Clinical analysis of the time of preoperative double J stent indwelling in transurethral flexible ureteroscopic lithotripsy
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摘要: 目的 分析不同的术前留置双J管预扩张输尿管时间,行经尿道输尿管软镜碎石术(flexible ureteroscopic lithotripsy,FURL)的有效性和安全性。方法 收集2018年1月—2021年4月北京积水潭医院泌尿外科CT确诊为肾或输尿管上段结石,结石最大直径≤2 cm,行FURL的患者315例。根据术前双J管留置时间分为A组(未留置组,40例),既往有排石史,或留置双J管史且入院前1个月已拔除;B组(58例):术前留置5 d;C组(120例):术前留置7 d;D组(50例):术前留置14 d;E组(47例):术前留置28 d及以上。收集有效和安全性相关数据并分析。结果 一期带导引鞘软镜置入成功率比较,A组:97.50%,B组:94.83%,C组:99.17%,D组:100.00%,E组:100.00%,各组间差异均无统计学意义(P>0.05)。手术时间比较,A组:(91.79±41.13) min,B组:(81.36±28.18) min,C组:(80.31±27.63) min,D组:(83.30±31.70) min,E组:(78.51±26.64) min,各组间差异均无统计学意义(P>0.05)。出血量比较,A组:(4.15±3.38) mL,B组:(5.64±4.86) mL,C组:(4.60±3.57) mL,D组:(7.50±10.50) mL,E组:(5.81±5.27) mL,其中C组较D组出血量少2.9 mL(P<0.05),其余A与C,B与C、C与E组间比较差异均无统计学意义(P>0.05)。术后1个月清石率比较,A组:95.00%,B组:93.10%,C组:98.33%,D组:98.00%,E组:95.74%,各组间差异均无统计学意义(P>0.05)。术后并发症发生率ClavienⅠ级比较,A组:62.50%,B组:67.24%,C组:60.83%,D组:56.00%,E组:61.70%,各组间差异均无统计学意义(P>0.05);ClavienⅡ级比较,A组:5.00%,B组:3.45%,C组:4.17%,D组:4.00%,E组:17.02%,E组较C组发生率高(P<0.05),其余A与C,B与C,C与D组间比较差异均无统计学意义(P>0.05)。术后住院天数比较,A组:(3.13±1.99) d,B组:(2.20±1.37) d,C组:(2.80±1.82) d,D组:(2.88±1.94) d,E组:(3.57±2.22) d,各组间比较差异均无统计学意义(P>0.05)。结论 经尿道输尿管软镜碎石术治疗肾结石和输尿管上段结石,术前留置双J管预扩张输尿管的时间,留置7 d可使得手术有效和安全,输尿管狭窄患者需延长至14 d,有经验的医师和医院可缩短至5 d,有确切上尿路自然排石史和留置双J管病史的患者术前可不留置,因上尿路感染和肾后性肾功能不全而留置双J管的患者可留置28 d以上,需警惕术后尿源性感染。Abstract: Objective To evaluate the efficacy and safety of different durations of preoperative double J stent indwelling in transurethral flexible ureteroscopic lithotripsy (FURL).Methods From January 2018 to April 2021, 315 cases were diagnosed as intrarenal and proximal ureteral stones by CT and treated by transurethral FURL in Beijing Jishuitan Hospital. The stone diameters were 2 cm or less. According to the indwelling duration, 40 cases in group A: no indwelling; 58 cases in group B: 5 days; 120 cases in Group C: 7 days; 50 cases in Group D: 14 days; 47 cases in group E: 28 days or more. Data were collected and analyzed.Results First-time success rates of indwelling flexible ureteroscopic channel sheath was A: 97.50%, B: 94.83%, C: 99.17%, D: 100.00%, E: 100.00%,P> 0.05. Operation time A: (91.79±41.13) min, B: (81.36±28.18) min, C: (80.31±27.63) min, D: (83.30±31.70) min, E: (78.51±26.64) min,P> 0.05. The blood loss A: (4.15±3.38) mL, B: (5.64±4.86) mL, C: (4.60±3.57) mL, D: (7.50±10.50) mL, E: (5.81±5.27) mL, only group C was 2.9 mL less than group D,P< 0.05, othersP> 0.05.One month after surgery, the stone removal rate A: 95.00%, B: 93.10%, C: 98.33%, D: 98.00%, E: 95.74% andP> 0.05. The incidence of postoperative complications of Clavien Ⅰ, A: 62.50%, B: 67.24%, C: 60.83%, D: 56.00%, E: 61.70%,P> 0.05. Clavien Ⅱ, A: 5.00%, B: 3.45%, C: 4.17%, D: 4.00%, E: 17.02%, between groups E and C,P< 0.05, othersP> 0.05. Postoperative hospitalization time A: (3.13±1.99) day, B: (2.20±1.37) day, C: (2.80±1.82) day, D: (2.88±1.94) day, E: (3.57±2.22) day,P> 0.05.Conclusion Double J stent indwelling duration of 7 days before transurethral flexible ureteroscopic lithotripsy on the treatment of intrarenal and proximal ureteral stones can make surgery effective and safe. Patients with ureteral stricture should be prolonged to 14 days. However, experienced doctors and hospitals can reduce to 5 days. Patients with an exact history of upper urinary tract stone discharged or indwelling double J stent can be free of indwelling. Patients with the upper urinary tract infection or postrenal insufficiency can be indwelt double J stent for more than 28 days, but postoperative urinary infection should be minded.
