張義楊嗣星宋超廖文彪劉凌琪
?
軟性輸尿管鏡鈥激光碎石術后雙J管放置時間的單中心隨機對照研究
張義1楊嗣星1宋超1廖文彪1劉凌琪1
1武漢大學人民醫(yī)院泌尿外科430060武漢
通信作者:楊嗣星,sxyang2004@ 163.com
收稿日期:2016-05-02
目的:探討軟性輸尿管鏡鈥激光碎石術后雙J管的最佳留置時間。方法:采用隨機對照的方法,選取248例腎結石患者,結石大小為(12.0±2.15)mm。所有患者均于術前留置雙J管被動擴張輸尿管2周后采用軟性輸尿管鏡鈥激光碎石術,術后常規(guī)留置F7號雙J管。其中121例作為實驗組,術后2周拔除雙J管;127例作為對照組,術后4周拔除雙J管。所有患者均于拔管后2周行泌尿系CT平掃檢查,了解清石率。同時記錄患者術后并發(fā)癥的發(fā)生情況。結果:實驗組的清石率為89.26%(108/ 121),對照組的清石率為88.19%(112/127),兩組間清石率比較差異無統(tǒng)計學意義(P<0.05)。統(tǒng)計學研究發(fā)現(xiàn),兩組患者術后出現(xiàn)肉眼血尿、小腹脹痛、腰部脹痛等并發(fā)癥差異無統(tǒng)計學意義(P>0.05),對照組術后出現(xiàn)尿路感染,膀胱刺激癥狀均明顯高于實驗組(P<0.05)。結論:軟性輸尿管鏡術后2周和4周拔出雙J管,清石率雖無明顯差異,但雙J管留置4周會明顯增加術后泌尿系感染和膀胱刺激癥狀的發(fā)生率。
軟性輸尿管鏡;鈥激光碎石;排石;雙J管留置時間
軟性輸尿管鏡鈥激光碎石術目前已經(jīng)成為治療<2 cm腎結石的一線治療方法之一,其具有創(chuàng)傷小、安全性高、住院時間短和結石清除率高等特點[1]。對于術后是否常規(guī)留置雙J管存在爭論。一些學者認為,術后常規(guī)留置雙J管并不能提高清石率,也不能降低感染及發(fā)熱的風險,他們建議對于術中結石已完全清除、又無明顯損傷的病例,可不留置雙J管[2~5]。但軟性輸尿管鏡碎石術中操作易引起輸尿管黏膜水腫,術后無支架管引流,常常引起腎絞痛等,同時術后結石碎屑排出容易形成石街以及引起腎絞痛。因此,一些研究者認為軟性輸尿管鏡術后應常規(guī)留置內(nèi)支架[6]。國內(nèi)軟性輸尿管鏡鈥激光碎石術常規(guī)留置雙J管,但至今沒有文獻報道術后雙J管應放置多長時間。因此,我們采用單中心隨機對照的方法,選取248例腎結石患者,探討軟性輸尿管鏡碎石術后雙J管最佳留置時間。
1.1臨床資料
所選患者納入標準:①所有結石直徑均<2.0 cm;②所選患者結石部位均較單純,無多發(fā)、復雜的結石存在,無下組腎盞結石存在。排除標準有:①術中明顯有輸尿管損傷,如輸尿管穿孔、撕裂患者;②有糖尿病史;③既往有泌尿系手術病史或存在泌尿系解剖學畸形;④息肉包裹結石至輸尿管明顯狹窄患者。所有患者均于術前留置雙J管被動擴張輸尿管2周。本研究共納入患者248例,其中男119例,女129例,年齡22~74歲,平均48歲,結石平均大小為1.2 cm。
1.2手術方法
1.2.1儀器設備
電子軟性輸尿管鏡(Olympus URF-V),先端部外徑F8.5,插入部外徑F9.9,工作通道內(nèi)徑F3.6,主動彎曲性能(向上180°/向下275°)。美國科醫(yī)人鈥激光治療機,鈥激光光纖直徑為200μm,Olympus電視監(jiān)視系統(tǒng)。
1.2.2手術方法
患者在氣管插管全身麻醉后取截石位,先用輸尿管硬鏡取出術前留置的雙J管,探查患側輸尿管,確定輸尿管內(nèi)無明顯迂曲狹窄等輸尿管病變,并上行至腎盂,置入斑馬導絲,退出輸尿管硬鏡。然后沿斑馬導絲將軟性輸尿管鏡送達鞘插入輸尿管,退出導絲和鞘的內(nèi)芯,將軟性輸尿管鏡沿鞘置入輸尿管上段。調整鏡鞘的位置,順利進入腎盂及腎盞,并尋找到結石,使用直徑200μm鈥激光光纖碎石(美國科醫(yī)人),鈥激光參數(shù)通常選擇頻率為0.8~1.2 J,能量為20~30 Hz,術中根據(jù)情況調整。術中若發(fā)現(xiàn)目標腎盞頸口有狹窄,均利用鈥激光適當切開盞頸口再行碎石。結石粉碎至最大直徑<3 mm碎片,以便結石排出,較大的結石采用套石籃取出。術后輸尿管內(nèi)常規(guī)留置F7號雙J管(美國巴德公司)。
