双侧同步内镜手术治疗双侧上尿路结石的临床效果

doi:10.19723/j.issn.1671-167X.2020.04.014

摘要/Abstract

摘要：

目的: 探讨双侧同步内镜手术(simultaneous bilateral endoscopic surgery, SBES)治疗双侧上尿路结石的有效性和安全性,并总结相关经验。方法: 选择2019年1月至2020年1月在北京朝阳医院泌尿外科诊断双侧上尿路结石、接受SBES手术治疗的患者进行回顾性研究。记录患者人口学和临床资料,统计手术情况、清石率(stone free rate, SFR)及术后并发症。主要终点事件为SFR,次要终点事件为术后并发症。结果: 23例患者接受SBES手术,19例患者顺利完成手术(男性12例,女性7例),平均年龄(41.3±12.0)岁, 其中改良仰卧位手术14例,俯卧分腿位5例,两组间人口学和临床基线资料差异无统计学意义。除1例患者接受俯卧分腿位右侧经皮肾镜(percutaneous nephrolithotomy, PCNL)和左侧多镜联合(endoscopic combined intra-renal surgery, ECIRS)碎石术,其余18例患者均接受一侧PCNL和对侧输尿管镜(retrograde intra-renal surgery, RIRS)同步手术。19例患者平均麻醉时间和手术时间分别为(128.7±26.5) min和(70.7±20.3) min,俯卧分腿位和改良仰卧位麻醉时间分别为(148.4±20.4) min和(121.6±25.3) min (t=-2.121,P=0.049);俯卧分腿位和改良仰卧位手术时间分别为(86.4±21.1) min和(65.1±17.4) min (t=-2.222,P=0.040),俯卧分腿位手术患者平均麻醉时间和手术时间显著长于改良仰卧位手术患者。肾造瘘管留置时间[俯卧分腿位和改良仰卧位分别为(2.6±0.9) d和(2.1±1.0) d,t=-0.880,P=0.391]和住院时间[俯卧分腿位和改良仰卧位分别为(6.0±2.7) d和(5.2±1.8) d,t=-0.731,P=0.475]两组间差异无统计学意义。术后1个月 SFR为78.9%, 3例患者出现围手术期轻微并发症(Clavien-Dindo分级Ⅰ/Ⅱ), 无严重并发症(Clavien-Dindo分级Ⅲ/Ⅳ/Ⅴ)发生。结论: 开展SBES手术可在保证清石率的前提下,减少手术时间和麻醉暴露,有助于降低手术并发症风险,尤其对于一般情况较差无法耐受再次手术或长时间手术及恐惧再次手术的患者尤为重要。

关键词: 双侧上尿路结石, 同步手术, 内镜手术

Abstract:

Objective: To discuss the efficacy and safety of simultaneous bilateral endoscopic surgery (SBES) for bilateral upper urinary tract calculi, and to summarize the initial experience. Methods: Patients diagnosed with bilateral upper urinary tract calculi who underwent SBES in the Department of Urology, Beijing Chao-Yang Hospital from January 2019 to January 2020 were enrolled retrospectively. The demographic and clinical data of the patients were recorded, and the operation status, stone free rate (SFR) and peri-operative complications were analyzed. The primary end point was SFR, and second end point was peri-operative complications. Results: A total of 23 patients underwent SBES, of which SBES was completed in 19 patients (12 males, and 7 females). The mean age was (41.3±12.0) years. Fourteen patients underwent modified supine position surgery and 4 patients in prone split-leg position. There was no statistical difference in the demographic and baseline clinical data of the patients in different positions. One patient underwent right percutaneous nephrolithotomy (PCNL) and left endoscopic combined intra-renal surgery (ECIRS) in the prone split-leg position, while 18 patients received simul-taneous surgery with PCNL and contralateral retrograde intra-renal surgery (RIRS). The mean anesthesia and operation time was (128.7±26.5) min and (70.7±20.3) min, respectively, which was significantly longer in the patients with prone split-leg position than in the patients with modified supine position, anesthesia time in the patients with prone split-leg position and modified supine position: (148.4±20.4) min vs. (121.6±25.3) min, respectively, t=-2.121, P=0.049, while the operation time in the patients with prone split-leg position and modified supine position: (86.4±21.1) min vs. (65.1±17.4) min, respectively, t=-2.222, P=0.040. There was no significant difference between the two groups in indwelling of nephrostomy [prone split-leg position and modified supine position: (2.6±0.9) d vs. (2.1±1.0) d, respectively; t=-0.880, P=0.391] and the length of hospital stay [prone split-leg position and modified supine position: (6.0±2.7) d vs. (5.2±1.8) d, respectively; t=-0.731, P=0.475]. One month after the operation, the SFR was 78.9%, and 3 patients had minor peri-operative complications (Clavien-Dindo grades Ⅰ/Ⅱ) without any serious complications (Clavien-Dindo grades Ⅲ/Ⅳ/Ⅴ). Conclusion: The simultaneous bilateral endoscopic surgery would decrease the operation time and anesthesia exposure under the premise of ensuring the SFR, which is helpful to reduce the risk of peri-operative complications, especially to the patients who can not tolerate the second-stage or long-time operation.

