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肾结石是一种常见的成人疾病,在儿童中较少见[1]。在过去的二十年中,儿童肾结石的发病率增加了37%,复发率随之增加[2]。增加的原因尚不清楚,可能与盐摄入量增加、液体消耗不足、肥胖等因素相关[3]。与成人不同,儿童泌尿系结石常常以腹痛为首发症状[4],可能存在长时间的无症状期,若诊断、治疗不及时,则会引起肾功能损害[5]。美国泌尿外科协会(American Urological Association,AUA)建议将体外冲击波碎石(extracorporeal shock wave lithotripsy,ESWL)和输尿管软镜(flexible ureteroscope,F-URS)作为<20 mm肾结石的一线治疗方式[6]。一项荟萃分析[7]提出ESWL和URS都是安全有效的,应该根据病人个人的情况来选择。数据[2]显示,三分之一以上的儿童和青少年出现超重或肥胖,超重或肥胖的儿童肾结石病人逐渐增多。然而,关于ESWL和URS在超重或肥胖的儿童肾结石病人中的应用和疗效,文献报道较少。因此,本研究通过纳入不同体质量指数(body mass index,BMI)的儿童肾结石病人,经评估后随机选择ESWL或F-URS治疗肾结石,分析碎石并发症及结局,为不同BMI儿童肾结石病人选择更佳治疗方式提供依据。
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选择2018年8月至2021年2月我院招募的单发性儿童肾结石病人,根据结石直径、BMI及个人意愿共纳入41例。依据BMI分为超重组(BMI ≥24.0 kg/m2)20例和非超重组(BMI < 24.0 kg/m2)21例。超重组根据治疗方式分为F-URS组和ESWL组,各10例,分别采用F-URS联合钬激光碎石术和ESWL治疗,2组性别、年龄、BMI、结石直径、家族史差异均无统计学意义(P>0.05)(见表 1)。非超重组根据治疗方式分为F-URS组10例和ESWL组11例,分别采用F-URS联合钬激光碎石术和ESWL治疗,2组性别、年龄、BMI、结石直径、家族史差异均无统计学意义(P>0.05)(见表 2)。
分组 n 年龄/岁 男 女 BMI/(kg/m2) 结石直径/cm 家族史 F-URS组 10 11.10±2.33 6(60.0) 4(40.0) 26.87±2.07 1.19±0.48 1(10.0) ESWL组 10 11.60±2.22 6(60.0) 4(40.0) 27.02±2.09 1.25±0.41 1(10.0) t — 0.49 — 0.16* 0.31 — P — >0.05 >0.05△ >0.05 >0.05 >0.05△ △示Fisher′s确切概率法;*示χ2值 表 1 超重组儿童肾结石病人基本资料(x±s)
分组 n 年龄/岁 男 女 BMI/(kg/m2) 结石直径/cm 家族史 F-URS组 10 11.10±2.42 6(60.0) 4(54.5) 20.16±1.78 1.15±0.38 1(10.0) ESWL组 11 11.55±2.43 6(60.0) 5(45.5) 20.23±1.68 1.09±0.45 2(18.2) t — 0.42 — 0.09* 0.33 — P — >0.05 >0.05△ >0.05 >0.05 >0.05 △示Fisher′s确切概率法;*示χ2值 表 2 非超重组儿童肾结石病人基本资料(x±s)
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纳入标准:(1)年龄8~14岁;(2)以B超检查为基础,并经腹部平片或CT检查确诊为肾结石;(3)符合ESWL、F-URS治疗适应证,告知家属相关风险,同意签署手术相关知情同意书。排除标准:(1)严重心肺疾病、肾功能不全,无法耐受手术者;(2)存在未纠正的凝血功能异常或尿路感染;(3)结石远端存在解剖性梗阻。
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(1) 术前准备:术前进行体温检测、血常规、尿常规、生化、凝血等常规检查,并排除手术禁忌证;对于感染性结石,抗生素治疗转阴后方可进行ESWL治疗;对于合并尿路感染或炎症者,术前1~3 d予以抗生素治疗。(2)术中操作:采用德国Dornier Compact Delta型碎石机;手术当日禁食,均采用仰卧位,辐射挡板保护生殖器及肺部;予以丙泊酚全身麻醉,对于不可耐受的部分大龄儿童,可采用全身麻醉;结石定位后,设置碎石参数:治疗能量1.0~1.5 Hz,工作电压8~11 kV,冲击次数500~2 000次;根据结石破碎情况,随时调节参数;术后采用B超、腹部平片检查判断治疗效果。如仍有结石存在,至少14 d后才可复震。
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(1) 术前准备:术前准备及评估与ESWL治疗方法类似;对于低龄儿童或结石较大者,经评估预置双J管2周。(2)术中操作:采用日本奥林巴斯电子输尿管软镜系统联合威孚莱钬激光碎石机;手术当日禁食,采用截石位,麻醉方式同ESWL治疗方法;将F8/9.8输尿管软镜经尿道置入输尿管,探查输尿管与肾盂;插入斑马导丝后,将F12输尿管软镜鞘固定于输尿管上端近肾盂口处;将F7.9电子输尿管软镜经F12鞘置入肾盂水平处,探查结石位置后置入钬激光光纤(200 μm),采用低能高频模式进行碎石;碎石经篮网取出后撤镜。两种碎石方式均由同一组医疗人员完成。
