發(fā)布時(shí)間：2018-09-03 08:28

【摘要】：目的通過對(duì)輸尿管軟鏡與微通道經(jīng)皮腎鏡碎石術(shù)治療輸尿管上段結(jié)石的對(duì)比研究，探討兩種術(shù)式的安全性及有效性，從而為在臨床工作中治療輸尿管上段結(jié)石選擇合適的手術(shù)方式提供有效幫助。 方法選取河北大學(xué)附屬醫(yī)院2012年12月至2013年11月符合病例入選標(biāo)準(zhǔn)的60例輸尿管上段結(jié)石患者為研究對(duì)象。按入院病歷單雙號(hào)分為奇、偶數(shù)，奇數(shù)為輸尿管軟鏡組，偶數(shù)為微通道經(jīng)皮腎鏡組，分別采用輸尿管軟鏡鈥激光碎石術(shù)和微通道經(jīng)皮腎鏡鈥激光碎石術(shù)治療。入選的60例患者中，男38例，女22例，年齡30～65歲；患右側(cè)輸尿管上段結(jié)石28例，左側(cè)輸尿管上段結(jié)石32例，結(jié)石直徑為1.50±0.25(0.9～2.0)cm；病程約2個(gè)月～18個(gè)月，均伴有輕度腎積水，入院時(shí)尿常規(guī)及血常規(guī)中白細(xì)胞及中性粒細(xì)胞未見異常。輸尿管軟鏡組中，男18例，女12例，年齡30～62歲，平均年齡48歲，右側(cè)輸尿管上段結(jié)石13例，左側(cè)輸尿管上段17例，結(jié)石直徑為1.51±0.26(0.9～2.0)cm；微通道經(jīng)皮腎鏡組中，，男20例，女10例，年齡32～65歲，平均年齡46歲，右側(cè)輸尿管上段結(jié)石15例，左側(cè)輸尿管上段15例，結(jié)石直徑為1.49±0.24(0.9～2.0)cm。對(duì)兩組患者手術(shù)時(shí)間、術(shù)中出血量、術(shù)后住院天數(shù)、結(jié)石清除率、舒適度、疼痛度及創(chuàng)傷指標(biāo)（血CRP、IL-6和血WBC）進(jìn)行比較。根據(jù)數(shù)據(jù)類型選用X2檢驗(yàn)、兩樣本t檢驗(yàn)，P0.05差異有統(tǒng)計(jì)學(xué)意義，全部統(tǒng)計(jì)學(xué)分析使用SPSS16.0軟件。 結(jié)果輸尿管軟鏡組與微通道經(jīng)皮腎鏡組相比，兩組患者手術(shù)時(shí)間分別為輸尿管軟鏡組86.50±12.81（min）、微通道經(jīng)皮腎鏡組81.83±12.76（min），差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。出血量分別為輸尿管軟鏡組2.20±0.58（ml）、微通道經(jīng)皮腎鏡組12.53±2.12（ml），術(shù)后住院時(shí)間分別為輸尿管軟鏡組3.33±0.61（d）、微通道經(jīng)皮腎鏡組5.47±0.73（d），輸尿管軟鏡組在出血量及術(shù)后住院時(shí)間明顯低于微通道經(jīng)皮腎鏡組，差異有統(tǒng)計(jì)學(xué)意義(P0.01)。兩組患者一期手術(shù)均成功，無穿刺及置輸尿管軟鏡失敗者。兩組患者術(shù)后1周內(nèi)查尿路平片觀察雙J管的位置均正常；碎石效果方面，輸尿管軟鏡組結(jié)石殘留23.33%(7/30)，微通道經(jīng)皮腎鏡組結(jié)石殘留20.00%(6/30)，后行ESWL治療。術(shù)后1個(gè)月結(jié)石清除率分別為輸尿管軟鏡組90.00%（27/30）、微通道經(jīng)皮腎鏡組96.70%（29/30），3個(gè)月結(jié)石清除率分別為輸尿管軟鏡組100%（30/30）、微通道經(jīng)皮腎鏡組100%（30/30）。通過比較輸尿管軟鏡組碎石清石率與微通道經(jīng)皮腎鏡組碎石清石率，兩組間無明顯差異(P＞0.05)。通過對(duì)兩組患者進(jìn)行問卷調(diào)查，輸尿管軟鏡組術(shù)后4、12、24、48h BCS舒適度評(píng)分分別為2.53±0.51、2.93±0.58、3.47±0.51、3.77±0.43均高于微通道經(jīng)皮腎鏡組1.27±0.78、1.63±0.57、2.67±0.58、2.90±0.61(P0.01)，輸尿管軟鏡組術(shù)后4、12、24、48h視覺模擬量表（VAS）測(cè)量疼痛評(píng)分分別為4.03±1.03、2.77±0.86、1.40±0.77、0.83±0.65均低于微通道經(jīng)皮腎鏡組6.90±1.49、5.50±1.20、3.63±1.16、2.37±0.93，差異有統(tǒng)計(jì)學(xué)意義(P0.01)。術(shù)前兩組CRP水平分別為5.13mg/L、5.09mg/L，無明顯差異性，而術(shù)后24小時(shí)兩組均有不同程度升高，尤其是經(jīng)微通道皮腎鏡組20.42mg/L，升高幅度明顯高于輸尿管軟鏡組平均水平10.91mg/L,經(jīng)比較兩種手術(shù)對(duì)血CRP的影響有明顯差異性(P0.05)。術(shù)前兩組IL-6水平分別為6.42ng/L、6.58ng/L，無明顯差異性，而術(shù)后24小時(shí)兩組均有不同程度升高，尤其是微通道經(jīng)皮腎鏡組15.56ng/L，升高幅度明顯高于輸尿管軟鏡組平均水平10.74ng/L,經(jīng)比較兩種手術(shù)對(duì)血IL-6的影響有明顯差異性(P0.05)。術(shù)前兩組血WBC均數(shù)分別為6.3×109/L、6.39×109/L，無明顯差異性，術(shù)后24小時(shí)兩組血WBC均有所增高，但均數(shù)在正常范圍內(nèi)，分別為7.49×109/L、7.4×109/L，只有輸尿管軟鏡組2例患者出現(xiàn)血WBC超出正常范圍，差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。 結(jié)論輸尿管軟鏡碎石術(shù)治療輸尿管上段結(jié)石較微通道經(jīng)皮腎鏡碎石術(shù)操作簡(jiǎn)單、創(chuàng)傷更小、更安全、療效確切，是目前治療輸尿管上段結(jié)石較理想的手術(shù)方式，值得臨床進(jìn)一步推廣應(yīng)用。
[Abstract]:Objective To investigate the safety and efficacy of two kinds of ureteroscopic lithotripsy for the treatment of upper ureteral calculi, so as to provide effective help for the selection of appropriate surgical methods for the treatment of upper ureteral calculi in clinical work.
