双侧经皮肾镜取石术同期手术与分期手术比较研究
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摘要
目的
比较双侧经皮肾镜取石术同期手术(SBPCNL)与分期手术(分期PCNL)术前、术中、术后主要临床指标,评价SBPCNL和分期PCNL的特点,探讨SBPCNL的安全性及疗效。
方法
运用前瞻性研究方法采集双侧复杂性上尿路结石住院患者132例,根据手术方式分为SBPCNL组(同期组)59例和分期PCNL组(分期组)73例,分别记录、检测和统计同期组与分期组术前、术中、术后相关指标,如性别、年龄、病程、结石大小、结石清除率、出血量、手术时间、手术并发症、血肌酐(SCr)、肾小球滤过率(GFR)等,遵循相互对照的原则,回顾性分析比较同期组与分期组两组主要临床指标。应用SPSS13.0统计软件进行数据处理,计量资料比较应用独立样本t检验,计数资料比较应用χ2检验,P<0.05认为有统计学意义。
结果
顺利完成SBPCNL 53例和分期PCNL 69例,手术成功率分别为88.1%和94.5%,结石清除率分别为86.4%和86.3%,两组比较差异均无统计学意义(P=0.270和P=0.117);术前一般情况如性别、年龄和病程两组比较差异均无统计学意义(P>0.05),而结石平均直径(25.6±0.6)mm和(29.9±0.7)mm两组比较差异有统计学意义(P=0.000);术中平均手术时间(105.3±35.6)min和(110.9±38.9)min,平均出血量(305.5±200.8)ml和(298.4±207.1)ml,两组比较差异均无统计学意义(P =0.141和P=0.107);两组总肾功能不全患者术后1周和1月SCr比较差异均有统计学意义(P=0.0056和P=0.0094);两组分肾功能不全患者在先术侧术后1周和1月时后术侧的GFR比较差异均有统计学意义(P=0.0004和P=0.0044),术后平均住院时间(7.5天和14.2天)、平均造瘘时间(4.8天和8.1天)、平均住院费用以及麻醉次数(1次和2次)等指标两组比较均有显著性差异。
结论
双侧PCNL是治疗双侧复杂性上尿路结石的首选方法;双侧PCNL有SBPCL与分期PCNL之分,二者相比,在病例选择合适的前提下,SBPCNL具有安全高效的特点,且有利于双肾功能的恢复;而在临床现实工作中,双侧分期PCNL也是不可缺少的手术方式。
Objective
To investigate the safety and efficacy of simultaneous bilateral percutaneous nephrolithotomy (SBPCNL) compared with staged percutaneous nephrolithotomy (PCNL) in cases of bilateral complex upper urinary tract stones, and assess the characters of the two
approaches of SBPCNL and staged PCNL.
Methods
A total of 132 cases of bilateral complex upper urinary tract stones, in which 59 patients undergoing SBPCNL (Group 1) comparing with a similar group of 73 patients undergoing a staged PCNL (Group 2), were selected into the study prospectively. The relative indexes of the two groups were detected and recorded to compare with each other. Preoperative indexes included gender, age, course and average stone size. Intraoperative indexes, such as operative time, blood loss, were recorded too. Postoperative indexes involved success rate, incidence of blood transfusion, stone-free rate, hospital stays, etc, were also presented. And serum creatinine (SCr), glomerular filtration rate (GFR) of the patients about renal failure were detected regularly to assess the renal function. The two-group t-test or x2-test were performed for statistical analysis.
Results
53 SBPCNLs were performed in group 1, 69 staged PCNLs were accomplished in group 2, with the success rate of 88.1% and 94.5% respectively. Both of the two groups were comparable in gender, age and course preoperatively, in mean total operative time and mean blood loss intraoperatively, in stone-free rate and success rate postoperatively. The comparison of average stone size (25.6±0.6) mm and (29.9±0.7) mm, preoperatively showed statistically significant (P=0.000), and postoperatively indicated significant statistical difference in SCr and GFR of the patients about renal failure between the two groups at week 1 and month 1 after the first side of PCNL (P=0.0056 and P=0.0094, P=0.0004 and P=0.0044). Detailed analysis has revealed a significant cost advantage and short length of hospital stay for SBPCNL versus staged bilateral PCNL.
Conclusions
Bilateral PCNL is the gold standard for the surgical management of bilateral complex upper urinary tract stones, and it includes two approaches of SBPCNL and staged PCNL. In properly selected patients, SBPCNL is safe and effective and has the advantage of improving bilateral renal function for SBPCNL versus staged PCNL. Despite the best of intentions, there are a number of anticipated SBPCNL cases might be limited to single-sided PCNL. Thus, it is indispensable for staged PCNL to be carried out at clinic.
