發(fā)布時(shí)間：2018-04-24 06:42

  本文選題：上尿路結(jié)石 + 微創(chuàng)經(jīng)皮腎鏡取石術(shù)�。� 參考：《廣州醫(yī)科大學(xué)》2017年碩士論文

【摘要】：背景目前,經(jīng)皮腎鏡取石術(shù)(percutaneous nephrolithotomy,PCNL)是處理直徑大于2cm上尿路結(jié)石,尤其是治療復(fù)雜性上尿路結(jié)石的首選方法。我國吳開俊、李遜教授等著名泌尿外科專家結(jié)合我國實(shí)際情況提出微創(chuàng)經(jīng)皮腎鏡取石術(shù)(minimally invasive percutaneous nephrolithotomy,MPCNL)。PCNL如今有兩種發(fā)展趨勢,第一是微創(chuàng)化,使經(jīng)皮腎穿刺通道較前進(jìn)一步變細(xì),從上世紀(jì)80年代的F30-F36發(fā)展到現(xiàn)在常用的F14-F18,使術(shù)后并發(fā)癥的發(fā)生與腎實(shí)質(zhì)損傷大大地減少;微創(chuàng)理念的基本要求是在盡可能少或小創(chuàng)傷的基礎(chǔ)上,令患者達(dá)到和保持最佳的內(nèi)環(huán)境狀態(tài)[1]。第二是無管化,即PCNL術(shù)后選擇性不放置腎造瘺管,甚至有部分同時(shí)也不放置D-J管,以實(shí)現(xiàn)完全無管化,從而減輕病人的痛苦及術(shù)后帶來的諸多不便。雖然PCNL已發(fā)展成為一種設(shè)計(jì)且改造精良的手術(shù)方式,但它仍然存在并發(fā)癥。EAU指南(2015年版)指出術(shù)后出血、發(fā)熱、尿外滲等是PCNL術(shù)后常見并發(fā)癥;在這其中,術(shù)后出血是臨床醫(yī)生非常關(guān)注的,Seitz等[2]綜合了2001年至2011年文獻(xiàn)綜述指出,PCNL術(shù)后出血可通過采用夾閉腎造瘺管、應(yīng)用氣囊腎造瘺管,壓迫腎實(shí)質(zhì)等方法來阻止靜脈出血,嚴(yán)重的動(dòng)脈出血?jiǎng)t需行選擇性腎動(dòng)脈栓塞術(shù)。但是PCNL術(shù)后留置腎造瘺管會(huì)增加患者術(shù)后不適,甚至疼痛,影響患者生活質(zhì)量和住院滿意度。目前國內(nèi)外學(xué)者雖然已先后對(duì)無管化PCNL的安全性和可行性做了相關(guān)的臨床研究,但對(duì)患者術(shù)后不適和生活質(zhì)量方面的關(guān)注較少,國外已有學(xué)者用SF-36健康調(diào)查量表來評(píng)價(jià)PCNL術(shù)后患者的生活質(zhì)量,在國內(nèi)關(guān)于這方面的報(bào)道仍較少。故本試驗(yàn)在研究無管化(不留置腎造瘺管,僅留置D-J管)MPCNL治療上尿路結(jié)石的有效性和安全性的同時(shí),也應(yīng)用SF-36健康調(diào)查量表來評(píng)價(jià)MPCNL術(shù)后患者的生活質(zhì)量。目的探討無管化MPCNL治療上尿路結(jié)石的有效性和安全性。SF-36健康調(diào)查量表在MPCNL術(shù)后患者生活質(zhì)量評(píng)估中的應(yīng)用。方法此研究選取2016年7月至2017年2月期間在本中心廣州醫(yī)科大學(xué)附屬第一醫(yī)院海印分院泌尿外科符合試驗(yàn)納入標(biāo)準(zhǔn)并行微創(chuàng)經(jīng)皮腎鏡取石術(shù)治療上尿路結(jié)石的患者共計(jì)129例,可分為兩組,即留置腎造瘺管組和不留置腎造瘺管組。分析兩組的手術(shù)時(shí)間、術(shù)后血紅蛋白下降值、術(shù)后血肌酐變化值、術(shù)后住院時(shí)間、術(shù)后并發(fā)癥發(fā)生情況、術(shù)后不同時(shí)間點(diǎn)的疼痛視覺模擬評(píng)分(Visual Analogue score,VAS)、術(shù)后止痛藥使用情況、不同時(shí)間點(diǎn)SF-36健康調(diào)查量表評(píng)分等相關(guān)指標(biāo)。結(jié)果129例患者中不留置腎造瘺管組因術(shù)后發(fā)現(xiàn)殘余結(jié)石及失訪者共10例,留置腎造瘺管組因術(shù)后發(fā)現(xiàn)殘余結(jié)石、出血需介入及失訪者共11例,予以排除出組,最終入選108例。108例患者術(shù)前一般資料如性別、年齡、BMI、術(shù)前合并癥、既往患側(cè)手術(shù)史、腎積水程度、結(jié)石部位及類型、結(jié)石表面積等均無統(tǒng)計(jì)學(xué)差異。兩組患者在手術(shù)時(shí)間、術(shù)后血紅蛋白下降值、術(shù)后血肌酐變化值等方面的比較上,差異均無統(tǒng)計(jì)學(xué)意義(p0.05);而兩組患者術(shù)后住院時(shí)間、術(shù)后疼痛的發(fā)生率的比較均有統(tǒng)計(jì)學(xué)差異(p0.05);術(shù)后6h、術(shù)后24h、術(shù)后48h的VAS評(píng)分不留置腎造瘺管組均低于留置腎造瘺管組,結(jié)果具有統(tǒng)計(jì)學(xué)意義(p0.05);無論是非甾體類藥物還是阿片類藥物的術(shù)后使用量,留置腎造瘺管組均多于不留置腎造瘺管組。兩組間并發(fā)癥Clavien分級(jí)有顯著統(tǒng)計(jì)學(xué)差異(p0.001),Clavien I級(jí)(p0.001)兩組間比較有統(tǒng)計(jì)學(xué)差異,而Clavien II級(jí)(p=1.000)、III級(jí)(p=0.985)兩組間比較均無統(tǒng)計(jì)學(xué)差異。兩組患者均未發(fā)生ClavienⅣ和ClavienⅤ級(jí)的并發(fā)癥;SF-36健康調(diào)查量表評(píng)分術(shù)后第一天PF生理功能的得分分別為69.2±8.4、79.2±8.5,BP軀體疼痛這一維度的得分分別為46.2±16.9、71.2±16.5,差異有明顯統(tǒng)計(jì)學(xué)意義(p0.001)。其他維度上同一時(shí)間點(diǎn)的得分均無統(tǒng)計(jì)學(xué)意義(p0.05)。結(jié)論無管化MPCNL能減少患者術(shù)后疼痛及止痛藥的使用,縮短住院時(shí)間,提高住院期間生活質(zhì)量,且不增加術(shù)后并發(fā)癥的發(fā)生。SF-36健康調(diào)查量表在MPCNL術(shù)后患者生活質(zhì)量的評(píng)估上有臨床價(jià)值,值得推廣。