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所有病人经碎石治疗后于门诊随诊,观察术后常见并发症(术后一过性血尿、术后发热)。一周后复查超声或CT检查,判断结石是否清除。根据影像学结果选择是否复震或置入双J管辅助治疗,单侧碎石次数不超过2次。影像学检查未发现结石或结石消失被认为结石清除,记录第1次、第2次碎石治疗以及随访的结果,比较一次碎石成功率。
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采用t检验、χ2检验和Fisher′s确切概率法。
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在非超重组中,ESWL组病人术后一过性血尿和术后发热发生率、置入双J管例数均低于F-URS组(P < 0.05),2组一次碎石成功率差异均无统计学意义(P>0.05)(见表 3)。
分组 n 一次碎石成功率 术后一过性血尿 术后发热 术后置入双J管 F-URS组 10 10(100.0) 8(80.0) 7(70.0) 6(60.0) ESWL组 11 9(81.8) 3(27.3) 2(18.2) 1(9.1) P — >0.05△ < 0.05△ < 0.05△ < 0.05△ △示Fisher′s确切概率法 表 3 非超重组儿童肾结石病人碎石效果比较[n; 百分率(%)]
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在超重组中,F-URS组病人一次碎石成功率高于ESWL组(P < 0.05),2组术后一过性血尿和术后发热发生率、置入双J管例数差异均无统计学意义(P>0.05)(见表 4)。
分组 n 一次碎石成功率 术后一过性血尿 术后发热 术后置入双J管 F-URS组 10 10(100.0) 7(70.0) 7(70.0) 5(50.0) ESWL组 10 5(50.0) 6(60.0) 7(70.0) 2(20.0) P — < 0.05△ >0.05△ >0.05△ >0.05△ △示Fisher′s确切概率法 表 4 超重组儿童肾结石病人碎石效果比较[n; 百分率(%)]
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非超重组1例男性儿童,10岁,患儿经ESWL碎石治疗,1周后复查B超,结石全部排出(见图 1)。
ESWL和F-URS在不同体质量儿童肾结石病人中的应用
Application of ESWL and F-URS in pediatric nephrolithiasis patients with different body mass
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摘要:
目的探讨体外冲击波碎石术(ESWL)与输尿管软镜碎石术(F-URS)在不同体质量儿童肾结石病人中的应用价值。 方法选取单发性儿童肾结石病人为研究对象, 根据结石大小、体质量指数(BMI)及个人意愿共纳入41例, 依据BMI分为超重组(BMI ≥24.0 kg/m2)20例和非超重组(BMI < 24.0 kg/m2)21例, 2组再根据治疗方式不同各分为ESWL组(采用ESWL治疗)和F-URS组(采用F-URS联合钬激光碎石术治疗)2个亚组。分别比较超重组和非超重组不同治疗方式亚组的术后常见并发症(术后一过性血尿、术后发热)、一次碎石成功率及术后置入双J管情况。 结果在非超重组中, ESWL组病人术后一过性血尿和术后发热发生率、置入双J管病人例数均低于F-URS组(P < 0.05), 2组一次碎石成功率差异均无统计学意义(P>0.05)。在超重组中, F-URS组病人一次碎石成功率高于ESWL组(P < 0.05), 2组术后一过性血尿和术后发热发生率、置入双J管病人例数差异均无统计学意义(P>0.05)。 结论在非超重儿童肾结石病人中, ESWL与F-URS治疗效果相似, 可根据病人情况或医院偏好选择。在超重儿童肾结石病人中, ESWL治疗效果下降, F-URS具有稳定的碎石效果, 更适合超重病人。 Abstract:ObjectiveTo investigate the application value of extracorporeal shock wave lithotripsy(ESWL) and flexible ureteroscope(F-URS) lithotripsy in pediatric nephrolithiasis patients with different body mass. MethodsA total of 41 cases with single pediatric nephrolithiasis were included according to stone size body mass index(BMI) and personal intention.According to BMI, the patients were divided into overweight group(BMI ≥24.0 kg/m2, n=20) and non-overweight group(BMI < 24.0 kg/m2, n=21).The patients in the two groups were further divided into two subgroups including ESWL group(treated with ESWL) and F-URS group(treated with