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HJS

Hans Journal of Surgery

2168-5584

Scientific Research Publishing

10.12677/HJS.2022.114019

HJS-60073

HJS20220400000_22672067.pdf

医药卫生

不同年资医生行输尿管软镜钬激光碎石术的疗效分析 Analysis of Curative Effect of Flexible Ureteroscope Holmium Laser Lithotripsy Performed by Doctors with Different Seniority

张

劲松

²¹柳

琦

²¹董

铮

²¹万

典

²¹张

长升

²¹

黄冈市中心医院泌尿外科，湖北黄冈

null

20122022

1104111116

2014

This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

目的：探讨不同年资的医生行输尿管软镜钬激光碎石术(RIRS)的临床疗效。方法：回顾性分析我院2020年6月至2022年1月行RIRS的139例上尿路结石患者的临床资料。男82例，女57例，年龄(48.83 ± 12.17)岁。结石最大CT值(1107.76 ± 356.83) HU，结石最大径(15.01 ± 6.12) mm。单侧肾结石47例，双肾结石8例，单侧输尿管上段结石62例，单侧输尿管上段结石合并肾结石22例。28例术前留置双J管。术前血白细胞(WBC) (6.84 ± 2.41) × 10^9/L，降钙素原(PCT) (1.27 ± 0.83) ng/ml。手术均采用全麻，患者取截石位。采用输尿管软镜联合钬激光碎石，软镜顺利进入肾盂后首先观察肾盂及各肾盏并寻及结石。使用200 μm光纤碎石，钬激光功率为15~45 w (0.8~1.8 J)，根据实际情况辅助取石网篮套取结石。术中检查各肾盂、肾盏，确保结石已完全粉末化，碎石结束留置双J管和尿管。手术随机由不同年资的术者完成。结果：所有手术均顺利完成，手术时间(86.71 ± 30.51) min，两组手术时间比较差异无统计学意义(t = 0.499, p = 0.063)。术中出血量(47.80 ± 22.86) ml，两组术中出血量比较差异无统计学意义(t = 1.183, p = 0.068)。术后第1天复查血WBC计数(6.84 ± 2.41) × 10^9/L，与术前比较差异有统计学意义(t = 1.127，p < 0.05)，两组术后WBC计数比较差异无统计学差异(t = 0.925, p = 0.128)；PCT (1.27 ± 0.83) ng/ml，与术前比较差异有统计学意义(t = 1.112, p < 0.05)，两组术后PCT比较差异无统计学差异(t = 0.964, p = 0.923)。住院时间(6.59 ± 2.47) d，两组住院时间比较差异无统计学意义(t = 0.672, p = 0.632)。术后返院拔双J管均获得随访，结石清除率(stone-free rate, SFR) 100%。结论：RIRS是上尿路中小结石患者的一种疗效确切的治疗方式，随着输尿管软镜国产化，RIRS操作简单、安全性高的优点，RIRS可向基层医院广泛推广。 Objective: The clinical efficacy of flexible ureteroscopic holmium laser lithotripsy (RIRS) performed by doctors of different seniority. Methods: The clinical data of 139 patients with upper urinary tract calculi who underwent RIRS in our hospital from June 2020 to January 2022 were retrospectively analyzed. There were 82 males and 57 females, aged (48.83 ± 12.17) years old. The maximum CT value of the stone was (1107.76 ± 356.83) HU, and the maximum stone diameter was (15.01 ± 6.12) mm. There were 47 cases of unilateral renal calculi, 8 cases of bilateral renal calculi, 62 cases of unilateral upper ureteral calculi, and 22 cases of unilateral upper ureteral calculi combined with renal calculi. Twenty-eight cases were preoperatively indwelled with double J tubes. Preoperative white blood cells (WBC) (6.84 ± 2.41) × 10^9/L, procalcitonin (PCT) (1.27 ± 0.83) ng/ml. All operations were performed under general anesthesia, and the patients were in the lithotomy position. The flexible ureteroscopy combined with holmium laser lithotripsy was used. After the flexible scope successfully entered the renal pelvis, the renal pelvis and the renal calyces were first observed and the calculi were found. Use 200 μm fiber lithotripsy, holmium laser power of 15~45 w (0.8~1.8 J), and assist the stone extraction basket to extract stones according to the actual situation. During the operation, the renal pelvis and renal calyces were checked to ensure that the stones had been completely powdered, and the double J tube and the urinary catheter were indwelled at the end of the stone crushing. The operations were performed randomly by surgeons with different seniority. Results: All operations were successfully completed, and the operation time was (86.71 ± 30.51) minutes. There was no sig-nificant difference in operation time between the two groups (t = 0.499, p = 0.063). The intraoperative blood loss was (47.80 ± 22.86) ml, and there was no significant difference in intraoperative blood loss between the two groups (t = 1.183, p = 0.068). The blood WBC count was re-examined on the 1st day after operation (6.84 ± 2.41) × 10^9/L, and the difference was statistically significant compared with that before operation (t = 1.127, p < 0.05). There was no statistical difference in WBC count between the two groups after operation. PCT (1.27 ± 0.83) ng/ml, the difference was statistically significant (t = 1.112, p < 0.05), and there was no statistical difference in postoperative PCT between the two groups’ academic difference (t = 0.964, p = 0.923). The length of hospital stay was (6.59 ± 2.47) days, and there was no significant difference in the length of hospital stay between the two groups (t = 0.672, p = 0.632). All patients were followed up after returning to the hospital to remove the double-J tube, and the stone-free rate (SFR) was 100%. Conclusions: RIRS is an effective treatment method for patients with small and medium stones in the upper urinary tract. With the localization of flexible ureteroscopy, RIRS has the advantages of simple operation and high safety. RIRS can be widely promoted in primary hospitals.

