Clinical comparative study between ureteroscopic laser lithotripsy and laparoscopic ureterolithotomy for the treatment of impacted ureteral stones
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摘要: 目的 探究输尿管镜激光碎石术(ureteroscopic lithotripsy，URL)与腹腔镜下输尿管切开取石术(laparoscopic ureterolithotomy，LU)治疗嵌顿性输尿管结石的临床效果。方法 回顾性分析2022年1月—2022年12月浙江省人民医院诊治的104例单侧嵌顿性输尿管结石的临床资料。根据手术方式分为URL组和LU组。研究纳入患者的年龄、性别、高血压、糖尿病、患侧、结石位置、结石长度、结石宽度、结石面积、输尿管壁厚度(ureteral wall thickness，UWT)、输尿管壁面积(ureteral wall area，UWA)、肾盂分离程度、有无输尿管狭窄、腹膜后纤维化情况、手术时间、术后住院时间、结石清除率及术后并发症情况等数据。采用描述性分析，检验2组间差异。利用回归分析和亚组分析进一步验证2种手术方式的治疗效果及预后。结果 104例单侧嵌顿性输尿管结石中，行URL 56例，行LU 48例。2组患者在性别、年龄、高血压、糖尿病、患侧、结石位置、结石长度、输尿管狭窄、腹膜后纤维化、结石宽度、结石面积、输尿管厚度、输尿管壁面积及肾积水等术前特征方面差异无统计学意义(P>0.05)。2组患者的手术时间和住院时长有显著差异(P < 0.05)，术后并发症发生率、1个月残石率、3个月输尿管狭窄发病率差异无统计学意义(P>0.05)。多因素回归分析发现，2组间术后住院时长有显著差异。亚组分析可见，URL组的术后住院时间明显短于LU组(P < 0.05)。当肾积水≥ 50 mm时，URL组术后1个月残石率明显高于LU组，差异有统计学意义(P < 0.05)。结论 相比LU，URL对于单侧嵌顿性输尿管结石的治疗，手术时间及术后住院时间更短，术后并发症发生率及残石率无明显差异，是临床治疗该类疾病的优选方案。肾积水≥50 mm的病例，更建议选用LU。Abstract: Objective To evaluate the clinical effects of ureteroscopic laser lithotripsy and laparoscopic ureterolithotomy for the treatment of impacted ureteral stones.Methods We retrospectively analyzed the clinical data of 104 cases of unilateral impacted ureteral stones diagnosed and treated in Zhejiang Provincial People's Hospital from January 2022 to December 2022. According to the surgical method, they were divided into the ureteroscopic laser lithotripsy group and the laparoscopic lithotomy group. The age, gender, hypertension, diabetes, affected side, stone location, stone length, stone width, stone area, ureteral wall thickness, ureteral wall area, hydronephrosis, presence of ureteral stenosis, retroperitoneal fibrosis, operation time, postoperative hospital stay, stone clearance rate and postoperative complications of the patients were included in this study. Descriptive analysis was employed to describe the potential risk factors in two groups. We used regression analysis and subgroup analysis to assess the association between surgical method and prognosis.Results Among the 104 patients, 56 underwent ureteroscopy and 48 underwent laparoscopic treatment. There were no significant differences between the two groups in terms of gender, age, hypertension, diabetes, affected side, stone location, stone length, ureteral stenosis, retroperitoneal fibrosis, stone width, stone area, ureteral thickness, ureteral wall area or hydronephrosis (P > 0.05). There were significant differences in the operation time and length of hospitalization between the two groups (P < 0.05). There were no significant differences in the incidence of postoperative complications, the rate of residual stones in one month and the incidence rate of ureteral stenosis in three months (P > 0.05). Multivariate regression analysis found significant difference in postoperative hospital stay between the two groups. Subgroup analysis showed that the postoperative hospitalization time of the ureteroscopy group was significantly shorter than that of the laparoscopic group (P < 0.05). When hydronephrosis≥50 mm, the residual stone rate in the ureteroscopic group was significantly higher than that in the laparoscopic group at 1 month after surgery, with a statistically significant difference (P < 0.05).Conclusion Compared with laparoscopic ureterolithotomy, ureteroscopic laser lithotripsy for the treatment of unilateral impacted ureteral stones has shorter surgical time and postoperative hospital stay but has no significant difference in the incidence of postoperative complications or residual stone rates, which make it the preferred clinical treatment for this type of disease. For hydronephrosis ≥50 mm, it is recommended to choose laparoscopic ureterolithotomy.