[Abstract]:Background, percutaneous nephrolithotomy (percutaneous nephrolithotomy, PCNL) is the first choice for the treatment of urinary calculi with a diameter larger than 2cm, especially in the treatment of complicated upper urinary calculi. Wu Kaijun, Professor Li Xun and other famous experts in our country have proposed a minimally invasive percutaneous nephrolithotomy (minimally invasive per) combined with the actual situation in our country. Cutaneous nephrolithotomy, MPCNL).PCNL now has two development trends. The first is minimally invasive, which makes the percutaneous renal puncture passage further thinner. From the F30-F36 of the 80s of last century to the commonly used F14-F18, the postoperative complications and renal parenchyma damage are greatly reduced; the basic requirements of the minimally invasive concept are as few as possible. On the basis of the small trauma, the patients reach and maintain the best internal environment, [1]. second is no tube, that is, the selective absence of nephrostomy after PCNL, or even part of the D-J tube at the same time, in order to achieve complete incannatization, thus alleviating the patient's pain and a lot of inconvenience after the operation. Although PCNL has developed into a kind of establishment. The.EAU Guide (2015 Edition) indicates that postoperative bleeding, fever, and extravasation of urine are common complications after PCNL; in which, postoperative bleeding is a great concern for clinicians, and Seitz and [2] combined from 2001 to 2011 that hemorrhage after PCNL can be used with clipping. Nephrostomy tube, air bag nephrostomy tube, compression of renal parenchyma and other methods to prevent venous bleeding, severe arterial bleeding requires selective renal artery embolization. However, after PCNL, indwelling renal fistulas will increase postoperative discomfort and even pain, affecting patients' quality of life and hospitalization satisfaction. The clinical study of the safety and feasibility of unmanaged PCNL has been made, but less attention has been paid to postoperative discomfort and quality of life. Foreign scholars abroad have used SF-36 health survey to evaluate the quality of life of patients after PCNL, and there are few reports in this area. The effectiveness and safety of MPCNL in the treatment of upper urinary calculi and the use of SF-36 health inventory to evaluate the quality of life of patients after MPCNL. Objective to explore the effectiveness and safety of the non tube MPCNL for the treatment of upper urinary calculi, and to evaluate the quality of life of the patients after MPCNL after the MPCNL operation. Methods a total of 129 patients were selected from July 2016 to February 2017 in the Department of Urology, the First Affiliated First Hospital of Guangzhou Medical University, the first hospital of the first hospital, the Department of Urology, the standard parallel minimally invasive percutaneous nephrolithotomy for the treatment of upper urinary calculi, which could be divided into two groups, that