Key words: Bilateral upper urinary tract calculi, Simultaneous surgery, Endoscopic surgery

中图分类号:

R693⁺.4

张军晖,蒋一航,蒋宇光,张际青,康宁. 双侧同步内镜手术治疗双侧上尿路结石的临床效果[J]. 北京大学学报（医学版）, 2020, 52(4): 672-677.

Jun-hui ZHANG,Yi-hang JIANG,Yu-guang JIANG,Ji-qing ZHANG,Ning KANG. Clinical outcomes of simultaneous bilateral endoscopic surgery for bilateral upper urinary tract calculi[J]. Journal of Peking University (Health Sciences), 2020, 52(4): 672-677.

图/表 4

图1

表1

患者人口学及临床数据"

Items	Total (n=19)	Modified supine position (n=14)	Prone split-leg position (n=5)	χ²/t	P
Male/female, n	12/7	9/5	3/2	0.029	0.865
Age/years, $x ?$ ±s	41.3±12.0	43.4±11.1	35.2±13.7	1.344	0.196
BMI/kg/m², $x ?$ ±s	26.5±4.5	26.0±4.7	28.0±3.9	-0.829	0.419
ASA score, $x ?$ ±s	1.7±0.5	1.7±0.5	1.8±0.4	-0.355	0.727
Stone size/mm, $x ?$ ±s
PCNL side	25.6±9.4	23.2±7.7	32.1±11.6	-1.921	0.072
RIRS side	18.2±7.4	17.8±7.8	19.1±6.8	-0.332	0.744
Hounsfield unit/HU, $x ?$ ±s
PCNL side	937.0±317.0	998.2±319.7	765.6±264.4	1.452	0.165
RIRS side	946.3±368.1	1 012.9±389.1	759.7±242.5	1.350	0.195
Stone composition, n				3.661	0.300
Calcium oxalate	13	10	3
Magnesium Ammonium phosphate	3	2	1
Uric acid	2	2	0
Cystine	1	0	1

表1

图2

表2

患者围手术期数据"

Items	Total (n=19)	Modified supine position (n=14)	Prone split-leg position (n=5)	χ²/t	P
Anesthesia time/min, $x ?$ ±s	128.7±26.5	121.6±25.3	148.4±20.4	-2.121	0.049
Operation time/min, $x ?$ ±s	70.7±20.3	65.1±17.4	86.4±21.1	-2.222	0.040
PCNL sheath (16F/24F), n	7/12	6/8	1/4	0.827	0.363
Indwelling of nephrostomy/d, $x ?$ ±s	2.3±1.0	2.1±1.0	2.6±0.9	-0.880	0.391
SFR, n(%)	15(78.9)	11(78.6)	4(80.0)	0.005	0.946
Complication by Clavien-Dindo grade Ⅰ/Ⅱ, n	3	2	1	0.090	0.764
Length of hospital stay/d, $x ?$ ±s	5.4±2.0	5.2±1.8	6.0±2.7	-0.731	0.475

表2

参考文献 14

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