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输尿管结石是泌尿系统常见疾病,是引起疼痛、血尿、泌尿道感染、肾积水、肾功能损害的常见原因。既往的二十多年间,输尿管镜下碎石已逐渐成为输尿管结石的一线治疗方法[1]。输尿管镜碎石通常是中、下段输尿管结石的首选,而上段输尿管结石通常采用体外冲击波碎石或经皮肾镜碎石,但随着小口径半硬质镜、输尿管软镜、拦截/取石装置、输尿管通道鞘、碎石激光的发展,输尿管镜下钬激光碎石对于各类困难结石、上段结石的治疗成功率不断提升,从而成为治疗输尿管各位置结石安全有效的方法[2]。临床工作中经常会遇到一些结石长期卡顿于一处即所谓“嵌顿性结石”病人,其手术难度较普通结石大,且术后输尿管狭窄发生率高,处理存在复杂性。碎石术后的输尿管狭窄作为后期并发症之一,往往因为病人长期无自觉症状而耽误诊治,最终导致永久性肾功能损害,故如何减少嵌顿性结石术后输尿管狭窄的发生一直是迫切需要解决的问题[3]。输尿管镜碎石术后双J管的置入可减少术后肾绞痛、肾积水的发生,并减少粘连,从而促进输尿管的愈合,尽管既往指南指出非复杂情况的输尿管镜碎石可以尝试不放置双J管,但实践中大多数医师还是将术后留置双J管作为常规[4]。经过我们的临床研究和实践发现,在对输尿管嵌顿性结石行钬激光碎石时,通过使用N-trap拦截网篮联合术中预防性放置2根F6号双J管,能降低术后输尿管狭窄的发生并保证手术的成功率及净石率。现作报道。
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2组病人年龄、性别构成、结石长径、嵌顿时长、结石侧别和结石部位差异均无统计学意义(P>0.05)(见表 1)。
分组 n 男 女 年龄/岁 结石长径/mm 嵌顿时长/周 结石侧别 结石部位 左侧 右侧 上段 中下段 单根F7双J管组 97 56 41 47.2±14.0 8.1±2.0 12.7±3.9 50 47 59 38 2根F6双J管组 97 60 37 44.3±18.1 7.8±2.1 13.3±3.4 61 36 66 31 t — 0.34* 1.25 1.02 1.14 2.55* 1.10* P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组病人一般情况比较(x±s)
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术后首日复查可见在联合N-trap网篮清石后病人总体净石率达到88.1%(171/194),2组净石率差异无统计学意义(P>0.05);拔除双J管后随访过程中共发现输尿管狭窄22例,总发生率为11.3%,其中单根F7双J管组输尿管狭窄发生率明显高于2根F6双J管组(P < 0.01),预防性留置2根F6双J管能减少嵌顿性结石钬激光碎石术后狭窄的发生(RR=0.294,95%CI 0.113~0.766);2组双J管相关尿路症状(发生肉眼血尿、尿急、尿频、下腹痛、腰痛中至少一项)发生率均接近100%,差异无统计学意义(P>0.05)(见表 2)。
分组 n 输尿管狭窄 结石净石率 支架相关尿路症状发生率 单根F7双J管组 97 17(17.5) 89(91.8) 96(97.9) 2根F6双J管组 97 5(5.2) 82(84.5) 95(99.0) χ2 — 7.38 2.42 — P — < 0.01 >0.05 >0.05△ △示Fisher′s确切概率法 表 2 2组病人治疗结果比较[n;百分率(%)]
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对22例术后发现输尿管狭窄病人进行统计,其输尿管平均狭窄长度(10.5±1.6)mm;位于左侧12例,右侧10例;上段狭窄18例,中下段狭窄4例。2组狭窄长度、狭窄侧别、狭窄部位差异均无统计学意义(P>0.05)(见表 3)。
分组 n 狭窄段长度/mm 狭窄侧别 狭窄部位 左侧 右侧 上段 中下段 单根F7双J管组 17 10.5±1.8 10(58.8) 7(41.2) 13 (76.5) 4 (23.5) 2根F6双J管组 5 10.6±1.0 2(40.0) 3(60.0) 5 (100) 0 (0.00) t — 0.12 — — P — >0.05 >0.05△ >0.05△ △示Fisher′s确切概率法 表 3 2组病人术后输尿管狭窄情况比较(x±s)
双重双J管置入联合N-trap网篮对嵌顿性输尿管结石钬激光碎石术后狭窄的预防作用
Protective effect of two double-J stents placement combined with N-trap stone basket agains postoperative ureteral stricture after ureteroscopic Ho: YAG lithotripsy
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摘要:
目的探讨输尿管镜钬激光碎石术后置入2根双J管联合术中N-trap网篮对术后输尿管狭窄的预防效果。 方法回顾性分析因嵌顿性结石行输尿管镜钬激光碎石术后留置单根F7双J管或2根F6双J管病人临床资料,按倾向性评分法,以结石长径及嵌顿时间匹配入组97对(n=194),比较2组病人术后狭窄发生率(置管8~10周,随访终点时间1年)、净石率及双J管相关尿路症状发生率。 结果术后首日复查病人总体净石率达到88.1%(171/194),2组净石率差异无统计学意义(P>0.05);拔除双J管后随访过程中共发现输尿管狭窄22例,总发生率为11.3%,其中单根F7双J管组输尿管狭窄发生率明显高于2根F6双J管组(P < 0.01),留置2根F6双J管是输尿管镜碎石术后输尿管狭窄发生的保护因素(RR=0.294,95%CI 0.113~0.766);2组双J管相关尿路症状(发生肉眼血尿、尿急、尿频、下腹痛、腰痛中至少一项)发生率均接近100%,差异无统计学意义(P>0.05)。 结论嵌顿性输尿管结石行输尿管镜钬激光碎石术后置入2根双J管配合术中N-trap网篮的使用能更为安全、可靠地降低术后输尿管狭窄的发生风险。 Abstract:ObjectiveTo investigate the protective effect of two double-J stents placement combined with N-trap stone basket against postoperative ureteral stricture after ureteroscopic Ho: YAG lithotripsy. MethodsInformation of patients with impacted ureteral stones who underwent single F7 or two F6 double-J stents placement during ureteroscopic Ho: YAG lithotripsy was retrospectively reviewed.A total of 97 pairs of patients (n=194) were distributed into two groups (single-F7 