输尿管软镜，钬激光碎石，疗效, Flexible Ureteroscopy Upperurinary Calculi Clinical Efficacy

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关键词

输尿管软镜，钬激光碎石，疗效

Analysis of Curative Effect of Flexible Ureteroscope Holmium Laser Lithotripsy Performed by Doctors with Different Seniority<sup> </sup>

Jinsong Zhang, Qi Liu, Zheng Dong, Dian Wan, Changsheng Zhang

Department of Urology, Huanggang Central Hospital, Huanggang Hubei

Received: Dec. 6^th, 2022; accepted: Dec. 29^th, 2022; published: Jan. 9^th, 2023

ABSTRACT

Objective: The clinical efficacy of flexible ureteroscopic holmium laser lithotripsy (RIRS) performed by doctors of different seniority. Methods: The clinical data of 139 patients with upper urinary tract calculi who underwent RIRS in our hospital from June 2020 to January 2022 were retrospectively analyzed. There were 82 males and 57 females, aged (48.83 ± 12.17) years old. The maximum CT value of the stone was (1107.76 ± 356.83) HU, and the maximum stone diameter was (15.01 ± 6.12) mm. There were 47 cases of unilateral renal calculi, 8 cases of bilateral renal calculi, 62 cases of unilateral upper ureteral calculi, and 22 cases of unilateral upper ureteral calculi combined with renal calculi. Twenty-eight cases were preoperatively indwelled with double J tubes. Preoperative white blood cells (WBC) (6.84 ± 2.41) × 10^9/L, procalcitonin (PCT) (1.27 ± 0.83) ng/ml. All operations were performed under general anesthesia, and the patients were in the lithotomy position. The flexible ureteroscopy combined with holmium laser lithotripsy was used. After the flexible scope successfully entered the renal pelvis, the renal pelvis and the renal calyces were first observed and the calculi were found. Use 200 μm fiber lithotripsy, holmium laser power of 15~45 w (0.8~1.8 J), and assist the stone extraction basket to extract stones according to the actual situation. During the operation, the renal pelvis and renal calyces were checked to ensure that the stones had been completely powdered, and the double J tube and the urinary catheter were indwelled at the end of the stone crushing. The operations were performed randomly by surgeons with different seniority. Results: All operations were successfully completed, and the operation time was (86.71 ± 30.51) minutes. There was no significant difference in operation time between the two groups (t = 0.499, p = 0.063). The intraoperative blood loss was (47.80 ± 22.86) ml, and there was no significant difference in intraoperative blood loss between the two groups (t = 1.183, p = 0.068). The blood WBC count was re-examined on the 1st day after operation (6.84 ± 2.41) × 10^9/L, and the difference was statistically significant compared with that before operation (t = 1.127, p < 0.05). There was no statistical difference in WBC count between the two groups after operation. PCT (1.27 ± 0.83) ng/ml, the difference was statistically significant (t = 1.112, p < 0.05), and there was no statistical difference in postoperative PCT between the two groups’ academic difference (t = 0.964, p = 0.923). The length of hospital stay was (6.59 ± 2.47) days, and there was no significant difference in the length of hospital stay between the two groups (t = 0.672, p = 0.632). All patients were followed up after returning to the hospital to remove the double-J tube, and the stone-free rate (SFR) was 100%. Conclusions: RIRS is an effective treatment method for patients with small and medium stones in the upper urinary tract. With the localization of flexible ureteroscopy, RIRS has the advantages of simple operation and high safety. RIRS can be widely promoted in primary hospitals.

