Preoperative predictive value of extrarenal exudation in flexible ureteroscopic lithotomy for urosepsis
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摘要: 目的 探讨CT平扫肾外渗出在一期输尿管软镜治疗输尿管上段结石术后发生尿源性脓毒症的术前预测价值。方法 分析2019年1月—2022年10月在复旦大学附属闵行医院诊断为输尿管上段结石接受一期输尿管软镜手术的398例患者的临床资料，按照回顾性队列研究设计，统计患者术前血常规、尿常规、中段尿培养、C反应蛋白(C-reactive protein，CRP)、降钙素原(procalcitonin，PCT)及平扫CT各项影像学特征，首先进行单因素分析，然后对差异有统计学意义的资料采用logistic回归方法进行多因素分析。结果 本研究398例患者中，肾外无渗出和肾外渗出患者分别为263例(66.1%)和135例(33.9%)，单因素分析结果提示术前血白细胞、CRP、PCT、尿细菌培养、肾盂积水程度、肾外渗出与术后高热及尿源性脓毒症相关，在调整了年龄、糖尿病、血白细胞、CRP及PCT情况后，结果发现，肾外渗出与术后高热及尿源性脓毒症有相关性(OR=8.67，95%CI：4.72~15.94，P < 0.001)。结论 CT平扫肾外渗出是一期输尿管软镜处理输尿管上段结石患者术后发生高热及尿源性脓毒症独立的高危因素，建议此类患者一期输尿管支架引流，控制感染后行二期输尿管软镜取石术。Abstract: Objective To investigate the preoperative predictive value of extrarenal exudation with CT non-contrast scanning in the development of urosepsis after primary flexible ureteroscopy in the treatment of upper ureteral stones.Methods We analyzed the clinical data of 398 patients diagnosed with upper ureteral stones in Minhang Hospital from January 2019 to October 2022 who underwent one stage of flexible ureteroscopic surgery. According to the retrospective cohort study design, preoperative blood routine, urinalysis, midstream urine culture, C-reactive protein (CRP), Procalcitonin (PCT) and non-contrast CT were counted. Univariate analysis was performed first, then multivariate analysis was performed by logistic regression method for statistically significant data.Results Among the 398 patients in this study, 135 cases (33.9%) were found extrarenal exudation. The results of univariate analysis showed that preoperative blood leukocytes, CRP, PCT, urine bacterial culture, degree of hydronephrosis, extrarenal exudation were associated with postoperative fever and urine sepsis. Age, diabetes, blood leukocytes, CRP and PCT were adjusted after this, then it was found that there was a statistically significant association between extrarenal exudation and postoperative fever, urosepsis (OR=8.67, 95%CI: 4.72-15.94, P < 0.001).Conclusion Extrarenal exudation with CT non-contrast scanning is a high-risk factor for fever and urosepsis after primary flexible ureteroscopic treatment of upper ureteral stones, and it is recommended that such patients undergo primary ureteral stent drainage and secondary flexible ureteroscopic lithotomy after infection control.
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Key words:
- extrarenal exudation /
- urosepsis /
- flexible ureteroscope
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表 1 输尿管上段结石CT平扫肾外渗出患者基本资料
例(%)，X±S 项目 肾周无渗出组(263例) 肾周渗出组(135例) t/χ2 P值 年龄/岁 48.27±14.0 57.88±14.43 -6.42 < 0.001 性别 0.41 0.520 男 193(73.4) 95(70.4) 女 70(26.6) 40(29.6) 糖尿病 20.55 < 0.001 否 253(96.2) 112(83.0) 是 10(3.8) 23(17.0) 肾积水程度 10.37 0.006 轻度 208(79.1) 87(64.4) 中度 30(11.4) 29(21.5) 重度 25(9.5) 19(14.1) 结石长径 0.61 0.810 < 1 cm 176(66.9) 92(68.1) ≥1 cm 87(33.1) 43(31.9) 
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表 2 输尿管上段结石一期软镜碎石术后高热及尿源性脓毒症的单因素分析
例(%) 变量 无高热及脓毒症(294例) 高热及脓毒症(104例) χ2 P值 OR 95%CI 下限 上限 肾外渗出 101.10 < 0.001 11.60 6.87 19.60 无 236(80.3) 27(26.0) 有 58(19.7) 77(74.0) 尿培养 12.51 < 0.001 4.66 1.85 11.76 阴性 286(97.3) 92(88.5) 阳性 8(2.7) 12(11.5) 血白细胞 4.84 0.030 1.77 1.06 2.94 正常 237(80.6) 73(70.2) 升高 57(19.4) 31(29.8) CRP 40.42 < 0.001 4.52 2.79 7.32 正常 239(81.3) 51(49.0) 升高 55(18.7) 53(51.0) PCT 34.37 < 0.001 12.10 4.36 33.54 正常 289(98.3) 86(82.7) 升高 5(1.7) 18(17.3)
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表 3 输尿管上段结石一期软镜碎石术后高热及尿源性脓毒症的多因素回归分析
变量 调整前 调整后a) OR 95%CI P值 OR 95%CI P值 肾外渗出 无b) 有 11.6 6.87~19.60 < 0.001 8.67 4.72~15.94 < 0.001 注：a)调整了年龄、糖尿病、肾积水、血白细胞、CRP、PCT；b)无肾外渗出组。
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