无管化经皮肾镜碎石取石术安全性与有效性的循证医学研究
发布时间：2018-08-20 15:08
【摘要】：研究背景与目的背景:泌尿道结石随着社会发展发病率呈现上升趋势,我国为结石高发国家,经过泌尿外科医师不断的开拓创新,泌尿道结石的治疗方法不断改进,特别是近半个世纪以来,更有效、更微创的治疗方式得到迅猛发展,经皮肾镜碎石取石术(PCNL)已经成为肾结石与输尿管上段结石治疗首选,而PCNL放置肾造瘘管和输尿管支架管一度是手术常规步骤。但置管带来的诸如术后疼痛、延长住院时间、增加感染风险、输尿管支架取出等等问题得到越来越多的泌尿外科医师的关注。一种无管化PCNL的手术方式开始被提出并被一定数量的临床实践证明了其安全性及有效性。但由于目前无管化PCNL还未得到公认,循证医学证据及大样本的随机临床对照实验不足,尤其目前在我国较为紧张的医患关系下更难以推广。目的:本研究拟通过对无管化与传统PCNL术的临床对比研究进行Meta分析以期探讨无管化经皮肾镜碎石取石术临床应用的安全性和有效性并指导实践。方法:参考Cochrane手册制定检索策略,计算机检索PubMed、临床对照试验资料库(CENTRAL)等数据库并手工辅助检索《中华泌尿外科杂志》、《现代泌尿外科学杂志》等在2006年至2016年关于无管化PCNL与传统PCNL临床对比研究的文献。严格按照纳入和排除标准对文献进行筛选,最后得到13篇文献研究,采用Jadad评分法对文献研究质量进行评价分析之后,运用RevMan5.3软件对阅读全文收集到的各研究中住院时间、手术时间、结石清除率、术后血红蛋白下降量、术后输血、术后疼痛VAS评分、术后镇痛药物需求量、术后尿外渗、术后发热及术后恢复正常活动时间的数据进行Meta分析。结果:入选的13篇文献样本量包括实验组602例,对照组590例;住院时间:有10篇文献统计分析了住院时间,结果显示实验组无管化PCNL比对照组传统PCNL平均缩短住院时间1.45天,95%CI为-1.45[-1.91,-0.99];Z=6.22(P0.00001);手术时间:10篇文献进行了统计,实验组无管化PCNL比对照组传统PCNL平均缩短手术时间0.3min;95%CI为-0.30[-0.44,-0.16],Z=4.29(P0.0001)。结石清除率:7篇进行了报道,95%CI为1.07[0.69,1.66],Z=0.30(P=0.76)表明两组间结石清除率差异没有统计学意义。血红蛋白下降量:5篇文献进行了报道,95%CI为-0.02[-0.22,0.17],Z=0.24(P=0.81)表明两组间术后血红蛋白下降量无明显差异。术后输血:9篇文献对术后输血进行了统计,95%CI为0.69[0.44,1.08],Z=1.62(P=0.10)表明两组间术后输血情况没有统计意义上的差异。术后疼痛VAS评分:5篇进行了VAS疼痛评分,95%CI为-2.67[-4.38,-0.97],表明实验组比对照组平均降低2.63;Z=3.07(P=0.002)。术后镇痛药物需要量:5篇研究数据Meta分析显示95%CI为-0.97[-1.42,-0.52],实验组比对照组使用镇痛药物量明显下降,Z=4.21(P0.0001)。手术并发症:术后尿外渗(Z=0.48 P=0.63)及术后发热(Z=1.96 P=0.05)两组之间差异没有统计学意义。术后恢复正常活动需要时间比较:4篇纳入的文献收集的数据分析显示95%CI为-1.36[-2.31,-0.41],Z=2.81(P=0.005),提示无管化组能使患者更早的恢复正常活动,差异有统计学意义。结论:对于符合入选标准的患者无管化PCNL结石清除率、手术输血、术后尿外渗、术后发热与传统PCNL相比无明显差异,并且具有缩短住院及手术时间,减轻患者的术后疼痛感的优势,是安全有效的手术方式、值得推广应用。
[Abstract]:BACKGROUND AND OBJECTIVE BACKGROUND: With the development of society, the incidence of urinary calculi is on the rise. China is a country with high incidence of urinary calculi. PCNL has become the first choice for the treatment of renal calculi and upper ureteral calculi, and PCNL placement of renal fistula and ureteral stent was once a routine procedure. Doctor's concern. An operation method of tubeless PCNL has been proposed and proved to be safe and effective by a certain number of clinical practices. However, it has not yet been recognized that tubeless PCNL, evidence-based medicine evidence and large sample randomized controlled clinical trials are insufficient, especially under the tense doctor-patient relationship in China. Objective: To explore the safety and effectiveness of the clinical application of tubeless percutaneous nephrolithotomy (PCNL) and to guide the practice through a meta-analysis of the clinical comparative study between tubeless and traditional PCNL. CENTRAL and other databases and manually assisted searches of the Chinese Journal of Urology and the Journal of Modern Urology were conducted from 2006 to 2016. Literatures on the clinical comparison between non-tubular PCNL and traditional PCNL were screened strictly according to inclusion and exclusion criteria, and 13 literatures were obtained. The Jadad scoring method was used to study the literatures. After evaluating and analyzing the quality of the study, RevMan 5.3 software was used to collect the data of hospitalization time, operation time, stone clearance rate, postoperative hemoglobin decrease, postoperative blood transfusion, postoperative pain VAS score, postoperative analgesic drug demand, postoperative urinary extravasation, postoperative fever and postoperative recovery time of normal activity. Results: The sample size of 13 articles included 602 cases in the experimental group and 590 cases in the control group; hospitalization time: 10 articles were statistically analyzed. The results showed that the average hospitalization time of the experimental group was 1.45 days, 95% CI was - 1.45 [- 1.91, - 0.99], Z = 6.22 (P 0.00001); operation time: 10 articles. Statistical results showed that the average operative time of PCNL in the experimental group was 0.3 minutes shorter than that in the control group; 95% CI was - 0.30 [- 0.44, - 0.16], Z = 4.29 (P 0.0001). Stone clearance rate: 7 papers were reported, 95% CI was 1.07 [0.69, 1.66], Z = 0.30 (P = 0.76) showed no significant difference between the two groups. Postoperative blood transfusion: There was no significant difference in postoperative hemoglobin loss between the two groups. Postoperative blood transfusion: Nine literatures analyzed postoperative blood transfusion, 95% CI 0.69 [0.44,1.08], Z = 1.62 (P = 0.10) showed no statistical difference in postoperative blood transfusion between the two groups. VAS pain score, 95% CI was - 2.67 [- 4.38, - 0.97], indicating that the experimental group than the control group decreased by an average