微创与标准通道经皮肾镜治疗肾结石合并肾功能不全的对比研究

doi:10.3877/cma.j.issn.1674-3253.2023.05.009

目的

比较微创经皮肾镜碎石取石术（MPCNL）与标准通道经皮肾镜碎石取石术（SPCNL）治疗肾结石合并肾功能不全的临床疗效。

方法

回顾性分析广东医科大学附属中山市人民医院2018年1月至2022年3月193例肾结石合并肾功能不全行经皮肾镜碎石取石术（PCNL）患者资料，其中MPCNL117例，SPCNL76例，比较两组患者的净石率（SFR）、肾功能变化、手术时间、输血率、并发症发生率等。

结果

两组患者人口学资料差异无统计学意义（P>0.05）。MPCNL组净石率为72.6%，SPCNL组为69.7%，两组差异无统计学意义（P>0.05）。MPCNL组输血率明显低于SPCNL组（7.7%vs 19.7%，P=0.013）。两组患者术后1个月复查肾功能均较术前有明显好转（P<0.05），两组肾功能改变量相比差异无统计学意义（P>0.05）。两组Clavien-Dindo分级并发症差异无统计学意义（P>0.05）。根据慢性肾脏病（CKD）分期不同将患者分为CKD3和CKD4两组，两组SFR及术后Clavien-Dindo分级并发症发生率差异均无统计学意义（P>0.05）。

结论

MPCNL和SPCNL对肾结石合并肾功能不全患者的治疗均有较高的SFR，总体肾功能均有明显改善，此外，MPCNL输血率更低，住院时间更短。对于肾结石合并肾功能不全患者，特别是CKD3及CKD4期患者，MPCNL可能是更好的治疗方法。

关键词: 肾功能不全, 肾结石, 经皮肾镜, 序贯器官衰竭评分, 慢性肾脏病

Objective

To compare the clinical efficacy of mini-percutaneous nephrolithotomy (MPCNL) and standard percutaneous nephrolithotomy(SPCNL) in the treatment of renal calculi with renal insufficiency.

Methods

The data of 193 patients with renal calculi and renal insufficiency who underwent percutaneous nephrolithotomy (PCNL) in Zhongshan People's Hospital Affiliated to Guangdong Medical University from January 2018 to March 2022 were retrospectively analyzed. The stone free rate(SFR), renal function, operation time, blood transfusion rate and complication rate of the two groups, including 117 cases of MPCNL and 76 cases of SPCNL were compared.

Results

There was no significant difference in demographic data between the two groups (P>0.05). The SFR was 72.6% in MPCNL group and 69.7% in SPCNL group, there was no significant difference in SFR between the two groups (P>0.05). The transfusion rate in MPCNL group was significantly lower than that in SPCNL group (7.7% vs 19.7%, P=0.013). The renal function of the two groups was significantly improved at 1 month after operation (P<0.05), but there was no significant difference in the change of renal function between the two groups (P>0.05). There was no significant difference in complications of Clavien-Dindo classification between the two groups (P>0.05). Patients were divided into two groups, CKD3 and CKD4, according to the different stages of CKD. The differences in SFR and postoperative Clavien-Dindo classification complication rates between the two groups were not statistically significant.

Conclusions

MPCNL and SPCNL have good effect in the treatment of patients with renal calculi and renal insufficiency, both have high SFR, and the overall renal function is significantly improved. In addition, MPCNL has lower transfusion rate and shorter hospital stay. MPCNL may be a better treatment for patients with renal calculi and renal insufficiency, especially in patients with CKD3 and CKD4.

