發(fā)布時(shí)間：2018-05-07 16:25

  本文選題：輸尿管結(jié)石 + 體外沖擊波碎石術(shù)�。� 參考：《第三軍醫(yī)大學(xué)》2014年碩士論文

【摘要】：背景與目的 目前輸尿管結(jié)石的微創(chuàng)治療方式主要有體外沖擊波碎石術(shù)（ESWL）、經(jīng)尿道輸尿管鏡碎石術(shù)（URL）、經(jīng)皮腎鏡碎石取石術(shù)（PCNL）、后腹腔鏡下輸尿管切開(kāi)取石術(shù)（RPLU）等，不同的治療方式對(duì)不同位置的輸尿管結(jié)石的治療各有優(yōu)劣。2007年Cochrane協(xié)作網(wǎng)與美國(guó)泌尿外科協(xié)會(huì)腎結(jié)石治療指南先后對(duì)輸尿管結(jié)石的治療進(jìn)行了系統(tǒng)評(píng)價(jià)。Cochrane協(xié)作網(wǎng)表明URL較ESWL有較高的結(jié)石清除率，但其在并發(fā)癥和住院日方面同樣較高，并且未說(shuō)明結(jié)石所在的位置；美國(guó)泌尿外科協(xié)會(huì)腎結(jié)石治療指南同樣認(rèn)為URL能獲得較高的結(jié)石清除率，且在下段輸尿管結(jié)石更為顯著，但對(duì)于上段輸尿管結(jié)石并未指出有明確優(yōu)勢(shì)的治療方法。因此，國(guó)內(nèi)外對(duì)于不同位置的輸尿管結(jié)石的治療方式的選擇仍存在爭(zhēng)議。本研究擬對(duì)不同位置的輸尿管結(jié)石的微創(chuàng)治療進(jìn)行循證醫(yī)學(xué)研究(系統(tǒng)評(píng)價(jià)與Meta分析)，為輸尿管結(jié)石的微創(chuàng)治療的選擇提供循證醫(yī)學(xué)依據(jù)，同時(shí)通過(guò)隨機(jī)對(duì)照臨床試驗(yàn)，比較PCNL與輸尿管軟鏡（F-URS）對(duì)輸尿管上段結(jié)石的治療效果與安全性，為輸尿管上段結(jié)石的治療提供進(jìn)一步的循證醫(yī)學(xué)證據(jù)。 材料和方法 檢索MEDLINE、EMBASE、Cochrane圖書(shū)館隨機(jī)對(duì)照試驗(yàn)注冊(cè)數(shù)據(jù)庫(kù)(CochraneCentral Register of Controlled Trails, CENTRAL)和中國(guó)生物醫(yī)學(xué)文摘數(shù)據(jù)庫(kù)(CBMDisc)等文摘數(shù)據(jù)庫(kù)，以及PUBMED、相關(guān)期刊論文(CNKI)、維普中文期刊數(shù)據(jù)庫(kù)(CQVIP)等全文數(shù)據(jù)庫(kù)，時(shí)間限制為1995年1月-2012年12月。納入文獻(xiàn)均為對(duì)比不同微創(chuàng)方式治療輸尿管結(jié)石的隨機(jī)對(duì)照試驗(yàn)研究。提取的結(jié)局觀測(cè)指標(biāo)數(shù)據(jù)包括初始結(jié)石清除率、整體結(jié)石清除率、重復(fù)治療率、平均手術(shù)時(shí)間、術(shù)后并發(fā)癥、平均住院日、術(shù)后第一天VAS疼痛評(píng)分等，數(shù)據(jù)采用RevMan5.1軟件進(jìn)行Meta分析。 隨機(jī)對(duì)照臨床試驗(yàn)共納入受試者120例，隨機(jī)分為軟鏡組（F-URS）和微創(chuàng)經(jīng)皮腎鏡組（MPCNL），每組各60例，兩組在年齡、性別、結(jié)石大小等方面無(wú)顯著差別。收集受試者的一般特征及手術(shù)時(shí)間、術(shù)后住院日、術(shù)后第一日視覺(jué)模擬疼痛評(píng)分（VAS）、術(shù)后Hb下降量、結(jié)石清除率、并發(fā)癥發(fā)生率等各項(xiàng)指標(biāo)數(shù)據(jù)。