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Journal of Peking University(Health Sciences) >

2025 , Vol. 57 >Issue 4: 676 - 683

DOI: https://doi.org/10.19723/j.issn.1671-167X.2025.04.008

Efficacy of rigid ureteroscopic laser lithotripsy combined with N-trap in the treatment of ureteral stones with a maximum diameter equal to or greater than 1.5 cm

  • Jinghui JI ,
  • Xiushi LIN ,
  • Dameng PAN ,
  • Zhiying WU ,
  • Zixuan XUE ,
  • Xiaojun TIAN ,
  • Shudong ZHANG ,
  • Binshuai WANG , * ,
  • Min QIU , *
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  • Department of Urology, Peking University Third Hospital, Beijing 100191, China
WANG Binshuai, e-mail,
QIU Min, e-mail,

Received date: 2025-02-24

  Online published: 2025-08-02

Supported by

the Peking University Third Hospital Clinical Key Project(BYSY2022059)

Peking University Third Hospital Innovation Transformation Fund(BYSYCY2024046)

Beijing Health Promotion Association Project(A76475)

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Abstract

Objective: To investigate the efficacy of rigid ureteroscopic laser lithotripsy combined with N-trap (RULL + N-trap), which is scoop-shaped, in the treatment of ureteral stones with a maximum diameter ≥ 1.5 cm. Methods: This retrospective cohort study included patients diagnosed with ureteral calculi who underwent rigid ureteroscopic lithotripsy (RULL) combined with N-Trap stone entrapment system at the Department of Urology, Peking University Third Hospital, by the same surgical team between June 2021 and September 2024. A total of 364 patients were initially enrolled. After excluding 21 patients due to missing critical outcome variables, two distinct cohorts were established: 38 patients with ureteral stones measuring ≥1.5 cm in maximum diameter, and 305 patients with stones < 1.5 cm in maximum diameter. To minimize selection bias and control for confounding variables, propensity score matching (PSM) was employed. This resulted in two well-balanced groups: 31 patients with stones ≥1.5 cm in maximum diameter and 31 patients with stones < 1.5 cm in maximum diameter, matched on baseline demographic and clinical characteristics. The primary outcomes assessed between the two groups included stone clearance. Secondary outcomes included changes in renal function indicators, specifically serum creatinine (SCr) and estimated glomerular filtration rate (GFR), and other factors like postoperative hospital stay and operative time. Results: In the matched cohort, the patients with stones ≥1.5 cm in maximum diameter had significantly longer operative time compared with those with smaller stones: (85.8±28.8) min vs. (62.4±24.6) min (P < 0.05). Postoperative length of hospital stay showed no significant difference: (2.26±1.79) d vs. (2.03 ± 0.80) d (P>0.05). The stone clearance on postoperative day one was 90.3% in the study group vs. 100.0% in the control group (P>0.05). One month postoperatively, the stone clearance was 93.5% vs. 100.0%, respectively (P>0.05). Changes in SCr were (-6.58±16.10) μmol/L vs. (-13.70±12.50) μmol/L, and changes in GFR were (5.92±14.90) mL/(min·1.73 m2) vs. (7.47±11.20) mL/(min·1.73 m2), with no statistically significant differences observed between the two groups for either renal function marker (P > 0.05). Conclusion: Ureteroscopic lithotripsy combined with N-trap is an optional method for treating ureteral stones with a maximum diameter ≥1.5 cm. The overall therapeutic efficacy is comparable, with the added benefit of significantly reducing the economic burden on patients.

Key words： Rigid ureteroscopic laser lithotripsy; N-trap; Urolithiasis

Cite this article

Jinghui JI , Xiushi LIN , Dameng PAN , Zhiying WU , Zixuan XUE , Xiaojun TIAN , Shudong ZHANG , Binshuai WANG , Min QIU . Efficacy of rigid ureteroscopic laser lithotripsy combined with N-trap in the treatment of ureteral stones with a maximum diameter equal to or greater than 1.5 cm[J]. Journal of Peking University(Health Sciences), 2025 , 57(4) : 676 -683 . DOI: 10.19723/j.issn.1671-167X.2025.04.008

