胃癌术后硬膜外镇痛与静脉镇痛对比的系统回顾与Meta分析

目的比较硬膜外与静脉镇痛在胃癌根治性手术中应用的效果。方法对胃癌根治术中硬膜外镇痛与静脉镇痛的随机对照试验进行系统回顾和荟萃分析。主要研究结果为术后24 h疼痛评分,次要结果包括术后并发症发生率、首次排气时间、住院时间。结果有6项随机对照研究共计393例患者纳入研究,其中英文4篇,中文2篇。Meta分析结果显示,与静脉镇痛组相比,硬膜外镇痛组术后24 h静息状态(WMD=-0.74,95%CI:-1.35^-0.13,P=0.02)、运动状态疼痛评分均较低(WMD=-1.5,95%CI:-1.95^-1.05,P<0.001),术后恶心、呕吐(RR=0.32,95%CI:0.18~0.58,P<0.001)及呼吸系统并发症发病率(RR=0.50,95%CI:0.29~0.85,P=0.01)较低,差异均具有统计学意义,术后泌尿系统并发症两组之间差异无统计学意义(RR=0.87,95%CI:0.38~1.96,P=0.73),但低血压的发生高于静脉镇痛组(RR=3.27,95%CI:1.28~8.32,P=0.01),术后首次排气时间(WMD=-14.01,95%CI:-22.85^-5.17,P=0.002)、术后住院时间(WMD=-0.69,95%CI:-0.90^-0.49,P<0.001)均短于静脉镇痛组。结论胃癌根治术患者镇痛的选择,硬膜外镇痛无论是静息还是动态时镇痛效果均优于静脉镇痛,虽会增加术后低血压发病率,但与肺部并发症、恶心呕吐的等并发症减少有关,并且具有促进胃癌术后肠道功能恢复及缩短住院时间的优势。     

经皮肾镜取石术与输尿管软碎石术治疗上尿路结石疗效的Meta分析

目的综合评价经皮肾镜取石术(PCNL)与经输尿管软镜取石术(FURL)两种方法在治疗上尿路结石上的疗效及安全性,为临床选择手术方式提供参考。方法通过计算机结合手工法检索并选取符合标准的中英文文献,以Meta分析完成数据的整理和分析,疗效评价表示为比值比(OR)、加权均数差(WMD)以及相应的95%置信区间(95%CI),应用漏斗图检测发表偏倚。结果此次Meta分析共纳入符合标准的文献18篇,英文文献10篇,中文文献8篇,共包括2 035例患者,结果显示:PCNL组总的结石清除率高于FURL组[OR=4.03,95%CI(2.65,6.11),P0.001],PCNL组术中出血量多于FURL组[WMD=2.86,95%CI(0.66,5.07),P0.05],FURL组住院时间少于PCNL组[WMD=2.45,95%CI(1.39,3.51),P0.001],两组患者在并发症发生率、手术时间的比较上差异无统计学意义。结论 PCNL治疗肾结石的一期结石清除率较高,FURL创伤小,恢复快,手术并发症和手术时间两组相当。     

不同无管化PCNL术治疗肾结石患者临床对比研究

目的:探讨部分和完全无管化经皮肾镜取石术(PCNL)治疗肾结石临床疗效差异,为手术适应证选择提供更多临床证据。方法:选取我院2016年1月～2018年7月收治符合手术指征肾结石患者共130例,采用部分无管化PCNL治疗的65例患者为部分组,采用完全无管化PCNL治疗的65例患者为完全组;比较两组清石效果、手术相关指标水平、手术前后生活质量评分差值及术后并发症发生率。结果:两组清石效果比较差异无统计学意义(P0.05);完全组手术用时显著少于部分组(P0.05);两组手术前后Hb差值、肾周积液消失时间、尿外渗消失时间、住院时间及总治疗费用比较差异无统计学意义(P0.05);完全组手术前后生活质量评分差值显著高于部分组(P0.05);完全组术后并发症发生率显著低于部分组(P0.05)。结论:完全无管化PCNL治疗肾结石能够显著降低操作难度,改善生存质量,并有助于预防术后并发症发生,价值优于部分无管化PCNL。     