統(tǒng)計(jì)分析采用SPSS16.0軟件，以χ2檢驗(yàn)比較計(jì)數(shù)資料；以兩組獨(dú)立樣本的t檢驗(yàn)比較計(jì)量資料；以Wilcoxon秩和檢驗(yàn)比較偏態(tài)分布數(shù)據(jù)；P＜0.05考慮為有統(tǒng)計(jì)學(xué)差異。 結(jié)果 檢索共獲得文獻(xiàn)612篇，，全面閱讀題目、摘要及全文，根據(jù)事先擬定的文獻(xiàn)納入及排除標(biāo)準(zhǔn)，篩選納入本次Meta分析的文獻(xiàn)共有15篇文獻(xiàn)。其中，6篇文獻(xiàn)描述針對(duì)輸尿管下段結(jié)石，ESWL與URL治療療效的對(duì)比；2篇文獻(xiàn)描述對(duì)輸尿管全段結(jié)石，ESWL與URL治療的療效對(duì)比，文中對(duì)某些觀測(cè)指標(biāo)如結(jié)石清除率分為上段結(jié)石和下段結(jié)石分別描述；3篇文獻(xiàn)描述針對(duì)輸尿管上段結(jié)石，ESWL與URL治療的療效對(duì)比；4篇文獻(xiàn)描述針對(duì)輸尿管上段結(jié)石，URL與PCNL的療效對(duì)比。分析顯示，對(duì)于輸尿管下段結(jié)石，ESWL組較URL組有較低的結(jié)石清除率及較高的重復(fù)治療率(P0.01)，而二者在術(shù)后并發(fā)癥及手術(shù)時(shí)間方面無(wú)顯著差異(P＞0.05)；對(duì)于輸尿管上段結(jié)石，ESWL組與URL組在結(jié)石清除率、術(shù)后并發(fā)癥及重復(fù)治療率方面均無(wú)顯著差異(P＞0.05)，而在平均治療時(shí)間方面ESWL組較URL組短(P0.01)；URL組與PCNL組治療上段結(jié)石的對(duì)比分析顯示PCNL組在結(jié)石清除率方面較URL組高(P0.01)，兩組在術(shù)后并發(fā)癥、平均手術(shù)時(shí)間及重復(fù)治療方面無(wú)顯著差異(P＞0.05)。 輸尿管軟鏡（F-URS）與微創(chuàng)經(jīng)皮腎鏡（MPCNL）治療輸尿管上段結(jié)石的隨機(jī)對(duì)照臨床研究結(jié)果顯示，F(xiàn)-URS組與MPCNL組初始結(jié)石清除率分別為68.33%和95.00%，兩組差異有統(tǒng)計(jì)學(xué)意義（P＜0.05），3月后結(jié)石清除率分別為96.67%和98.33%，兩組差異無(wú)統(tǒng)計(jì)學(xué)意義（P＞0.05）；F-URS組和MPCNL組手術(shù)時(shí)間分別為（35.33±11.57）min和（53.75±17.31）min，術(shù)后住院日分別為（3.05±0.62）d和（5.43±1.84）d，術(shù)后第1天VAS分別為（1.70±1.37）分和（3.68±1.57）分，兩組患者比較差異均有統(tǒng)計(jì)學(xué)意義（P＜0.05）；兩組患者術(shù)后血紅蛋白（Hb）下降量及并發(fā)癥發(fā)生率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義（P＞0.05）。 結(jié)論 通過(guò)對(duì)輸尿管結(jié)石微創(chuàng)治療的系統(tǒng)評(píng)價(jià)我們認(rèn)為對(duì)于輸尿管下段結(jié)石的治療，與ESWL相比，URL具有結(jié)石清除率高及重復(fù)治療率低等優(yōu)點(diǎn)，值得推薦；而隨機(jī)對(duì)照試驗(yàn)研究結(jié)果則表明，對(duì)于輸尿管上段結(jié)石，在結(jié)石清除率方面F-URS與MPCNL療效相當(dāng)，且F-URS與MPCNL相比安全性更高、術(shù)后住院日更短，在有條件開(kāi)展F-URS的科室應(yīng)列為首選治療方法。
[Abstract]:Background and Purpose

