Factors that predict failure in the treatment of ureteral stones less than 1 cm with extracorporeal shock wave lithotripsy
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摘要: 目的 分析 < 1 cm输尿管结石体外冲击波碎石术(ESWL)治疗失败的预测因素。方法 回顾性分析2019年1月—2022年3月南京医科大学第一附属医院泌尿外科诊治的经ESWL治疗的最大径 < 1 cm输尿管单一结石患者的临床资料。共纳入148例患者(男106例，女42例)，成功组100例，失败组48例。比较ESWL治疗失败和成功患者的临床及影像学资料。临床资料包括性别、年龄、体重指数(BMI)、结石患侧、结石位置。影像学资料包括结石大小、结石密度(MSD)、结石处输尿管壁最大厚度(UWT)、积水程度(HG)、结石上方输尿管内径(PUD)及结石皮肤距离(SSD)。其中结石大小包括结石最大上下径(MCD)、横径最大值(MATD)、横径最小值(MITD)及结石体积(SV)。采用单因素及多因素回归分析筛选预测 < 1 cm输尿管结石ESWL治疗失败的独立预测因子。绘制受试者工作特征(ROC)曲线并分析独立预测因素的预测能力。结果 单因素分析结果显示结石大小(包括MCD、MATD、MITD和SV)、MSD、UWT、HG差异有统计学意义(P < 0.05)。多因素分析结果显示仅UWT为ESWL治疗 < 1 cm的输尿管结石失败的独立影响因素[OR=5.608(2.836~11.092)，P < 0.001]。ROC曲线下面积(AUC)为0.785(95%CI：0.698~0.872，P < 0.001)，以UWT界值为2.65 mm预测 < 1 cm输尿管结石ESWL治疗失败，其敏感度为68%，特异度为84%。结论 结石处UWT对 < 1 cm的输尿管结石ESWL治疗效果具有较好的预测价值，并为小负荷输尿管结石治疗方案的选择提供帮助。Abstract: Objective To analyze the factors predicting treatment failure of ureteral stones less than 1 cm with extracorporeal shock wave lithotripsy (ESWL).Methods We retrospectively evaluated the clinical and radiographic data of patients with solitary ureteral stone less than 1 cm who underwent ESWL from January 2019 to March 2022. A total of 148 patients were included (106 males and 42 females) and divided into two groups as success group (n=100) and failure group (n=48) according to the treatment outcomes. Clinical and radiographic data were compared between the two groups. Clinical data included sex, age, body mass index (BMI), stone laterality and location. Radiographic data included stone size, mean stone density (MSD), ureteral wall thickness (UWT), hydronephrosis grade (HG), proximal ureter diameter (PUD) and skin-to-stone distance (SSD). Stone size included maximal craniocaudal diameter (MCD), maximal transverse diameter (MATD), minimal transverse diameter (MITD) and stone volume (SV). Univariate and multivariate analyses were used to identify the independent prognostic factors of ESWL failure for ureteral stones less than 1 cm. The receiver operating characteristic curve (ROC) was used to analyze the performance of independent prognostic factors.Results Univariate analysis showed significant difference in stone size (including MCD, MATD, MITD and SV), MSD, UWT and HG between success and failure group. Multivariate analysis showed that only UWT was an independent predictor of ESWL failure for ureteral stones less than 1 cm (OR=5.608[2.836-11.092], P < 0.001). Area under the ROC curve was 0.785 (95%CI: 0.698-0.872, P < 0.001), and the optimal cut-off value of UWT was 2.65 mm, with sensitivity of 68% and specificity of 84%.Conclusion UWT can serve as a preoperative factor to predict ESWL failure for ureteral stones less than 1 cm and may help urologists to optimize the management of ureteral stones with small size.
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表 1 ESWL治疗失败组和成功组的临床及影像学资料比较
例(%)，M(P25，P75)，X±S 项目 失败组(48例) 成功组(100例) P值 性别 0.540 男 36(75.0) 70(70.0) 女 12(25.0) 30(30.0) 年龄/岁 55(25，88) 46(23，84) 0.061 BMI 24.94±3.78 24.59±3.02 0.379 患侧 0.213 右侧 27(56.3) 46(46.0) 左侧 21(43.7) 54(54.0) 位置 0.380 上段 25(52.1) 49(49.0) 中段 6(12.5) 19(19.0) 下段 17(35.4) 32(32.0) 结石特征 MCD/mm 7.8(6.2，9.7) 6.7(6.1，9.8) 0.001 MATD/mm 6.12±0.76 5.33±0.59 0.001 MITD/mm 5.88±0.63 5.13±0.65 0.001 SV/mm3 133.64
(85.04，282.60)98.53
(43.96，235.92)＜0.001 MSD/HU 1059
(500，1580)890
(303，1590)0.034 UWT/mm 3.2(1.4，5.2) 1.8(1.3，3.5) ＜0.001 HG 2(1，4) 2(1，4) 0.004 PUD/mm 8.1±0.92 7.51±1.75 0.093 SSD/mm 106.58±17.55 108.65±18.43 0.187 
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表 2 < 1 cm输尿管结石ESWL治疗失败预测因子的AUC面积
变量 AUC 95%CI P值 MCD 0.710 0.656~0.818 ＜0.001 MATD 0.739 0.653~0.824 ＜0.001 MITD 0.737 0.656~0.818 ＜0.001 SV 0.752 0.686~0.829 ＜0.001 MSD 0.596 0.501~0.691 0.061 UWT 0.785 0.698~0.872 ＜0.001 HG 0.651 0.551~0.752 0.003
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