stents group and two-F6 stents group) by means of propensity score matching with stone size and impaction period being predictors.Postoperative ureteral stricture rate (with stents in place for 8 to 10 weeks and 1 year follow-up), stone-free rate and stent-related urinary symptom incidence were compared between two groups. ResultsOn the first day after operation, the overall stone free rate of patients reached 88.1% (171/194), and there was no significant difference between the two groups (P>0.05).During follow-up after stent removal, 22 cases of ureteral stricture (overall incidence 11.3%) were diagnosed.The incidence of ureteral stenosis in the single-F7 stents group was significantly higher than that in the two-F6 stents group (P < 0.01).Indwelling two F6 double-J stents was a protective factor for ureteral stricture after ureteroscopic lithotripsy (RR=0.294, 95%CI: 0.113-0.766).Incidence of stent-related urinary symptoms (at least one of gross hematuria, urgency, frequent urination, lower abdominal pain, flank pain) reached almost 100% in both groups, and showed no significant difference(P>0.05). ConclusionsAfter ureteroscopic Ho: YAG lithotripsy for incarcerated ureteral calculi, the placement of two double-J stents combined with N-trap stone basket can safely and reliably reduce the risk of postoperative ureteral stricture. -
表 1 2组病人一般情况比较(x±s)
分组 n 男 女 年龄/岁 结石长径/mm 嵌顿时长/周 结石侧别 结石部位 左侧 右侧 上段 中下段 单根F7双J管组 97 56 41 47.2±14.0 8.1±2.0 12.7±3.9 50 47 59 38 2根F6双J管组 97 60 37 44.3±18.1 7.8±2.1 13.3±3.4 61 36 66 31 t — 0.34* 1.25 1.02 1.14 2.55* 1.10* P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组病人治疗结果比较[n;百分率(%)]
分组 n 输尿管狭窄 结石净石率 支架相关尿路症状发生率 单根F7双J管组 97 17(17.5) 89(91.8) 96(97.9) 2根F6双J管组 97 5(5.2) 82(84.5) 95(99.0) χ2 — 7.38 2.42 — P — < 0.01 >0.05 >0.05△ △示Fisher′s确切概率法 表 3 2组病人术后输尿管狭窄情况比较(x±s)
分组 n 狭窄段长度/mm 狭窄侧别 狭窄部位 左侧 右侧 上段 中下段 单根F7双J管组 17 10.5±1.8 10(58.8) 7(41.2) 13 (76.5) 4 (23.5) 2根F6双J管组 5 10.6±1.0 2(40.0) 3(60.0) 5 (100) 0 (0.00) t — 0.12 — — P — >0.05 >0.05△ >0.05△ △示Fisher′s确切概率法 -
[1] BADER MJ, EISNER B, PORPIGLIA F, et al. Contemporary management of ureteral stones[J]. Eur Urol, 2012, 61(4): 764. doi: 10.1016/j.eururo.2012.01.009 [2] LEONE NT, GARCIA-ROIG M, BAGLEY DH. Changing trends in the use of ureteroscopic instruments from 1996 to 2008[J]. J Endourol, 2010, 24(3): 361. doi: 10.1089/end.2009.0222 [3] TEPELER A, RESORLU B, SAHIN T, et al. Categorization of intraoperative ureteroscopy complications using modified Satava classification system[J]. World J Urol, 2014, 32(1): 131. doi: 10.1007/s00345-013-1054-y [4] BEYSENS M, TAILLY TO. Ureteral stents in urolithiasis[J]. Asian J Urol, 2018, 5(4): 274. doi: 10.1016/j.ajur.2018.07.002 [5] 宋小飞, 巫嘉文. F6/7.5输尿管镜联合双管扩张法在处理输尿管结石合并狭窄患者中的疗效观察[J]. 