Effect of bladder emptying on ureteral access sheath insertion resistance and ureteral injury: a prospective randomized controlled trail
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摘要: 目的 评估排空膀胱对输尿管通道鞘(UAS)置入阻力和输尿管损伤的影响，以指导UAS置入过程中减少输尿管损伤。方法 80例输尿管软镜碎石患者在置鞘前随机分组，分别排空膀胱和不干预，使用IMADA-50N测力计及配套软件测量并记录UAS置入时的阻力，评估输尿管损伤分级，比较2组置鞘平均阻力、全程最大阻力、分段最大阻力、输尿管损伤情况等。结果 排空膀胱组在置鞘平均阻力、置鞘最大阻力、输尿管下段置鞘最大阻力上均显著低于未排空膀胱组(P < 0.001)。横向对比中，BMI≥25 kg/m2的患者在置鞘平均阻力、置鞘最大阻力、下段最大组力上均高于BMI < 25 kg/m2的患者(P < 0.05)；而男性和女性以及年龄≥50岁和年龄 < 50岁患者的5项置鞘阻力比较，差异均无统计学意义。排空膀胱组PULS 1~2级输尿管损伤发生率低于未排空膀胱组(35% vs 55%，P=0.045)，差异主要体现在输尿管下段(22.5% vs 55%，P=0.006)，输尿管中段及上段损伤差异无统计学意义(P>0.05)。结论 置入UAS前排空膀胱，可有效降低UAS置入阻力和输尿管下段损伤风险。Abstract: Objective To evaluate the effect of bladder emptying status on ureteral access sheath (UAS) insertion resistance and ureteral injury, so as to guide the UAS insertion procedure to reduce ureteral injury.Methods Eighty patients with retrograde intrarenal surgery (RIRS) were randomly divided into two groups before UAS placement, bladder emptying group and non intervention group, respectively. IMADA-50N dynamometer was used to measure UAS insertion resistance, and the ureteral injury was evaluated and graded. The average UAS insertion resistance, the maximum resistance in the whole process, the maximum resistance in ureteral segments, and ureteral injury were compared between the two groups.Results The mean resistance, maximum resistance in whole process and distal ureter in the emptying bladder group were significantly lower than those in the non emptying bladder group (P < 0.001). Patients with BMI≥25 kg/m2 had higher mean UAS insertion resistance, maximum resistance in whole process and distal ureter than patients with BMI < 25 kg/m2(P < 0.05), while there was no significant difference between men and women, age≥50 years old and age < 50 years old. The incidence of PULS grade 1-2 ureteral injury in the empting bladder group was lower than that in the non intervention group (35% vs 55%, P=0.045), mainly in distal ureteral injury (22.5% vs 55%, P=0.006), while there was no significant difference in middle or upper ureter.Conclusion Emptying the bladder before UAS insertion can effectively reduce the UAS insertion resistance and the risk of distal ureteral injury in RIRS.
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表 1 2组患者一般资料
例(%)，X±S 指标 排空膀胱组(40例) 未排空膀胱组(40例) P值 年龄/岁 45.9±13.3 43.3±12.5 0.356 男/女 26/14 23/17 0.646 BMI/(kg·m-2) 22.1±3.3 23.4±4.0 0.127 结石直径/mm 13.2±4.2 13.1±4.4 0.938 结石面积/mm2 198.9±92.5 230.2±98.1 0.146 结石位置 0.436 肾盂 13(32.5) 8(20.0) 肾盏 10(25.0) 11(27.5) 多发 17(42.5) 21(52.5) 术前血红蛋白/(g·L-1) 126.4±17.3 129.5±14.3 0.388 术前血肌酐/(μmol·L-1) 83.7±18.6 89.7±21.5 0.184 术前尿常规阳性 15(37.5) 18(45.0) 0.650 术前尿培养阳性 5(12.5) 6(15.0) 1.000 高血压 14(35.0) 12(30.0) 0.811 糖尿病 5(12.5) 9(22.5) 0.380 
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表 2 2组患者术中置鞘阻力比较
N，X±S 指标 排空膀胱组(40例) 未排空膀胱组(40例) P值 平均阻力 3.12±0.49 4.28±0.52 < 0.001 最大阻力 5.17±0.72 6.39±0.96 < 0.001 输尿管上段最大阻力 4.94±0.86 5.01±0.81 0.685 输尿管中段最大阻力 4.14±0.86 4.15±0.82 0.957 输尿管下段最大阻力 3.07±0.75 6.18±1.17 < 0.001
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表 3 性别对置鞘力的影响
N，X±S 指标 男性(49例) 女性(31例) P值 平均阻力 3.60±0.79 3.85±0.71 0.148 最大阻力 5.69±1.09 5.93±0.97 0.328 输尿管上段最大阻力 4.97±0.90 4.99±0.74 0.931 输尿管中段最大阻力 4.04±0.86 4.31±0.79 0.171 输尿管下段最大阻力 4.44±1.85 4.91±1.85 0.273
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表 4 年龄对置鞘力的影响
N，X±S 指标 年龄≥50岁(28例) 年龄 < 50岁(52例) P值 置鞘平均阻力 3.64±0.92 3.73±0.68 0.632 置鞘最大阻力 5.73±1.17 5.81±0.98 0.737 输尿管上段最大阻力 4.92±0.80 5.01±0.86 0.659 输尿管中段最大阻力 4.09±0.92 4.17±0.79 0.654 输尿管下段最大阻力 4.59±1.99 4.64±1.79 0.901
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表 5 BMI对置鞘力的影响
N，X±S 指标 BMI≥25 kg/m2(18例) BMI < 25 kg/m2(62例) P值 置鞘平均阻力 4.10±0.63 3.58±0.77 0.010 置鞘最大阻力 6.26±1.02 5.65±1.02 0.028 输尿管上段最大阻力 5.09±0.72 4.94±0.87 0.527 输尿管中段最大阻力 4.25±0.87 4.11±0.83 0.533 输尿管下段最大阻力 5.56±1.70 4.35±1.81 0.013
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表 6 2组患者输尿管损伤及术后结果比较
例(%)，X±S 指标 排空膀胱组(40例) 未排空膀胱组(40例) P值 输尿管损伤分级 0.045 PULS 0 26(65.0) 18(45.0) PULS 1 12(30.0) 13(32.5) PULS 2 2(5.0) 9(22.5) 输尿管上段损伤 14(35.0) 15(37.5) 1.000 输尿管中段损伤 11(27.5) 13(32.5) 0.810 输尿管下段损伤 9(22.5) 22(55.0) 0.006 碎石时间/min 23.0±11.3 23.9±10.6 0.729 术后血红蛋白/(g·L-1) 126.1±17.1 128.9±13.9 0.421 术后血红蛋白下降量/(g·L-1) 0.3±1.2 0.6±1.9 0.481 术后血肌酐/(μmol·L-1) 85.3±17.9 90.4±20.2 0.229 结石清除 33(82.5) 32(80.0) 1.000 术后疼痛评分 0.377 BCS 3 9(22.5) 5(12.5) BCS 4 31(77.5) 35(87.5) 术后发热 8(20.0) 4(10.0) 0.348 术后脓毒症发生 0(0) 1(2.5) 1.000 术后住院天数/d 0.9±0.4 0.8±0.5 0.964
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