泌尿系结石是一种常见病、多发病，其发病率在不同国家，以及同一国家内的不同地区存在较大差异，其中北美洲泌尿系结石发病率为7%~13%，欧洲地区发病率为5%~9%，亚洲地区发病率为1%~5%[1]。根据一项研究显示，中国泌尿系结石在2022年的发病率约为8%[2]。输尿管结石为泌尿系结石的一种类型，一般源于肾结石排入或碎石过程中掉落至输尿管。输尿管结石发病率目前暂无确切数据，有文献报道大约占泌尿系结石的1/3[3]。结石体积或大小是输尿管结石分类的重要依据之一，且直接影响治疗方案。当结石体积过大，彻底堵塞输尿管，则可能导致肾积水，甚至肾衰竭。结石位置越高，导致输尿管扩张积水的可能性越大[4]。对于最大径≥1.5 cm的输尿管结石，我们之前报道输尿管硬镜联合勺状阻石篮激光碎石术(rigid ureteroscopic laser lithotripsy combined with N-trap, RULL + N-trap)治疗输尿管中上段结石的效果较好[5]，后续又增加了病例数量。此次收集近4年RULL + N-trap治疗的输尿管结石患者，根据结石大小分组分析，探讨RULL+N-trap用于治疗最大径≥1.5 cm输尿管结石的安全性与可行性。

1 资料与方法

1.1 临床资料

术前资料：包括年龄、性别、体重指数(body mass index, BMI)、化验及相关影像学资料，特别是计算机断层影像(computing tomography, CT)，如图 1。
图1 最大径≥1.5 cm输尿管结石的术前影像学表现

Figure 1 Imaging characteristics of urolithiasis with largest diameter ≥ 1.5 cm

A, coronal CT image, with the arrow indicating the left ureteral calculus, measuring greater than 1.5 cm in length; B, axial CT image, where the arrow marks the location of the calculus; C, sagittal CT image, with the arrow identifying the calculus; notable hydronephrosis due to ureteral obstruction is observed above the calculus (indicated by the triangle); D, the kidneys, ureters, and bladders appearance of a ureteral calculus with a maximum dia-meter of ≥1.5 cm, highlighted by the arrow.

与手术过程相关的指标：包括手术时间、术后住院日。
手术治疗的结局变量：包括术前与术后的肌酐(serum creatinine, SCr)差值、术前与术后的肾小球滤过率(glomerular filtration rate, GFR)差值、术后第1天及术后1个月清石率，清石率为主要结局指标，其中清石率定义如下：查看患者术后第1天以及术后第30天影像学检查结果，如肾、输尿管和膀胱(kidneys, ureters, and bladders, KUB)检查或CT，未检出结石或检出结石最大径 < 4 mm为清石成功，计算清石成功患者的比例即为清石率。
病例遴选方法：选取2021年6月至2024年9月于北京大学第三医院泌尿外科同一医疗组手术治疗输尿管结石的364例患者，采用RULL + N-trap治疗，其中38例患者结石最大径≥1.5 cm，326例患者输尿管结石最大径 < 1.5 cm，排除21例术后结石清除情况缺失的患者，得到38例最大径≥ 1.5 cm输尿管结石患者队列和305例最大径 < 1.5 cm输尿管结石患者队列，队列总人数为343例。两队列的基线数据如表 1所示。两队列患者在术前SCr水平、术前GFR水平、结石与肾盂输尿管连接部(ureteropelvic junction, UPJ)的距离、结石的CT值方面差异有统计学意义(P < 0.05)，提示两队列患者基线数据并不平衡，需要进行倾向性评分匹配(propensity score matching, PSM)操作。
表1 匹配前患者基线数据

Table 1 Baseline statistics of patients before match

Items Urolithiasis patients with largest diameter ≥ 1.5 cm (n=38) Urolithiasis patients with largest diameter < 1.5 cm (n=305) P value
Age/years, M (Min, Max) 48.0 (19.0, 73.0) 48.0 (21.0, 78.0) 0.659
Gender, n(%) 0.398
  Male 7 (18.4) 80 (26.2)
  Female 31 (81.6) 225 (73.8)
BMI/(kg/m2), M (Min, Max) 24.8 (17.9, 32.7) 25.6 (17.4, 38.8)b 0.331
Preoperative SCr/(μmol/L), M (Min, Max) 97.5 (70.0, 190.0) 85.0 (47.0, 237.0) 0.001
Preoperative GFR /[mL/(min·1.73 m2)], M (Min, Max) 87.0 (44.0, 114.0) 94.9 (31.0, 143.0) 0.020
Distance/mma, M (Min, Max) 17.5 (0.0, 181.0) 59.0 (0.0, 244.0)c < 0.001
CT value of stones/HU, M (Min, Max) 1 120 (424, 1 660) 800 (116, 1 780)c < 0.001

a, distance refers to that from stone to ureteropelvic junction; b, data of one patient missed; c, data of two patients missed. BMI, body mass index; SCr，serum creatinine; GFR，glomerular filtration rate.