Keywords:Flexible Ureteroscopy, Upperurinary Calculi, Clinical Efficacy

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

1. 引言

尿路结石也称为尿石症，是泌尿外科领域最常见疾病之一。全球约有10%~15%的人经历过该疾病 [1]。我国成人尿石症患病率为6.5%，其中单纯上尿路结石占95%以上 [2]。输尿管软镜钬激光碎石术(retrograde intrarenal surgery, RIRS)，逐步成为上尿路结石的主要治疗手段之一。输尿管软镜逆行于人体泌尿管道，在视频直视下配合钬激光进行碎石，安全性高，疗效较可靠 [3]。随着RIRS逐渐广泛的开展，大约三分之一的RIRS是由住院医师完成的 [4]，不同年资医生行RIRS的疗效及安全性是否有区别有待研究。本文回顾性分析我院行RIRS病例139例。详细报告如下。

2. 资料与方法 2.1. 一般资料

选取自2020年6月至2021年1月本院收治的上尿路结石行RIRS的患者139例为研究对象，根据主刀手术医生年资不同分组。A组为低年资医生组，即住院医师及低年资主治医师组(69例)：女30例，男39例；年龄22~72岁，平均(49.95 ± 12.34)岁；结石直径0.7~2.9 cm，平均(17.36 ± 21.10) mm；结石CT值413~1597 Hu，平均1089.52 ± 348.13 Hu；BMI指数18.5~30.1 kg/m²，平均(24.13 ± 3.21) kg/m²。B组为高年资医师组，即高年资主治医师及副主任医师组(70例)：女28例，男42例；年龄24~73岁，平均(47.65 ± 12.20)岁；结石直径0.6~3.0 cm，平均(12.55 ± 3.63) mm；结石CT值421~1643 Hu，平均1126.90 ± 373.81 Hu；BMI指数18.2~30.1 kg/m²，平均(24.12 ± 3.42) kg/m²。两组一般资料比较差异无统计学意义(P > 0.05)，具有可比性。见表1。

Table 1 General information of the two groups of patient

组别	A组	B组	t/χ²	P值
年龄(岁)	49.95 ± 12.34	47.65 ± 12.20	0.601	0.973
性别			1.468	0.575
男	30	28
女	39	42
BMI (kg/m²)	24.13 ± 3.21	24.12 ± 3.42	1.224	0.092
结石长径(mm)	17.36 ± 21.10	12.55 ± 3.63	1.006	0.030
发现结石病程(m)	4.00 ± 8.10	10.20 ± 27.15	−1.001	0.113
结石CT值(Hu)	1089.52 ± 348.13	1126.90 ± 373.81	−0.331	0.496
术前留置双J管(例)	17	11	0.784	0.725

