经皮肾穿刺造瘘联合输尿管镜钬激光碎石微创治疗输尿管结石伴肾积水

 目的  通过前瞻性随机对照研究探讨经皮肾穿刺造瘘联合输尿管镜钬激光碎石治疗第4腰椎(fourth lumbar vertebrae, L4)水平以下输尿管结石合并中重度肾积水的疗效、作用和临床意义。方法  选取2014年6月至2017年10月复旦大学附属浦东医院泌尿外科收治的112例L4水平以下输尿管结石合并中重度肾积水患者,男64例,女48例。年龄17～90岁。术前均行B超、CT明确输尿管结石位于L4水平以下,肾盂分离25～60 mm。根据试验设计样本量抽样生成两组随机号,每组各56例,分别行经皮肾穿刺造瘘联合输尿管镜钬激光碎石(肾穿刺联合组)和单纯输尿管镜钬激光碎石(输尿管镜组),对比两组的术后降钙素原、C反应蛋白、血白细胞计数、血红细胞计数、体温、尿源性脓毒症、结石残留等。结果  肾穿刺联合组和输尿管镜组术后比较,降钙素原分别为(0.34±0.76) ng/mL及(2.82±8.58) ng/mL (P=0.006),C反应蛋白分别为(24.55±42.53) mg/L及(15.19±23.55) mg/L (P=0.528),血白细胞计数分别为(7.59±2.12)×10⁹/L及(9.18±4.2)×10⁹/L (P=0.040),血红细胞计数分别为(3.98±0.53)×10¹²/L及(4.13±0.52)×10¹² /L(P=0.126),体温分别为(37.3±0.5) ℃及(37.5±0.7) ℃ (P=0.119),严重尿源性脓毒症发生例数分别为1例及4例(P=0.384),结石残留发生例数分别为4例及8例(P=0.247)。结论  对于L4水平以下输尿管结石合并中重度肾积水者,经皮肾穿刺造瘘联合输尿管镜钬激光碎石较单纯输尿管镜钬激光碎石能有效降低全身细菌感染的发生。

Percutaneous nephrostomy combined with ureteroscopic holmium laser lithotripsy in the treatment of ureteral calculi with hydronephrosis

Objective  To perform a perspective randomized controlled study to assess the efficacy of percutaneous nephrostomy combined with ureteroscopic holmium laser lithotripsy in the treatment of ureteral calculi complicated with moderate or severe hydronephrosis below the fourth lumbar vertebrae (L4). Methods  From Jun., 2014 to Oct., 2017, 112 cases of ureteral calculi complicated with moderate or severe hydronephrosis below L4 were admitted in the Department of Urology, Pudong Hospital, Fudan University. Sixty-four males and 48 females aged from 17 to 90 years old and degree of hydronephrosis from 25 to 60 mm confirmed by B ultrasound tomogrph and CT before the operation. The patients were randomized divided into two groups:percutaneous nephrostomy combined with ureteroscopic holmium laser lithotripsy group (nephrostomy combined group, n=56) and ureteroscopic holmium laser lithotripsy group (ureteroscopic group, n=56). The perioperative data of two groups were collected and compared. Perioperative data included procalcitonin, C-reactive protein, blood leukocyte count, blood red cell count, body temperature, urinary sepsis and residual stone. Results  The postoperative data of the two groups was compared: procalcitonin was (0.34±0.76) ng/mL in nephrostomy combined group and (2.82±8.58) ng/mL in ureteroscopic group (P=0.006); blood leukocyte count was (7.59±2.12)×10⁹/L in nephrostomy combined group and (9.18±4.2)×10⁹/L in ureteroscopic group (P=0.040). There were no significant differences between the two groups in C-reactive protein ［(24.55±42.53) mg/L vs.(15.19±23.55) mg/L, P=0.528］, blood red cell count ［(3.98±0.53)×10¹²/L vs. (4.13±0.52)×10¹²/L,  P=0.126］, body temperature ［(37.3±0.5)℃ vs. (37.5±0.7)℃, P=0.119］ and severe urinary sepsis (1 case vs. 4 cases, P=0.384) and residual stone (4 cases vs. 8 cases, P=0.247). Conclusions  For patients with ureteral calculi associated with moderate or severe hydronephrosis below fourth lumbar vertebrae, percutaneous nephrostomy combined with ureteroscopic holmium laser lithotripsy can effectively reduce the incidence of systemic bacterial infection compared with ureteroscopic holmium laser lithotripsy.