经皮肾镜碎石取石术联合负压吸引治疗肾结石的Meta分析

目的比较经皮肾镜碎石取石术（PCNL）联合负压吸引与无负压的PCNL在治疗肾结石的安全性和有效性。 方法检索英文数据库PubMed、EMBASE、the Cochrane Controlled Trial Register of Controlled Trials;中文数据库中国知网（CNKI）、万方、中国生物医学数据库（建刊至今）。收集两种术式治疗肾结石的随机对照研究,2位研究者独立进行文献筛选、资料提取和质量评价后,采用RevMan 5.3软件进行Meta分析。 结果共纳入12篇随机对照研究（RCT）,样本量为1 100例肾结石患者（负压组538例,无负压组562例）。Meta分析表明,两组在感染性休克[RR=0.43,95%CI（0.12,1.63）,P=0.22]、ClavienⅠ级并发症[RR=0.83,95%CI（0.47,1.48）,P=0.53]及ClavienⅢ级以上并发症[RR=1.12,95%CI（0.40,3.15）,P=0.83]方面差异无统计学意义,但PCNL联合负压吸引组结石清除率更高[RR=1.11,95%CI（1.00,1.23）,P=0.05],在手术时间[MD=-10.03,95%CI（-15.79,-4.27）,P=0.0006]、术后发热[RR=0.41,95%CI（0.27,0.61）,P<0.001]、出血量[MD=-71.63,95%CI（-136.89,-6.37）,P=0.03]、Clavien总体并发症[RR= 0.54,95%CI（0.41,0.71）,P<0.001]、ClavienⅡ级并发症[RR=0.43,95%CI（0.30,0.60）,P<0.001]及肾盂内压方面[MD=-10.47%,95%CI（-11.49,-9.45）,P<0.001]也优于无负压组。 结论与无负压组相比,PCNL联合负压吸引能够提高结石清除率,缩短手术时间,降低肾盂内压,减少术后发热、出血等并发症。同时并未增加感染性休克、ClavienⅠ级及Ⅲ级以上并发症的发生率。     

输尿管软镜碎石术与经皮肾镜取石术治疗肾下盏结石患者的Meta分析

目的:系统评价逆行输尿管软镜碎石术(RIRS)与经皮肾镜取石术(PCNL)治疗肾下盏结石的有效性及安全性,为临床决策提供参考。方法:计算机检索Pubmed、Embase、Web of Science及中国生物医学文献数据库、中国期刊全文数据库、万方数据库等数据库,全面收集有关上述两种手术方式治疗肾下盏结石的随机对照试验和非随机的对照试验,在文献筛选、资料提取和文献质量评价后,采用Stata 12.0软件进行Meta分析。结果:共纳入7个研究,随机对照试验1个,回顾性对照试验6个,共计研究对象595例。Meta分析结果显示:RIRS的结石清除率低于PCNL(OR=0.31;95%CI,0.18~0.54;P0.01),而在术后住院时间(WMD=-0.85;95%CI,-1.03~-0.67;P0.01)上则优于PCNL。两种手术方式在术后并发症(OR=0.66;95%CI,0.37~1.17;P=0.16)、平均手术时间(WMD=11.91;95%CI,-3.64~27.46;P=0.13)、辅助治疗率(OR=1.02;95%CI,0.35~3.01;P=0.97)和重复治疗率(OR=1.09;95%CI,0.41~2.89;P=0.86)方面差异无统计学意义。结论:对于肾下盏结石的治疗,PCNL能获得更好的结石清除率,而RIRS能显著缩短住院时间。     