表1. 两组患者一般情况

2.2. 纳入与排除标准

纳入标准：经泌尿系CT等影像学检查确诊的上尿路结石，并排除手术相关禁忌证。患者均签署知情同意书；本研究经院伦理委员会同意。

2.3. 手术方法

A、B两组手术方法相同。即：全身麻醉成功后，取截石位，以F8/8.5输尿管镜经尿道入膀胱，找到输尿管开口，置入斑马导丝(若有预置双J管予以拔除)，硬镜上行至肾盂(若为输尿管上段结石，将结石推入肾盂)，留置斑马导丝至肾盂，退输尿管硬镜，并沿导丝逆行置入F12输尿管软镜鞘，置入F7.5软镜，检查各肾盏，找到结石并确定位置，置入200 um钬激光光纤，钬激光功率为15~45 w (0.8~1.8 J)，贴近结石，将结石粉碎至碎片及粉末，如有较大结石碎片予以套石篮套出，确保结石完全粉末化后退出输尿管软镜，留置双J管和尿管。术后常规行相关检查复查结石残留情况及支架位置。低年资医师主刀手术时有高年资医师旁边监督指导，确保手术安全。

2.4. 观察指标

对比两组手术情况，包括手术用时、术中失血量、住院天数。对比两组术后随访时的SFR，以结石残屑 ≤ 3 mm为清除成功。

2.5. 统计学方法

采用SPSS23.0统计学软件处理数据。计量资料以均数 ± 标准差(x±s)表示，采用独立样本t检验；计数资料采用频数和百分百(%)表示，采用χ²检验。P < 0.05表示差异有统计学意义。

3. 结果

139例手术均顺利完成，两组在术中出血量、手术时间、住院时间上比较无统计学差异(t = 1.183, 0.499, −1.448, p = 0.068, 0.063, 0.119)。术后拔双J管时随访均达到了满意的SFR。术后第1天复查血WBC计数(6.84 ± 2.41) × 10^9/L，与术前比较差异有统计学意义(t = 1.127, p < 0.05)，两组术后WBC计数比较差异无统计学差异(t = 0.925, p = 0.128)；PCT (1.27 ± 0.83) ng/ml，与术前比较差异有统计学意义(t = 1.112, p < 0.05)，两组术后PCT比较差异无统计学差异(t = 0.964, p = 0.923)。见表2。

Table 2 Intraoperative blood loss, operation time and postoperative hospital stay of the two group

组别	A组	B组	t	P值
术中出血量(ml)	51.90 ± 24.83	43.50 ± 20.33	1.183	0.068
手术时间(min)	89.05 ± 25.96	84.25 ± 35.20	0.499	0.063
住院时间(d)	6.05 ± 2.04	7.15 ± 2.80	−1.448	0.119
结石清除率(SFR)	100%	100%	-	-
术后WBC计数(×10^9/L)	6.12 ± 2.63	5.98 ± 2.34	0.925	0.128
术后PTC (ng/ml)	1.23 ± 0.58	1.19 ± 0.67	0.964	0.923

表2. 两组患者术中出血量、手术时间以及术后住院时间

4. 讨论

随着近年科技的进步、腔内技术的发展及手术器械的改进，开放手术逐渐被抛弃，微创治疗手段成为一种趋势，包括体外碎石(ESWL)、经皮肾镜取石(PCNL)，输尿管镜碎石(URSL)，后腹腔镜输尿管切开取石(RLUL)。对于较大的结石及崁顿结石，ESWL效果不尽人意。PCNL及RLUL相对于URSL创伤较大。但URSL对于上尿路结石有局限性。随着光学技术及电子技术的发展，软镜技术由于其可弯曲性及延展性，使得其具备高清石率、微创性等特点备受关注及应用，被欧洲泌尿外科协会指南等广泛推荐 [1] [5]。

