输尿管软镜与微通道经皮肾镜碎石术在输尿管上段结石治疗中的疗效对比

发布时间：2018-09-03 08:28

【摘要】：目的通过对输尿管软镜与微通道经皮肾镜碎石术治疗输尿管上段结石的对比研究，探讨两种术式的安全性及有效性，从而为在临床工作中治疗输尿管上段结石选择合适的手术方式提供有效帮助。方法选取河北大学附属医院2012年12月至2013年11月符合病例入选标准的60例输尿管上段结石患者为研究对象。按入院病历单双号分为奇、偶数，奇数为输尿管软镜组，偶数为微通道经皮肾镜组，分别采用输尿管软镜钬激光碎石术和微通道经皮肾镜钬激光碎石术治疗。入选的60例患者中，男38例，女22例，年龄30～65岁；患右侧输尿管上段结石28例，左侧输尿管上段结石32例，结石直径为1.50±0.25(0.9～2.0)cm；病程约2个月～18个月，均伴有轻度肾积水，入院时尿常规及血常规中白细胞及中性粒细胞未见异常。输尿管软镜组中，男18例，女12例，年龄30～62岁，平均年龄48岁，右侧输尿管上段结石13例，左侧输尿管上段17例，结石直径为1.51±0.26(0.9～2.0)cm；微通道经皮肾镜组中，，男20例，女10例，年龄32～65岁，平均年龄46岁，右侧输尿管上段结石15例，左侧输尿管上段15例，结石直径为1.49±0.24(0.9～2.0)cm。对两组患者手术时间、术中出血量、术后住院天数、结石清除率、舒适度、疼痛度及创伤指标（血CRP、IL-6和血WBC）进行比较。根据数据类型选用X2检验、两样本t检验，P0.05差异有统计学意义，全部统计学分析使用SPSS16.0软件。结果输尿管软镜组与微通道经皮肾镜组相比，两组患者手术时间分别为输尿管软镜组86.50±12.81（min）、微通道经皮肾镜组81.83±12.76（min），差异无统计学意义(P＞0.05)。出血量分别为输尿管软镜组2.20±0.58（ml）、微通道经皮肾镜组12.53±2.12（ml），术后住院时间分别为输尿管软镜组3.33±0.61（d）、微通道经皮肾镜组5.47±0.73（d），输尿管软镜组在出血量及术后住院时间明显低于微通道经皮肾镜组，差异有统计学意义(P0.01)。两组患者一期手术均成功，无穿刺及置输尿管软镜失败者。两组患者术后1周内查尿路平片观察双J管的位置均正常；碎石效果方面，输尿管软镜组结石残留23.33%(7/30)，微通道经皮肾镜组结石残留20.00%(6/30)，后行ESWL治疗。术后1个月结石清除率分别为输尿管软镜组90.00%（27/30）、微通道经皮肾镜组96.70%（29/30），3个月结石清除率分别为输尿管软镜组100%（30/30）、微通道经皮肾镜组100%（30/30）。通过比较输尿管软镜组碎石清石率与微通道经皮肾镜组碎石清石率，两组间无明显差异(P＞0.05)。通过对两组患者进行问卷调查，输尿管软镜组术后4、12、24、48h BCS舒适度评分分别为2.53±0.51、2.93±0.58、3.47±0.51、3.77±0.43均高于微通道经皮肾镜组1.27±0.78、1.63±0.57、2.67±0.58、2.90±0.61(P0.01)，输尿管软镜组术后4、12、24、48h视觉模拟量表（VAS）测量疼痛评分分别为4.03±1.03、2.77±0.86、1.40±0.77、0.83±0.65均低于微通道经皮肾镜组6.90±1.49、5.50±1.20、3.63±1.16、2.37±0.93，差异有统计学意义(P0.01)。术前两组CRP水平分别为5.13mg/L、5.09mg/L，无明显差异性，而术后24小时两组均有不同程度升高，尤其是经微通道皮肾镜组20.42mg/L，升高幅度明显高于输尿管软镜组平均水平10.91mg/L,经比较两种手术对血CRP的影响有明显差异性(P0.05)。术前两组IL-6水平分别为6.42ng/L、6.58ng/L，无明显差异性，而术后24小时两组均有不同程度升高，尤其是微通道经皮肾镜组15.56ng/L，升高幅度明显高于输尿管软镜组平均水平10.74ng/L,经比较两种手术对血IL-6的影响有明显差异性(P0.05)。术前两组血WBC均数分别为6.3×109/L、6.39×109/L，无明显差异性，术后24小时两组血WBC均有所增高，但均数在正常范围内，分别为7.49×109/L、7.4×109/L，只有输尿管软镜组2例患者出现血WBC超出正常范围，差异无统计学意义(P＞0.05)。结论输尿管软镜碎石术治疗输尿管上段结石较微通道经皮肾镜碎石术操作简单、创伤更小、更安全、疗效确切，是目前治疗输尿管上段结石较理想的手术方式，值得临床进一步推广应用。
[Abstract]:Objective To investigate the safety and efficacy of two kinds of ureteroscopic lithotripsy for the treatment of upper ureteral calculi, so as to provide effective help for the selection of appropriate surgical methods for the treatment of upper ureteral calculi in clinical work.
Methods Sixty patients with upper ureteral calculi who met the enrollment criteria from December 2012 to November 2013 in the Affiliated Hospital of Hebei University were divided into odd, even, odd ureteroscopic group and even microchannel percutaneous nephrolithotomy group according to their admission records. Percutaneous nephrolithotomy with holmium laser lithotripsy was performed in 60 patients, including 38 males and 22 females, aged 30-65 years; 28 patients with right upper ureteral calculi, 32 patients with left upper ureteral calculi, the diameter of calculi was 1.50 (+ 0.25) (0.9-2.0) cm; the course of the disease was about 2 months to 18 months, all with mild hydronephrosis, and the urinary and blood routine were white at admission. There were 18 males and 12 females with an average age of 30-62 years, 13 right upper ureteral calculi, 17 left upper ureteral calculi with a diameter of 1.51 (+ 0.26) (0.9-2.0) cm, and 20 males and 10 females with an average age of 32-65 years and 46 right upper ureteral calculi in the microchannel percutaneous nephroscopy group. There were 15 cases of upper ureteral calculi, 15 cases of upper left ureteral calculi, and the diameters of calculi were 1.49 [(0.9-2.0) cm. The operative time, intraoperative bleeding volume, postoperative hospital stay, stone clearance rate, comfort degree, pain degree and trauma index (blood CRP, IL-6 and WBC) were compared between the two groups. The difference was statistically significant, all statistical analysis using SPSS16.0 software.