Methods Sixty patients with upper ureteral calculi who met the enrollment criteria from December 2012 to November 2013 in the Affiliated Hospital of Hebei University were divided into odd, even, odd ureteroscopic group and even microchannel percutaneous nephrolithotomy group according to their admission records. Percutaneous nephrolithotomy with holmium laser lithotripsy was performed in 60 patients, including 38 males and 22 females, aged 30-65 years; 28 patients with right upper ureteral calculi, 32 patients with left upper ureteral calculi, the diameter of calculi was 1.50 (+ 0.25) (0.9-2.0) cm; the course of the disease was about 2 months to 18 months, all with mild hydronephrosis, and the urinary and blood routine were white at admission. There were 18 males and 12 females with an average age of 30-62 years, 13 right upper ureteral calculi, 17 left upper ureteral calculi with a diameter of 1.51 (+ 0.26) (0.9-2.0) cm, and 20 males and 10 females with an average age of 32-65 years and 46 right upper ureteral calculi in the microchannel percutaneous nephroscopy group. There were 15 cases of upper ureteral calculi, 15 cases of upper left ureteral calculi, and the diameters of calculi were 1.49 [(0.9-2.0) cm. The operative time, intraoperative bleeding volume, postoperative hospital stay, stone clearance rate, comfort degree, pain degree and trauma index (blood CRP, IL-6 and WBC) were compared between the two groups. The difference was statistically significant, all statistical analysis using SPSS16.0 software.
Results Compared with the micro-channel percutaneous nephroscopy group, the operation time of the two groups were 86.50 (+ 12.81) min in the soft ureteroscope group and 81.83 (+ 12.76) min in the micro-channel percutaneous nephroscopy group, with no significant difference (P > 0.05). The postoperative hospitalization time was 3.33 [0.61] (d) in the flexible ureteroscopy group, 5.47 [0.73] (d) in the microchannel percutaneous nephroscopy group, and significantly lower than that in the microchannel percutaneous nephroscopy group (P The lithotripsy effect was 23.33% (7/30) in the flexible ureteroscope group, 20.00% (6/30) in the microchannel percutaneous nephroscope group, and ESWL was performed. The stone clearance rate was 90.00% (27/30) in the flexible ureteroscope group and 96.70% (29/30) in the microchannel percutaneous nephroscope group, respectively. The lithotripsy rate of the two groups was 100% (30/30) in the flexible ureteroscope group and 100% (30/30) in the microchannel percutaneous nephroscope group, respectively. S comfort scores were 2.53 (+ 0.51), 2.93 (+ 0.58), 3.47 (+ 0.51), 3.77 (+ 0.43) higher than those of microchannel percutaneous nephroscopy group (1.27 (+ 0.78), 1.63 (+ 0.57), 2.67 (+ 0.58), 2.90 (+ 0.61) (P 0.01). Visual analogue scale (VAS) scores were 4.03 (+ 1.03), 2.77 (+ 0.86), 1.40 (+ 0.77), and 650.83 (+ 0.83) lower than those of microchannel group (P 0.01). The levels of CRP in the two groups were 5.13mg/L and 5.09mg/L before operation, respectively. There was no significant difference between the two groups. The levels of CRP in the two groups increased in different degrees 24 hours after operation, especially 20.42mg/L in the microchannel group, which was significantly higher than that in the ureteroscopic group. The levels of IL-6 in the two groups were 6.42 ng/L and 6.58 ng/L before operation, respectively. However, the levels of IL-6 in the two groups increased in different degrees 24 hours after operation, especially in the microchannel percutaneous nephroscopy group (15.56 ng/L), which was significantly higher than the average level of 10.74 in the flexible ureteroscopy group (10.74 ng/L). The mean WBC of the two groups were 6.3 *109/L and 6.39 *109/L before operation, respectively. There was no significant difference between the two groups. The WBC of the two groups increased 24 hours after operation, but the mean values were within the normal range, 7.49 *109/L and 7.4 *109/L respectively. Only 2 patients in the ureteroscopic group had WBC ultrasonography. There was no significant difference in normal range (P > 0.05).
Conclusion Compared with micro-channel percutaneous nephrolithotomy, flexible ureteroscopic lithotripsy is a simple, less invasive, safe and effective method for the treatment of upper ureteral calculi.
【學(xué)位授予單位】：河北大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R699.4

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