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Key words:
- urinary tract stone /
- flexible ureteroscope /
- double J stent /
- predilation
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表 1 各组一般资料比较
X±S 组别 例数 性别/例 年龄/岁 结石最大直径/mm 男 女 范围 平均 A组 40 30 10 22~83 52.52 13.85±4.23 B组 58 38 20 20~75 46.46 13.53±4.40 C组 120 91 29 18~86 47.85 13.29±3.99 D组 50 37 13 21~79 49.74 14.44±4.02 E组 47 33 14 25~87 52.04 13.19±5.33 χ2/F 2.397 1.712 0.781 P值 0.663 0.147 0.538 表 2 各组术中情况比较
X±S 组别 术前双J管留置时间/d 一期带导引鞘软镜置入成功率/例(%) 手术时间/min 出血量/mL A组 0 39(97.50) 91.79±41.13 4.15±3.38 B组 5 55(94.83) 81.36±28.18 5.64±4.86 C组 7 119(99.17) 80.31±27.63 4.60±3.57 D组 14 50(100.00) 83.30±31.70 7.50±10.50 E组 >28 47(100.00) 78.51±26.64 5.81±5.27 χ2/F 4.999 1.189 2.792 P值 0.147 0.316 0.026 表 3 出血量的组间Dunnett t(双侧)检验
组别 均值差 标准误 P值 95%CI 下限 上限 A与C组 -0.425 1.043 0.988 -3.023 2.173 B与C组 0.883 0.914 0.781 -1.393 3.158 D与C组 2.900 0.962 0.011 0.503 5.295 E与C组 1.291 0.983 0.601 -1.240 3.657 表 4 各组术后情况比较
例(%),X±S 组别 术前双J管留置时间/d Clavien术后并发症发生率 术后1个月结石清除率 术后住院时间/d Ⅰ级 Ⅱ级 A组 0 25(62.50) 2(5.00) 38(95.00) 3.13±1.99 B组 5 39(67.24) 2(3.45) 54(93.10) 2.20±1.37 C组 7 73(60.83) 5(4.17) 118(98.33) 2.80±1.82 D组 14 28(56.00) 2(4.00) 49(98.00) 2.88±1.94 E组 >28 29(61.70) 8(17.02) 45(95.74) 3.57±2.22 χ2/F 1.487 8.769 4.085 3.393 P值 0.829 0.047 0.347 0.010 表 5 术后住院时间的组间Dunnett t(双侧)检验
组别 均值差 标准误 P值 95%CI 下限 上限 A与C组 0.283 0.341 0.859 -0.566 1.133 B与C组 -0.533 0.299 0.253 -1.277 0.211 D与C组 0.088 0.314 0.997 -0.695 0.872 E与C组 0.783 0.322 0.058 -0.018 1.583 -
[1] 王振超. 软性输尿管镜治疗上尿路结石的研究进展[J]. 国际泌尿系统杂志, 2020, 40(2): 351-354. doi: 10.3760/cma.j.issn.1673-4416.2020.02.045
[2] 施柳辉, 王莉, 施飞, 等. 输尿管软镜技术在飞行员肾结石诊治中价值及应用策略[J]. 生物医学工程与临床, 2020, 24(1): 29-33. https://www.cnki.com.cn/Article/CJFDTOTAL-SGLC202001007.htm
[3] Ma YC, Jian ZY, Yuan C, et al. Risk Factors of Infectious Complications after Ureteroscopy: A Systematic Review and Meta-Analysis Based on Adjusted Effect Estimate[J]. Surg Infect(Larchmt), 2020, 21(10): 811-822. doi: 10.1089/sur.2020.013
[4] 张钦尧. 术前留置输尿管支架管(双J管)对输尿管软镜碎石术治疗肾或输尿管上段结石治疗效果的影响分析[J]. 临床研究, 2020, 28(2): 74-75. https://www.cnki.com.cn/Article/CJFDTOTAL-LCYN202002039.htm
[5] 那彦群, 叶章群, 孙颖浩, 等. 2014版中国泌尿外科疾病诊断治疗指南[M]. 北京: 人民卫生出版社, 2014: 136-142.
