean hospital day and VAS pain score on the first day of operation , were searched . The data were analyzed by RevMan5.1 software .

120 patients were randomly divided into soft lens group ( F - URS ) and minimally invasive percutaneous nephroscope group ( MPC NL ) .
comparing the measured data with the t - test of the two groups of independent samples ;
comparing partial bias distribution data with Wilcoxon rank sum test ;
P & lt ; 0.05 was considered to be statistically different .

Results

A total of 612 articles were retrieved , fully read the title , abstract and full text , and 15 articles were included in the literature which were included in this meta - analysis according to the previously prepared literature and exclusion criteria .
Two literatures describe the curative effect of the treatment of total ureteral calculi , extracorporeal shock wave lithotripsy and URL therapy , and some observation indexes such as stone clearance rate are divided into upper and lower stones respectively ;
Three literatures describe the curative effect of the treatment of upper ureteral calculi , extracorporeal shock wave lithotripsy and URL therapy .
The results showed that , for lower ureteral calculi , lower stone clearance and higher rate of repeat treatment were found in the lower group than in the URL group ( P0.01 ) , but there was no significant difference between the two groups in postoperative complications and operative time ( P > 0.05 ) .
There was no significant difference in the rate of stone clearance , postoperative complications and the rate of repeated treatment for upper ureteral calculi ( P > 0.05 ) .
Compared with PCNL group , PCNL group had higher urinary stone clearance ( P0.01 ) , and there was no significant difference between the two groups ( P > 0.05 ) .

The results of the randomized controlled clinical study on the treatment of upper ureteral calculi with flexible ureteroscope ( F - URS ) and minimally invasive percutaneous nephroscope ( MPC NL ) showed that the initial stone clearance of F - URS group was 68.33 % and 95.00 % , respectively , and the stone clearance rate was 96.67 % and 98.33 % , respectively , and no significant difference was found between the two groups ( P > 0.05 ) .
The operative time of F - URS group and MPC NL group were ( 35.33 卤 11.57 ) min and ( 53.75 卤 17.31 ) min , respectively , and the postoperative hospitalization days were ( 3.05 卤 0.62 ) d and ( 5.43 卤 1.84 ) d , respectively , and the VAS in postoperative day 1 was ( 1 . 70 卤 1 . 37 ) min and ( 3.68 卤 1 . 57 ) respectively .
There was no significant difference in hemoglobin ( Hb ) and complication rate between the two groups ( P > 0.05 ) .

Conclusion

Through the systematic evaluation of the minimally invasive treatment of ureteral calculi , we believe that the URL has the advantages of high stone clearance rate and low repetition rate compared with the treatment of lower ureteral calculi , and it is worth recommending .
The results of the randomized controlled trial showed that the F - URS of the upper ureteral calculi was comparable to that of the MPC NL in terms of stone clearance , and the F - URS was higher in safety compared to the MPC NL and shorter in the postoperative hospital day , and that the department with the F - URS should be listed as the preferred treatment method .

【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R699.4

【引证文献】