比较双侧经皮肾镜取石术同期手术(SBPCNL)与分期手术(分期PCNL)术前、术中、术后主要临床指标,评价SBPCNL和分期PCNL的特点,探讨SBPCNL的安全性及疗效。
方法
运用前瞻性研究方法采集双侧复杂性上尿路结石住院患者132例,根据手术方式分为SBPCNL组(同期组)59例和分期PCNL组(分期组)73例,分别记录、检测和统计同期组与分期组术前、术中、术后相关指标,如性别、年龄、病程、结石大小、结石清除率、出血量、手术时间、手术并发症、血肌酐(SCr)、肾小球滤过率(GFR)等,遵循相互对照的原则,回顾性分析比较同期组与分期组两组主要临床指标。应用SPSS13.0统计软件进行数据处理,计量资料比较应用独立样本t检验,计数资料比较应用χ2检验,P<0.05认为有统计学意义。
结果
顺利完成SBPCNL 53例和分期PCNL 69例,手术成功率分别为88.1%和94.5%,结石清除率分别为86.4%和86.3%,两组比较差异均无统计学意义(P=0.270和P=0.117);术前一般情况如性别、年龄和病程两组比较差异均无统计学意义(P>0.05),而结石平均直径(25.6±0.6)mm和(29.9±0.7)mm两组比较差异有统计学意义(P=0.000);术中平均手术时间(105.3±35.6)min和(110.9±38.9)min,平均出血量(305.5±200.8)ml和(298.4±207.1)ml,两组比较差异均无统计学意义(P =0.141和P=0.107);两组总肾功能不全患者术后1周和1月SCr比较差异均有统计学意义(P=0.0056和P=0.0094);两组分肾功能不全患者在先术侧术后1周和1月时后术侧的GFR比较差异均有统计学意义(P=0.0004和P=0.0044),术后平均住院时间(7.5天和14.2天)、平均造瘘时间(4.8天和8.1天)、平均住院费用以及麻醉次数(1次和2次)等指标两组比较均有显著性差异。
结论
双侧PCNL是治疗双侧复杂性上尿路结石的首选方法;双侧PCNL有SBPCL与分期PCNL之分,二者相比,在病例选择合适的前提下,SBPCNL具有安全高效的特点,且有利于双肾功能的恢复;而在临床现实工作中,双侧分期PCNL也是不可缺少的手术方式。
Objective
To investigate the safety and efficacy of simultaneous bilateral percutaneous nephrolithotomy (SBPCNL) compared with staged percutaneous nephrolithotomy (PCNL) in cases of bilateral complex upper urinary tract stones, and assess the characters of the two
approaches of SBPCNL and staged PCNL.
Methods
A total of 132 cases of bilateral complex upper urinary tract stones, in which 59 patients undergoing SBPCNL (Group 1) comparing with a similar group of 73 patients undergoing a staged PCNL (Group 2), were selected into the study prospectively. The relative indexes of the two groups were detected and recorded to compare with each other. Preoperative indexes included gender, age, course and average stone size. Intraoperative indexes, such as operative time, blood loss, were recorded too. Postoperative indexes involved success rate, incidence of blood transfusion, stone-free rate, hospital stays, etc, were also presented. And serum creatinine (SCr), glomerular filtration rate (GFR) of the patients about renal failure were detected regularly to assess the renal function. The two-group t-test or x2-test were performed for statistical analysis.
Results
53 SBPCNLs were performed in group 1, 69 staged PCNLs were accomplished in group 2, with the success rate of 88.1% and 94.5% respectively. Both of the two groups were comparable in gender, age and course preoperatively, in mean total operative time and mean blood loss intraoperatively, in stone-free rate and success rate postoperatively. The comparison of average stone size (25.6±0.6) mm and (29.9±0.7) mm, preoperatively showed statistically significant (P=0.000), and postoperatively indicated significant statistical difference in SCr and GFR of the patients about renal failure between the two groups at week 1 and month 1 after the first side of PCNL (P=0.0056 and P=0.0094, P=0.0004 and P=0.0044). Detailed analysis has revealed a significant cost advantage and short length of hospital stay for SBPCNL versus staged bilateral PCNL.
Conclusions
Bilateral PCNL is the gold standard for the surgical management of bilateral complex upper urinary tract stones, and it includes two approaches of SBPCNL and staged PCNL. In properly selected patients, SBPCNL is safe and effective and has the advantage of improving bilateral renal function for SBPCNL versus staged PCNL. Despite the best of intentions, there are a number of anticipated SBPCNL cases might be limited to single-sided PCNL. Thus, it is indispensable for staged PCNL to be carried out at clinic.
