Safety and efficacy of a tip bendable suction ureteral access sheath combined with retrograde intrarenal surgery versus percutaneous nephrolithotomy in the treatment of multiple upper urinary tract stones 2-3 cm in diameter
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摘要: 目的 分析头端可弯负压吸引鞘(tip bendable suction ureteral access sheath，S-UAS)联合逆行输尿管软镜手术(retrograde intrarenal surgery，RIRS)对比经皮肾镜取石术(percutaneous nephrolithotomy，PCNL)治疗总直径2~3 cm多发肾和(或)输尿管上段结石的安全性和有效性。方法 回顾性分析2023年1月—2024年12月在清华大学附属北京清华长庚医院接受S-UAS联合RIRS对比PCNL治疗的97例2~3 cm多发肾和(或)输尿管上段结石患者的临床资料。根据治疗方式不同分为2组，其中S-UAS联合RIRS组44例，PCNL组53例。记录年龄、性别、体重指数(BMI)、结石数量、结石总直径、CT值和是否合并基础疾病等参数。使用t检验、Mann-Whitney U检验、χ2检验分析数据。结果 2组具有相似的基线特征。S-UAS联合RIRS组与PCNL组在术后即刻清石率和最终清石率方面比较均差异无统计学意义(P>0.05)。S-UAS联合RIRS组的中位手术时间长于PCNL组(86 min vs 64 min，P=0.001)，术中出血量低于PCNL组(2 mL vs 10 mL，P < 0.001)。术后观察指标提示S-UAS联合RIRS组的术后1 d血红蛋白下降值显著低于PCNL组[(4.18±6.24) g/L vs (9.89±9.79) g/L，P=0.001]。感染相关指标方面，S-UAS联合RIRS组的中位术后1 d C-反应蛋白(CRP)升高值(0.05 mg/L vs 6.16 mg/L，P=0.014)及术后1 d降钙素原(PCT)升高值(0 ng/mL vs 0.02 ng/mL，P=0.015)低于PCNL组。S-UAS联合RIRS组术后发热情况优于PCNL组(2.3% vs 17.0%，P=0.02)，中位术后住院时间明显短于PCNL组(2 d vs 5 d，P < 0.001)。结论 S-UAS联合RIRS与PCNL在治疗总直径2~3 cm多发肾和(或)输尿管上段结石的清石率方面比较差异无统计学意义，但前者在术中出血量更少、术后感染控制更佳，术后住院天数更少，体现出S-UAS联合RIRS在治疗总直径2~3 cm多发上尿路结石方面具有良好的安全性和有效性。
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关键词:
- 逆行输尿管软镜碎石术 /
- 头端可弯负压吸引鞘 /
- 经皮肾镜取石术 /
- 多发上尿路结石
Abstract: Objective To study the safety and efficacy of tip bendable suction ureteral access sheath(S-UAS) combined with retrograde intrarenal surgery(RIRS) versus percutaneous nephrolithotomy(PCNL) in the treatment of multiple upper urinary tract stones with a total diameter of 2-3 cm.Methods Clinical data were retrospectively collected from 97 patients who received S-UAS combined with RIRS or PCNL for the treatment of 2-3 cm multiple renal and/or upper ureteral stones at Beijing Tsinghua Changgung Hospital from January 2023 to December 2024. The patients were divided into two groups according to the treatment modality: 44 in the S-UAS combined RIRS group and 53 in the PCNL group. Parameters such as age, gender, BMI, number of stones, total stone diameter, CT value and comorbidities were recorded. Data were analyzed using t-test, Mann-Whitney U-test, and chi-square test.Results The two groups had similar baseline characteristics. By comparing the data of the two groups, there was no statistically significant difference between the S-UAS combined with RIRS group and the PCNL group in terms of the immediate postoperative stone free rate(SFR) or the final SFR(P>0.05). The median operation time in the S-UAS combined with RIRS group was longer than that in the PCNL group(86 min vs 64 min, P=0.001), but the intraoperative bleeding was less than that in the PCNL group(2 mL vs 10 mL, P < 0.001). Postoperative observational indexes suggested that the hemoglobin drop