1.2.3分組及方法
按照隨機對照表分組。其中121例作為實驗組,術后2周拔除雙J管,127例作為對照組,術后4周拔除雙J管。兩組患者資料見表1。兩組患者術后均采用局部麻醉下經(jīng)尿道膀胱鏡內(nèi)拔除雙J管,均于拔管后2周行泌尿系CT平掃,了解清石率。
1.3統(tǒng)計學方法
采用SPSS 17.0軟件進行統(tǒng)計分析。計量資料用t檢驗,計數(shù)資料用卡方檢驗。P<0.05為差異有統(tǒng)計學意義。
表1 兩組患者一般資料比較
兩組患者在年齡(t=15.173)、性別(χ2= 0.012 5)、體質指數(shù)(t=1.545)、結石大?。╰= 0.458)及手術時間(t=1.305)方面均差異無統(tǒng)計學意義(P>0.05)。實驗組的清石率為89.26%(108/121),對照組的清石率為88.19%(112/ 127),實驗組和對照組的清石率比較差異無統(tǒng)計學意義(t=0.004 19,P=0.791)。統(tǒng)計學研究表明,實驗組和對照組在術后并發(fā)肉眼血尿(χ2= 0.118)、小腹脹痛(χ2=0.0378)以及腰部脹痛(χ2=0.000 151)等方面差異無統(tǒng)計學意義(P>0.05),而對照組在術后并發(fā)尿路感染(χ2= 7.714)和膀胱刺激癥狀(χ2=8.419)均明顯高于實驗組(P<0.05)(表2)。
表2 兩組患者留置雙J管相關并發(fā)癥比較
軟性輸尿管鏡鈥激光碎石術是目前治療腎結石的常用方法之一,術后是否需要放置雙J管及雙J管的留置時間仍有爭論。早期Tawfiek等[7]建議輸尿管鏡術后均放置雙J管,以減少術后輸尿管梗阻及狹窄。但Hosking等[8]對此提出質疑,他們觀察發(fā)現(xiàn),輸尿管鏡術中若無輸尿管損傷,可不留置雙J管;但Hollenbeck等[9]總結了266例未放置雙J管的病例發(fā)現(xiàn),未放置雙J管會明顯增加術后并發(fā)癥的發(fā)生;Wong等[10]在輸尿管手術后常規(guī)不放置上雙J管。而國內(nèi)大部分臨床工作者在輸尿管鏡術后建議留置雙J管。我們在臨床工作中也發(fā)現(xiàn),未放置雙J管的患者更容易發(fā)生腎絞痛、發(fā)熱、輸尿管梗阻、狹窄等。此外,留置雙J管可以被動擴張輸尿管,促進碎石排出[11]。但術后雙J管的留置時間仍有爭論。
Torricelli等[12]建議軟性輸尿管鏡術中若無明顯輸尿管損傷,術后3~7 d可拔除雙J管,但輸尿管是否有損傷難以完全確認,且其術后發(fā)熱及腰痛的概率明顯增加;Atis等[13]建議軟性輸尿管鏡術后2周拔除雙J管,在處理小于2 cm結石時清石率高達92.3%,術后主要并發(fā)癥為泌尿系感染,無輸尿管梗阻及狹窄等并發(fā)癥;Cheng等[14]建議術后3~5周拔出雙J管;Damiano等[15]建議術后雙J管留置4周,但報道術后并發(fā)癥較多。我們的研究發(fā)現(xiàn),軟性輸尿管鏡碎石術后雙J管放置2周和4周,其清石率無明顯差別,但放置4周會明顯增加術后并發(fā)癥。
臨床上,留置雙J管后常見的并發(fā)癥包括肉眼血尿、膀胱刺激癥狀、腰部脹痛、小腹脹痛、泌尿系感染等。Joshi等[16]報道放置雙J管后大多數(shù)患者有尿路刺激癥狀,嚴重影響患者的生活質量;Damiano等[11]報道雙J管留置4周內(nèi)的并發(fā)癥除上述以外還包括:發(fā)熱,腎積水,支架移位,結殼,支架斷裂和破損。我們的研究證實,術后2周和4周拔除雙J管,肉眼血尿、腰部脹痛及小腹脹痛等并發(fā)癥的發(fā)生率無明顯差異,但術后4周拔除雙J管,泌尿系感染和膀胱刺激癥狀的發(fā)生率明顯增高,主要原因是雙J管作為一種異物存在于體內(nèi)刺激膀胱黏膜且很容易被病原體黏附;研究表明:支架管表面形成可形成細菌生物膜導致泌尿道感染及嚴重的敗血癥,同時尿液的反流可導致反流性腎盂腎炎等[17]。
