Retrograde endoscopic balloon dilation and endoscopic holmium laser incision combined with balloon dilation in the treatment of benign ureteral stricture
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摘要: 目的 评估钬激光内切开联合球囊扩张术和单纯球囊扩张术治疗良性输尿管狭窄的效果差异。方法 收集2016年1月-2020年1月北京佑安医院泌尿外科行输尿管镜逆行球囊扩张术和钬激光内切开联合球囊扩张术治疗单侧良性输尿管狭窄患者的临床资料, 根据治疗方式分为联合治疗组(钬激光内切开联合球囊扩张术)和球囊扩张组, 分析输尿管镜直视下2种手术方式治疗良性输尿管狭窄的效果差异。结果 共纳入82例患者, 其中联合治疗组35例, 球囊扩张组47例。联合治疗组的整体1年有效率(80.0% vs 68.1%)和2年有效率(62.9% vs 46.8%)虽均高于球囊扩张组, 但差异无统计学意义; 对于长段狭窄(2.0~2.5 cm), 联合治疗组的1年有效率(77.2% vs 44.4%, P=0.033)和2年有效率(66.6% vs 22.2%, P=0.01)高于球囊扩张组, 差异有统计学意义。多因素分析显示, 狭窄长度(OR=18.505, P=0.001)和狭窄程度(OR=0.095, P=0.002)为影响1年有效率的危险因素, 狭窄长度(OR=92.122, P=0.001)、手术方式(OR=0.046, P=0.002)和狭窄程度(OR=0.012, P=0.001)为影响2年有效率的危险因素。2组患者均未出现严重术后并发症。结论 钬激光内切开联合球囊扩张术治疗良性输尿管狭窄的远期疗效优于单纯球囊扩张手术, 在大于2 cm输尿管狭窄、狭窄程度重的合适病例中可以作为一种可选择的治疗方式。Abstract: Objective To evaluate the effect of holmium laser incision combined with balloon dilation (HBD) and balloon dilation (BD) in benign ureteral stricture.Methods Medical records of HBD and BD in patients with benign ureteral stricture in Beijing Youan Hospital from January 2016 to January 2020 were retrospectively reviewed. Patients were divided into HBD group and BD group according to operation method, then the difference of the effect of two kinds of operation under ureteroscope in the treatment of benign ureteral stricture was analyzed.Results A total of 82 patients were enrolled, including 35 in the HBD group and 47 in the BD group. The overall 1-year effective rate (80.0% vs 68.1%) and 2-year effective rate (62.9% vs 46.8%) in the HBD group were higher than those in the BD group, but there was no statistical difference. For long stenosis (2.0-2.5 cm), the 1-year effective rate (77.2% vs 44.4%, P=0.033) and 2-year effective response rate (66.6% vs 22.2%, P=0.01) in the HBD group were significantly higher than those in the BD group with statistical differences. Multivariate analysis showed that stricture length (OR=18.505, P=0.001) and stricture degree (OR=0.095, P=0.002) were risk factors affecting the 1-year effective rate, while stenosis length (OR=92.122, P=0.001), surgical method (OR=0.046, P=0.002), and stricture degree (OR=0.012, P=0.001) were risk factors affecting the 2-year effective rate. There were no serious postoperative complications occurred in both groups.Conclusion HBD has definite long-term efficacy in the treatment of benign ureteral stricture. It is superior to BD alone, so it can be used as a priority in suitable cases of ureteral stricture larger than 2 cm and higher stricture degree.
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表 1 入组患者临床资料比较
例(%)，X±S 项目 联合治疗组(35例) 球囊扩张组(47例) χ2/t P值 男/女/例 22/13 26/21 0.47 0.493 年龄/岁 44.3±11.9 48.1±12.3 1.402 0.163 狭窄位置 上段 23(65.7) 21(44.7) 3.569 0.059 中段 3(8.6) 11(23.4) 3.333 0.136 下段 9(25.7) 15(31.9) 0.373 0.542 患侧(左/右) 15/20 29/18 2.865 0.091 病因 医源性损伤 19(54.3) 23(48.9) 0.418 0.518 炎性狭窄 9(25.7) 17(36.2) 2.965 0.085 UPJO 4(11.4) 2(4.3) 1.511 0.394 妇科手术 2(5.7) 4(8.5) 0.237 1.000 不明原因 1(2.9) 1(2.1) 0.044 1.000 肾积水程度 轻 14(40.0) 22(46.8) 0.378 0.539 中 11(31.4) 12(25.5) 0.346 0.557 重 10(28.6) 13(27.7) 0.008 1.000 狭窄长度/cm 1.81±0.49 1.54±0.74 2.010 0.048 狭窄程度 轻-中 27(77.1) 35(74.5) 0.078 0.780 重 8(22.9) 12(25.5) 0.078 0.780 单发狭窄 33(94.3) 45(95.7) 0.091 1.000 失败后手术方式 腹腔镜或开放成型术 3(8.6) 7(14.9) 0.749 0.387 Allium 1(2.9) 2(4.3) 0.114 0.736 MemoKath 1(2.9) 1(2.1) 0.044 0.833 普通支架维持治疗 2(5.7) 5(10.6) 0.623 0.430 
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表 2 2组术后有效率比较
例(%) 疗效 联合治疗组(35例) 球囊扩张组(47例) χ2 P值 有效(1年) 28(80.0) 32(68.1) 1.451 0.228 有效(2年) 22(62.9) 22(46.8) 2.078 0.149
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表 3 不同狭窄段长度对手术有效率的影响
例(%) 疗效 ≥2 cm χ2 P值 < 2 cm χ2 P值 联合治疗组
(22例)球囊扩张组
(18例)联合治疗组
(13例)球囊扩张组
(29例)有效(1年) 17(77.2) 8(44.4) 4.552 0.033 11(84.6) 24(82.8) 0.022 0.881 有效(2年) 12(54.5) 4(22.2) 6.061 0.010 10(76.9) 18(62.1) 0.891 0.345
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表 4 术后1年有效率的多因素logistic回归分析
变量 B SE Wald P值 OR 95%CI 手术方式 -1.356 0.725 3.501 0.061 0.258 0.062~1.067 狭窄程度 -2.352 0.757 9.660 0.002 0.095 0.022~0.419 单发狭窄 -0.585 1.561 0.140 0.708 0.557 0.026~11.882 狭窄长度 2.918 0.855 11.642 0.001 18.505 3.462~98.911
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表 5 术后2年有效率的多因素logistic回归分析
变量 B SE Wald P值 OR 95%CI 手术方式 -3.069 0.999 9.440 0.002 0.046 0.007~0.329 狭窄程度 -4.394 1.257 12.214 0.001 0.012 0.001~0.145 单发狭窄 1.282 1.628 0.619 0.431 3.602 0.148~87.639 狭窄长度 4.523 1.161 15.176 0.001 92.122 9.464~896.748
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