[6] 黄建生, 房杰群, 余舟, 等. 输尿管软镜钬激光碎石术在 > 2 cm肾结石治疗中的应用体会[J]. 临床泌尿外科杂志, 2019, 34(4): 264-267. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=baac1724-5005-4f4b-a57a-568423f4dd4d
[7] 王俊, 郭志新, 吴洪磊, 等. 输尿管软镜钬激光碎石术治疗输尿管上段结石并发输尿管狭窄的危险因素分析[J]. 临床泌尿外科杂志, 2018, 33(7): 532-536. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=aa3d18d6-45ca-459c-a045-b1ac37d2cd2c
[8] 魏瑞峰. 术前留置双J管对经尿道输尿管软镜碎石术疗效的影响[J]. 河南医学研究, 2018, 27(1): 125-126. doi: 10.3969/j.issn.1004-437X.2018.01.078
[9] 单保华, 尤祥云, 喻俊峰, 等. 输尿管镜钬激光碎石术后早期并发症的Clavien-Dindo分级及影响因素分析[J/OL]. 中国现代医学杂志, 2020, 22(1): 1-9.
[10] 李建兴, 肖博. 软性输尿管镜手术临床应用要点[J]. 临床泌尿外科杂志, 2018, 33(7): 507-510. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=ecdf36e0-930c-47bf-9cb3-9247a6f5c94e
[11] Karaaslan M, Tonyali S, Yilmaz M, et al. Ureteral access sheath use in retrograde intrarenal surgery[J]. Arch Ital Urol Androl, 2019, 91(2): 112-114.
[12] 姚碧海, 黎承杨. 输尿管通道鞘安置相关影响因素的分析[J]. 临床泌尿外科杂志, 2021, 36(10): 806-811. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=a2ed780b-7fcb-4e9e-ab40-95d26683d477
[13] 廖文彪, 蒋立量, 余娅兰, 等. 输尿管软镜术中成功置入输尿管通道鞘的多因素分析: 单中心回顾性研究[J]. 微创泌尿外科杂志, 2018, 7(5): 314-317. https://www.cnki.com.cn/Article/CJFDTOTAL-WCMN201805007.htm
[14] 张彩祥, 王娟, 肖荆, 等. 输尿管支架管置入后引起疼痛、排尿症状、一般健康问题的危险因素分析[J]. 临床泌尿外科杂志, 2020, 35(6): 471-474, 481. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=59d159da-a6fd-4ce0-a49b-f4a62ae1308a
[15] 周志均, 李响. 输尿管软镜碎石术前预置双J管必要性的荟萃分析[J]. 中华泌尿外科杂志, 2020, 41(2): 138-146. doi: 10.3760/cma.j.issn.1000-6702.2020.01.011
[16] 黄晨, 李逊, 徐桂彬, 等. 预留双J管与球囊扩张在输尿管软镜碎石取石术中的比较[J/OL]. 中华腔镜泌尿外科杂志, 2019, 13(5): 309-312.
[17] Hu Q, Ji Y, Wang Z, et al. Is a ureteral stent required before flexible ureteroscopy?[J]. Transl Androl Urol, 2020, 9(6): 2723-2729. doi: 10.21037/tau-20-1458
[18] 王昊星, 乃比江·毛拉库尔班, 王峰, 等. 术前留置双J管对输尿管软镜手术效果的影响[J/OL]. 中华腔镜泌尿外科杂志, 2017, 11(2): 118-121.
[19] 詹运运, 吴天鹏, 孙超, 等. 术前留置双J管时间长短对输尿管软镜治疗肾结石的疗效影响[J]. 武汉大学学报(医学版), 2020, 41(6): 963-966. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYK202006021.htm
[20] 沈柏华, 林奕伟. 输尿管软镜碎石术相关尿源性脓毒症的防治策略[J]. 临床泌尿外科杂志, 2020, 35(9): 696-698. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=e07c66ea-7027-4def-9892-7911d07625b7
[21] 宣寒青, 陈奇, 仲海, 等. 输尿管软镜下钬激光碎石术日间手术模式的可行性分析[J]. 中国激光医学杂志, 2018, 27(2): 115. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGJG201802160.htm