经皮肾镜取石术与输尿管软镜碎石术治疗肾结石的Meta分析

目的:系统评价经皮肾镜取石术(PCNL)与输尿管软镜碎石术(RIRS)治疗肾结石的有效性及安全性,为临床选择提供依据。方法:制定检索策略后分别检索PubMed、Embase、Cochrane Library、中国知网、万方、维普数据库,全面收集有关上述两种手术方式治疗肾结石的随机对照研究(RCT),检索年限为建库至2016年5月,制定纳入和排除标准并据此筛选文献,资料提取后利用Revman 5.3软件进行Meta分析。结果:共纳入6篇文献的6项相互独立的随机对照研究,共计389例患者,其中PCNL组195例,RIRS组194例。Meta分析结果显示,PCNL的结石清除率大于RIRS(OR=2.48,95%CI 1.3~4.73,P=0.006),按照结石大小不同进行亚组分析,2cm的肾结石PCNL的结石清除率大于RIRS(OR=4.53,95%CI 1.81~11.3,P=0.001),而2cm的肾结石两者间差异无统计学意义(OR=2.78,95%CI 0.71~10.94,P=0.14);而在血红蛋白下降值方面,RIRS优于PCNL(MD=0.51,95%CI 0.17~0.85,P=0.004);另外,手术并发症(OR=2.0,95%CI 0.89~4.47,P=0.09)、术后住院时间(MD=0.74,95%CI-0.09~1.56,P=0.08)、平均手术时间(MD=0.24,95%CI-10.48~10.96,P=0.97)及重复治疗率(OR=0.85,95%CI 0.30~2.42,P=0.76)上,两者差异无统计学意义。结论:对于肾结石治疗,PCNL有更好的结石清除率(尤其是对于2cm的肾结石);而RIRS治疗肾结石失血量更少。     

机器人与腹腔镜胃癌D2根治术近期疗效对比Meta分析

目的系统评价达芬奇机器人手术系统与腹腔镜手术在治疗胃癌时行D2淋巴结清扫的近期疗效。方法手动检索多个国内外数据库,收集2005年1月至2015年11月公开发表的有关于机器人胃癌手术(robotic gastrectomy,RG)和腹腔镜胃癌根治术(laparoscopic gastrectomy,LG)临床疗效的相关对比的文献,按照纳入和排除标准进行筛选文献,提取相关数据后进行Meta分析。计量资料使用加权均数差(weighted mean difference,WMD)及用95%可信区间(95%CI)为合并统计量,二分类资料采用比值比(odds ratio,OR)及95%CI表示。采用I~2用来评估异质性的大小。结果共有6篇文献纳入此次研究,累计样本量1 177例,其中RG组419例,LG组758例。Meta分析结果显示:两组在选择病人时体质量指数上无明显差异(WMD=0.0;95%CI:-0.49,0.48);与LG组比较,RG组手术时间相对较长(WMD=58.89;95%CI:24.31,93.47),但术中出血量更少(WMD=-44.41;95%CI:-60.60,-28.22)、术后首次进食更早(WMD=-0.27;95%CI:-0.48,-0.06)和术后住院时间更短(WMD=-1.02;95%CI:-1.83,-0.24),同时在术中淋巴清扫数目(WMD=0.52;95%CI:-1.86,2.90)与术后并发症发生率(OR=0.59;95%CI:0.33,1.04)等方面差异无统计学意义。结论运用机器人系统在治疗胃癌时行D2根治术具有一定的安全性及可行性,但仍需多中心、大样本随机对照研究来验证。     

