北京大学学报(医学版) ›› 2015, Vol. 47 ›› Issue (1): 170-174.

• 论著 • 上一篇    下一篇

无管化经皮肾镜和输尿管镜碎石术处理最大径线1.5 cm以上输尿管上段结石的比较

张力杰,叶雄俊△,黄晓波,熊六林,马凯,李建兴,王晓峰   

  1. (北京大学人民医院泌尿外科,北京100044)
  • 出版日期:2015-02-18 发布日期:2015-02-18

Comparison of tubeless-percutaneous nephrolithotomy and ureteroscopic lithotripsy in treatment of upper-ureteral calculi sized ≥1.5 cm

ZHANG Li-jie,YE Xiong-jun△,HUANG Xiao-bo,XIONG Liu-lin, MA Kai,LI Jian-xing, WANG Xiao-feng   

  1. (Department of Urology,Peking University People’s Hospital,Beijing 100044,China)
  • Online:2015-02-18 Published:2015-02-18

摘要: 目的:比较无管化经皮肾镜碎石术(tubeless percutaneous nephrolithotomy,tubeless-PCNL)和输尿管镜碎石术(ureteroscopic lithotripsy,URL)处理输尿管上段结石的有效性和安全性。 方法:回顾性分析2009年9月至2013年7月就诊于北京大学人民医院的输尿管结石患者资料,结石最大径线在1.5 cm以上的输尿管上段结石(L4以上)纳入本组研究,182例患者分别接受tubeless-PCNL(54例)或URL(128例)两种手术方式治疗。比较两种方法的手术成功率,对比手术时间、术中出血量(平均血红蛋白减少量)、并发症、平均住院时间和结石残留率等。结果:54例患者行tubeless-PCNL手术治疗,结石最大径线平均为(1.9±0.4) cm,2例患者术后留置了肾造瘘管,52例手术成功(96.3%),这52例成功tubeless-PCNL手术的患者平均手术时间(30.1±14.8) min,平均血红蛋白减少量为(10.2±6.1) g/L,术后平均住院时间为(3.0±1.4) d,结石残留率为2%(1/52)。术后并发症为肾周血肿(1例)、术后发热(2例)、白细胞升高(11例)、术后疼痛(3例)。128例患者行URL,URL组结石最大径线平均为(1.7±0.3) cm。URL组手术失败19例(10例改行PCNL,5例放弃手术留置DJ管碎石,4例结石返回肾盂),109例患者手术成功(85.1%)。这109例URL手术成功的患者平均手术时间(51.3±25.5) min,平均血红蛋白减少量为(5.2±7.2) g/L,术后平均住院时间(2.9±1.3) d;结石残留率为11.9%(13/109)。术后并发症主要为术后发热(3例)、白细胞升高(42例)、术后尿道口或胁腹部疼痛(13例)。两组相比,结石大小差异无统计学意义,tubeless-PCNL组取石成功率高于URL组,除平均血红蛋白减少量tubeless-PCNL组略高于URL组以外,平均手术时间、结石残留率和并发症发生率,tubeless-PCNL组均低于URL组。 结论:最大径线1.5 cm以上的输尿管上段结石URL手术难度相对较大,与URL相比PCNL手术难度降低。对于有丰富PCNL手术经验的医师,采用tubeless-PCNL手术成功率更高,而且tubeless-PCNL并不增加患者并发症与住院时间,比采用URL更为有效。

关键词: 输尿管结石, 输尿管镜检查, 肾造口术, 经皮, 碎石术

Abstract: Objective: To compare the efficacy and safety of tubeless percutaneous nephrolithotomy (tubeless-PCNL) and ureteroscopic lithotripsy(URL) in treatment of impacted upper-ureteral calculi ≥1.5 cm in size. Methods:Patients with ureteral stones sized ≥1.5 cm and lodged above the fourth lumbar vertebra who were treated between September 2009 and July 2013 in Peking University People’s Hospital were retrospectively analyzed. In the study, 182 patients underwent tubeless-PCNL or URL treatment respectively, and the operation success rates were compared. The duration of operation, intraoperative blood loss(average hemoglobin decrease), complications, mean hospital stay and residual stone rates were also compared. Results: Fifty-four patients underwent tubeless-PCNL treatment,the average stone size was (1.9±0.4) cm,nephrostomy tubes were placed in two patients,and the operation success rate was 96.3%(52/54). In the rest of the 52 patients,and the mean operation time was (30.1±14.8) minutes with an average postoperative hemoglobin decrease of (10.2±6.1) g/L, and the mean hospital stay was (3.0±1.4) days. Only one of the patients had residual fragments (2%). The main complications included minor perirenal hematoma in 1 patient, fever in 2 patients,elevated blood WBC in 11 patients,and analgesics requirement in 3 patients. In the study, 128 patients were treated with URL,the average stone size was (1.7±0.3) cm. 19 procedures failed,and 10 patients were converted to PCNL,extracorporeal shock wave lithotripsy was executed subsequently after double-J stent placement in 5 patients,and migration of calculi or stone fragments happened in 4 patients. The mean operative time was (51.3±25.5) minutes for the remaining 109 patients with a hemoglobin reduction of (5.2±7.2) g/L. The mean hospital stay was (2.9±1.3) days, and residual stones were found in 13 of the 109 patients (11.9%). The main complications included fever in 3 patients, elevated blood WBC in 42 patients, analgesics requirement in 13 patients because of pain in the urethra or flank. The size of the stones between the two group didn’t show significant difference,but the success rate of the tubeless-PCNL procedure was significantly higher. Except that hemoglobin decrease was slightly higher in the tubeless-PCNL group,the mean operative time, the rate of residual stones and rate of complications of the tubeless-PCNL group were lower significantly. Conclusion:  Treating stones above 4th lumbar vertebra larger than 1.5 cm were challenging. It is difficult to treat these stones with URL because of a high probability to fail, but on the contrary, tubeless-PCNL was more likely to be performed successfully. For surgeons experienced with the PCNL technology, treating stones≥1.5 cm with tubeless-PCNL procedure may turn out to be more efficient and with a higher operation success rate, and the risk of complications was lower without lengthening the postoperative hospital stay.

Key words: SUreteral calculi, Ureteroscopy, Nephrostomy, percutaneous, Lithotripsy

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