of 2.63; Z = 3.07 (P = 0.002). Postoperative analgesic drug requirements: 5 research data Meta analysis showed that 95% CI was - 0.97 [- 1.42, - 0.52], the experimental group compared with the control group using analgesic drugs significantly decreased, Z = 4.21 (P 0.0001). Surgical complications: postoperative urinary tract. There was no significant difference between the two groups (Z = 0.48 P = 0.63) and postoperative fever (Z = 1.96 P = 0.05). Conclusion: There is no significant difference in stone clearance rate, blood transfusion, postoperative urinary extravasation, postoperative fever and postoperative pain between PCNL and traditional PCNL, and it is a safe and effective surgical method.
【学位授予单位】：南昌大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699
本文编号：2194078
[Abstract]:BACKGROUND AND OBJECTIVE BACKGROUND: With the development of society, the incidence of urinary calculi is on the rise. China is a country with high incidence of urinary calculi. PCNL has become the first choice for the treatment of renal calculi and upper ureteral calculi, and PCNL placement of renal fistula and ureteral stent was once a routine procedure. Doctor's concern. An operation method of tubeless PCNL has been proposed and proved to be safe and effective by a certain number of clinical practices. However, it has not yet been recognized that tubeless PCNL, evidence-based medicine evidence and large sample randomized controlled clinical trials are insufficient, especially under the tense doctor-patient relationship in China. Objective: To explore the safety and effectiveness of the clinical application of tubeless percutaneous nephrolithotomy (PCNL) and to guide the practice through a meta-analysis of the clinical comparative study between tubeless and traditional PCNL. CENTRAL and other databases and manually assisted searches of the Chinese Journal of Urology and the Journal of Modern Urology were conducted from 2006 to 2016. Literatures on the clinical comparison between non-tubular PCNL and traditional PCNL were screened strictly according to inclusion and exclusion criteria, and 13 literatures were obtained. The Jadad scoring method was used to study the literatures. After evaluating and analyzing the quality of the study, RevMan 5.3 software was used to collect the data of hospitalization time, operation time, stone clearance rate, postoperative hemoglobin decrease, postoperative blood transfusion, postoperative pain VAS score, postoperative analgesic drug demand, postoperative urinary extravasation, postoperative fever and postoperative recovery time of normal activity. Results: The sample size of 13 articles included 602 cases in the experimental group and 590 cases in the control group; hospitalization time: 10 articles were statistically analyzed. The results showed that the average hospitalization time of the experimental group was 1.45 days, 95% CI was - 1.45 [- 1.91, - 0.99], Z = 6.22 (P 0.00001); operation time: 10 articles. Statistical results showed that the average operative time of PCNL in the experimental group was 0.3 minutes shorter than that in the control group; 95% CI was - 0.30 [- 0.44, - 0.16], Z = 4.29 (P 0.0001). Stone clearance rate: 7 papers were reported, 95% CI was 1.07 [0.69, 1.66], Z = 0.30 (P = 0.76) showed no significant difference between the two groups. Postoperative blood transfusion: There was no significant difference in postoperative hemoglobin loss between the two groups. Postoperative blood transfusion: Nine literatures analyzed postoperative blood transfusion, 95% CI 0.69 [0.44,1.08], Z = 1.62 (P = 0.10) showed no statistical difference in postoperative blood transfusion between the two groups. VAS pain score, 95% CI was - 2.67 [- 4.38, - 0.97], indicating that the experimental group than the control group decreased by an average of 2.63; Z = 3.07 (P = 0.002). Postoperative analgesic drug requirements: 5 research data Meta analysis showed that 95% CI was - 0.97 [- 1.42, - 0.52], the experimental group compared with the control group using analgesic drugs significantly decreased, Z = 4.21 (P 0.0001). Surgical complications: postoperative urinary tract. There was no significant difference between the two groups (Z = 0.48 P = 0.63) and postoperative fever (Z = 1.96 P = 0.05). Conclusion: There is no significant difference in stone clearance rate, blood transfusion, postoperative urinary extravasation, postoperative fever and postoperative pain between PCNL and traditional PCNL, and it is a safe and effective surgical method.
【学位授予单位】：南昌大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699
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