value on postoperative day 1 was significantly lower in the S-UAS combined with RIRS group than in the PCNL group([4.18±6.24] g/L vs[9.89±9.79] g/L, P=0.001). Regarding infection-related indicators, the median 1-day postoperative C-reactive protein(CRP) elevation value(0.05 mg/L vs 6.16 mg/L, P=0.014) and 1-day postoperative procalcitonin(PCT) elevation value(0 ng/mL vs 0.02 ng/mL, P=0.015) were lower in S-UAS combined with RIRS group than in PCNL group. Postoperative fever was less in the S-UAS combined with RIRS group than in the PCNL group (2.3% vs 17.0%, P=0.02), and the median postoperative hospitalization was significantly shorter(2 days vs 5 days, P < 0.001).Conclusion There was no significant difference in SFR between S-UAS combined with RIRS and PCNL in the treatment of multiple upper urinary tract stones with a total diameter of 2-3 cm, but the former had less intraoperative bleeding, better postoperative infection control, and fewer postoperative hospitalization days, which demonstrated the good safety and efficacy of S-UAS combined with RIRS in the treatment of multiple upper urinary tract stones with a total diameter of 2-3 cm. -
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表 1 S-UAS联合RIRS组与PCNL组术前一般资料比较
例(%)，X±S，M(IQR) 项目 S-UAS联合RIRS组(44例) PCNL组(53例) P值 年龄/岁 51.95±10.81 51.85±15.03 0.968 BMI/(kg/m2) 25.2(4.1) 25.1(4.2) 0.797 性别 1.000 男 30(68.2) 36(67.9) 女 14(31.8) 17(32.1) 同侧结石手术史 0.839 有 20(45.5) 26(49.1) 无 24(54.5) 27(50.9) 术前尿培养阳性 20(45.5) 32(60.4) 0.218 术前血肌酐/(μmol/L) 81.5±31.4 85.00±40.00 0.235 肾积水程度 0.625 无/轻度肾积水 32(72.73) 35(66.04) 中/重度肾积水 12(27.27) 18(33.96) 结石数量/个 2(1) 3(1) 0.285 结石总直径/mm 22.5(4.0) 25.0(7.5) 0.298 结石CT值/HU 881.25±326.14 940.02±261.14 0.327 结石位置 0.026 肾 28(63.6) 45(84.9) 输尿管上段 1(2.3) 1(1.9) 肾合并输尿管上段 15(34.1) 7(13.2) 结石侧别 0.355 左侧 23(52.3) 31(58.5) 右侧 21(47.7) 19(41.5) 合并症 高血压病 17(38.6) 19(35.8) 0.834 糖尿病 14(31.8) 14(26.4) 0.654 高脂血症 15(34.1) 13(24.5) 0.370 代谢综合征 9(20.5) 7(13.2) 0.411 结石成分分析 0.904 草酸钙结石[一水和(或)二水草酸钙] 16(36.4) 19(35.8) 感染性结石[六水磷酸铵镁和(或)碳酸磷灰石] 5(11.4) 10(18.9) 胱氨酸 1(2.3) 1(1.9) 无水尿酸 1(2.3) 1(1.9) 混合性结石(含以上≥2种成分) 21(47.7) 22(41.5) 
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表 2 S-UAS联合RIRS组与PCNL组术中及术后相关指标比较
例(%)，X±S，M(IQR) 相关指标 S-UAS联合RIRS组(44例) PCNL组(53例) P值 手术时间/min 86(51.0) 64(27.0) 0.001 术中出血量/mL 2(1) 10(15) < 0.001 Clavien-Dindo分级 0.072 Ⅰ 5(11.36) 15(28.30) Ⅱ 0(0) 0(0) Ⅲ 0(0) 0(0) Ⅳ 0(0) 0(0) 术后并发症 发热(Clavien-Dindo Ⅰ级) 1(2.3) 9(17.0) 0.020 镇静药物应用(Clavien-Dindo Ⅰ级) 4(9.1) 6(11.3) 1.000 术后1 d肌酐升高值/(μmol/L) 0.05(2.99) 2(13.5) 0.752 术后1 d血红蛋白下降值/(g/L) 4.18±6.24 9.89±9.79 0.001 术后1 d WBC升高值/(×109/L) 3.07(4.12) 3.31(4) 0.825 术后1 d CRP升高值/(mg/L) 0.05(4.12) 6.16(13.46) 0.014 术后1 d PCT升高值/(ng/mL) 0(0.01) 0.02(0.17) 0.015 术后住院时间/d 2(2) 5(2) < 0.001 即刻SFR(术后1 d) 33(75.0) 39(73.8) 1.000 最终SFR(术后1个月) 36(81.8) 42(79.2) 0.802
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