Comparative study between retroperitoneal laparoscopic ureterolithotomy and ureteroscopic laser lithotripsy in the treatment of incarcerated stones in the upper ureter
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摘要: 目的 探讨后腹腔镜输尿管切开取石术(retroperitoneal laparoscopic ureterolithotomy，RPLU)与输尿管镜碎石术(ureteroscopic lithotripsy，URSL)在治疗输尿管上段嵌顿性结石的疗效差异。方法 回顾性分析2018年1月—2021年8月东南大学医学院附属江阴医院收治的116例输尿管上段嵌顿性结石患者的临床资料，分为RPLU组(67例)及URSL组(49例)。男64例、女52例，平均年龄为(39.2±7.8)岁。分别对2组患者术前的结石负荷、结石CT值、尿白细胞计数及细菌计数、患侧肾小球滤过率(glomerular filtration rate，GFR)、手术时间、术后发热率、手术并发症、结石清除率等参数进行比较分析。结果 所有患者均一次性手术成功。2组患者在术前结石负荷[(1.7±0.3) cm vs (1.8±0.4) cm，P=0.214]、结石CT值[(549.7±37.2) HU vs (554.6±43.7) HU，P=0.183]、术前尿细菌计数[(103.4±13.6)个/μL vs (112.9±17.5)个/μL，P=0.173]、术前尿白细胞计数[(315.9±27.9)个/μL vs (348.6±36.2)个/μL，P=1.05]、术前患肾GFR[(25.6±9.8) mL/min vs (28.2±11.4) mL/min，P=0.097]方面比较差异均无统计学意义。RPLU组与URSL组手术时间比较差异无统计学意义[(70.9±17.7) min vs (63.6±13.1) min，P=0.237]。虽然URSL组在术中出血量[(53.5±12.9) mL vs (37.2±14.1) mL，P=0.033]、术后住院时间[(7.3±0.9) d vs (4.9±1.1) d，P=0.041]及术后视觉模拟疼痛(VAS)评分[(6.4±1.7)分vs (4.3±1.4)分，P=0.011]均好于RPLU组，但RPLU组在术后发热率(7.5% vs 16.3%，P=0.006)及住院总费用[(15 707.7±535.4)元vs (17 384.1±474.8)元，P=0.038]方面均优于URSL组。术后手术并发症方面RPLU组显著少于URSL组(17.9% vs 46.9%，P＜0.001)。术后3次复查结果显示RPLU组结石清除率均显著高于URSL组：第1周(94.0% vs 79.6%，P=0.018)、第1个月(97.0% vs 83.7%，P=0.001)、第3个月(98.5% vs 87.8%，P=0.016)。结论 RPLU较URSL在降低术后感染及提高结石清除率方面效果更加显著。对于一些基层医院泌尿外科来说，RPLU也许能成为处理此类结石的更好选择。Abstract: Objective To further explore the difference between retroperitoneal laparoscopic ureterolithotomy(RPLU) and ureteroscopic lithotripsy(URSL) in the treatment of upper ureteral incarcerated stones.Methods One hundred and sixteen patients with incarcerated upper ureteral stones admitted to our department from January 2018 to August 2021 were divided into the RPLU group (67 cases) and the URSL group (49 cases). Among the patients, there were 64 males and 52 females with an average age of (39.2±7.8) years. The main parameters such as diameter of the stones, preoperative urine leukocyte and bacterial count, preoperative renal glomerular filtration rate (GFR) in the affected side, operative time, postoperative fever rate, surgical complications rate, CT value of stones and stone removal rate were compared and analyzed.Results All patients were successfully operated. There was no significant difference between the two groups in terms the diameter of the stones ([1.7±0.3] cm vs [1.8±0.4] cm, P=0.214), CT value of stones ([549.7±37.2] HU vs [554.6±43.7] HU, P=0.183), preoperative urinary bacteria count ([103.4±13.6]/μL vs [112.9±17.5]/μL, P=0.173), preoperative leukocyte count ([315.9±27.9]/μL vs [348.6±36.2]/μL, P=1.05), or renal GFR in the affected side ([25.6±9.8] mL/min vs [28.2±11.4] mL/min, P=0.097). Also, there was no significant difference in operative