羅懷景+林超祿++陳建德++余豐++肖錟++董興模
[摘要] 目的 探討輸尿管軟鏡治療腎結(jié)石的臨床療效及對(duì)腎功能的影響作用。 方法 選擇2016年2月~2017年1月76例腎結(jié)石患者,根據(jù)手術(shù)治療方法分為兩組,各38例。對(duì)照組采用傳統(tǒng)碎石手術(shù)進(jìn)行治療,輸尿管軟鏡組則采用輸尿管軟鏡治療。比較兩組腎結(jié)石清除率;腎結(jié)石清除時(shí)間、手術(shù)過(guò)程丟失的血液量、術(shù)后平均住院天數(shù);干預(yù)前后患者尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白;手術(shù)并發(fā)癥發(fā)生率。 結(jié)果 輸尿管軟鏡組腎結(jié)石清除率高于對(duì)照組(P<0.05);輸尿管軟鏡組腎結(jié)石清除時(shí)間、手術(shù)過(guò)程丟失的血液量、術(shù)后平均住院天數(shù)低于對(duì)照組(P<0.05);干預(yù)前兩組尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白相近(P>0.05);干預(yù)后輸尿管軟鏡組尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白低于對(duì)照組(P<0.05)。輸尿管軟鏡組手術(shù)并發(fā)癥發(fā)生率顯著低于對(duì)照組(P<0.05)。 結(jié)論 輸尿管軟鏡治療腎結(jié)石療效確切,可提高結(jié)石清除率,減少手術(shù)創(chuàng)傷,減少術(shù)中出血和并發(fā)癥,加速患者術(shù)后康復(fù),縮短住院時(shí)間,且對(duì)腎功能的影響較小,值得推廣。
[關(guān)鍵詞] 輸尿管軟鏡;腎結(jié)石;腎功能;并發(fā)癥;結(jié)石清除率
[中圖分類號(hào)] R692.4 [文獻(xiàn)標(biāo)識(shí)碼] B [文章編號(hào)] 1673-9701(2017)29-0047-03
Clinical efficacy of flexible ureteroscope in the treatment of renal calculus and its eEffect on renal function
LUO Huaijing LIN Chaolu CHEN Jiande YE Feng XIAO Tan DONG Xingmo
Department of Urinary Surgery, Longyan First Hospital of Fujian Medical University, Longyan 364000, China
[Abstract] Objective To investigate the clinical effect of flexible ureteroscope in the treatment of renal calculi and its effect on renal function. Methods A total of 76 patients with renal calculi were collected from February 2016 to January 2017 and were assigned to groups according to the surgical methods, with 38 patients in each group. The control group was given traditional lithotripsy, and the flexible ureteroscopy group was given flexible ureteroscopy. The clearance rate of kidney stones; kidney stones removal time, the amount of blood loss during surgery, the average length of hospital stay after surgery; serum levels of urea nitrogen, serum creatinine levels, neutrophil gelatinase-related apolipoproteins before and after intervention; the incidence rate of surgical complications were compared between the two groups. Results The removal rate of kidney stones in flexible ureteroscope group was higher than that in control group(P<0.05). The removal time of kidney stones, the amount of blood loss during the operation and average length of stay after surgery in the flexible ureteroscope group were lower