两种肾盂减压方式治疗上尿路结石合并尿源性脓毒血症的效果比较

目的比较留置输尿管支架和经皮肾造瘘两种肾盂减压方式治疗上尿路结石合并尿源性脓毒血症的效果。方法回顾性分析天津医科大学第二医院2013年6月至2019年6月收治的429例上尿路结石合并脓毒血症患者的临床资料。根据肾盂减压方式,将患者分为留置输尿管支架(US)组和经皮肾造瘘(PCN)组。US组304例,男94例,女210例;年龄(56.2±9.4)岁;体温(39.1±2.4)℃;体质指数(BMI)(25.6±6.3)kg/m^2;191例合并糖尿病;血白细胞计数(16.2±4.2)×10^9/L,C-反应蛋白(CRP)(67.2±14.2)mg/L;结石位于左侧155例,右侧149例;肾积水程度为轻度147例,中度99例,重度58例;结石位于肾盂输尿管连接处(UPJ)15例,输尿管上段167例、中段80例、下段42例;结石最大径(1.4±0.5)cm;121例存在休克。PCN组125例,男35例,女90例;年龄(58.5±13.1)岁;体温(38.7±1.9)℃;BMI(26.6±4.6)kg/m^2;77例合并糖尿病;血白细胞计数(15.7±6.4)×10^9/L,CRP(69.1±15.6)mg/L;结石位于左侧61例,右侧64例;肾积水程度为轻度56例,中度44例,重度25例;结石位于UPJ 5例,输尿管上段71例、中段34例、下段15例;结石最大径(1.5±0.5)cm;56例存在休克。记录合并休克与非休克患者采用两种肾盂减压方式的成功率、感染相关指标(体温、血白细胞计数、CRP)恢复正常的时间、减压后30 min内感染进展率、控制感染住院天数及并发症情况。比较US组和PCN组二期输尿管镜碎石术的手术时间、结石清除率、软镜使用率及术后发热率。结果非休克患者中,US组的肾盂减压成功率(165/183)低于PCN组(68/69)(P=0.025);减压后30 min内感染进展率(25/183)高于PCN组(3/69)(P=0.036)。US组和PCN组感染性指标恢复正常的时间及控制感染住院天数差异无统计学意义(P>0.05)。US组二期输尿管镜碎石术的手术时间[(38.5±6.9)min]长于PCN组[(32.8±4.5)min](P=0.000),软镜使用率(53/183)高于PCN组(7/69)(P=0.0002),结石清除率(163/183)低于PCN组(67/69)(P=0.044)。合并休克的患者中,US组的肾盂减压成功率(106/121)低于PCN组(55/56)(P=0.022);感染相关指标恢复正常的时间长于PCN组[体温恢复正常:(49.1±5.7)h与(40.6±4.8)h,P=0.000;血白细胞计数恢复正常:(5.4±1.7)d与(4.8±0.9)d,P=0.003;CRP恢复正常:(6.9±2.2)d与(5.2±2.2)d,P=0.000];减压后30 min内感染进展率(16/121)高于PCN组(2/56)(P=0.048)。US组二期输尿管镜碎石术的手术时间[(36.6±7.3)min]长于PCN组[(33.8±6.1)min](P=0.017),软镜使用率(45/121)高于PCN组(9/56)(P=0.005),结石清除率(111/121)低于PCN组(54/56)(P=0.024)。结论治疗上尿路结石合并脓毒血症时,US和PCN均能有效地控制感染。对于合并感染性休克的患者,经PCN缓解感染的速度快于US,且PCN有利于提高二期输尿管镜碎石术的结石清除率,减少软镜使用率。

The comparison of two surgical decompressions for patients with upper urinary tract calculi and sepsis

Objective To compare the effectivity and safety of ureteral stenting and percutaneous nephrostomy for patients with upper urinary calculi and sepsis.Methods From June 2013 to June 2019,429 patients with upper urinary calculi and urosepsis were accepted in the second hospital of Tianjin Medical University.According to surgical decompression,patients were divided into two groups,ureteral stenting(US,n=304)and percutaneous nephrostomy(PCN,n=125).121 patients were accompanied with septic shock in US group,56 in PCN group.The effectivity of decompression was analyzed separately in patients with or without shock.For decompression,data included the success rate of decompression,the time of infection related parameters(temperature,blood WBC and CRP)returning to normal and the complications(progress of infection within 30min after decompression,perforation of ureter or pelvis).When urosepsis was cured,ureteroscopic lithotripsy was followed for all patients.The operation time,the stone free rate,the rate of using RIRS and the complications were compared.Results For patients without septic shock,the success rate of decompression in PCN was higher(68/69)than that of US(165/183)(P=0.025);there was no significant difference in hospital stay for infection control and the time of infection related parameters(temperature,blood WBC and CRP)returning to normal(P>0.05).The rate of infection progress within 30min in US(25/183)was higher than PCN(3/69)(P=0.036).When ureteroscopic lithotripsy was mentioned,the operation time in US(38.5±6.8 min)was longer than PCN(32.8±4.5 min)(P=0.000),the stone free rate and the rate of using RIRS were lower in PCN(P=0.044,P=0.0002).For patients with septic shock,the success rate of decompression in PCN was higher(55/56)than that of US(106/121)(P=0.022).The rate of infection progress within 30min after decompression was still higher in US(P=0.048),the time of infection related parameters(temperature,blood WBC and CRP)returning to normal was shorter in PCN(P=0.000,P=0.003,P=0.000).For lithotripsy,the operation time was longer in US(P=0.017),the stone free rate and the rate of using RIRS were lower in PCN(P=0.024,P=0.005).Conclusions For patients with upper urinary calculi and urosepsis,both ureteral stenting and percutaneous nephrostomy can drainage the pelvis effectively.PCN provides quick recovery,especially when septic shock is involved.For the following ureteroscopic lithotripsy,PCN contributes to less operation time and higher stone free rate,reduces the use of flexible ureteroscope.