輸尿管鏡術后放置雙J管對預防術后輸尿管狹窄有重要的意義。Clavica等[18]通過動物實驗發(fā)現(xiàn),留置雙管后尿液主要是通過導管周圍引流入膀胱,在置管后1周輸尿管就被動擴張。查澤玉[19]的動物實驗表明,輸尿管內(nèi)留置雙J管3 d即可達到擴張輸尿管目的,輸尿管內(nèi)留置雙J管10 d后輸尿管水腫完全消失,炎癥反應輕微,因此,術后雙J管留置2周后,此時輸尿管的炎性水腫基本消退,黏膜也完全修復,同時輸尿管擴張明顯,此時輸尿管條件良好,沒有必要推遲至術后4周拔管。我們建議術后拔管時間不宜過早,以14 d左右為宜,可在維持雙J管支架引流效果情況下,使置管相關并發(fā)癥發(fā)生率最低。當然,本研究的不足之處是樣本量太小,后續(xù)大樣本的研究仍需進行。
綜上所述,軟性輸尿管鏡鈥激光碎石術后2周拔除雙J管,既能保證碎石的清石率,也能明顯降低泌尿系感染的發(fā)生率。
[1]孫穎浩,那彥群,葉章群.中國泌尿外科疾病診斷治療指南2014版.北京:人民衛(wèi)生出版社,2014:428-429.
[2]Byrne RR,Auge BK,Kourambas J,et al.Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy:a randomized trial.J Endourol,2002,16(1):9-13.
[3]Pengfei S,Yutao L,Jie Y,et al.The results of ureteral stenting after ureteroscopic lithotripsy for ureteral calculi:a systematic review and meta-analysis.J Urol,2011,186(5):1904-1909.
[4]Baseskioglu B,Sofikerim M,Demirtas A,et al.Is ureteral stenting really necessary after ureteroscopic lithotripsy with balloon dilatation of ureteral orifice?A multi-institutional randomized controlled study. World J Urol,2011,29(6):731-736.
[5]Cevik I,Dillioglugil O,Akdas A,et al.Is stent placement necessary after uncomplicated ureteroscopy for removal of impacted ureteral stones?J Endourol,2010,24(8):1263-1267.
[6]Shields JM,Bird VG,Graves R,et al.Impact of preoperative ureteral stenting on outcome of ureteroscopic treatment for urinary lithiasis.J Urol,2009,182(6):2768-2774.
[7]Tawfiek ER,Bagley DH.Management of upper urinary tract calculi with ureteroscopic techniques. Urology,1999,53(1):25-31.