1.2 手术方法

硬膜外麻醉后，患者取截石位，常规消毒铺巾。插入12F(1 mm=3F)硅胶尿管，用0.9%(体积分数)生理盐水作冲洗液，直视下经尿道置入型号为F8/9.8输尿管镜，观察膀胱黏膜及双侧输尿管口情况。向患侧输尿管口插入导丝后进入输尿管口，如进镜困难则更换型号为F6/7.5、F4.5/6.5等管径较小的输尿管镜。输尿管镜沿导丝进入输尿管，探查输尿管全长直至肾盂，寻找结石。确认结石状态后经输尿管镜操作通道置入勺状阻石篮(N-trap)防止结石上移(图 2)，再置入钬激光光纤粉碎结石，用N-trap取出其中较大的结石残片留作标本。将导丝上行至肾盂，沿导丝顺利留置输尿管支架管，撤出输尿管镜，留置导尿管，术毕。
图2 RULL + N-trap术中图像

Figure 2 Photograph in RULL + N-trap

The blue, green, yellow and black arrow respectively points at the calculus, the N-trap, the dual-flex guidewire and the wall of ureter. RULL + N-trap, rigid ureteroscopic laser lithotripsy combined with N-trap.

1.3 统计学分析

采集上述数据后，首先进行匹配前分析，采用Logistic回归分析探究影响清石率的混杂因素，并参考其结果对原343例患者进行PSM，得到基线数据(包括年龄、BMI、术前SCr、结石与UPJ距离)平衡的最大径≥ 1.5 cm输尿管结石组以及最大径 < 1.5 cm输尿管结石组。分析对比两组患者的清石率、术后住院时长等指标，得出RULL+N-trap治疗最大径≥1.5 cm输尿管结石的治疗效果。
数据分析软件为R 4.4.2，对符合正态分布、方差齐条件的连续变量采用t检验，否则采用Wilcoxon秩和检验；对于等级变量以及分类变量，均采用Wilcoxon秩和检验；对于两组率数据的检验则采用卡方检验或Fisher’s精确检验。检验水准α=0.05。
PSM使用R包“MatchIt”中的“matchit”函数。

2 结果

2.1 匹配前分析

为探明影响术后清石率的混杂因素，以指导后续PSM过程中应当平衡的因素，分别以术后1 d及术后1个月清石率为因变量，对38例最大径≥1.5 cm输尿管结石患者以及305例最大径 < 1.5 cm输尿管结石患者分别进行Logistic回归分析，结果如表 2及表 3所示。Logistic回归分析结果表明，术后1个月清石率可能受术前SCr水平(P < 0.05)的影响，其他因素(如年龄、性别、BMI等)并未发现其对术后清石率有明显影响，但为保证匹配后最大径≥1.5 cm输尿管结石患者和最大径 < 1.5 cm输尿管结石患者的基线数据平衡，表 2、3中出现的变量均进行PSM处理。
表2 术后1 d清石率影响因素的Logistic回归分析

Table 2 Logistic regression analysis of factors affecting stone clearance on 1 d after surgery

Variables B Standard error Wald df P value Exp(B) 95% CI for Exp(B)
Gender 0.305 0.400 0.761 1 0.446 1.356 0.574 - 3.215
Age -0.014 0.016 0.922 1 0.357 0.986 0.957 - 1.017
Preoperative SCr -0.014 0.009 1.481 1 0.139 0.987 0.969 - 1.005
Preoperative GFR -0.013 0.014 0.898 1 0.369 0.987 0.960 - 1.015
Diameter of stone -0.004 0.036 0.118 1 0.906 0.996 0.931 - 1.066
CT value of stones -0.001 0.001 1.837 1 0.066 0.999 0.999 - 1.000
Constant 5.421 2.523 2.149 1 0.032 224.801

SCr, serum creatinine; GFR, glomerular filtration rate.

