妊娠期输尿管结石的处理与转归

doi:10.3877/cma.j.issn.1674-3253.2023.04.013

目的

探讨妊娠期输尿管结石的处理方法，并观察其术后转归情况。

方法

2017年7月至2021年2月，广州医科大学附属第一医院共收治204例妊娠合并输尿管结石患者。入院后均给予保守治疗，保守治疗症状无明显改善或者符合外科手术治疗指征者采用外科手术（输尿管镜检、输尿管镜碎石取石和肾造瘘）治疗，治疗前后均采用视觉模拟评分（VAS）评估患者疼痛情况。所有患者随访1年，记录患者的处理与转归情况。

结果

经保守治疗后83例症状缓解，产后复查显示结石排出82例，需输尿管镜碎石1例。121例外科手术治疗患者均症状缓解，其中109例结石排净，12例结石残留，产后需输尿管镜碎石9例，辅助体外碎石3例。204例患者治疗后症状和肾积水均缓解，199例分娩出正常胎儿，流产5例。随访1年，母婴均未发现明显异常，其中2例伴有肾功能不全患者经外科手术治疗后肾功能恢复正常。采用保守治疗的患者治疗后VAS评分为（1.84±0.37）分，低于其治疗前VAS评分（6.85±0.94）分（P<0.001）。采用外科手术治疗的患者治疗后VAS评分为（1.05±0.25）分，低于其治疗前VAS评分（6.89±0.96）分（P<0.001）。

结论

保守治疗是妊娠期输尿管结石患者的首选治疗方式，但对于保守治疗效果不佳的患者，宜尽早外科手术干预，输尿管镜取石术、输尿管置管或肾造瘘引流治疗同样安全有效。

关键词: 妊娠期, 输尿管结石, 保守治疗, 输尿管镜检术, 输尿管镜碎石取石术, 肾造瘘, 术后转归

Objective

To explore the management of ureteral calculi in pregnancy, and to observe the postoperative outcomes.

Methods

204 pregnant patients with ureteral calculi were admitted to the First Affiliated Hospital of Guangzhou Medical University from July 2017 to February 2021. Conservative treatment was administrated after admission, if symptoms had no obvious improvement, or indications of operation was noted, patitens got a surgical management, such as ureteroscopy, ureteroscopic lithotripsy and nephrostomy. Visual analog scale (VAS) was used to evaluate the pain before and after treatment. All patients were followed up for 1 year, the treatment and outcomes were recorded.

Results

The symptoms were relieved after conservative treatment in 83 cases. 82 cases were stone free in postpartum review, and 1 case required ureteroscopic lithotripsy. 121 patients received surgical treatment and the symptoms were relieved, of which 109 cases were stone free, 9 cases required ureteroscopic lithotripsy after delivery, and 3 cases received auxiliary extracorporeal lithotripsy. Symptoms and hydronephrosis were all relived in all 204 cases, 199 cases delivered normal fetus , abortion was noted in 5 cases. In one-year follow-up, no obvious abnormality was found in mother and infant. Renal insufficiency restored to normal after surgical treatment in 2 patients. The VAS score of patients who adopted conservative treatment after treatment was (1.84±0.37), which was lower than that (6.85±0.94) before treatment (P<0.001). The VAS score of surgical patients after treatment was (1.05±0.25), which was lower than that (6.89±0.96) before treatment (P<0.001).

Conclusions

Conservative treatment is the first choice for ureteral calculi in pregnancy. However, surgical treatment is reqiured in patients with poor response to conservative treatment, uroteroscopic lithotripsy, ureteral stenting or percutaneous nephrostomy are also safe and effective.

Key words: Pregnancy, Ureteral calculi, Conservative treatment, Ureteroscopy, Ureteroscopic lithotripsy, Nephrostomy, Postoperative outcomes

表1 妊娠期输尿管结石患者的临床特征(例)

临床特征	保守治疗（n=83）	手术治疗（n=121）	合计（n=204）
年龄
< 25岁	15	12	27
25~34岁	53	91	1440
≥35岁	15	18	33
孕期
早孕	17	10	27
中孕	42	80	1220
晚孕	24	31	55
孕产史
初产	34	48	82
经产	49	73	1220
症状
腰腹痛	83	1210	2040
恶心	57	88	1450
呕吐	29	52	81
发热	01	12	13
肉眼血尿	05	04	09
尿路刺激征	14	17	31
实验室检查
血白细胞>10×10⁹/L	46	72	1180
镜下脓尿	31	69	1000
镜下血尿	63	99	1620
彩超肾盂积水程度
轻度积水	83	1180	2010
中度积水	00	02	02
重度积水	00	01	01
结石部位
左输尿管	44	64	1080
右输尿管	36	55	91
双侧输尿管	03	02	05
输尿管上段	33	61	94
输尿管中段	05	11	16
输尿管下段	45	49	94
结石长径大小
<6 mm	48	40	88
6~10 mm	28	49	77
>10 mm	07	32	39
结石横径大小
<6 mm	75	98	1730
6~10 mm	08	23	31
合并症
急性肾盂肾炎	00	08	08
肾积脓	00	03	03
急性肾功能不全	00	02	02
脓毒性休克	00	02	02

表1 妊娠期输尿管结石患者的临床特征(例)

临床特征	保守治疗（n=83）	手术治疗（n=121）	合计（n=204）
年龄
< 25岁	15	12	27
25~34岁	53	91	1440
≥35岁	15	18	33
孕期
早孕	17	10	27
中孕	42	80	1220
晚孕	24	31	55
孕产史
初产	34	48	82
经产	49	73	1220
症状
腰腹痛	83	1210	2040
恶心	57	88	1450
呕吐	29	52	81
发热	01	12	13
肉眼血尿	05	04	09
尿路刺激征	14	17	31
实验室检查
血白细胞>10×10⁹/L	46	72	1180
镜下脓尿	31	69	1000
镜下血尿	63	99	1620
彩超肾盂积水程度
轻度积水	83	1180	2010
中度积水	00	02	02
重度积水	00	01	01
结石部位
左输尿管	44	64	1080
右输尿管	36	55	91
双侧输尿管	03	02	05
输尿管上段	33	61	94
输尿管中段	05	11	16
输尿管下段	45	49	94
结石长径大小
<6 mm	48	40	88
6~10 mm	28	49	77
>10 mm	07	32	39
结石横径大小
<6 mm	75	98	1730
6~10 mm	08	23	31
合并症
急性肾盂肾炎	00	08	08
肾积脓	00	03	03
急性肾功能不全	00	02	02
脓毒性休克	00	02	02

图1 妊娠期输尿管结石处理流程图

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Management and outcome of ureteral calculi in pregnancy

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Management and outcome of ureteral calculi in pregnancy