完全无管化经皮肾镜取石术治疗上尿路结石安全性和疗效的荟萃分析

目的:系统评价完全无管化经皮肾镜取石术(PCNL)与标准PCNL治疗上尿路结石的安全性和疗效。方法:计算机检索Embase、The Cochrane Library、PubMed、CNKI、VIP及万方数据库,全面收集有关完全无管化PCNL和标准PCNL比较的RCT,检索时限为1984年1月～2017年11月。由2名评价者按照纳入与排除标准选择试验、提取资料和评价质量后,采用RevMan 5.3软件进行荟萃分析。结果:共纳入12篇研究,共885例患者。结果显示:与标准PCNL相比,完全无管化PCNL住院时间更短(MD=-1.56,95%CI:-1.95～-1.17,P0.000 01),手术时间更短(MD=-2.36,95%CI:-3.75～-0.98,P=0.000 8),重返工作时间更短(MD=-6.77,95%CI:-11.57～-1.96,P=0.006),术后VAS疼痛评分更低(MD=-2.09,95%CI:-3.38～-0.80,P=0.002),而在结石清除率、漏尿、发热、输血、术后血红蛋白下降量、术后肌酐下降量、总并发症方面差异均无统计学意义(P0.05)。结论:完全无管化PCNL是安全、有效的,与标准PCNL相比,可缩短住院时间、减轻患者术后疼痛不适、快速康复,在把握适应证的情况下,建议在临床推广应用。     

经尿道双极等离子前列腺剜除术与电切术治疗体积大于60 mL前列腺增生的安全性与有效性的Meta分析

目的 探讨经尿道等离子双极前列腺剜除术（PKEP）与经尿道等离子双极前列腺电切术（PKRP）治疗体积>60mL良性前列腺增生（BPH）的安全性与有效性。方法 检索国内外各大常用数据库中比较PKEP与PKRP治疗体积>60mLBPH的随机对照研究（RCT）,检索日期为2012年1月1日至2017年3月2日,按照纳入排除标准进行文献筛选和数据提取,并进行文献质量评价,使用RevMan5.3软件进行Meta分析。结果 与PKRP相比,PKEP的前列腺切除质量较多｛WMD=15.29,95%CI（9.18,21.40）,P<0.001｝,手术时间较短｛WMD=-17.44,95%CI（-28.69,-6.19）,P=0.002｝,留置导尿管时间较短｛WMD=-26.51,95%CI（-36.49,-16.54）,P<0.001｝,术中出血量较少｛WMD=-77.82,95%CI（-120.90,-34.74）,P<0.001｝,住院天数较少及术后最大尿流率较大,但后两者敏感性较低。PKEP与PKRP术后并发症发生率无统计学差异。结论 比较PKEP与PKRP治疗体积>60mLBPH,PKEP切除前列腺增生腺体更完全,所需手术时间短,留置导尿管时间较短,术中出血量少,较PKRP安全有效,但由于原始研究质量较低,后期仍需大量高质量、大样本RCT验证后方可进一步临床推广。     

单孔与传统腹腔镜胆囊切除术的比较：随机对照试验的Meta 分析

目的：评价单孔腹腔镜胆囊切除术（SILC）与传统腹腔镜胆囊切除术（CLC）的安全性和有效性。方法：计算机检索各数据库中有关SILC与CLC的前瞻性随机对照试验。检索时限均为建库至2012年11月。按Cochrane系统评价员手册对纳入文献的方法学质量进行评价后,提取数据,采用RevMan 5.1统计软件行Meta分析。结果：筛选后最终纳入17个研究,共1 267例患者,其中SILC组654例,CLC组613例。Meta分析结果显示,手术时间SILC组长于CLC组（WMD=13.02,95%CI=7.95~18.09,P<0.001）;术后切口外观评分和患者满意度评分SILC组优于CLC组（WMD=1.21,95%CI=0.70~1.72,P<0.001;WMD=0.76,95%CI=0.53~1.00,P<0.001）;术后并发症、术后疼痛评分和住院时间两组间差异无统计学意义（RR=1.13,95%CI=0.87~1.48,P=0.35;WMD=0.03,95%CI= -0.82~0.88,P=0.95;WMD=-0.06,95%CI=-0.40~0.28,P=0.73）。结论：对于治疗非复杂性的胆囊良性疾病,SILC是一项安全而有效的手术操作;它具有良好的切口外观和患者满意的优点。     

The efficacy and safety of tubeless percutaneous nephrolithotomy: a systematic review and meta-analysis