表3 术后1个月清石率影响因素的Logistic回归分析

Table 3 Logistic regression analysis of factors affecting stone clearance on 1 month after surgery

Variables B Standard error Wald df P value Exp(B) 95% CI for Exp(B)
Gender 0.514 0.393 1.313 1 0.189 1.671 0.758 - 3.672
Age -0.029 0.016 1.847 1 0.065 0.971 0.936 - 1.008
Preoperative SCr -0.019 0.009 5.493 1 0.032 0.981 0.963 - 0.999
Preoperative GFR -0.025 0.014 3.031 1 0.081 0.976 0.948 - 1.004
Diameter of Stone -0.003 0.004 0.066 1 0.947 0.998 0.992 - 1.005
CT value of stones 0.000 0.000 0.002 1 0.958 1.000 0.999 - 1.000
Constant 6.837 2.504 2.730 1 0.006 9.307

SCr, serum creatinine; GFR, glomerular filtration rate.

2.2 匹配后基线数据分析

纳入性别、年龄、术前SCr水平、术前GFR水平、术前结石与UPJ距离、术前结石CT值等因素，使用PSM算法筛选出31例最大径≥1.5 cm输尿管结石患者以及与之相匹配的31例最大径 < 1.5 cm输尿管结石患者，匹配后基线数据总结如表 4。两组基线数据的比较分析中，年龄、性别、BMI、术前SCr差异均无统计学意义(P>0.05)，仅两组患者的结石CT值差异有统计学意义(P < 0.05)，基线数据总体平衡。另外，31例结石最大径≥1.5 cm的患者中有7例(22.58%)存在输尿管狭窄，31例最大径 < 1.5 cm输尿管结石患者中输尿管狭窄的患者有12例(38.71%)，均使用了比F8/9.8型号更细的输尿管镜。
表4 匹配后患者基线数据

Table 4 Baseline statistics of patients after match

Items Urolithiasis patients with largest diameter ≥ 1.5 cm (n=31) Urolithiasis patients with largest diameter < 1.5 cm (n=31) P value
Age/years, M (Min, Max) 47.0 (19.0, 73.0) 38.0 (22.0, 72.0) 0.292
Gender, n(%) 1.000
  Male 26 (83.9) 26 (83.9)
  Female 5 (16.1) 5 (16.1)
BMI/(kg/m2), ${\bar x}$±s 25.00 ± 2.64 24.70 ± 2.59 0.688
Preoperative SCr/(μmol/L), M (Min, Max) 91.0 (70.0, 158.0) 93.0 (53.0, 156.0) 0.844
Preoperative GFR /[mL/(min·1.73 m2)], M (Min, Max) 88.3 (44.0, 114.0) 97.3 (40.0, 143.0) 0.130
Distance/mma, M (Min, Max) 17 (0, 181) 25.0 (0, 189) 0.773
CT value of stones/HU, ${\bar x}$±s 1 140 ± 330 910 ± 291 0.005

a, distance refers to that from stone to ureteropelvic junction; BMI, body mass index; SCr，serum creatinine; GFR，glomerular filtration rate.

匹配后，原最大径≥1.5 cm输尿管结石队列38例中，有31例患者被匹配上，7例患者未匹配上，匹配前后的基线数据对比见表 5，所有基线数据差异均无统计学意义(P > 0.05)。匹配后，原最大径 < 1.5 cm输尿管结石队列305例中有31例患者被匹配上，274例患者未匹配上，匹配上与未匹配上的患者的基线数据对比见表 6，除结石与UPJ距离差异有统计学意义外(P < 0.05)，其余基线数据差异均无统计学意义(P > 0.05)。这提示PSM后得到的最大径≥1.5 cm输尿管结石患者和最大径 < 1.5 cm输尿管结石患者均能够良好地反映原队列的实际情况。
表5 最大径≥1.5 cm输尿管结石患者匹配上和未匹配上的基线数据对比

Table 5 Baseline statistics of urolithiasis patients with largest diameters≥1.5 cm matched and not matched

