经皮肾镜术中不同憩室颈部处理方式治疗肾盏憩室结石的长期预后

doi:10.19723/j.issn.1671-167X.2021.04.014

摘要/Abstract

摘要：

目的: 比较经皮肾镜术中切开法与扩张法两种不同处理憩室颈部的方式治疗肾盏憩室结石的长期预后。方法: 选择2009年6月至2019年1月在北京大学人民医院经皮肾镜取石术治疗肾盏憩室结石患者的临床资料进行回顾性分析,记录年龄、性别、体重指数(body mass index,BMI)、美国麻醉师协会(American Society of Anesthesiology, ASA)分级和术前症状等患者基本情况,结石位置、大小等结石特征数据,皮肾通道长度、手术时长等手术相关数据,以及术后血红蛋白下降幅度、Clavien并发症分级、无石率等围手术期临床资料,并进行了5年以上的长期随访。结果: 53例患者纳入本研究,根据术中处理憩室颈部方式的不同分为扩张组(n=37)和切开组(n=16), 其中男性患者24例(45.3%), 女性29例(54.7%),平均年龄为(39.96±12.88)岁,大多数憩室结石位于肾上极(n=32,60.38%)和背侧(n=41,77.4%),以单发结石为主(n=36,67.9%),两组间人口学数据及结石特征数据除年龄及结石负荷外差异无统计学意义。45例(84.9%)患者术后达到无石状态,44例(83.0%)患者术后症状得到改善。术后12例患者失访,41例患者的平均随访时间为77个月。在术后1年时有1例出现复发。截止2021年3月,15例患者术后随访未满5年,剩余26例术后5年复发率为34.6%。两组患者围手术期并发症发生率、术后无石率及复发率差异均无统计学意义,术后5年复发率均较术后1年时明显升高,保持无石状态和残石状态患者所占比例明显下降。结论: 经皮肾镜处理憩室结石术中切开法和扩张法处理憩室颈部均可达到令人满意的术后无石率,术后5年时憩室结石复发率为30%~40%。

关键词: 经皮肾镜取石术, 憩室结石, 憩室颈部处理方式, 长期随访

Abstract:

Objective: To compare the short-term effects and long-term outcomes of incisional procedure and dilatation procedure to manage diverticular neck in percutaneous nephrolithotomy for diverticular stones. Methods: Clinical data of 61 patients with diverticular stones who underwent percutaneous nephrolithotomy from June 2009 to January 2019 were retrospectively collected and analyzed, which was as follous:(1) basic information: age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) classifications and preoperative symptoms.(2)stone characteristic and procedure-related data: location and size of stone, skinned renal access length and procedure time.(3)perioperative clinical data: hemoglobin drop, Clavien’s classification and stone-free rate. Long-term follow-ups were performed for more than 5 years after the patients were discharged. Results: Fifty-three patients were included based on the inclusion and exclusion criteria, and were divided into the dilation group (n=37) and the incision group (n=16) by the treatment methods of diverticular neck. There were 24 male patients (45.3%) and 29 female patients (54.7%), with a mean age of 39.96±12.88 years. Stones were mainly located in the upper pole (n=32,60.38%) and posterior area (n=41, 77.4%), with a predominance of single stone (n=36, 67.9%). There was no statistically significant difference in demographic data and stone characteristics between the two groups except for age and stone burden. Forty-five patients (84.9%) reached stone-free status after surgeries, and 44 patients (83.0%) postoperative symptoms improved. Twelve patients were lost to the follow-ups, and 41 cases were followed up for an average of 77 months. One recurrence occurred 1 year after surgery. Fifteen patients underwent operations within the past 5 years and the overall 5-year recurrence rate for the remaining 26 patients was 34.6%. There was no statistically significant difference in the incidence of perioperative complications, postoperative stone-free rate and recurrence rate between the two groups, and the recurrence rate was significantly higher 5 years postoperatively than 1 year postoperatively. The proportion of the patients who remained lithotripsy-free and residual stone status decreased significantly. Conclusion: Both incisional and dilatation procedures in percutaneous nephrolithotomy to manage diverticular neck could bring the satisfactory postoperative stone free rate. The recurrence rate was about 30% to 40% 5 years after surgery.

