四种微创方式治疗1 275例输尿管上段结石的临床研究

Four minimally invasive treatment methods for proximal ureteral stones：experiences from 1 275 patients

摘要:

目的：探讨输尿管上段结石最佳微创治疗方式。方法：采用体外冲击波碎石（extracorporeal shockwave lithotripsy，SWL）、输尿管硬镜碎石取石术（rigid ureteroscopy，RURS）、输尿管软镜碎石取石术（flexible ureteroscopy，FURS）和经皮肾镜碎石取石术（percutaneous nephrolithotomy，PCNL）中任一种治疗的输尿管上段结石1 275例进行分层分析，各治疗方式组根据结石大小、病程长短和输尿管扩张程度分为3个亚组，统计分析各亚组清除率、复发率和并发症率。结果：RURS清除率高于SWL，低于FURS和PCNL（P<0.01）。RURS、FURS和PCNL复发率无差异（P>0.01），均低于SWL（P<0.01）。对于并发症率，在结石<1 000 mm3、病程<3月和输尿管扩张直径<10 mm 3个亚组中四者无差异（P >0.05）；在结石≥1 000 mm3亚组中RURS高于SWL、FURS和PCNL（P<0.01）；在病程≥3月亚组中SWL高于RURS、FURS和PCNL（P<0.01）；在输尿管扩张直径≥ 10 mm亚组中FURS和PCNL低于SWL和RURS（P<0.01）。结论：结石大小、病程长短和输尿管扩张程度对选择输尿管上段结石的治疗方式有重要参考意义。SWL是结石<1 000 mm3、病程<3月和输尿管扩张直径<10 mm三者兼有的结石首选。PCNL是结石≥1 000 mm3、病程≥3月和输尿管扩张直径≥10 mm三者兼有的结石首选。结石≥1 000 mm3者不单独使用RURS。病程≥3月者不单独使用SWL。

Abstract:

Objective：To compare extracorporeal shockwave lithotripsy（SWL），rigid ureteroscopy（RURS），flexible ureteroscopy（FURS） and percutaneous nephrolithotomy（PCNL） and to determine which method was appropriate for proximal ureteral stones. Methods：During six-year period，1 275 patients with proximal ureteal stones were prospectively selected and assigned into groups of SWL，RURS，FURS and PCNL on the basis of patients’ choice. Each group was allocated into three subgroups according to stone size，du－ration and dilated ureter diameter. Stone-free rate，recurrence rate and complication rate were analyzed. Results：Regarding stone-free rate，RURS was higher than SWL while lower than FURS and PCNL（P<0.01）. As for recurrence rate，there’s no difference among RURS，FURS and PCNL（P>0.01）；recurrence rate was lower in RURS，FURS，PCNL than in SWL（P<0.01）. When looking at com－plication rate，there’s no difference among three subgroups of stone size < 1 000 mm3，duration < 3 months and dilated ureter diameter <10 mm（P >0.05）；in the subgroup of stone size≥1 000 mm3，RURS was higher than SWL，FURS and PCNL（P<0.01）；in the subgroup of duration≥3 months，SWL was higher than RURS，FURS and PCNL（P<0.01）；in the subgroup of dilated ureter diameter≥10 mm，FURS and PCNL was lower than SWL and RURS（P<0.01）. Conclusion：Stone size，duration and dilated ureter diameter should be taken into consideration to determine which approach is appropriate. SWL remains the first-choice in the combination of stone size <1 000 mm3，duration < 3 months and dilated ureter diameter<10 mm. PCNL should be the most appropriate approach in the combination of stone size≥1 000 mm3，duration≥3 months and dilated ureter diameter≥10 mm. RURS should be the least preferred single ap－proach for stone size≥1 000 mm3. SWL is not recommended any more for duration≥3 months alone.