is, the indwelling nephrostomy tube group and the non indwelling nephrostomy tube group. Analysis of the two groups of operation time, postoperative hemoglobin decreased value, postoperative blood creatinine change value, postoperative hospitalization time, postoperative complications, postoperative pain visual analog score (Visual Analogue score, VAS), postoperative analgesics use, not the same time point SF-36 health survey scale scores and other related indicators. Results 1 In the 29 cases, there were 10 cases of residual stones and lost visitors in the group of non indwelling nephrostomy tubes. The residual stones were found in the group of renal fistulas after operation. 11 cases of bleeding need to intervene and lose the visitors. The group was excluded, and the general data of 108.108 patients were selected, such as sex, age, BMI, preoperative complication, and history of side surgery. There was no significant difference in the degree of hydronephrosis, the place and type of stone, and the surface area of the stone. There was no significant difference between the two groups in the operation time, the decrease of hemoglobin and the change of blood creatinine after operation (P0.05), but the rate of postoperative hospital residence time and postoperative pain was statistically significant in the two groups. Difference (P0.05); postoperative 6h, postoperative 24h, and VAS score of 48h after operation were lower than that of the left renal fistulae group, and the results were statistically significant (P0.05); the amount of postoperative use of non steroid or opioids was more than that of the non indwelling nephrostomy tube group. The complications of the two groups were classified as Clavien classification. There were significant statistical differences (p0.001), Clavien I grade (p0.001) two groups had statistical differences, but Clavien II (p=1.000), III class (p=0.985) two groups were not statistically significant differences. Two groups of patients did not have Clavien IV and Clavien grade complications; SF-36 Health Questionnaire score score on the first day after the score points of physiological function score points The score was 69.2 + 8.4,79.2 + 8.5, and the score of BP body pain was 46.2 + 16.9,71.2 + 16.5 respectively. The difference was statistically significant (p0.001). There was no statistical significance in the same time point on other dimensions (P0.05). Conclusion no tube MPCNL can reduce the pain and use of painkillers after operation, shorten the time of hospitalization and improve hospitalization. The quality of life, without the increase of postoperative complications, is of clinical value in the assessment of the quality of life of the patients after MPCNL, which is worthy of promotion.

【學(xué)位授予單位】：廣州醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R699

【參考文獻(xiàn)】

相關(guān)期刊論文 前7條

1 曾國華;麥贊林;夏術(shù)階;馬金香;吳文起;王志平;張克勤;倪少濱;王力;龍永福;史少東;趙志健;邵怡;岳中瑾;馬俊飛;崔澤林;秦景;曾滔;劉e，

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