Comparison between rigid ureteroscopic holmium laser lithotripsy and flexible ureteroscopic holmium laser lithotripsy in treatment of the different segments of upper ureteral calculi
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摘要: 目的 比较输尿管硬镜钬激光碎石术与输尿管软镜钬激光碎石术治疗输尿管上段不同部位结石的临床疗效。方法 分析2018年4月—2021年3月行输尿管硬镜钬激光碎石术和输尿管软镜钬激光碎石术治疗输尿管上段直径>1.0 cm结石患者321例，按其术式不同分为硬镜组145例，软镜组176例，将上段输尿管以肾下极、腰4横突、骶髂关节上缘为界分为上中下3个部位后，对2组3个细分部位结石患者的手术成功率、手术时间、严重并发症和结石清除率进行比较。结果 在手术成功率方面，硬镜上部组(74.4%)明显低于软镜上部组(95.5%)，差异有统计学意义(P< 0.05);硬镜中部组(91.1%)与软镜中部组(93.1%)比较差异无统计学意义(P>0.05);硬镜下部组(94.7%)与软镜下部组(96.2%)比较差异无统计学意义(P>0.05)。对2组手术成功患者进行比较：在手术时间方面，硬镜上部组(64.4±19.5) min、中部组(66.2±20.9) min、下部组(61.2±17.1) min分别低于软镜上部组(85.4±24.9) min、中部组(82.9±23.5) min、下部组(80.7±21.1) min，差异均有统计学意义(均P< 0.05)。在严重并发症方面，硬镜上部组(6.2%)、中部组(4.9%)、下部组(7.4%)分别与软镜上部组(6.3%)、中部组(7.4%)、下部组(6.0%)比较，差异均无统计学意义(P>0.05)。在结石清除率方面，硬镜上部组(59.4%)低于软镜上部组(85.7%)，差异有统计学意义(P< 0.05);硬镜中部组(82.9%)与软镜中部组(87.0%)比较差异无统计学意义(P>0.05);硬镜下部组(87.0%)与软镜下部组(86.0%)比较，差异无统计学意义(P>0.05)。结论 输尿管硬镜与输尿管软镜钬激光碎石术的严重并发症无明显差异，均为目前临床上比较安全的手术方式。对于输尿管上段上部结石，软镜钬激光碎石术的手术成功率和结石清除率显著高于硬镜，是该部位相对硬镜更优的手术方式。对于输尿管上段中部和下部结石，硬镜与软镜碎石术的手术成功率和结石清除率比较差异无统计学意义，但硬镜碎石术的疗程及手术时间更短。Abstract: Objective To compare the clinical efficacy and safety between rigid ureteroscopic holmium laser lithotripsy (RURL) with N-Trap and flexible ureteroscopic holmium laser lithotripsy (FURL) in the treatment of upper ureteral calculi.Methods The clinical data of 321 patients with unilateral upper ureteral calculi treated from Apr. 2018 to Mar. 2021 were retrospectively analyzed, including 145 cases treated with RURL with the application of N-Trap and 176 cases treated with FURL. After dividing the upper ureter into the proximal, intermediate and distal segment by the lower pole of the kidney, the transverse process of the lumbar 4 and the upper edge of the sacroiliac joint, we compared the two groups in operation success rate and compared the successful operation cases of the two groups in operation time, incidence of serious complications and stone clearance in the different segments of upper ureter respectively.Results The operation success rate of the proximal segment of rigid group (74.4%) was lower than that of the proximal segment of flexible group (95.5%) (P< 0.05). While there was no significant difference between the intermediate segment of rigid group (91.1%) and the intermediate segment of flexible group (93.1%) (P> 0.05), and also there was no significant difference between the distal segment in rigid group (94.7%) and the distal segment in flexible group (96.2%) (P> 0.05). The clinical indexes of the successful operation cases of the two groups were analyzed as follows. The operation times of the rigid ureteroscopic successful group [(64.4±19.5) min for the proximal segment, (66.2±20.9) min for the intermediate segment, (61.2±17.1) min for the distal segment] were shorter than those of the flexible ureteroscopic successful group [(85.4±24.9) min, (82.9±23.5) min, (80.7±21.1) min] respectively (P< 0.05). There were no significant differences in the incidence of serious complications between the rigid ureteroscopic successful group (6.2% for the proximal segment, 4.9% for the intermediate segment, 7.4% for the distal segment) and the flexible ureteroscopic successful group (6.3%, 7.4%, 6.0%) respectively (P> 0.05). The stone clearance of the proximal segment of rigid ureteroscopic successful group (59.4%) was lower than that of the proximal segment of flexible ureteroscopic successful group (85.7%) (P< 0.05). While there was no significant difference between the intermediate segment of rigid successful group (82.9%) and the intermediate segment of flexible successful group (87.0%) (P> 0.05), and also there was no significant difference between the distal segment in rigid successful group (87.0%) and the distal segment in flexible successful group (86.0%) (P> 0.05).Conclusion Both RURL and FURL are safe treatments for the upper ureteral calculi with the similar incidence of serious complications. For the proximal segment of upper ureteral calculi, the success rate and stone clearance rate were higher in FURL than those in RURL; hence FURL is a better choice than RURL in this segment. For the intermediate segment and the distal segment of upper ureteral calculi, the success rate and stone clearance rate were similar between RURL and FURL; while the treatment course and the operation time of RURL was shorter than that of FURL.