The objective of this study was to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of tubeless versus standard percutaneous nephrolithotomy (PCNL). Relevant randomized or quasi-randomized controlled trials studies were identified from electronic database (Cochrane CENTRAL, Medline and EMBASE et al.). The retrieval time ended in August 2010. The quality of the included trials was assessed and the data were extracted independently by two reviewers. We divided the participants who received standard PCNL into two subgroups: small tube (4–10 F) group and big tube (14–24 F) group to reduce heterogeneity and bias. Efficacy (hospital stay time, operative time, stone-free rate) and safety (postoperative pain and analgesia requirement, postoperative fever, blood transfusion, urine leakage) were explored by using review manager v5.0. Fourteen randomized controlled trials comprising 776 subjects met the inclusion criteria. Our meta-analysis showed that there were statistically significant differences in hospital stay, postoperative analgesic requirement and urine leakage between tubeless and standard PCNL. In operative time, significant difference was found between tubeless and big tube group. No statistically significant differences were found in stone-free rate, postoperative fever, and blood transfusion between tubeless and standard PCNL. In conclusion, Tubeless PCNL was an effective and safe procedure for treatment of renal stones in selected patients, with shorter hospital stay, less analgesic requirement, lower urine leakage and without increased complications. Patients can receive great benefit from tubeless PCNL and it will become more palatable to patients as well as more cost-effective than standard PCNL in the future.     

完全无管化和不置肾造瘘管部分无管化经皮肾镜取石术的对照研究

目的比较完全无管化组（既不留置肾造瘘管也不留置双J管）与不置造瘘管（部分无管化,单置双J管）的经皮肾镜取石术（PCNL）的临床效果,评价完全无管化PCNL的临床可行性及应用价值。方法选择2010年11月至2011年9月符合特定筛选条件的上尿路结石患者72例,按手术次序的奇偶数分为完全无管化PCNL组和部分无管化PCNL组。比较两组患者手术时间、术后血红蛋白下降值、镇痛药物的需求、平均住院时间及并发症的发生率、医疗费用、术后恢复正常生活及工作时间等指标的区别。结果 72例患者手术均一期顺利完成,完全无管化PCNL组手术时间、术后血红蛋白下降值、镇痛药物的需求、平均住院时间及并发症的发生率等与部分无管化组PCNL组相当（P〉0.05）,两组在医疗费用分别为（9 566.4±523.7）元和（11 351.2±825.3）元、术后恢复正常生活及工作时间分别为（9.6±1.6）d和（16.8±1.2）d,完全无管化PCNL组要优于部分无管化PCNL组（P〈0.05）。结论有条件地实施完全无管化PCNL是安全的,与部分无管化PCNL相比,并不增加术后相关并发症风险,既节约了医疗成本,又缩短了术后恢复正常生活及工作的时间,有一定的临床应用价值,值得推广应用。     

Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis

Background

To update a previously published systematic review and meta-analysis on the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

Methods

A systematic literature search of EMBASE, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using Stata SE 12.0.

Results

Fourteen randomized controlled trials (RCTs) involving 1148 patients were included. Combined results demonstrated that tubeless PCNL was significantly associated with shorter operative time (weighted mean difference [WMD], ?3.79 min; 95% confidence interval [CI], ?6.73 to ?0.85; P = 0.012; I² = 53.8%), shorter hospital stay (WMD, ?1.27 days; 95% CI, ?1.65 to ?0.90; P < 0.001; I² = 98.7%), faster time to return to normal activity (WMD, ?4.24 days; 95% CI, ?5.76 to ?2.71; P < 0.001; I² = 97.5%), lower postoperative pain scores (WMD, ?16.55 mm; 95% CI, ?21.60 to ?11.50; P < 0.001; I² = 95.7%), less postoperative analgesia requirements (standard mean difference, ?1.09 mg; 95% CI, ?1.35 to ?0.84; P < 0.001; I² = 46.8%), and lower urine leakage (Relative risk [RR], 0.30; 95% CI 0.15 to 0.59; P = 0.001; I² = 41.2%). There were no significant differences in postoperative hemoglobin reduction (WMD, ?0.02 g/dL; 95% CI, ?0.04 to 0.01; P = 0.172; I² = 41.5%), stone-free rate (RR, 1.01; 95% CI, 0.97 to 1.05; P = 0.776; I² = 0.0%), postoperative fever rate (RR, 1.05; 95% CI, 0.57 to 1.93; P = 0.867; I² = 0.0%), or blood transfusion rate (RR, 0.79; 95% CI, 0.36 to 1.70; P = 0.538; I² = 0.0%). The results of subgroup analysis were consistent with the overall findings. The sensitivity analysis indicated that most results remained constant when total tubeless or partial tubeless or mini-PCNL studies were excluded respectively.