Items Urolithiasis patients with largest diameter ≥ 1.5 cm not matched (n=7) Urolithiasis patients with largest diameter ≥ 1.5 cm matched (n=31) P value
Age/years, ${\bar x}$±s 50.3 ± 13.7 48.8 ± 13.6 0.706
Gender, n(%) 0.820
  Male 2 (28.6) 26 (83.9)
  Female 5 (71.4) 5 (16.1)
BMI/(kg/m2), ${\bar x}$±s 24.90 ± 2.88 25.00 ± 2.64 0.825
Preoperative SCr/(μmol/L), M (Min, Max) 116.0 (74.0, 190.0) 91.0 (70.0, 158.0) 0.057
Preoperative GFR/[mL/(min·1.73 m2)], ${\bar x}$±s 81.3 ± 11.1 86.2 ± 19.6 0.228
Distance/mma, M (Min, Max) 18.0 (0.0, 57.8) 17.0 (0.0, 181.0) 0.865
CT value of stones/HU, ${\bar x}$±s 850 ± 371 1 140 ± 330 0.060

a, distance refers to that from stone to ureteropelvic junction. BMI, body mass index; SCr, serum creatinine; GFR, glomerular filtration rate.

表6 最大径 < 1.5 cm输尿管结石组患者匹配上和未匹配上的基线数据对比

Table 6 Baseline statistics of urolithiasis patients with largest diameters < 1.5 cm matched and not matched

Items Urolithiasis patients with largest diameter < 1.5 cm not matched (n=274) Urolithiasis patients with largest diameter < 1.5 cm matched (n=31) P value
Age/years, M (Min, Max) 48.0 (21.0, 78.0) 38.0 (22.0, 72.0) 0.150
Gender, n(%) 0.253
  Male 75 (27.5) 26 (83.9)
  Female 199 (72.6) 5 (16.1)
BMI/(kg/m2), M (Min, Max) 25.6 (17.4, 38.8)b 24.7 (18.0, 30.8) 0.121
Preoperative SCr/(μmol/L), M (Min, Max) 84.0 (47.0, 237.0) 93.0 (53.0, 156.0) 0.069
Preoperative GFR/[mL/(min·1.73 m2)], M (Min, Max) 94.5 (31.0, 142.0) 97.3 (40.0, 143.0) 0.669
Distance/mma, M (Min, Max) 68.0 (0.0, 244.0)c 25.0 (0.0, 189.0) < 0.001
CT value of stones/HU, M (Min, Max) 790 (116, 1 780)c 950 (348, 1 510) 0.113

a, distance refers to that from stone to ureteropelvic junction; b, data of one patient missed; c, data of two patients missed. BMI, body mass index; SCr, serum creatinine; GFR, glomerular filtration rate.

2.3 术后结局变量分析

患者于RULL + N-trap术后1 d及1个月时分别完善KUB检查，如图 3所示。
图3 RULL + N-trap术后KUB表现

Figure 3 KUB after RULL + N-trap

A, KUB finished on 1 d after RULL + N-trap; B, KUB finished in 1 month after RULL + N-trap. KUB, kidneys, ureters and bladders; RULL + N-trap, rigid ureteroscopic laser lithotripsy combined with N-trap.

RULL + N-trap术后31例最大径≥1.5 cm输尿管结石患者与31例最大径 < 1.5 cm输尿管结石患者相比结果如表 7所示。另外，31例最大径≥1.5 cm输尿管结石患者中，有3例最终行一期输尿管软镜手术治疗，其中2例在置入N-trap过程中结石即上移，另外1例则是在结石碎取过程中部分结石碎块上移。
表7 匹配后病例的RULL + N-trap手术治疗结果

Table 7 RULL + N-trap outcomes of cases after matching

Items Urolithiasis patients with largest diameter ≥1.5 cm (n=31) Urolithiasis patients with largest diameter < 1.5 cm (n=31) P value
Largest diameter of stone/mma, M (Min, Max) 17.0 (15.0, 27.1) 10.8 (4.0, 14.0) < 0.001
ΔSCr/(μmol/L)b, ±s -6.58 ± 16.10 -13.70 ± 12.50 0.149
ΔGFR/[mL/(min·1.73 m2)]c, ±s 5.92 ± 14.90 7.47 ± 11.20 0.508
Hospitalization after surgery/d, ±s 2.26 ± 1.79 2.03 ± 0.80 0.927
Operating time/min, ±s 85.8 ± 28.8 62.4 ± 24.6 0.001
Stone clearance 1 d, n(%) 0.237
  Success 28 (90.3) 31 (100.0)
  Fail 3 (9.7) 0 (0.0)
Stone clearance 1 month, n(%) 0.472
  Success 29 (93.5) 31 (100.0)
  Fail 2 (6.5) 0 (0.0)

a, largest diameter refers to that of stones; b, ΔSCr means perioperative SCr changes; c, ΔGFR means perioperative GFR changes. RULL + N-trap, rigid ureteroscopic laser lithotripsy combined with N-trap; BMI, body mass index; SCr, serum creatinine; GFR, glomerular filtration rate.

