摘要
目的分析4种腔镜术式治疗输尿管上段直径〉1cm结石的临床疗效。方法回顾性分析2012年7月至2015年9月分别采用输尿管硬镜碎石术（URL）、后腹腔镜输尿管切开取石术（RLU）、经皮肾镜取石术（PCNL）和输尿管软镜碎石术（FURL）治疗的150例输尿管上段结石患者的临床资料。根据手术方式不同，分为URL组、RLU组、PCNL组和FURL组。URL组39例，男25例，女14例；年龄（48.8±10.2）岁；左侧26例，右侧13例。RLU组32例，男19例，女13例；年龄（49.8±8.1）岁；左侧22例，右侧10例。PCNL组36例，男23例，女13例；年龄（50.7±8.4）岁；左侧25例，右侧11例。FURL组43例，男29例，女14例；年龄（51.9±6.8）岁；左侧31例，右侧12例。除RLU组和PCNL组结石直径明显大于URL组和FURL组外（P〈0.05），4组在性别、年龄、结石位置、术前尿白细胞升高患者比例及体外冲击波碎石（ESWL）治疗失败比例等方面比较，差异均无统计学意义（P〈0.05）。比较4组手术时间、术后住院时间、术后肠道恢复时间、血红蛋白降低值、术后需ESWL治疗的比率、并发症、术后3 d和1个月结石清除率等。结果URL组、RLU组、PCNL组和FURL组手术时间分别为（38.5±13.0）min、（83.4±6.1）min、（69.6±13.0）min和（50.1±6.3）min, 4组间比较差异均有统计学意义（P〈0.05）。URL组、RLU组、PCNL组和FURL组术后住院时间分别为（6.5±0.6）d、（9.5±0.7）d、（8.4±0.7）d和（7.7±0.7）d，4组间比较差异均有统计学意义（P〈0.05）。URL组、RLU组、PCNL组和FURL组术后3 d结石清除率分别为79.5 %（31/39）、100.0%（32/32）、94.4%（34/36）和88.4%（38/43），术后1个月结石清除率分别为82.1%（32/39）、100.0%（32/32）、97.2%（35/36）和95.3%（41/43）。RLU组术后3 d及术后1个月结石清除率均显著高于URL组（P〈0.05），但PCNL组与RLU组间术后3d及术后1个月结石清除率比较，差异均无统计学意义（P〉0.05）。URL组、RLU组、PCNL组和FURL组术后需ESWL治疗的比率分别为12.8%（5/39）、0、2.8%（1/3）、4.7%（2/43），差异无统计学意义（P〉0.05）。术后PCNL组血红蛋降低值[（1.44±0.63）g/L]高于URL组和RLU组[分别为（0.51±0.30）、（0.62±0.41） g/L，P〈0.05]，FURL组[（0.82±0.32） g/L]高于URL组（P〈0.05）；其中PCNL组1例术后出现大出血需要输血治疗，其余患者均未输血。4组总体并发症发生率分别为23.1%（9/39）、9.4%（3/32）、13.9%（5/36）、9.3%（4/43），差异无统计学意义（P〉0.05）。结论根据不同的病例特点灵活应用或联合使用4种腔镜，对治疗输尿管上段直径〉1 cm的结石具有创伤小、恢复快等优点。URL操作简单，损伤小，术后恢复快，但清石率低。FURL对术者技术要求较高，可作为直径〈2 cm的输尿管上段、肾盂、肾盏结石的有效治疗手段，避免了额外的ESWL治疗，但成本高。PCNL损伤大，对术者技术熟练程度要求高，结石清除率高。RLU结石清除率高，手术难度较高，可作为FURL或PCNL失败的补救治疗。
ObjectiveTo analyze the four types of laparoscopic operation in the treatment of upper ureteral calculi with diameter more than 1cm.MethodsFrom July 2012 to September 2015, 150 cases of patients with upper ureteral calculi diameter more than 1cm were analyzed. According to the different surgical methods, patients were divided into four groups. There are 39 cases in URL group, 32 cases in RLU group, 36 cases in PCNL group and 43 cases in FURL group. The diameter of calculi in RLU group and PCNL group was much larger than those in URL group and FURL group（P〈0.05）. There was no difference in terms of sex, age, stone location, stone composition, and the ESWL treatment failure rate among the four groups（P〉0.05）. The operation time, postoperative hospitalization days, postoperative bowel recovery, postoperative ESWL rate, complications and postoperative calculi clearance rate were compared among the four groups.ResultsIn RLU , PCNL , URL and FURL group, the operation time were （38.5±13.0）min, （83.4±6.1）min, （69.6±13.0）min and（50.1±6.3）min, respectively, and there were significant differences among the four groups （RLU group〉PCNL group〉FURL group〉URL group, P〈0.05）. Postoperative hospitalization days of RLU group , PCNL group , URL group and FURL group were （6.5±0.6）d, （9.5±0.7）d, （8.4±0.7）d and（7.7±0.7）d respectively, and there were significant differences in terms of hospitalization days （RLU group〉PCNL group〉FURL group〉URL group, P〈0.05）. The calculi clearance rates of RLU group, PCNL group, URL group and FURL group were 79.5%, 100.0%, 94.4% and 88.4% at 3 days after operation, and 82.1%, 100.0%, 97.2% and 95.3% at 1 month after operation. The postoperative calculi clearance rates at 3 days and 1 month in RLU group were higher than those in URL group（P〈0.05）, but there was no difference between PCNL group and RLU group （P〉0.05）. Postoperative ESWL rates of RLU group, PCNL group, URL group and FURL group were 12.8%, 0, 2.8% and 4.7% , and there was no difference among the four groups. The decreased value of RBC in PCNL group and FURL group was higher than that of URL group and RLU group（P〈0.05）. One patient in PCNL group suffered from massive hemorrhage, and required blood transfusion. The complication rates in the four groups were 23.1%（9/39）, 9.4%（3/32）, 13.9%（5/36） and 9.3%（4/43） respectively, and there was no difference of complication among them（P〉0.05）.ConclusionsFour types of endoscopes have the advantages of safety, small wound and quick recovery for ureter calculi larger than 1 cm . The URL operation is simple, with less injury, quick recovery, but low stone clearance rate. FURL requires high level of skill for the operator, and is an effective treatment for ureteric, renal pelvic, and kidney stones which are smaller than 2 cm. FURL avoids the extra ESWL treatment, but costs much. PCNL has more injury and requires high-level surgical skills with a high stone clearance rate. RLU has a high stone clearance rate but is much difficult, which can be used as a remedy for the failure of FURL or PCNL.
作者
张斌斌
强亚勇
郭巍
马亚东
贺晓龙
李义
高继学
汪峰
Zhang Binbin;Qiang Yayong;Guo Wei;Ma Yadong;He Xiaolong;Li Yi;Gao Jixue;Wang Fen(Department of Urology, Yan＇an University Affiliated Hospital, Yan′an 716000, China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2018年第4期300-304,共5页
Chinese Journal of Urology
关键词
输尿管结石
腹腔镜
输尿管镜
经皮肾镜
Ureteral calculi
Laparoscopy
Ureteroscope
Percutaneous nephrolithotomy