Conclusions

Tubeless PCNL is an available and safe option in carefully evaluated and selected patients. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores, less analgesia requirement, and reduced urine leakage.

     

Totally tubeless percutaneous nephrolithotomy in selected patients

PURPOSE: Significant early postoperative discomfort after percutaneous procedures is usually secondary to nephrostomy tubes and externalized ureteral catheters. We describe our modification of the traditional percutaneous nephrolithotomy (PCNL) approach that we name "totally tubeless PCNL." PATIENTS AND METHODS: Between June 2000 and May 2001, 60 consecutive PCNLs were performed at our centers. At the end of the surgery, we omitted the nephrostomy tube and removed the externalized catheter in selected patients: no solitary kidney, stone size <3 cm, and without any obstructions or arterial bleeding. A total of 30 patients underwent totally tubeless PCNL (group 1). We compared their results with those of a control group of 30 patients who underwent standard PCNL (group 2). The incidence of complications, analgesic requirements, length of hospitalization, and time to return to normal activities were compared in the two groups. RESULTS: In both groups, PCNL was performed successfully without any significant complications. A 90% stone-free rate was achieved in both groups, and in the remaining patients, small residual stones (<4 mm) were detected. No urinoma was demonstrated by postoperative ultrasound scanning in group 1. The average length of hospitalization was 1.5 days for group 1 and 3 days for group 2. The average analgesic requirements were 30 mg of pentazosin in group 1 and 90 mg in group 2. No transfusion was needed. There were three complications: 2 patients (6.6%) had urinary tract infection in group 1 and 1 (3.3%) in group 2. All were managed medically. CONCLUSIONS: Omitting the percutaneous nephrostomy tube and removing ureteral catheter at the end of surgery in selected patients were safe and accompanied by significantly reduced postoperative discomfort, length of hospitalization, and analgesic requirements. Further studies are needed to determine the role of this technique.     

超微经皮肾镜与输尿管软镜处理<3 cm肾结石的Meta分析

目的系统回顾分析输尿管软镜碎石取石术（RIRS）与超微经皮肾镜碎石取石术（micro-PCNL）处理肾结石（<3 cm）的有效性与安全性。 方法通过检索Pubmed、Cochrane图书馆、Embase、中国知网、万方数据库及中国生物医学文献服务系统等数据库（2011-01-01至2017-03-01）,获得有关micro-PCNL与RIRS处理中小肾结石的相关临床试验的中英文文献。根据研究纳入及排除标准,对纳入文献提取相关临床试验数据,经Revman 5.0分析软件分析得出结论。 结果本研究总共纳入4篇文献,2篇为随机对照试验,2篇为回顾性分析试验,所有文献总共纳入328例患者。RIRS与micro-PCNL的住院时间[WMD=2.71,95%CI（-3.78,9.20）],手术时间[WMD=6.56,95%CI（-22.94,36.05）]、及术后并发症[OR=0.99,95%CI（0.51,1.95）]等差异无统计学意义,而在结石清除率中,micro-PCNL优于RIRS[OR=2.30,95%CI（1.24,4.26）],且差异具有统计学意义。 结论两种术式均安全有效,micro-PCNL结石清除率高于RIRS。     