[8]Hosking DH,McColm SE,Smith WE.Is stenting following ureteroscopy for removal of distal ureteral calculi necessary?J Urol,1999,161(1):48-50.
[9]Hollenbeck BK,Schuster TG,Seifman BD,et al. Identifying patients who are suitable for stentless ureteroscopy following treatment of urolithiasis.J Urol,2003,170(1):103-106.
[10]Wong KA,Sahai A,Patel A,et al.Is percutaneous nephrolithotomy in solitary kidneys safe?Urology,2013,82(5):1013-1016.
[11]Damiano R,Autorino R,Esposito C,et al.Stent positioning after ureteroscopy for urinary calculi: the question is still open.Eur Urol,2004,46(3):381-388.
[12]Torricelli FC,De S,Hinck B,et al.Flexible ureteroscopy with a ureteral access sheath:when to stent?Urology,2014,83(2):278-281.
[13]Atis G,Gurbuz C,Arikan O,et al.Retrograde intrarenal surgery for the treatment of renal stones in patients with a solitary kidney.Urology,2013,82(2):290-294.
[14]Cheng F,Yu W,Zhang X,et al.Minimally invasive tract in percutaneous nephrolithotomy for renal stones.J Endourol,2010,24(10):1579-1582.
[15]Damiano R,Oliva A,Esposito C,et al.Early and late complications of double pigtail ureteral stent. Urol Int,2004,69(2):136-140.
[16]Joshi HB,Stainthorpe A,Macdonagh RP,et al.Indwelling ureteral stents:evaluation of symptoms,quality of life and utility.J Urol,2003,169(3):1065-1069.
[17]Riedl CR,Witkowski M,Plas E,et al.Heparin coating reduces encrustation of ureteral stents:a preliminary report.Int J Antimicrob Agents,2002,19(6):507-510.
[18]Clavica F,Zhao X,Elmahdy M,et al.Investigating the flow dynamics in the obstructed and stented ureter by means of a biomimetic artificial model.PLoS One,2014,9(2):e87433.
[19]查澤玉.留置雙J管后分期輸尿管軟鏡手術時機選擇的動物實驗研究.蚌埠醫(yī)學院,2014.
The optimal drainage duration of double J stent after holmium laser lithotripsy under flexible ureteroscopy:A randomized controlled single center study
Zhang Yi1Yang Sixing1Song Chao1Liao Wenbiao1Liu Lingqi1
(1Department of Urology,Renmin Hospital of Wuhan University,Wuhan 430060,China)
Corresponding author:Yang Sixing,sxyang2004@163.com
Objective:To explore the optimal indwelling time of double-J stent after flexible ureteroscopy. Methods:Using randomized controlled methods,248 patients with kidney stones were selected with the diameter of(12.0±2.15)mm.All patients were preseted double J tube to expand the ureter passively for two weeks.Then the renal stones were treated with flexible ureteroscopy and the F7double J stent was placed in the ureter postoperatively.In which,121 patients whose double J stent were removed at 2nd week postoperatively were assigned to experimental group,and 127 patients whose double J stent were removed at 4th week postoperatively were assigned to control group.Computed tomography was done at 2nd week after the double-J stent being removed cystoscopically to assess stone-free rate(SFR).Postoperative complications were recorded.Results:The SFR in the experimental group and control group was 89.26%(108/121)and 88.19%(112/127)respectively(P>0.05). Gross hematuria,abdomen pain,waist pain,urinary tract infection,irritation sign of bladder were recorded in two groups.There was no significant difference in gross hematuria,abdomen pain as well as waist pain between two groups(P>0.05).The incidence of postoperative complications as urinary tract infection and irritation sign of bladder was statistically higher in the control groups than that in the experimental group(P<0.05).Conclusions:The 4-week indwelling of double J stent may increase the incidence of urinary tract infection and irritation sign of bladder as compared with the 2-week indwelling although the SFR showed no statisticall significant difference.
flexible ureteroscopy;holmium laser lithotripsy;stone-free rate;double J tube indwelling time
R691
A
2095-5146(2016)04-199-04
國家自然科學基金項目(31400835)