覆膜金属输尿管支架维持性治疗输尿管镜碎石术后难治性输尿管狭窄的远期疗效评价

doi:10.19723/j.issn.1671-167X.2022.04.015

摘要/Abstract

摘要：

目的: 评价覆膜金属输尿管支架治疗输尿管镜碎石术后难治性输尿管狭窄(ureteroscopic lithotripsy related refractory ureteral stricture, URL-rUS)的远期疗效。方法: 选择2018年9月—2021年8月因URL-rUS在北京大学人民医院行输尿管镜下覆膜金属输尿管支架置入术患者的病例资料进行回顾性分析，将最后一次复查设定为随访终点，收集患者的基本信息、输尿管狭窄特征及覆膜金属支架置入前肾盂减压措施。将血肌酐(serum creatine, Scr)浓度及肾盂宽度(renal pelvis width, RPW)作为肾功能评价指标，记录围术期及覆膜金属支架留置的远期并发症及结局。针对术前留置D-J管的患者，使用输尿管支架症状量表(ureteral stent symptom questionnaire, USSQ)评价患者的生活质量。结果: 共纳入30例(31侧)URL-rUS患者，平均年龄为(45.5±9.3)岁，中位随访时间为14(6~36)个月。所有患者术前均曾接受过失败的内镜下球囊扩张或狭窄段内切开术。所有覆膜金属支架均一期放置成功，手术时间为60 (30~195) min，未见围术期严重并发症发生。随访中，有28侧(90.3%)覆膜金属支架始终保持通畅。仅1侧(3.2%)出现移位，1侧(3.2%)出现支架内结壳, 1侧(3.2%)出现反复严重泌尿系感染。患者的术前平均Scr浓度为(90.7±19.5) μmol/ L，RPW为(2.5±1.3) cm，终末随访时Scr浓度下降为(83.1±18.5) μmol/ L(P < 0.01)，RPW降为(1.9±0.8) cm(P < 0.01)。对于术前留置D-J(double J)管的26名患者，USSQ平均得分为100.4±6.6；在留置覆膜金属支架后，患者USSQ得分下降为(82.1±4.9，P < 0.01)，表明患者的生活质量得到显著改善。结论: 覆膜金属支架置入术是一种较为安全的微创输尿管狭窄治疗手段，术后远期通畅率较高，患者的肾功能可以得到恢复，生活质量有所提高，可以成为传统内镜治疗方式失败后的输尿管镜碎石术后输尿管狭窄患者的维持性治疗选择。

关键词: 覆膜金属支架, 难治性, 输尿管镜碎石术后输尿管狭窄, 维持性治疗, 有效性

Abstract:

Objective: To comprehensively evaluate the long-term efficacy and safety of coated metal stent implantation for ureteroscopic lithotripsy related refractory ureteral stricture (URL-rUS). Methods: Electronic medical records of 30 patients (31 affected renal units) receiving coated metal stent implantation for URL-rUS from Sept. 2018 to Aug. 2021 at Peking University People' s Hospital were reviewed for analysis. Coated metal stents were implanted in retrograde approach via ureteroscope. Last outpatient follow-up was set as endpoint. Baseline information, stricture characteristics and decompression strategy before coated metal stent implantation were retrospectively collected. Serum creatinine (Scr) concentration and renal pelvis width (RPW) were used as renal function indicators. Peri-operative and long-term complications and according outcomes were recorded. For the patients who had double J tubes implanted for drainage before operation, Ureteral Stent Symptom Questionnaire (USSQ) was applied to evaluate the stent-related discomforts and quality of life (QoL) before and after surgery. Data analysis was conducted with SPSS (version 25.0; SPSS, Chicago, IL, USA). Results: Totally 30 patients with 31 affected renal units were included. All the patients previously underwent unsuccessful traditional endoscopic balloon dilation or endoureterotomy before receiving coated metal stent implantation. The mean age was (45.5±9.3) years old. The median follow-up time were 14 (6-36) months. All coated metal stents were successfully placed with a median duration of 60 (30-195) min. No severe peri-operative complications occurred. At endpoint, 28 (90.3%) sides of coated metal stents remained unobstructed with a longest indwelling time of 36 months. Causes of failures included stent migration (1 case, 3.2%), encrustation (1 case, 3.2%) and repeated stent related urinary tract infection (1 case, 3.2%). When compared with the baseline, significant reductions were observed in both Scr concentration and RPW at endpoint [(90.7±19.5) mmol/L vs. (83.1±18.5) μmol/L, P < 0.01, for Scr; (2.5±1.3) cm vs. (1.9±0.8) cm, P < 0.01, for RPW], indicating good preservation of renal function and remission of hydronephrosis. For 26 patients with double J stents before operation, significant reduction of USSQ average score (100.4±6.6 vs. 82.1±4.9, P < 0.01) evidenced better life quality preserving ability of coated metal stent versus double J stent. Conclusion: Coated metal stent implantation is a safe and minimally invasive management of ureteral stricture providing a satisfying long-term patency rate, after which the patients' quality of life and renal function could be both improved. This method could serve as a promising alternative long-term maintenance treatment option for patients with URL-US, especially when traditional endoscopic interventions failed.

Key words: Coated metal stent, Refractory, Ureteroscopic lithotripsy related ureteral stricture, Maintenance treatment, Efficacy

中图分类号:

R691.4

张春龙,王明瑞,王起,许克新,徐涛,胡浩. 覆膜金属输尿管支架维持性治疗输尿管镜碎石术后难治性输尿管狭窄的远期疗效评价[J]. 北京大学学报（医学版）, 2022, 54(4): 674-679.

Chun-long ZHANG,Ming-rui WANG,Ming-rui WANG,Ke-xin XU,Tao XU,Hao HU. Long-term efficacy evaluation of coated metal stent implantation for ureteroscopic lithotripsy related refractory ureteral stricture[J]. Journal of Peking University (Health Sciences), 2022, 54(4): 674-679.

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参考文献 32

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Category		Number
Lateral	Left	18 (58.1%)
	Right	11 (36.7%)
	Bilateral	1 (3.2%)
Location	Ureteropelvic junction	1 (3.2%)
	Upper tract	15 (48.4%)
	Middle tract	9 (29.0%)
	Lower tract	4 (13.0%)
	Multiple sites	2 (6.4%)
Stricture length	＞2 cm	7 (21.9%)
	≤2 cm	25 (78.1%)
Previous stone history	Kidney stones	10 (32.2%)
	Ureteral stones	16 (51.6%)
	Both	5 (16.1%)
Onset symptom	Pain	24 (80.0%)
	LUTS	3 (10.0%)
	Fever	3 (10.0%)
	None	16 (25.8%)
Previous decompression	Nephrostomy	2 (6.4%)
	Balloon dilation	30 (100.0%)
	Endoureterotomy	1 (3.3%)
	Ureteral stent	26 (83.8%)

Items	Baseline	Day 1 post-operation	Last follow-up
Serum creatinine/(μmol/L)	90.7±19.5	83.1±18.5^#	83.4±14.9^*
Renal pelvis width/cm	2.5±1.3	-	1.9±0.8^#

Items	U	P	G	W	S	A	Total
Pre-operation	35.3±2.7	18.5±2.7	17.1±2.0	11.9±2.0	4.7±2.4	12.9±1.4	100.4±6.6
Post-operation	29.2±2.2	14.0±1.3	13.9±2.0	10.3±1.7	4.0±1.7	10.7±1.6	82.1±4.9
P value for paired t test	P < 0.01	P < 0.01	P < 0.01	P < 0.01	P < 0.01	P < 0.01	P < 0.01

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