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Key words:
- impacted ureteral stones /
- ureteroscope /
- laparoscope /
- clinical effects
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表 1 2组患者基本资料比较
例(%)，X±S，M(P25，P75) 项目 LU组(48例) URL组(56例) P值 年龄/岁 60(50，65) 54(44，65) 0.123 性别 0.880 男 25(52.1) 30(53.6) 女 23(47.9) 26(46.4) 高血压 0.261 有 23(47.9) 33(58.9) 无 25(52.1) 23(41.1) 糖尿病 0.725 有 17(35.4) 18(32.1) 无 31(64.6) 38(67.9) 患侧 0.976 左 23(47.9) 27(48.2) 右 25(52.1) 29(51.8) 结石位置 0.314 肾盂输尿管交界 5(10.4) 11(19.6) 上段 12(25.0) 12(21.4) 中段 22(45.8) 18(32.1) 下段 9(18.8) 15(26.8) 结石长度/mm 19.1±6.0 21.3±6.3 0.066 结石宽度/mm 13.8±3.4 13.1±3.8 0.328 结石面积/mm2 100.9±23.3 93.9±20.7 0.108 UWT/mm 6.2±0.7 6.5±1.3 0.156 UWA/mm2 99.1±16.1 94.0±17.1 0.122 肾积水/mm 53.7±17.5 51.4±11.4 0.423 输尿管狭窄 0.498* 有 0 2(3.6) 无 48(100.0) 54(96.4) 腹膜后纤维化 0.462* 有 1(2.1) 0 无 47(97.9) 56(100.0) 注：*使用Fisher精确检验。 
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表 2 2组患者的围术期结果及术后复查情况比较
例(%)，X±S，M(P25，P75) 项目 LU组(48例) URL组(56例) P值 手术时间/min 195.0(155.0，233.5) 98.5(85.3，106.0) < 0.001 术后住院时间/d 4.4±0.7 1.9±0.6 < 0.001 术后并发症 0.498* 有 0 2(3.6) 无 48(100.0) 54(96.4) 术后1个月残石 0.400 有 5(10.4) 9(16.1) 无 43(89.6) 47(83.9) 术后3个月输尿管狭窄 0.999* 有 1(2.1) 1(1.8) 无 47(97.9) 55(98.2) 注：*使用Fisher精确检验。
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表 3 围术期及术后复查情况的回归分析结果
变量 单因素回归分析结果 多因素回归分析结果* OR(95%CI) P值 OR(95%CI) P值 术后住院时间 0.08(0.06，0.10) < 0.001 0.08(0.06，0.11) < 0.001 术后1个月残石 0.61(0.19，1.95) 0.403 0.66(0.13，3.48) 0.624 术后3个月输尿管狭窄 1.17(0.07，19.23) 0.912 - - 注：*调整年龄、性别、高血压、糖尿病、结石长度、UWT、UWA、肾积水。
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表 4 围术期及术后复查情况的亚组分析结果
变量 肾积水 < 50 mm 肾积水≥50 mm OR(95%CI) P值 OR(95%CI) P值 术后住院时间 0.07(0.04，0.12) < 0.001 0.10(0.06，0.17) < 0.001 1个月残石 0.003(0.00，1.75) 0.073 573.48(5.20，63275.32) 0.008 3个月输尿管狭窄 - -
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