Ureteroscopic lithotripsy ( URL ) , percutaneous nephrolithotripsy ( PCNL ) and retroperitoneal laparoscopic ureterotomy ( RPLU ) were used to evaluate the treatment of ureteral calculi .
In the same time , there is still a dispute about the treatment of ureteral calculi at different locations .

Materials and Methods

All - text databases , including initial stone clearance , total stone clearance , repeat treatment rate , average operation time , postoperative complications , mean hospital day and VAS pain score on the first day of operation , were searched . The data were analyzed by RevMan5.1 software .

120 patients were randomly divided into soft lens group ( F - URS ) and minimally invasive percutaneous nephroscope group ( MPC NL ) .
comparing the measured data with the t - test of the two groups of independent samples ;
comparing partial bias distribution data with Wilcoxon rank sum test ;
P & lt ; 0.05 was considered to be statistically different .

Results

A total of 612 articles were retrieved , fully read the title , abstract and full text , and 15 articles were included in the literature which were included in this meta - analysis according to the previously prepared literature and exclusion criteria .
Two literatures describe the curative effect of the treatment of total ureteral calculi , extracorporeal shock wave lithotripsy and URL therapy , and some observation indexes such as stone clearance rate are divided into upper and lower stones respectively ;
Three literatures describe the curative effect of the treatment of upper ureteral calculi , extracorporeal shock wave lithotripsy and URL therapy .
The results showed that , for lower ureteral calculi , lower stone clearance and higher rate of repeat treatment were found in the lower group than in the URL group ( P0.01 ) , but there was no significant difference between the two groups in postoperative complications and operative time ( P > 0.05 ) .
There was no significant difference in the rate of stone clearance , postoperative complications and the rate of repeated treatment for upper ureteral calculi ( P > 0.05 ) .
Compared with PCNL group , PCNL group had higher urinary stone clearance ( P0.01 ) , and there was no significant difference between the two groups ( P > 0.05 ) .

The results of the randomized controlled clinical study on the treatment of upper ureteral calculi with flexible ureteroscope ( F - URS ) and minimally invasive percutaneous nephroscope ( MPC NL ) showed that the initial stone clearance of F - URS group was 68.33 % and 95.00 % , respectively , and the stone clearance rate was 96.67 % and 98.33 % , respectively , and no significant difference was found between the two groups ( P > 0.05 ) .
The operative time of F - URS group and MPC NL group were ( 35.33 鹵 11.57 ) min and ( 53.75 鹵 17.31 ) min , respectively , and the postoperative hospitalization days were ( 3.05 鹵 0.62 ) d and ( 5.43 鹵 1.84 ) d , respectively , and the VAS in postoperative day 1 was ( 1 . 70 鹵 1 . 37 ) min and ( 3.68 鹵 1 . 57 ) respectively .
There was no significant difference in hemoglobin ( Hb ) and complication rate between the two groups ( P > 0.05 ) .

Conclusion

Through the systematic evaluation of the minimally invasive treatment of ureteral calculi , we believe that the URL has the advantages of high stone clearance rate and low repetition rate compared with the treatment of lower ureteral calculi , and it is worth recommending .
The results of the randomized controlled trial showed that the F - URS of the upper ureteral calculi was comparable to that of the MPC NL in terms of stone clearance , and the F - URS was higher in safety compared to the MPC NL and shorter in the postoperative hospital day , and that the department with the F - URS should be listed as the preferred treatment method .

【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R699.4

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 邸彥橙;田河;于峰;張智慧;白吉祥;;經(jīng)尿道腔鏡下取石術(shù)治療輸尿管結(jié)石伴腎積水的療效[J];醫(yī)學(xué)綜述;2017年03期

本文編號(hào)：1857621