Key words: Renal insufficiency, Renal calculi, PCNL, SOFA, CKD

表1 两组肾结石患者术前一般资料比较

组别	例数	年龄[岁，(±s)]	性别（例）		结石直径[mm，(±s)]	结石数目（例）		结石CT值[Hu，(±s)]	术前尿培养阳性（例）
组别	例数	年龄[岁，(±s)]	男	女	结石直径[mm，(±s)]	1枚	≥2枚	结石CT值[Hu，(±s)]	术前尿培养阳性（例）
微创PCNL(MPCNL)组	117	58±10	82	35	44±21	15	102	1032±386	13
标准通道PCNL(SPCNL)组	76	55±13	56	20	40±21	16	60	997±390	5
统计值		t=1.957	χ²=0.293		t=1.151	χ²=2.316		t=0.616	χ²=1.119
P值		0.052	0.588		0.251	0.128		0.539	0.290
组别	术前血红蛋白浓度(g/L)	术前血白细胞计数(×10⁹/L)	术前eGFR（ml/min/1.73m²）	肾积水程度（例）
组别	术前血红蛋白浓度(g/L)	术前血白细胞计数(×10⁹/L)	术前eGFR（ml/min/1.73m²）	无	轻	中	重
微创PCNL(MPCNL)组	123±22	8.1±2.6	38±25	42	46	16	13
标准通道PCNL(SPCNL)组	126±24	8.3±2.8	39±14	19	25	18	14
统计值	t=-0.688	t=-0.373	t=-0.329	χ²=6.627
P值	0.492	0.709	0.742	0.085

表1 两组肾结石患者术前一般资料比较

组别	例数	年龄[岁，(±s)]	性别（例）		结石直径[mm，(±s)]	结石数目（例）		结石CT值[Hu，(±s)]	术前尿培养阳性（例）
组别	例数	年龄[岁，(±s)]	男	女	结石直径[mm，(±s)]	1枚	≥2枚	结石CT值[Hu，(±s)]	术前尿培养阳性（例）
微创PCNL(MPCNL)组	117	58±10	82	35	44±21	15	102	1032±386	13
标准通道PCNL(SPCNL)组	76	55±13	56	20	40±21	16	60	997±390	5
统计值		t=1.957	χ²=0.293		t=1.151	χ²=2.316		t=0.616	χ²=1.119
P值		0.052	0.588		0.251	0.128		0.539	0.290
组别	术前血红蛋白浓度(g/L)	术前血白细胞计数(×10⁹/L)	术前eGFR（ml/min/1.73m²）	肾积水程度（例）
组别	术前血红蛋白浓度(g/L)	术前血白细胞计数(×10⁹/L)	术前eGFR（ml/min/1.73m²）	无	轻	中	重
微创PCNL(MPCNL)组	123±22	8.1±2.6	38±25	42	46	16	13
标准通道PCNL(SPCNL)组	126±24	8.3±2.8	39±14	19	25	18	14
统计值	t=-0.688	t=-0.373	t=-0.329	χ²=6.627
P值	0.492	0.709	0.742	0.085

表2 两组肾结石患者术后临床资料比较

组别	例数	结石取净(例)	输血(例)	栓塞(例)	血红蛋白下降量[g/L，M(Q)]	手术时间[min，(±s)]	术后住院时间[d，(±s)]
MPCNL组	117	85	8	2	9.50(2.25，17.00)	93±42	6.92±3.80
SPCNL组	76	53	15	3	7.00(0.00，15.00)	86±43	9.16±4.16
统计值		χ² =0.192	χ² =7.303	-	Z=-1.422	t=1.135	t=-3.772
P值		0.661	0.007	0.384	0.155	0.258	<0.001
组别	发热≥38℃(例)	感染性休克(例)	并发症（Clavien-Dindo）(例)
组别	发热≥38℃(例)	感染性休克(例)	Ⅰ	Ⅱ	Ⅲa	Ⅲb	Ⅳa	Ⅳb
MPCNL组	10	3	19	10	1	2	3	0
SPCNL组	5	1	9	15	1	4	0	1
统计值	χ² =0.249	-	χ²=0.696
P值	0.618	1.000	0.058

表2 两组肾结石患者术后临床资料比较

组别	例数	结石取净(例)	输血(例)	栓塞(例)	血红蛋白下降量[g/L，M(Q)]	手术时间[min，(±s)]	术后住院时间[d，(±s)]
MPCNL组	117	85	8	2	9.50(2.25，17.00)	93±42	6.92±3.80
SPCNL组	76	53	15	3	7.00(0.00，15.00)	86±43	9.16±4.16
统计值		χ² =0.192	χ² =7.303	-	Z=-1.422	t=1.135	t=-3.772
P值		0.661	0.007	0.384	0.155	0.258	<0.001
组别	发热≥38℃(例)	感染性休克(例)	并发症（Clavien-Dindo）(例)
组别	发热≥38℃(例)	感染性休克(例)	Ⅰ	Ⅱ	Ⅲa	Ⅲb	Ⅳa	Ⅳb
MPCNL组	10	3	19	10	1	2	3	0
SPCNL组	5	1	9	15	1	4	0	1
统计值	χ² =0.249	-	χ²=0.696
P值	0.618	1.000	0.058