than those in the control group(P<0.05). The levels of serum urea nitrogen, serum creatinine, neutrophil gelatinase-related apolipoprotein were similar in the two groups before intervention(P>0.05). The level of serum urea nitrogen, serum creatinine level and neutrophil gelatinase-related apolipoprotein in the flexible ureteroscope group were lower than those in the control group after intervention (P<0.05). The incidence rate of surgical complications in the flexible ureteroscope group was significantly lower than that in the control group(P<0.05). Conclusion Flexible ureteroscope in the treatment of kidney stones is effective, which can improve the removal rate of stones, reduce surgical trauma, reduce intraoperative bleeding and complications, accelerate the rehabilitation of patients, shorten the length of stay,and the impact on renal function is small,which is worthy of promotion.endprint
[Key words] Flexbile ureteroscope; Renal calculi; Renal function; Complications; Clearance rate of stones
腎結(jié)石在臨床較為常見,具有高發(fā)病率,患者以腰痛、血尿、發(fā)熱等為主要表現(xiàn),臨床首選手術(shù)治療。傳統(tǒng)碎石手術(shù)可帶來(lái)較大創(chuàng)傷,對(duì)合并出血性疾病和肥胖者不適用[1-3]。近年來(lái),輸尿管軟鏡在泌尿科應(yīng)用越來(lái)越廣泛,具有創(chuàng)傷小,安全性較高等優(yōu)勢(shì),為了探討更安全有效的手術(shù)方法,本研究將2016年2月~2017年1月76例腎結(jié)石患者作為研究對(duì)象,根據(jù)方法分為兩組,各38例,分別用輸尿管軟鏡和傳統(tǒng)手術(shù)進(jìn)行比較,分析輸尿管軟鏡治療腎結(jié)石的臨床療效及對(duì)腎功能的影響作用,現(xiàn)報(bào)道如下。
1 資料與方法
1.1 一般資料
選2016年2月~2017年1月76例腎結(jié)石患者,根據(jù)方法分為兩組,各38例。納入標(biāo)準(zhǔn):(1)符合腎結(jié)石標(biāo)準(zhǔn);(2)無(wú)手術(shù)禁忌證,麻醉ASA分級(jí)Ⅰ~Ⅱ級(jí);(3)無(wú)合并機(jī)體其他嚴(yán)重疾病。排除標(biāo)準(zhǔn):(1)手術(shù)禁忌者。(2)合并腫瘤、血常規(guī)異常、凝血異常等患者。輸尿管軟鏡組男23例,女15例;年齡21~65歲,平均(43.18±2.88)歲。對(duì)照組男24例,女14例;年齡22~65歲,平均(43.67±2.82)歲。兩組一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.2 方法
對(duì)照組:采用傳統(tǒng)碎石手術(shù)進(jìn)行治療,患者采取截石位,蛛網(wǎng)膜下腔麻醉,常規(guī)消毒手術(shù)部位,超聲下建立腎中、下盞工作通道,確定結(jié)石位置后行氣壓彈道碎石或鈥激光碎石治療,調(diào)節(jié)功率40~60 W,光纖550 μm,術(shù)后給予雙J管和腎造瘺管留置[4-5]。
輸尿管軟鏡組:采用輸尿管軟鏡治療?;颊卟扇〗厥唬刖W(wǎng)膜下腔麻醉,常規(guī)消毒手術(shù)部位,患側(cè)放置斑馬導(dǎo)絲,用擴(kuò)張鞘和內(nèi)芯沿著斑馬導(dǎo)絲將輸尿管插入,深度達(dá)腎盂下方2~3 cm左右,保留擴(kuò)張鞘,退出內(nèi)芯,沿著插入的擴(kuò)張鞘將輸尿管軟鏡置入,進(jìn)入腎盂,在輸尿管軟鏡下確定結(jié)石位置,并實(shí)施碎石手術(shù),調(diào)節(jié)功率10~15 W,光纖200 μm,術(shù)后給予雙J管和導(dǎo)尿管留置[6]。
1.3 觀察指標(biāo)
比較兩組腎結(jié)石清除率;腎結(jié)石清除時(shí)間、手術(shù)過(guò)程丟失的血液量、術(shù)后平均住院天數(shù);干預(yù)前后患者尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白;手術(shù)并發(fā)癥發(fā)生率。
