Application of ureteroscopic holmium laser lithotripsy in patients with oral antithrombotic drugs combined with upper urinary calculi
-
摘要: 目的 评价输尿管镜钬激光碎石术在口服抗血栓药物合并上尿路结石患者中的应用情况，探究输尿管镜钬激光碎石术围手术期是否需要停用口服抗血小板或抗凝药物。方法 回顾性分析303例上尿路结石合并长期接受抗血小板或抗凝药物治疗患者的临床资料，所有患者均行输尿管镜钬激光碎石术。试验组123例患者围手术期未停止口服抗血小板或抗凝药物，其中70例患者口服阿司匹林、35例口服氯吡格雷、18例口服华法林。对照组180例患者在手术前5 d停止抗血小板或抗凝治疗。记录并分析各组患者一般、围手术期资料及并发症。结果 试验组与对照组血红蛋白值比较差异有统计学意义(P＜0.05)，手术时间、住院时间、术后1个月无石率、抗血栓治疗时间等比较差异均无统计学意义(P＞0.05)。围手术期各组均未发生脑梗死、心肌梗死或死亡等严重不良事件。结论 输尿管镜钬激光碎石术安全、有效，可作为长期抗凝治疗上尿路结石患者的一线治疗方式，这些类患者不用停止抗血栓治疗，降低血栓栓塞的风险，并发症发生率低，并且可获得满意结石清除效果。Abstract: Objective To evaluate the application of ureteroscopic holmium laser lithotripsy in patients with oral antithrombotic drugs combined with upper urinary calculi, and to explore whether oral antiplatelet/anticoagulant drugs should be discontinued during perioperative period of ureteroscopic holmium laser lithotripsy.Methods The clinical data of 303 patients with upper urinary calculi complicated with long-term antiplatelet or anticoagulant drugs were retrospectively analyzed. All patients underwent ureteroscopic holmium laser lithotripsy. Patients in the experimental group did not stop oral antiplatelet or anticoagulant drugs during perioperative period. One hundred and eighty patients in the control group stopped antiplatelet or anticoagulant therapy at least 5 days before surgery. In the trial group, 70 patients took aspirin orally, 35 patients took clopidogrel orally, 18 patients took warfarin orally. Baseline data, perioperative data and complications of each group were recorded and analyzed.Results There were statistically significant differences in the decrease value of hemoglobin between the experimental group and the control group (P< 0.05), while there were no statistically significant differences in the operation time, length of hospital stay, stone-free rate 1 month after surgery or duration of antithrombotic treatment (P> 0.05). No serious adverse events such as cerebral infarction, myocardial infarction or death were observed in all groups during perioperative period.Conclusion Ureteroscopic holmium laser lithotripsy is safe and effective, and can be used as a first-line treatment for patients with upper urinary calculi and long-term anticoagulant therapy. These patients do not have to discontinue antithrombotic therapy, thus reducing the risk of thromboembolism, short-term complications, and enhancing stone removal.
-
Key words:
- ureteroscopy /
- anticoagulants /
- Ho∶YAG laser /
- kidney stone
-
-
表 1 抗血栓治疗的原因
例 原因 对照组 阿司匹林组 氯吡格雷组 华法林组 脑梗死 56 27 14 5 冠心病 100 37 19 6 深静脉血栓形成 2 2 1 2 房颤 18 3 1 3 肺栓塞 4 1 0 2 合计 180 70 35 18 
下载: 导出CSV
表 2 患者一般资料
组别 年龄/岁 BMI/(kg·m-2) ASA评分 结石直径/mm INR 对照组 62.5±7.5 26.8±3.3 3.0(3.0，3.0) 15.0(12.0，20.0) 0.9(0.9，1.0) 阿司匹林组 63.8±7.9 26.5±3.7 3.0(3.0，3.0) 15.0(10.8，17.3) 0.9(0.9，1.0) 氯吡格雷组 61.8±8.5 25.6±2.6 3.0(2.0，3.0) 15.0(12.0，17.0) 0.9(0.9，1.0) 华法林组 62.4±13.0 26.5±2.8 3.0(3.0，3.0) 14.5(10.0，15.3) 2.6(2.0，2.7)1) 与其他组比较，1)P＜0.05。
下载: 导出CSV
表 3 患者围手术期资料
组别 手术时间/min 住院时间/d 无石率/例(%) 抗血栓治疗时间/年 血红蛋白下降值/(g·L-1) 对照组 62.0(50.3，81.0) 5.0(4.0，6.0) 162(90.0) 5.0(2.0，10.0) 4.6±8.1 阿司匹林组 61.0(49.0，77.0) 5.0(4.0，7.0) 64(91.4) 5.0(2.0，10.0) 9.9±7.61) 氯吡格雷组 63.5(52.8，77.3) 5.0(4.0，6.0) 31(88.6) 3.0(1.0，10.0) 8.5±8.31) 华法林组 53.5(41.8，70.5) 5.0(4.0，6.0) 16(88.9) 9.0(3.0，13.0) 12.4±7.41) 与对照组比较，1)P＜0.05。
下载: 导出CSV
表 4 术后并发症
例 项目 对照组 阿司匹林组 氯吡格雷组 华法林组 术中出血视野不清导致手术中止 1 0 0 1 输血 0 0 0 0 尿脓毒症 5 1 1 0 肺栓塞 0 0 0 0 肾被膜下血肿 1 0 0 0 房颤 1 0 0 0 心肌梗死 0 0 0 0 脑梗死 0 0 0 0
下载: 导出CSV
-