31例最大径≥1.5 cm输尿管结石患者与31例最大径 < 1.5 cm输尿管结石患者相比，除外手术时间，其余变量两组间差异无统计学意义。术后1 d及术后1个月的清石率对比如表 8、9所示，两组在术后的清石率差异无统计学意义，且最大径≥1.5 cm输尿管结石患者术后1 d及1个月的清石率均在90%以上。
表8 RULL + N-trap术后1 d清石率

Table 8 Stone clearance on 1 d after RULL + N-trap

Items Total Success, n(%) Fail, n(%) χ2 P
Urolithiasis patients with largest diameter ≥1.5 cm 31 28 (90.3) 3 (9.7) 1.401 0.237
Urolithiasis patients with largest diameter < 1.5 cm 31 31 (100.0) 0 (0.0)

RULL + N-trap, rigid ureteroscopic laser lithotripsy combined with N-trap.

表9 RULL + N-trap术后1个月清石率

Table 9 Stone clearance on 1 month after RULL + N-trap

Items Total Success, n(%) Fail, n(%) χ2 P
Urolithiasis patients with largest diameter ≥1.5 cm 31 29 (93.5) 2 (6.5) 0.517 0.472
Urolithiasis patients with largest diameter < 1.5 cm 31 31 (100.0) 0 (0.0)

RULL + N-trap, rigid ureteroscopic laser lithotripsy combined with N-trap.