time between the RPLU group and the URSL group ([70.9±17.7] min vs [63.6±13.1] min, P=0.237). Although the URSL group had less intraoperative blood loss ([53.5±12.9] mL vs [37.2±14.1] mL, P=0.033), postoperative hospital stay ([7.3±0.9] days vs [4.9±1.1] days, P=0.041)and postoperative VAS scores ([6.4±1.7] scores vs [4.3±1.4] scores, P=0.011) than the RPLU group, the RPLU group was superior to the URSL group in terms of postoperative fever rate (7.5% vs 16.3%, P=0.006)and total hospitalization expenses ([15 707.7±535.4] Yuan vs [17 384.1±474.8]Yuan, P=0.038) after surgery. In terms of postoperative complications, the RPLU group was significantly less than the URSL group (17.9% vs 46.9%, P < 0.001). The results of three postoperative examinations showed that the stone clearance rate of the RPLU group was significantly higher than that of the URSL group: the first week(94.0% vs 79.6%, P=0.018), the first month (97.0% vs 83.7%, P=0.001), and the third month (98.5% vs 87.8%, P=0.016).Conclusion Compared with URSL group, RPLU is more effective in reducing postoperative infection and improving stone clearance. For some primary hospitals of urology, RPLU may be a better choice for dealing with such stones.
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Key words:
- ureteral calculi /
- laparoscopic /
- holmium laser /
- surgery /
- clinical study
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表 1 RPLU组与URSL组临床基准资料比较
例(%)，X±S 项目 RPLU组(67例) URSL组(49例) χ2/t P值 性别 1.315 0.251 男 40(59.7) 24(49.0) 女 27(40.3) 25(51.0) 年龄/岁 37.1±9.7 39.6±6.9 1.297 0.193 结石负荷/cm 1.7±0.3 1.8±0.4 0.335 0.214 尿白细胞计数/(个/μL) 315.9±27.9 348.6±36.2 0.183 0.105 尿细菌计数/(个/μL) 103.4±13.6 112.9±17.5 1.452 0.173 中性粒细胞百分比/% 78.6±7.4 83.1±6.8 1.314 0.215 结石位置 0.008 0.930 左侧 35(52.2) 26(53.1) 右侧 32(47.8) 23(46.9) 积水程度 1.316 0.518 轻度 8(11.9) 4(8.2) 中度 47(70.1) 39(79.6) 重度 12(18.0) 6(12.2) 结石硬度CT值/HU 549.7±37.2 554.6±43.7 1.531 0.183 
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表 2 RPLU组与URSL组围手术期参数比较
例(%)，X±S 指标 RPLU组(67例) URSL组(49例) t/χ2 P值 手术时间/min 70.9±17.7 63.6±13.1 0.30 0.237 发热 5(7.5) 8(16.3) 7.68 0.006 术后住院时间/d 7.3±0.9 4.9±1.1 2.17 0.041 拔除双J管时间/d 30.6±3.7 28.2±2.3 1.71 0.097 中性粒百分比变化率/% 8.1±6.8 15.7±5.4 2.19 0.036 手术并发症 19.20 ＜0.001 黏膜损伤 2(3.0) 5(10.2) 血尿 6(9.0) 8(16.3) 结石移位 4(6.0) 10(20.4) 住院总费用/元 15 707.7±535.4 17 384.1±474.8 2.29 0.038 出血量/mL 53.5±12.9 37.2±14.1 0.32 0.033 VAS评分/分 6.4±1.7 4.3±1.4 6.81 0.011
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表 3 RPLU组与URSL组随访结果比较
X±S 组别 结石清除率/% 术前患肾GFR/(mL/min) 术后患肾GFR变化百分比/% 第1周 第1个月 第3个月 第1个月 第3个月 RPLU组 94.0 97.0 98.5 25.6±9.8 11.1±1.2 26.7±3.4 URSL组 79.6 83.7 87.8 28.2±11.4 10.6±1.7 25.1±2.9 χ2/t 5.560 6.400 5.770 1.705 0.723 0.974 P值 0.018 0.011 0.016 0.097 0.476 0.318
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