输尿管软镜钬激光碎石术(RIRS)的临床适应症主要包括：1) 输尿管上段结石；2) ESWL失败或术后残余的结石；3) 不适合采取ESWL、PCNL的直径小于20 MM的肾结石；4) 特殊类型的肾结石，如肾盏憩室内结石、肾下盏结石、合并肾盂旁囊肿的肾结石；5) 特殊类型的患者，如肥胖、严重脊柱畸形等。有学者研究发现，PCNL后残留的结石也可采用输尿管软镜处理 [6] [7]。在处理大于20 mm的上尿路结石时，在综合分析患者结石的直径大小、部位和集合系统的解剖结构等因素后采取输尿管软镜的疗效与经皮肾镜相当 [8]。本文统计了一例30 mm结石行输尿管软镜碎石，由低年资医师独立完成，虽然手术时间较长(超过2小时)，但术中患者生命体征平稳，术中术后均未发生严重并发症如：尿源性脓毒血症、出血等。术后复查结石基本已粉末化，效果较好。当然结石负荷较大碎石后结石颗粒也越多，术后排石时间较长，这种情况下术后是否放双J管、放多大双J管，放置多长时间值得进一步研究。特别是对于合并有感染的情况。本文统计了一例这种情况病例，软镜碎石术后持续发热，术后3天再次手术拔双J管，发现较多结石颗粒及脓苔堵在上尿路，取出部分结石颗粒及脓苔后未再次放入双J管，再次术后患者自行排出较多结石颗粒，体温恢复正常。输尿管软镜经自然腔道进入，可重复性强，不需要特殊设备辅助，初学者易于掌握。输尿管软镜对于特殊人群如：儿童、妊娠期妇女、双侧上尿路结石、异位肾结石、马碲肾结石、孤立肾结石、过度肥胖等患者有较好的安全性及微创的优势 [4]。输尿管软镜碎石主要风险包括感染、出血、输尿管石街形成、输尿管损伤等。严重的感染包括尿源性脓毒血症、感染性休克等。输尿管损伤较为严重，包括输尿管黏膜损伤、撕脱，以及输尿管穿孔等，多是由于输尿管输送鞘的置入或暴力进镜或退镜所致 [6]。本文统计了一例输尿管部分撕脱病例，由高年资医师行输尿管软镜碎石，进输尿管输送鞘的时候发生，后直接中止手术，放双J管，1个月后再次输尿管镜检发现输尿管损伤处已经愈合。

由于新冠疫情形势下医务人员特殊性(可能因为人手不够、隔离的需要等等)，因此需要各级医师掌握RIRS技术以备平时和“战时”需要。但输尿管软镜购置价格昂贵，维修成本高，操作不当容易损坏。而且输尿管软镜钬激光碎石取石术操作复杂、手法精细，需要肩关节、肘关节、腕关节和拇指的协调配合并进行不断的微调来调整角度，无疑延长输尿管软镜的学习曲线。国外Komori M等学者研究发现为减少严重并发症的发生，需要进行100例左右的手术 [9]。Botoca M等学者认为需要至少50例才达到满意的技能 [10]。国内有学者研究发现术者跨越其学习曲线达到熟练操作约需积累24例手术 [11]。本文研究发现早期我们使用输尿管软镜碎石的手术时间普遍较长。近一年来，特别是随着一次性输尿管软镜的引进，手术时间明显缩短。而且无论高年资医师还是低年资医师均能较好地掌握手术技巧，顺利完成手术。Pallauf M等学者研究发现无论低年资住院医师还是高年资医师，使用一次性输尿管软镜行碎石手术，在手术并发症、结石清除率，残石率等方面无统计学差异 [4]。所以输尿管软镜适合逐步向基层推广，更加方便了病患就医，进一步保障了分级诊疗政策的落实。

文章引用

张劲松,柳琦,董铮,万典,张长升. 不同年资医生行输尿管软镜钬激光碎石术的疗效分析Analysis of Curative Effect of Flexible Ureteroscope Holmium Laser Lithotripsy Performed by Doctors with Different Seniority[J]. 外科, 2022, 11(04): 111-116. https://doi.org/10.12677/HJS.2022.114019

参考文献

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