F-URS combined with holmium laser lithotripsy) according to the treatment method.The common postoperative complications(transient hematuria and postoperative fever), the success rate of one-time lithotripsy and the placement of double-J catheter after operation were compared between subgroups with different treatment method in overweight group and non-overweight group, respectively. ResultsIn the non-overweight group, the incidence of transient hematuria and postoperative fever, and the number of patients with double-J catheter in the ESWL group were lower than those in the F-URS group(P < 0.05), and there was no significant difference in the success rate of one-time lithotripsy between the two groups(P>0.05).In the overweight group, the success rate of one-time lithotripsy in the F-URS group was higher than that in the ESWL group(P < 0.05), and there was no significant difference in the incidence of transient hematuria and postoperative fever, and the number of patients with double-J catheter between the two groups(P>0.05). ConclusionsIn non-overweight patient with pediatric nephrolithiasis, ESWL and F-URS have similar therapeutic effects, which can be selected according to the patient's condition or hospital preference.In overweight patient with pediatric nephrolithiasis, the treatment effect of ESWL decreases, while F-URS has a stable lithotripsy effect and is more suitable for overweight patient. -
表 1 超重组儿童肾结石病人基本资料(x±s)
分组 n 年龄/岁 男 女 BMI/(kg/m2) 结石直径/cm 家族史 F-URS组 10 11.10±2.33 6(60.0) 4(40.0) 26.87±2.07 1.19±0.48 1(10.0) ESWL组 10 11.60±2.22 6(60.0) 4(40.0) 27.02±2.09 1.25±0.41 1(10.0) t — 0.49 — 0.16* 0.31 — P — >0.05 >0.05△ >0.05 >0.05 >0.05△ △示Fisher′s确切概率法;*示χ2值 表 2 非超重组儿童肾结石病人基本资料(x±s)
分组 n 年龄/岁 男 女 BMI/(kg/m2) 结石直径/cm 家族史 F-URS组 10 11.10±2.42 6(60.0) 4(54.5) 20.16±1.78 1.15±0.38 1(10.0) ESWL组 11 11.55±2.43 6(60.0) 5(45.5) 20.23±1.68 1.09±0.45 2(18.2) t — 0.42 — 0.09* 0.33 — P — >0.05 >0.05△ >0.05 >0.05 >0.05 △示Fisher′s确切概率法;*示χ2值 表 3 非超重组儿童肾结石病人碎石效果比较[n; 百分率(%)]
分组 n 一次碎石成功率 术后一过性血尿 术后发热 术后置入双J管 F-URS组 10 10(100.0) 8(80.0) 7(70.0) 6(60.0) ESWL组 11 9(81.8) 3(27.3) 2(18.2) 1(9.1) P — >0.05△ < 0.05△ < 0.05△ < 0.05△ △示Fisher′s确切概率法 表 4 超重组儿童肾结石病人碎石效果比较[n; 百分率(%)]
分组 n 一次碎石成功率 术后一过性血尿 术后发热 术后置入双J管 F-URS组 10 10(100.0) 7(70.0) 7(70.0) 5(50.0) ESWL组 10 5(50.0) 6(60.0) 7(70.0) 2(20.0) P — < 0.05△ >0.05△ >0.05△ >0.05△ △示Fisher′s确切概率法 -
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