RLP与PCNL治疗肾盂单发结石的安全性及有效性的Meta分析

目的 系统评价后腹腔镜肾盂切开取石术(RLP)与经皮肾镜取石术(PCNL)治疗肾盂单发结石的安全性与有效性。方法 检索PubMed、EMBASE、Cochrane Library、Science Direct、中国生物医学文献数据库(CBM)、中文期刊全文数据库(CNKI)和万方数据库,纳入关于两种术式的所有对照性研究,包括随机对照研究、队列研究及病例对照研究。采用RevMan 5.3软件对两组数据进行统计分析。结果 共纳入11项研究,包括2项随机对照研究与9项病例对照研究。Meta分析结果显示,RLP组较PCNL组手术时间延长（WMD=18.93,P=0.009）,住院时间缩短（WMD=-1.09,P<0.001）,术中出血量减少（WMD=-46.48,P<0.001）,结石清除率更高（RR=1.21,P<0.001）,术后发热率（RR=0.41,P<0.001）、输血率（RR=0.23,P=0.003）及其他并发症发生率更低（RR=0.32,P<0.001）,差异均有统计学意义。然而,两组的术后尿漏率比较,差异无统计学意义（RR=1.13,P=0.730）。结论 RLP治疗肾盂单发结石在结石清除率、住院时间、术中出血量和术后发热及术后输血等并发症发生率方面均优于PCNL。     

无管化经皮肾镜的病例选择和术中决策

目的探讨无管化经皮肾镜的病例选择和术中决策。 方法2017年1月至2018年3月，我院泌尿外科共收治上尿路结石患者364例，根据术前综合评估标准筛选拟行无管化经皮肾病例，根据术中情况决定是否留置肾造瘘管，分为无管化经皮肾镜组和传统经皮肾镜组，分别评价两组的术后住院天数、结石清除率、术中出血量、可视化疼痛评分（VAS）及围手术期并发症。 结果经术前评估，42例患者符合拟行无管化经皮肾镜条件，根据术中评估，最终37例实行了无管化。术后两组患者的结石均清除干净。两组患者Ⅰ级并发症发生率差异无明显统计学意义（P=0.424），无Ⅱ级以上并发症。两组的平均手术时间（P=0.207）、术中出血量（P=0.450）差异无统计学意义。手术当天（P=0.029）、术后第一天（P<0.001）及出院当天（P=0.025）无管化组的可视化疼痛评分（VAS）均比传统组明显减轻。无管化组平均住院天数比传统组明显缩短（P<0.001）。 结论术前需从四个方面选择合适病例，术中注意四个关键操作，做到五个确认，无管化经皮肾镜是安全的，并且术后疼痛明显减轻，住院时间明显缩短。     

Use of hemostatic sealant in tubeless percutaneous nephrolithotomy: Experience of a single institution from Taiwan

ObjectiveTubeless percutaneous nephrolithotomy (PCNL) offers several advantages over standard PCNL, including a shorter hospital stay, less analgesic requirement, and less postoperative pain. Using a fibrin sealant to seal the nephrostomy tract had become a widely accepted technique at the conclusion of tubeless PCNL. Our objective is to evaluate the efficacy and safety of tubeless PCNL using hemostatic matrix.Materials and methodsThis is a retrospective review of PCNL database at our hospital between June 2014 and March 2016. During this period, a total of 139 PCNLs were performed, including 41 with tubeless technique with adjunct of hemostatic matrix (Floseal; Baxter, Deerfield, IL, USA) at the conclusion of the PCNL procedure. The standard PCNL group and the tubeless PCNL group were compared in terms of demographic characteristics, perioperative data, stone characteristics, and complication rate.ResultsOf all 123 patients included in this study, 41 underwent tubeless PCNL. Demographic data of the two groups were comparable except for a higher proportion of male patients in the tubeless PCNL group (73.2% vs. 53.7%). Stone characteristics were also comparable in the two groups. Perioperative variables, including operative time, drop of serum hemoglobin level, and perioperative complication rate, revealed no statistical difference between the two groups. Tubeless PCNL was associated with less postoperative pain, less analgesic requirement, and a shorter hospital stay (p < 0.01).ConclusionTubeless PCNL with adjunct use of a hemostatic sealant can be considered as a safe treatment option for renal calculi with favorable outcome, without an increase in complications. Compared with standard PCNL, tubeless PCNL with hemostatic sealant use is associated with less pain, use of fewer narcotic agents, and a shorter hospital stay.     