表3 两组肾结石患者术后肾功能改变情况(±s)

组别	例数	术前eGFR(ml/min/1.73m²)	术后30 d eGFR(ml/min/1.73m²)
MPCNL组	117	38±25	48±26
SPCNL组	76	39±14	52±27
t值		-0.329	-0.989
P值		0.742	0.324

表3 两组肾结石患者术后肾功能改变情况(±s)

组别	例数	术前eGFR(ml/min/1.73m²)	术后30 d eGFR(ml/min/1.73m²)
MPCNL组	117	38±25	48±26
SPCNL组	76	39±14	52±27
t值		-0.329	-0.989
P值		0.742	0.324

表4 不同慢性肾脏病(CKD)分期患者术后净石率及并发症情况

组别		例数	结石取净(例)	并发症（Clavien-Dindo）(例)
组别		例数	结石取净(例)	Ⅰ	Ⅱ	Ⅲa	Ⅲb	Ⅳa	Ⅳb
MPCNL组	CKD3	78	60	8	5	1	2	2	0
MPCNL组	CKD4	39	25	11	5	0	0	1	0
统计值			χ²=2.151	-
P值			0.143	0.064
SPCNL组	CKD3	55	39	8	8	1	4	0	0
SPCNL组	CKD4	21	14	2	6	0	0	0	1
统计值			χ²=0.130	-
P值			0.719	0.304

表4 不同慢性肾脏病(CKD)分期患者术后净石率及并发症情况

组别		例数	结石取净(例)	并发症（Clavien-Dindo）(例)
组别		例数	结石取净(例)	Ⅰ	Ⅱ	Ⅲa	Ⅲb	Ⅳa	Ⅳb
MPCNL组	CKD3	78	60	8	5	1	2	2	0
MPCNL组	CKD4	39	25	11	5	0	0	1	0
统计值			χ²=2.151	-
P值			0.143	0.064
SPCNL组	CKD3	55	39	8	8	1	4	0	0
SPCNL组	CKD4	21	14	2	6	0	0	0	1
统计值			χ²=0.130	-
P值			0.719	0.304

表5 两组肾结石患者术后1个月慢性肾脏病(CKD)分期变化情况

组别	术前CKD分期	例数	术后1月CKD分期[例(%)]
组别	术前CKD分期	例数	1~2	3	4	5
MPCNL组	3	78	33(42.3)	37(47.4)	7(9.0)	1(1.3)
MPCNL组	4	39	7(17.9)	7(17.9)	23(59.0)	2(5.1)
SPCNL组	3	55	24(43.6)	29(52.7)	2(3.6)	0(0.0)
SPCNL组	4	21	1(4.8)	8(38.1)	12(57.1)	0(0.0)

表5 两组肾结石患者术后1个月慢性肾脏病(CKD)分期变化情况

组别	术前CKD分期	例数	术后1月CKD分期[例(%)]
组别	术前CKD分期	例数	1~2	3	4	5
MPCNL组	3	78	33(42.3)	37(47.4)	7(9.0)	1(1.3)
MPCNL组	4	39	7(17.9)	7(17.9)	23(59.0)	2(5.1)
SPCNL组	3	55	24(43.6)	29(52.7)	2(3.6)	0(0.0)
SPCNL组	4	21	1(4.8)	8(38.1)	12(57.1)	0(0.0)

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Comparison of mini-percutaneous nephrolithotomy and standard percutaneous nephrolithotomy in the treatment of renal calculi with renal insufficiency

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Comparison of mini-percutaneous nephrolithotomy and standard percutaneous nephrolithotomy in the treatment of renal calculi with renal insufficiency