1.4 統(tǒng)計(jì)學(xué)方法
采用SPSS21.0軟件統(tǒng)計(jì)數(shù)據(jù),計(jì)量資料用(x±s)的形式表示,采用t檢驗(yàn),計(jì)數(shù)資料用χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組腎結(jié)石清除率比較
輸尿管軟鏡組腎結(jié)石清除率高于對(duì)照組(P<0.05)。見表1。
2.2 兩組干預(yù)前后尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白比較
干預(yù)前兩組尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白相近(P>0.05);干預(yù)后輸尿管軟鏡組尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白均低于對(duì)照組(P<0.05)。見表2。
注:與干預(yù)前比較,#P<0.05;與對(duì)照組比較,*P<0.05
2.3 兩組腎結(jié)石清除時(shí)間、手術(shù)過(guò)程丟失的血液量、術(shù)后平均住院天數(shù)比較
輸尿管軟鏡組腎結(jié)石清除時(shí)間、手術(shù)過(guò)程丟失的血液量、術(shù)后平均住院天數(shù)均低于對(duì)照組(P<0.05)。見表3。
2.4 兩組手術(shù)并發(fā)癥發(fā)生率比較
輸尿管軟鏡組手術(shù)并發(fā)癥發(fā)生率顯著低于對(duì)照組(P<0.05)。見表4。
3 討論
隨著微創(chuàng)技術(shù)不斷發(fā)展,輸尿管軟鏡在臨床應(yīng)用越來(lái)越廣泛,其具有微創(chuàng)性,對(duì)各種患者均有良好的適應(yīng)證,可滿足不同患者需求,且術(shù)后康復(fù)快,并發(fā)癥少,結(jié)石清除率高[7-8]。但輸尿管軟鏡術(shù)對(duì)腎結(jié)石患者腎功能的影響但需進(jìn)一步探討。血肌酐是腎功能判斷重要指標(biāo),其水平越高說(shuō)明腎功能損傷越嚴(yán)重。而中性粒細(xì)胞明膠酶相關(guān)載脂蛋白是一種小分子量分泌蛋白,在受損腎小管中可高度表達(dá),其水平越高說(shuō)明腎小管損傷越嚴(yán)重[9-11]。而尿素氮水平升高也是腎損傷的一種常見內(nèi)源性指標(biāo)。本研究中,術(shù)后輸尿管軟鏡組尿素氮水平、血肌酐水平、中性粒細(xì)胞明膠酶相關(guān)載脂蛋白低于對(duì)照組(P<0.05),說(shuō)明輸尿管軟鏡術(shù)對(duì)腎結(jié)石患者腎功能的影響比較小,可減輕腎周圍臟器損傷[12-15]。有研究顯示[16-20],輸尿管軟鏡治療腎結(jié)石提高結(jié)石清除率,創(chuàng)傷也比較輕微,出血少,是腎結(jié)石的有效手術(shù)方式,但其對(duì)于直徑≥2 cm的結(jié)石治療效果欠佳,而對(duì)于直徑小于2 cm的結(jié)石應(yīng)用輸尿管軟鏡治療,可提高碎石成功率。在本次研究中,我們所納入的患者結(jié)石直徑均不高于2 cm。
本研究中,對(duì)照組采用傳統(tǒng)碎石手術(shù)進(jìn)行治療,輸尿管軟鏡組則采用輸尿管軟鏡治療。結(jié)果顯示,輸尿管軟鏡組腎結(jié)石清除率高于對(duì)照組,說(shuō)明輸尿管軟鏡治療腎結(jié)石療效確切,可更好更徹底地清除結(jié)石,這是因?yàn)檩斈蚬苘涚R可以治療普通輸尿管鏡無(wú)法治療的輸尿管上段的結(jié)石、以及部分較小的腎盂、腎盞結(jié)石,提高結(jié)石清除的徹底性。輸尿管軟鏡組腎結(jié)石清除時(shí)間、手術(shù)過(guò)程丟失的血液量、術(shù)后平均住院天數(shù)低于對(duì)照組,這是因?yàn)榕c體外碎石相比,輸尿管鏡碎石術(shù)避免了反復(fù)多次治療、等待排石過(guò)程長(zhǎng)、碎石效果的不確定性等問(wèn)題,且不在身體上做任何切口,可減少創(chuàng)傷,通常1 d就可以出院,在有些醫(yī)院可以進(jìn)行門診日間手術(shù)。但需要注意的是,雖然輸尿管軟鏡下鈥激光碎石術(shù)治療腎結(jié)石單次隨時(shí)成功率高,但仍可殘留部分結(jié)石,可經(jīng)套石籃成功將結(jié)石取出。另外,輸尿管軟鏡下鈥激光碎石術(shù)治療若長(zhǎng)時(shí)間主動(dòng)彎曲輸尿管軟鏡,加上鈥激光熱作用,可對(duì)組織產(chǎn)生較大損傷,因此需注意操作,合理掌握操作時(shí)間,避免因意外操作增加并發(fā)癥風(fēng)險(xiǎn)。endprint
綜上所述,輸尿管軟鏡治療腎結(jié)石療效確切,可提高結(jié)石清除率,減少手術(shù)創(chuàng)傷,減少術(shù)中出血和并發(fā)癥,加速患者術(shù)后康復(fù),縮短住院的時(shí)間,且對(duì)腎功能的影響較小,值得推廣。
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(收稿日期:2017-08-14)endprint