Results Compared with the micro-channel percutaneous nephroscopy group, the operation time of the two groups were 86.50 (+ 12.81) min in the soft ureteroscope group and 81.83 (+ 12.76) min in the micro-channel percutaneous nephroscopy group, with no significant difference (P > 0.05). The postoperative hospitalization time was 3.33 [0.61] (d) in the flexible ureteroscopy group, 5.47 [0.73] (d) in the microchannel percutaneous nephroscopy group, and significantly lower than that in the microchannel percutaneous nephroscopy group (P The lithotripsy effect was 23.33% (7/30) in the flexible ureteroscope group, 20.00% (6/30) in the microchannel percutaneous nephroscope group, and ESWL was performed. The stone clearance rate was 90.00% (27/30) in the flexible ureteroscope group and 96.70% (29/30) in the microchannel percutaneous nephroscope group, respectively. The lithotripsy rate of the two groups was 100% (30/30) in the flexible ureteroscope group and 100% (30/30) in the microchannel percutaneous nephroscope group, respectively. S comfort scores were 2.53 (+ 0.51), 2.93 (+ 0.58), 3.47 (+ 0.51), 3.77 (+ 0.43) higher than those of microchannel percutaneous nephroscopy group (1.27 (+ 0.78), 1.63 (+ 0.57), 2.67 (+ 0.58), 2.90 (+ 0.61) (P 0.01). Visual analogue scale (VAS) scores were 4.03 (+ 1.03), 2.77 (+ 0.86), 1.40 (+ 0.77), and 650.83 (+ 0.83) lower than those of microchannel group (P 0.01). The levels of CRP in the two groups were 5.13mg/L and 5.09mg/L before operation, respectively. There was no significant difference between the two groups. The levels of CRP in the two groups increased in different degrees 24 hours after operation, especially 20.42mg/L in the microchannel group, which was significantly higher than that in the ureteroscopic group. The levels of IL-6 in the two groups were 6.42 ng/L and 6.58 ng/L before operation, respectively. However, the levels of IL-6 in the two groups increased in different degrees 24 hours after operation, especially in the microchannel percutaneous nephroscopy group (15.56 ng/L), which was significantly higher than the average level of 10.74 in the flexible ureteroscopy group (10.74 ng/L). The mean WBC of the two groups were 6.3 *109/L and 6.39 *109/L before operation, respectively. There was no significant difference between the two groups. The WBC of the two groups increased 24 hours after operation, but the mean values were within the normal range, 7.49 *109/L and 7.4 *109/L respectively. Only 2 patients in the ureteroscopic group had WBC ultrasonography. There was no significant difference in normal range (P > 0.05).
Conclusion Compared with micro-channel percutaneous nephrolithotomy, flexible ureteroscopic lithotripsy is a simple, less invasive, safe and effective method for the treatment of upper ureteral calculi.
【学位授予单位】：河北大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R699.4

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