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Key words:
- ureteral calculi /
- rigid ureteroscopy /
- flexible ureteroscopy /
- holmium laser lithotripsy
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表 1 2组患者基本资料的比较
例(%)，X ± S 项目 硬镜上部组
(n=43)软镜上部组
(n=66)硬镜中部组
(n=45)软镜中部组
(n=58)硬镜下部组
(n=57)软镜下部组
(n=52)性别 男 30(69.8) 45(68.2) 32(71.1) 38(65.5) 38(66.7) 33(63.5) 女 13(30.2) 21(31.8) 13(28.9) 20(34.5) 19(33.3) 19(36.5) 年龄/岁 57.1±12.3 59.1±11.8 56.0±12.2 59.7±12.3 57.6±12.2 60.1±9.6 侧别 左 23(53.5) 38(57.6) 24(53.3) 30(51.7) 31(54.4) 31(59.6) 右 20(46.5) 28(42.4) 21(46.7) 28(48.3) 26(45.6) 21(40.4) 结石长径 1~1.5 cm 29(67.4) 47(71.2) 35(77.8) 45(77.6) 47(82.5) 42(80.8) ＞1.5~2.0 cm 12(27.9) 16(24.2) 9(20.0) 13(22.4) 8(14.0) 9(17.3) ＞2.0 cm 2(4.7) 3(4.6) 1(2.2) 0 2(3.5) 1(1.9) 患侧肾盂分离宽度 ≤1.5 cm 13(30.2) 16(24.2) 11(24.4) 13(22.4) 8(14.0) 6(11.5) ＞1.5~3.0 cm 27(62.8) 46(69.7) 28(62.2) 37(63.8) 37(64.9) 37(71.2) ＞3.0~4.0 cm 3(7.0) 3(4.6) 5(11.1) 8(13.8) 10(17.5) 7(13.5) >4.0 cm 0 1(1.5) 1(2.2) 0 2(3.5) 2(3.8) 
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表 2 2组各项临床指标的比较
例(%)，X ± S 项目 硬镜
上部组
(n=43)软镜
上部组
(n=66)t/χ2 P值 硬镜
中部组
(n=45)软镜
中部组
(n=58)t/χ2 P值 硬镜
下部组
(n=57)软镜
下部组
(n=52)t/χ2 P值 手术成功率 32(74.4) 63(95.5) 10.292 0.001 41(91.1) 54(93.1) 0.14 0.708 54(94.7) 50(96.2) 0.125 0.724 手术成功患者 手术时间/min 64.4±19.5 85.4±24.9 4.498 0 66.2±20.9 82.9±23.5 3.646 0.001 61.2±17.1 80.7±21.9 5.05 < 0.001 严重并发症 2(6.2) 4(6.3) 0 1 2(4.9) 4(7.4) 0.252 0.616 4(7.4) 3(6.0) 0.082 0.775 结石清除率 19(59.4) 54(85.7) 8.273 0.004 34(82.9) 47(87.0) 0.313 0.576 47(87.0) 43(86.0) 0.024 0.877
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