Key words: Percutaneous nephrolithotomy, Diverticular calculi, Diverticular neck management, Long-term follow-up

中图分类号:

R692.4

戴翔,左美妮,张晓鹏,胡浩,徐涛. 经皮肾镜术中不同憩室颈部处理方式治疗肾盏憩室结石的长期预后[J]. 北京大学学报（医学版）, 2021, 53(4): 704-709.

DAI Xiang,ZUO Mei-ni,ZHANG Xiao-peng,HU Hao,XU Tao. Comparison of long-term outcomes in different managements of diverticular neck in percutaneous nephrolithotomy for diverticular calculi[J]. Journal of Peking University (Health Sciences), 2021, 53(4): 704-709.

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参考文献 12

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Variable	Total	Dilation group	Incision group	P
n	53	37	16
Age/years, $\bar{x}±s$	39.96±12.88	42.89±11.96	33.19±12.72	<0.01
Gender, n(%)				0.654
Male	24 (45.3)	18 (48.6)	6 (37.5)
Female	29 (54.7)	19 (51.4)	10 (62.5)
BMI /(kg/m²)	24.2±3.63	24.47±3.34	23.57±4.28	0.414
ASA classification, n(%)				0.363
1	36 (67.9)	23 (62.2)	13 (81.2)
2	16 (30.2)	13 (35.1)	3 (18.8)
3	1 (1.9)	1 (2.7)	0 (0)
Stone site, n(%)				0.419
Left	26 (49.1)	20 (54.1)	6 (37.5)
Right	27 (50.9)	17 (45.9)	10 (62.5)
Pre-operative manifestation, n(%)				0.256
None	7 (13.2)	4 (10.8)	3 (18.7)
Slight discomfort	6 (11.3)	5 (13.5)	1 (6.3)
Pain	31 (58.5)	21 (56.9)	10 (62.4)
Gross hematuria	4 (7.5)	3 (8.1)	1 (6.3)
Urinary irritation	5 (9.5)	4 (10.8)	1 (6.3)

Variable	Total	Dilation group	Incision group	P
Classification of diverticular				0.454
Ⅰ	24	18	6
Ⅱ or Ⅲ	29	19	10
Anterior/posterior, n(%)				0.382
Anterior	12 (22.6)	9 (24.3)	3 (18.8)
Posterior	41 (77.4)	28 (75.7)	13 (81.2)
Single/multiple, n(%)				0.665
Single	36 (67.9)	25 (67.6)	11 (68.8)
Multiple	17 (32.1)	12 (32.4)	5 (31.2)
Localization, n(%)				0.263
Upper	32 (60.38)	25 (67.6)	7 (43.8)
Middle	16 (30.19)	9 (24.3)	7 (43.8)
Lower	5 (9.43)	3 (8.1)	2 (12.5)
Stone burden/mm², $\bar{x}±s$	138.1±144.5	143.7±160.2	122.3±84.5	<0.05
SHA.LIN score, $\bar{x}±s$	9.47±0.67	9.50±0.76	9.40±0.52	0.705

Variable	Total	Dilation group	Incision group	P
Mean hospitalization period /d	6.6±2.6	6.2±2.6	7.3±2.6	0.202
Mean operation time/min	75.0±37.0	74.3±37.6	76.6±36.9	0.842
Mean hemoglobin drop/(g/L)	21.1±15.4	22.4±16.7	17.9±11.9	0.334
Mean hemoglobin drop percentage/%	14.8±10.5	16.0±11.0	13.0±8.0	0.370
Post-operative complication^*, n(%)				0.392
None	40 (75.47)	27 (73.0)	13 (81.2)
Grade Ⅰ to Ⅱ	4 (7.55)	4 (5.4)	0 (0.0)
Grade Ⅲ to Ⅳ	9 (16.98)	6 (16.2)	3 (18.8)
Post-operative stone free status, n(%)	45 (84.9)	33 (89.1)	12 (75.0)	0.538