3 讨论

最大径≥1.5 cm的输尿管结石往往导致输尿管严重阻塞，远期可能导致肾功能不可逆减退，而短期内亦可导致输尿管内部菌落数量增加，进而导致尿路感染，甚至入血引发脓毒血症等严重后果。输尿管结石患者远期罹患肾功能损伤的唯一相关因素为解除输尿管梗阻的时间，如超过2周则有更高概率发生肾功能损伤[6]。术后尿源性脓毒症的术前危险因素包括年龄≥60岁、女性、术前尿培养阳性、术前发热、结石直径≥20 mm[7-8]。肾盂内压力≥30 mmHg，且持续时间超过60 s时术后尿源细菌入血感染的发生率达36.1%[9]，术后出现感染中毒性休克的风险较高[10]。因此，对于最大径≥1.5 cm的输尿管结石，及时碎取结石，解除输尿管梗阻尤为重要。
为保证清石率，现阶段常规使用输尿管软镜配合钬激光碎石术治疗最大径≥1.5 cm中上段输尿管结石，针对肾盂、UPJ等部位的最大径≥2 cm的结石可采用经皮肾镜取石术治疗，对于复杂结石如鹿角形结石等还可采用腹腔镜输尿管切开取石术治疗，此类治疗方式清石率满意，手术时间较短[11-12]。经皮肾镜和输尿管切开取石均存在皮肤伤口，且出血量较多，术后恢复时间延长[13-14]。对于输尿管梗阻较严重的病例，术前尿培养阳性、手术时间延长等均与经皮肾镜取石术后感染甚至脓毒症有关[15]。输尿管软镜操作灵活，在探查、碎取结石时较有优势，可保证高水平的清石率，但其对输尿管管径有较高要求，合并输尿管狭窄患者往往无法进行一期输尿管软镜治疗，强行使用则存在手术失败的风险[16]。因此，本研究采用RULL + N-trap治疗最大径≥1.5 cm输尿管结石: (1)RULL + N-trap利用尿道及输尿管自然腔道作为手术入路，无需额外切口，对患者创伤小，患者出血量少，术后恢复所需时间较短。(2)N-trap可有效阻止结石碎块上移入肾盂，手术过程中可让助手向输尿管管腔内手动注水，保证视野清楚的同时，可以让注入腔道内的水带走激光碎石产生的部分热量，减小术后发生输尿管狭窄的概率，基于N-trap的阻石作用，手动注水不会导致结石上移。在取石方面，硬镜碎石后可直接经阻石篮将结石碎块以及大部分粉末完整取出，提高清石率，同时减少了套石篮的使用，降低了花费。如果结石落入肾盂，对于部分病例，N-trap可将肾盂中的结石捞回输尿管再进行粉碎，部分弥补了输尿管硬镜无法弯曲的短板。(3)输尿管硬镜存在多种不同管径，对于合并狭窄的病例可以选用细输尿管镜完成手术。总体来讲，RULL + N-trap灵活易用，且可保证较高清石率。
本中心既往研究显示，RULL + N-trap应用于28例中上段输尿管结石患者，最大径0.8~2.5 cm，平均最大径1.2 cm，术后1 d及术后1个月的清石率分别为89.3%和96.4%，表明该技术治疗输尿管结石有效[5]。后期不断增加病例数量，本研究达到364例，其中31例结石最大径≥1.5 cm，术后1 d及术后1个月的清石率分别达到90.3%和93.5%，与之匹配的最大径 < 1.5 cm的31例输尿管结石患者清石率达到100.0%。本研究结果显示，相比最大径 < 1.5 cm输尿管结石，最大径≥1.5 cm输尿管结石患者手术时间更长，这与结石体积增大、硬度更高，以及刺激导致的输尿管炎症及狭窄加重可能相关。两组患者术式相同，术后清石率差异无统计学意义，且结石最大径超过1.5 cm的患者同样可于术后2 d左右出院，说明此种手术方式可以用于治疗最大径≥1.5 cm输尿管结石。
对于最大径≥1.5 cm的输尿管结石，我们的手术经验如下：(1)术前仔细阅片，特别是CT检查资料，观察结石位置、大小，及输尿管积水情况，如发现结石径线较长、位置较高、结石上方输尿管积水较重，说明术中结石更容易掉入肾盏，此时术前应准备软镜。本组31例研究组中有3例转行输尿管软镜碎石，其中2例在置入N-trap过程中结石即上移，另外1例则是在结石碎取过程中部分结石碎块上移。(2)患者应采取头高脚低体位，防止结石上移入肾盏。探查结石过程中，待导丝通过结石和输尿管壁之间的缝隙后，用N-trap经输尿管操作通道越过结石到达其上方至少1 cm处后打开并回拉，待结石位置稳定后再撤出导丝。术中应当控制冲洗流速，探查结石过程中一般不额外向输尿管内注水，视野不清时利用输尿管硬镜自身的低速水流逐渐暴露视野。(3)碎石使用高频低能激光使结石粉末化，如0.6 J、30 Hz激光，使用低能量激光可减小碎石过程中结石的位移，同时助手手动注水减少热损伤。(4)结石部分粉末化后，N-trap携带结石碎块向下移动，前往更安全的区域粉碎，可使结石更难以上移，并减少同一区域持续激光碎石带来的输尿管热损伤可能性。如遇到输尿管狭窄段无法下行通过时，则使用N-trap携带结石一并上移，再次激光碎石后下拉，其中较大的结石碎块可直接使用N-trap带出输尿管。(5)碎石完成后应当再次探查输尿管，如发现结石碎块则清除，保证清石率。
RULL + N-trap治疗也有一定的局限性：(1)输尿管硬镜对伴发严重狭窄者则同样存在一期手术失败的可能，只能一期留置输尿管支架。(2)输尿管硬镜所搭配钬激光可能导致术后远期输尿管发生狭窄。基于周兰芳等[17]构建的预测模型，结石嵌顿、结石最大径＞1 cm、结石病程＞5个月、输尿管损伤、激光的使用及患者肾积水程度均为输尿管结石患者术后并发输尿管狭窄的危险因素。陈思鹭等[18]也指出医源性输尿管损伤与输尿管畸形均为成人肾积水的常见原因，导致远期肾功能受损。为减少出现狭窄的可能性，本研究采用高频低能的激光调校策略，并辅以手术助手手动注水操作。(3)本研究缺乏与输尿管软镜联合钬激光碎石等治疗方法的直接对比，后续会通过进一步扩充病例数量以完善对比研究。
综上所述，RULL + N-trap治疗最大径≥1.5 cm输尿管结石以及最大径 < 1.5 cm输尿管结石在治疗效果上差异无统计学意义。

利益冲突    所有作者均声明不存在利益冲突。

作者贡献声明    冀竞辉、林秀石：分析整理数据，撰写文章；潘大猛、吴芝莹、薛子璇：收集、处理数据；田晓军、张树栋、王滨帅、邱敏：设计实验方案，审阅文章。

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