[1] Donaldson JF, Lardas M, Scrimgeour D, et al. Systematic review and meta-analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower-pole renal stones[J]. Eur Urol, 2015, 67(4): 612-616. doi: 10.1016/j.eururo.2014.09.054
[2] Fang MC, Singer DE. Anticoagulation for atrial fibrillation[J]. Cardiol Clin, 2004, 22(1): 47-62. doi: 10.1016/S0733-8651(03)00115-2
[3] Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50, 279 patients at risk for coronary artery disease[J]. Eur Heart J, 2006, 27(22): 2667-2674. doi: 10.1093/eurheartj/ehl334
[4] Albqami N, Janetschek G. Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma[J]. Nat Clin Pract Urol, 2006, 3(1): 32-37. doi: 10.1038/ncpuro0384
[5] Johnson GB, Grasso M. Exaggerated primary endoscope deflection: initial clinical experience with prototype flexible ureteroscopes[J]. BJU Int, 2004, 93(1): 109-114. doi: 10.1111/j.1464-410X.2004.04567.x
[6] 曾国华, 朱玮. 输尿管软镜钬激光碎石术: 热潮中的冷思考[J]. 临床泌尿外科杂志, 2019, 34(3): 169-172. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=a1bd5dbd-2544-40a9-9441-aee910cd7460
[7] Toepfer NJ, Baylor K, Henry Y, et al. The effect of antiplatelet and anticoagulant therapy on the clinical outcome of patients undergoing ureteroscopy[J]. Urology, 2013, 82(4): 773-779. doi: 10.1016/j.urology.2013.05.019
[8] Patrono C, Baigent C, Hirsh J, et al. Antiplatelet drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)[J]. Chest, 2008, 133(6 Suppl): 199S-233S.
[9] O'Riordan JM, Margey RJ, BLAKE G, et al. Antiplatelet agents in the perioperative period[J]. Arch Surg, 2009, 144(1): 69-76. doi: 10.1001/archsurg.144.1.69
[10] Mega JL, Simon T. Pharmacology of antithrombotic drugs: an assessment of oral antiplatelet and anticoagulant treatments[J]. Lancet, 2015, 386(9990): 281-291. doi: 10.1016/S0140-6736(15)60243-4
[11] Kałuza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting[J]. J Am Coll Cardiol, 2000, 35(5): 1288-1294. doi: 10.1016/S0735-1097(00)00521-0
[12] Sharaf A, Amer T, Somani BK, et al. Ureteroscopy in Patients with Bleeding Diatheses, Anticoagulated, and on Anti-Platelet Agents: A Systematic Review and Meta-Analysis of the Literature[J]. J Endourol, 2017, 31(12): 1217-1225. doi: 10.1089/end.2017.0253
[13] Turna B, Stein RJ, Smaldone MC, et al. Safety and efficacy of flexible ureterorenoscopy and holmium: YAG lithotripsy for intrarenal stones in anticoagulated cases[J]. J Urol, 2008, 179(4): 1415-1419. doi: 10.1016/j.juro.2007.11.076
[14] Westerman ME, Sharma V, Scales J, et al. The Effect of Antiplatelet Agents on Bleeding-Related Complications After Ureteroscopy[J]. J Endourol, 2016, 30(10): 1073-1078. doi: 10.1089/end.2016.0447
[15] Koras O, Bozkurt IH, Karakoyunlu AN, et al. Safety and Efficacy of Flexible Ureterorenoscopy Surgery in Different Age Groups[J]. J Coll Physicians Surg Pak, 2021, 30(6): 679-685.
[16] Watterson JD, Girvan AR, Cook AJ, et al. Safety and efficacy of holmium: YAG laser lithotripsy in patients with bleeding diatheses[J]. J Urol, 2002, 168(2): 442-445. doi: 10.1016/S0022-5347(05)64654-X
[17] 蒋燕, 刘克军, 仇立军. 输尿管结石致肾被膜下血肿1例报告[J]. 现代泌尿外科杂志, 2009, 14(6): 429. doi: 10.3969/j.issn.1009-8291.2009.06.036
[18] Hiller SC, Qi J, Leavitt D, et al. Ureteroscopy in Patients Taking Anticoagulant or Antiplatelet Therapy: Practice Patterns and Outcomes in a Surgical Collaborative[J]. J Urol, 2021, 205(3): 833-840. doi: 10.1097/JU.0000000000001416
[19] 沈宸, 范博, 李先承, 等. 输尿管软镜钬激光碎石术治疗肾下盏结石的有效性分析[J]. 临床泌尿外科杂志, 2021, 36(8): 622-626. http://lcmw.cbpt.cnki.net/WKC/WebPublication/paperDigest.aspx?paperID=4f06f7d1-f5d7-4df3-bf28-41c0ca640934
[20] Guyatt GH, Akl EA, Crowther M, et al. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J]. Chest, 2012, 141(2 Suppl): 7S-47S.
-