引文
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[1] Fernstrom I, Johansson B. Percutaneous pyelolithotomy: A new extraction technique[J]. Scand J Urol Nephrol, 1976, 10 (3):257-259.
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[1] Fernstrom I, Johansson B. Percutaneous pyelolithotomy: A new extraction technique[J]. Scand J Urol Nephrol, 1976, 10 (3):257-259.
[2] Osman M, Wendt-Nordahl G, Heger K, et al. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases[J]. BJU Int, 2005, 96 (6): 875-878.
[3] Makhoul B, Yatim M, Guinard J, et al. How to operate kidney puncture in percutaneous nephrolithotomy[J]. Ann Urol(Paris), 2006, 40 (2): 139-148.
[4] Bilen CY, asci R, Sarikaya S, et al. Laser-Assisted fluoroscopic puncture:A new technology for accessing the kidney [J]. Endourol 2003,7 (8):485-491.
[5] Nikesh T, Hugh M, Gaurang U. Planning percutaneous nephrolithotomy usingmultidetector computed tomography urography, multiplanar reconstruction and three-dimensional reformatting[J]. BJU International, 2005, 95 (2) : 1280-1284.
[6] Radecka E,brehmer M, holmgren K, et al. Pelvicaliceal biomodeling as an aid to achieving optimal access in percutaneous nephrolithotripsy [J]. Endourol, 2006,10 (9): 92-101.
[7] Yuhico MP, Ko R. The current status of percutaneous nephrolithotomy in the manage- ement of kidney stones[J]. Minerva Urol Nefrol, 2008,60 (3):159-175.
[8] Wickham JE, Miller RA, Kellett MJ, et al. Percutaneous nephrolithotomy: one stage or two? [J]. Br J Urol,1984, 56 (7):582-584.
[9] Winfield HN, Weyman P, Clayman RV. Percutaneous nephrostolithotomy: complications of premature nephrostomy tube removal[J]. J Urol, 1986, 136 (4): 77-79.
[10] Bellman GC, Davidoff R, Candela J, et al. Tubeless percutaneous renal surgery[J]. J Urol, 1997, 157 (33):1578-1582.
[11] Delnay KM, Wake RW. Safety and efficacy of tubeless percutaneous nephrostolitho- tomy[J]. World J Urol , 1998, 16 (8): 375-377.
[12] Goh M, Wolf JS. Almost totally tubeless percutaneous nephrolithotomy: further evolution of the technique[J]. J Endourol, 1999, 13 (4):177-180.
[13] Lojanapiwat B, Soonthornphan S, Wudhikarn S, et al. Tubeless percutaneous nephro- lithotomy in selected patients[J]. Journal of Endourology, 2001, 15 (3): 711-713.
[14] Feng MI, Tamaddon K, Mikhail A, et al. Prospective randomized study of various techniques of percutaneous nephrolithotomy[J]. Urology, 2001, 58 (1): 345-350.
[15] Limb J, Bellman GC. Tubeless percutaneous renal surgery: review of the first 112 patients[J]. Urology, 2002, 59 (6): 527-531.
[16] Mikhail AA, Kaptein JS, Bellman GC, et al. Use of fibrin glue in percutaneous neph- rolithotomy[J]. Urology, 2003, 61 (8): 910-914.
[17] Colon-Perez B, Canto RJ, Ramos ME. Simultaneous bilateral nephrostolitholithotomy: Immediate results in three cases[J]. J Endourol 1987,1 (5): 209.
[18] Williams SK, Hoenig DM. Synchronous bilateral percutaneous nephrostolithotomy[J]. J Endourol. 2009, 23 (10): 1707-1712.
[19] Holman E, Salah MA, Toth C.Comparison of 150 simultaneous bilateral and 300 uni- lateral percutaneous nephrolithotomies[J].J Endourol, 2002, 16 (8): 33-36.
[20]蒋志强,蒋先镇,何乐业,等.双侧上尿路结石手术处理原则的探讨(附53例报告)[J].临床泌尿外科杂志, 2004, 19 (12): 727-728.
[21]卢国平,高新,等.超声引导下经皮肾镜一期手术治疗双侧复杂性尿路结石的疗效观察附67例报告[J].新医学, 2006, 37 (12): 797-798.
[22]郭丰富,邵志强,王广健,等. B超引导下经皮肾镜气压弹道联合超声碎石术治疗复杂性肾结石[J].中华泌尿外科杂志, 2008, 29 (10): 678-680.
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