国际泌尿系统杂志, 2018, 38(5): 705. [6] DE LA ROSETTE J, DENSTEDT J, GEAVLETE P, et al. The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11, 885 patients[J]. J Endourol, 2014, 28(2): 131. doi: 10.1089/end.2013.0436 [7] EL-ABD AS, SULIMAN MG, ABO FARHA MO, et al. The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: a long-term study at two academic centres[J]. Arab J Urol, 2014, 12(2): 168. doi: 10.1016/j.aju.2013.11.004 [8] DONG H, PENG Y, LI L, et al. Prevention strategies for ureteral stricture following ureteroscopic lithotripsy[J]. Asian J Urol, 2018, 5(2): 94. doi: 10.1016/j.ajur.2017.09.002 [9] YAMAGUCHI K, MINEI S, YAMAZAKI T, et al. Characterization of ureteral lesions associated with impacted stones[J]. Int J Urol, 1999, 6(6): 281. doi: 10.1046/j.1442-2042.1999.00067.x [10] SEITZ C, TANOVIC E, KIKIC Z, et al. Impact of stone size, location, composition, impaction, and hydronephrosis on the efficacy of holmium: YAG-laser ureterolithotripsy[J]. Eur Urol, 2007, 52(6): 1751. doi: 10.1016/j.eururo.2007.04.029 [11] DARWISH AE, GADELMOULA MM, ABDELKAWI IF, et al. Ureteral stricture after ureteroscopy for stones: a prospective study for the incidence and risk factors[J]. Urol Ann, 2019, 11(3): 276. doi: 10.4103/UA.UA_110_18 [12] TAŞS, TUǦCU V, MUTLU B, et al. Incidence of ureteral stricture after ureterorenoscopic pneumatic lithotripsy for distal ureteral calculi[J]. Arch Ital Urol Androl, 2011, 83(3): 141. [13] ROBERTS WW, CADEDDU JA, MICALI S, et al. Ureteral stricture formation after removal of impacted calculi[J]. J Urol, 1998, 159(3): 723. doi: 10.1016/S0022-5347(01)63711-X [14] BRITO AH, MITRE AI, SROUGI M. Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi[J]. Int Braz J Urol, 2006, 32(3): 295. doi: 10.1590/S1677-55382006000300006 [15] FAM XI, SINGAM P, HO CC, et al. Ureteral stricture formation after ureteroscope treatment of impacted calculi: a prospective study[J]. Korean J Urol, 2015, 56(1): 63. doi: 10.4111/kju.2015.56.1.63 [16] FOREMAN D, PLAGAKIS S, FULLER AT. Should we routinely stent after ureteropyeloscopy?[J]. BJU Int, 2014, 114(Suppl 1): 6. [17] LIU JS, HREBINKO RL. The use of 2 ipsilateral ureteral stents for relief of ureteral obstruction from extrinsic compression[J]. J Urol, 1998, 159(1): 179. doi: 10.1016/S0022-5347(01)64050-3 [18] IBRAHIM HM, MOHYELDEN K, ABDEL-BARY A, et al. Single versus double ureteral stent placement after laser endoureterotomy for the management of benign ureteral strictures: a randomized clinical trial[J]. J Endourol, 2015, 29(10): 1204. doi: 10.1089/end.2015.0445 [19] 刘杰, 薛江辉, 冉光勇, 等. 同侧两根双J管引流在结石伴息肉导致输尿管狭窄患者中的应用[J/CD]. 中华腔镜泌尿外科杂志(电子版), 2019, 13(4): 251. doi: 10.3877/cma.j.issn.1674-3253.2019.04.009 [20] CHRISTMAN MS, KASTURI S, LAMBERT SM, et al. Endoscopic management and the role of double stenting for primary obstructive megaureters[J]. J Urol, 2012, 187(3): 1018. doi: 10.1016/j.juro.2011.10.168 [21] 刘洪凯, 王金清, 李焕军, 等. 输尿管镜钬激光联合球囊扩张与单纯球囊扩张治疗输尿管狭窄的疗效分析[J]. 国际泌尿系统杂志, 2016, 36(4): 567. [22] DAMIANO R, AUTORINO R, DE SIO M, et al. Does the size of ureteral stent impact urinary symptoms and quality of life?A prospective randomized study[J]. Eur Urol, 2005, 48(4): 673. [23] JOSHI HB, OKEKE A, NEWNS N, et al. Characterization of urinary symptoms in patients with ureteral stents[J]. Urology, 2002, 59(4): 511. [24] KAWAHARA T, ITO H, TERAO H, et al. Ureteral stent encrustation, incrustation, and coloring: morbidity related to indwelling times[J]. J Endourol, 2012, 26(2): 178. [25] DRETLER SP, YOUNG RH. Stone granuloma: a cause of ureteral stricture[J]. J Urol, 1993, 150(6): 1800.