Tubeless procedure reduces hospitalization and pain after percutaneous nephrolithotomy: results of a multivariable analysis

The objective of the study was to assess the efficacy and safety of tubeless percutaneous nephrolithotomy (t-PCNL) in comparison with standard PCNL (s-PCNL). We retrospectively evaluated 317 consecutive PCNL and compared perioperative results, time of hospitalization and analgesic requirement of t-PCNL (114; 36.0 %) to s-PCNL (203; 64.0 %). The decision to perform a tubeless PCNL was made at the end of the procedures depending on the surgeon’s preference and according to the following inclusion criteria: (a) no serious bleeding or perforation in the collecting system during the procedure; (b) patients with no more than one access; and (c) residual stone burden needing a second-stage nephroscopy. Staghorn stones and anatomic anomalies were not considered as exclusion criteria for t-PCNL. Univariate analyses were conducted with one-way ANOVA, Fisher’s exact test, Pearson’s Chi-square and linear-by-linear association test as appropriate. Stepwise multivariable regression analyses were used to assess the independent correlation between demographics and clinical variables and the clinical outcomes. There were no significant differences between the two groups in terms of stone-free rate, hemoglobin decrease, blood transfusion and complication rate. Mean hospital stay was significantly shorter in the t-PCNL group (3.3 vs. 4.6 days; P < 0.001). Tubeless PCNL was associated with less analgesia requirement (68.4 vs. 86.7 %; P < 0.001) and with lower analgesic dose requirement (1.6 vs. 2.1 mean doses; P = 0.010). Multivariable analyses showed that t-PCNL (P < 0.001), postoperative fever (P < 0.001), transfusions (P < 0.001), operative time (P = 0.002), postoperative hydronephrosis (P = 0.005) and residual fragment dimension (P = 0.024) were independently correlated with duration of hospitalization, while analgesic dose requirement was independently influenced by hemoglobin decrease (P < 0.001), t-PCNL (P = 0.005) and stone number (P = 0.044). Our study confirmed that t-PCNL has similar outcomes to s-PCNL in terms of stone-free rate without increasing complications in selected cases. t-PCNL is a factor independently associated with shorter hospitalization and lower analgesic requirement.     

Effectiveness of totally tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized study

Objectives  Compared with the standard technique, the number of percutaneous nephrolithotomy (PCNL) operations without a drainage catheter is increasing in recent years. In this prospective randomized study, we compared the morbidity of totally tubeless (tubeless and stentless) PCNL operations with the standard operation technique in a single center with a selected patient population. Methods  Ninety patients who fulfilled the criteria were included. Forty-five patients underwent totally tubeless PCNL (Group 1) and a 14F malecot nephrostomy catheter was used in another set of 45 patients (Group 2). Inclusion criteria for the study were no serious bleeding or perforation in the collecting system during the operation, stone free or clinically insignificant residual fragments (CIRF <4 mm), and no more than one access. Results  When two groups were compared with regard to age, stone volume, postoperative hemoglobin change, transfusion rate, and operation time, no significant differences were found between the two groups. However, a significant difference was found in hospitalization time between the two groups (P < 0.05). The amount of non-steroidal analgesic (tenoxicam) needed and non-steroidal analgesia-resistant pain which was resolved with narcotic analgesics (meperidine) were significantly lower in Group 1 (P < 0.05). Complications were observed in two patients (4.5%) in Group 1 (one retroperitoneal hematoma, one long-lasting renal colic) and in six patients (13.3%) in Group 2 (five prolonged urine drainage, one long-lasting fever) (P < 0.05). Conclusions  Tubeless and stentless PCNL is a safe method and reduces hospitalization time and analgesic requirement, and promotes quality of life in selected patients.