Clinical application of percutaneous nephroscope combined with flexible ureteroscopy in "horseback archery" position for complex kidney stones: meta-analysis
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摘要: 目的 利用meta分析的方法评价“骑马射箭”一体位下经皮肾镜联合输尿管软镜治疗复杂性肾结石的临床应用价值。方法 检索2010年1月—2023年12月国内外有关“骑马射箭”一体位下双镜联合治疗复杂性肾结石中的临床研究，按Cochrane系统评价方法提取资料，由2名评价员对纳入文献的质量进行评价，采用RevMan5.3统计软件进行统计分析。结果 meta分析最终纳入9篇文献，其中中文7篇，英文2篇，共计907例患者，其中采用“骑马射箭”体位下双镜联合456例，常规俯卧位经皮肾镜451例。结果显示，2组在手术时间(MD=-2.83，95%CI：-8.18~2.51，P=0.30)、术后发热(OR=0.62，95%CI：0.37~1.02，P=0.06)等方面比较差异无统计学意义，但在术后结石清除率(OR=3.77，95%CI：2.66~5.34，P < 0.000 01)、住院时间(MD=-1.23，95%CI：-2.21~-0.25，P=0.01)、总并发症发生率(OR=0.38，95%CI：0.26~0.56，P < 0.000 01)、出血量(MD=-47.98，95%CI：-50.86~-45.09，P < 0.000 01)、血红蛋白下降幅度(MD=-3.47，95%CI：-6.94~-0.01，P=0.05)及输血例数(OR=0.44，95%CI：0.21~0.90, P=0.02)等方面比较差异有统计学意义。结论 与俯卧位经皮肾镜比较，“骑马射箭”一体位下双镜联合治疗复杂性肾结石在结石清除率、住院时间、总并发症发生率、出血量、血红蛋白下降幅度及输血例数等方面具有明显优势，但鉴于纳入文献有限，有待于多中心、高质量的随机对照试验进一步验证。Abstract: Objective To evaluate the clinical value of percutaneous nephroscope combined with flexible ureteroscopy in "horseback archery" position for complex kidney stones.Methods Domestic and foreign clinical studies on percutaneous nephroscope combined with flexible ureteroscopy in "horseback archery" position for complex kidney stones from January 2010 to December 2023 were searched. Two reviewers independently screened the studies for eligibility, evaluated the quality and extracted the data. The RevMan5.3 software was used for statistical analysis.Results Eventually 9 articles were enrolled. There were 7 articles in Chinese and 2 in English, with a total of 907 patients. Of these patients, 456 cases were treated with the double endoscopies combination in "horseback archery" position, while 451 cases were treated with percutaneous nephroscope in prone position. There was no significant difference in operation time(MD=-2.83, 95%CI: -8.18-2.51, P=0.30) or postoperative fever(OR=0.62, 95%CI: 0.37-1.02, P=0.06) between the two groups, but the postoperative stone clearance rate(OR=3.77, 95%CI: 2.66-5.34, P < 0.000 01), hospitalization time(MD=-1.23, 95%CI: -2.21--0.25, P=0.01), total complications(OR=0.38, 95%CI: 0.26-0.56, P < 0.000 01), blood loss(MD=-47.98, 95%CI: -50.86- -45.09, P < 0.000 01), hemoglobin decrease value(MD=－3.47, 95%CI: －6.94-－0.01, P=0.05) and blood transfusion(OR=0.44, 95%CI: 0.21-0.90, P=0.02) showed significant difference.Conclusion The combined treatment in "horseback archery" position for complex kidney stones has obvious advantages in the postoperative stone clearance rate, the total complication rate, blood loss, the number of postoperative blood transfusion cases, and the length of hospital stay. However, additional high-quality, RCTs with larger study populations are needed.
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表 1 纳入文献基本特征及方法学质量评分
第1作者/年份 语种 观察组/对照组 年龄/岁 BMI/(kg/m2) 结石直径/cm 男/女/例 研究类型 得分 结局指标 观察组 对照组 观察组 对照组 观察组 对照组 观察组 对照组 Wen JM 2016[12] 英语 33/34 43.18± 14.11 45.76± 13.25 22.5± 2.97 21.33± 3.33 — — 20/13 19/15 RCT 9a) ①③④⑤ ⑥⑦⑧⑩ Leng SB 2018[13] 英语 44/33 46.182± 12.743 45.767± 11.223 — — 5.171± 0.942 5.277± 0.903 25/19 27/16 队列 8b) ①②③④ ⑤⑥⑦⑧ 胡永文2018[14] 中文 30/30 42.62± 3.83 42.63± 3.85 — — 4.21± 1.05 4.21± 3.85 19/11 20/10 RCT 6a) ①⑧ 闫兵2019[15] 中文 41/42 43~67 39~63 — — 3.4~ 6.0 3.2~ 5.7 23/18 21/21 队列 7b) ①②③④ ⑤⑥⑧⑨ 崔磊2020[16] 中文 112/106 43.1± 8.9 46.2± 6.8 26.3± 2.7 27.1± 2.2 4.7± 1.1 4.9± 1.5 62/50 55/51 回顾 6b) ①③④⑤ ⑥⑧ 肖峰2020[17] 中文 36/36 31~72 29~69 — — — — 21/15 19/17 RCT 8a) ①③④⑤ ⑧⑨ 黄海文2021[18] 中文 50/50 48.56± 11.09 48.16± 11.33 30.34± 1.44 30.2± 1.54 4.84± 11.09 4.76± 0.50 33/17 31/19 RCT 7a) ①③④⑤ ⑦⑧⑩ 丁瑞2022[19] 中文 50/50 42.28± 4.13 42.35± 4.26 — — 3.15± 4.29 31.82± 4.33 28/22 30/20 队列 7b) ①③④⑤ ⑦⑧ 刘斌2022[20] 中文 60/60 44.95± 2.31 45.12± 2.26 — — — — 38/22 37/23 队列 7b) ①③④ ⑤⑥⑦⑧ 注：观察组为斜仰卧位下经皮肾镜联合输尿管软镜；对照组为常规俯卧位下经皮肾镜。a)Jadad评分，b)NOS评分。①手术时间；②术后血红蛋白下降幅度；③术后住院时间；④总并发症发生率，如术后发热、尿路感染、血尿、输血、胸膜损伤、尿源性脓毒症、尿瘘及血红蛋白下降幅度等；⑤发热；⑥输血；⑦胸膜损伤；⑧结石清除率；⑨出血量。 
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