【摘要】：研究背景與目的背景:泌尿道結(jié)石隨著社會(huì)發(fā)展發(fā)病率呈現(xiàn)上升趨勢(shì),我國(guó)為結(jié)石高發(fā)國(guó)家,經(jīng)過泌尿外科醫(yī)師不斷的開拓創(chuàng)新,泌尿道結(jié)石的治療方法不斷改進(jìn),特別是近半個(gè)世紀(jì)以來(lái),更有效、更微創(chuàng)的治療方式得到迅猛發(fā)展,經(jīng)皮腎鏡碎石取石術(shù)(PCNL)已經(jīng)成為腎結(jié)石與輸尿管上段結(jié)石治療首選,而PCNL放置腎造瘺管和輸尿管支架管一度是手術(shù)常規(guī)步驟。但置管帶來(lái)的諸如術(shù)后疼痛、延長(zhǎng)住院時(shí)間、增加感染風(fēng)險(xiǎn)、輸尿管支架取出等等問題得到越來(lái)越多的泌尿外科醫(yī)師的關(guān)注。一種無(wú)管化PCNL的手術(shù)方式開始被提出并被一定數(shù)量的臨床實(shí)踐證明了其安全性及有效性。但由于目前無(wú)管化PCNL還未得到公認(rèn),循證醫(yī)學(xué)證據(jù)及大樣本的隨機(jī)臨床對(duì)照實(shí)驗(yàn)不足,尤其目前在我國(guó)較為緊張的醫(yī)患關(guān)系下更難以推廣。目的:本研究擬通過對(duì)無(wú)管化與傳統(tǒng)PCNL術(shù)的臨床對(duì)比研究進(jìn)行Meta分析以期探討無(wú)管化經(jīng)皮腎鏡碎石取石術(shù)臨床應(yīng)用的安全性和有效性并指導(dǎo)實(shí)踐。方法:參考Cochrane手冊(cè)制定檢索策略,計(jì)算機(jī)檢索PubMed、臨床對(duì)照試驗(yàn)資料庫(kù)(CENTRAL)等數(shù)據(jù)庫(kù)并手工輔助檢索《中華泌尿外科雜志》、《現(xiàn)代泌尿外科學(xué)雜志》等在2006年至2016年關(guān)于無(wú)管化PCNL與傳統(tǒng)PCNL臨床對(duì)比研究的文獻(xiàn)。嚴(yán)格按照納入和排除標(biāo)準(zhǔn)對(duì)文獻(xiàn)進(jìn)行篩選,最后得到13篇文獻(xiàn)研究,采用Jadad評(píng)分法對(duì)文獻(xiàn)研究質(zhì)量進(jìn)行評(píng)價(jià)分析之后,運(yùn)用RevMan5.3軟件對(duì)閱讀全文收集到的各研究中住院時(shí)間、手術(shù)時(shí)間、結(jié)石清除率、術(shù)后血紅蛋白下降量、術(shù)后輸血、術(shù)后疼痛VAS評(píng)分、術(shù)后鎮(zhèn)痛藥物需求量、術(shù)后尿外滲、術(shù)后發(fā)熱及術(shù)后恢復(fù)正�；顒�(dòng)時(shí)間的數(shù)據(jù)進(jìn)行Meta分析。結(jié)果:入選的13篇文獻(xiàn)樣本量包括實(shí)驗(yàn)組602例,對(duì)照組590例;住院時(shí)間:有10篇文獻(xiàn)統(tǒng)計(jì)分析了住院時(shí)間,結(jié)果顯示實(shí)驗(yàn)組無(wú)管化PCNL比對(duì)照組傳統(tǒng)PCNL平均縮短住院時(shí)間1.45天,95%CI為-1.45[-1.91,-0.99];Z=6.22(P0.00001);手術(shù)時(shí)間:10篇文獻(xiàn)進(jìn)行了統(tǒng)計(jì),實(shí)驗(yàn)組無(wú)管化PCNL比對(duì)照組傳統(tǒng)PCNL平均縮短手術(shù)時(shí)間0.3min;95%CI為-0.30[-0.44,-0.16],Z=4.29(P0.0001)。結(jié)石清除率:7篇進(jìn)行了報(bào)道,95%CI為1.07[0.69,1.66],Z=0.30(P=0.76)表明兩組間結(jié)石清除率差異沒有統(tǒng)計(jì)學(xué)意義。血紅蛋白下降量:5篇文獻(xiàn)進(jìn)行了報(bào)道,95%CI為-0.02[-0.22,0.17],Z=0.24(P=0.81)表明兩組間術(shù)后血紅蛋白下降量無(wú)明顯差異。術(shù)后輸血:9篇文獻(xiàn)對(duì)術(shù)后輸血進(jìn)行了統(tǒng)計(jì),95%CI為0.69[0.44,1.08],Z=1.62(P=0.10)表明兩組間術(shù)后輸血情況沒有統(tǒng)計(jì)意義上的差異。術(shù)后疼痛VAS評(píng)分:5篇進(jìn)行了VAS疼痛評(píng)分,95%CI為-2.67[-4.38,-0.97],表明實(shí)驗(yàn)組比對(duì)照組平均降低2.63;Z=3.07(P=0.002)。術(shù)后鎮(zhèn)痛藥物需要量:5篇研究數(shù)據(jù)Meta分析顯示95%CI為-0.97[-1.42,-0.52],實(shí)驗(yàn)組比對(duì)照組使用鎮(zhèn)痛藥物量明顯下降,Z=4.21(P0.0001)。手術(shù)并發(fā)癥:術(shù)后尿外滲(Z=0.48 P=0.63)及術(shù)后發(fā)熱(Z=1.96 P=0.05)兩組之間差異沒有統(tǒng)計(jì)學(xué)意義。術(shù)后恢復(fù)正�；顒�(dòng)需要時(shí)間比較:4篇納入的文獻(xiàn)收集的數(shù)據(jù)分析顯示95%CI為-1.36[-2.31,-0.41],Z=2.81(P=0.005),提示無(wú)管化組能使患者更早的恢復(fù)正�；顒�(dòng),差異有統(tǒng)計(jì)學(xué)意義。結(jié)論:對(duì)于符合入選標(biāo)準(zhǔn)的患者無(wú)管化PCNL結(jié)石清除率、手術(shù)輸血、術(shù)后尿外滲、術(shù)后發(fā)熱與傳統(tǒng)PCNL相比無(wú)明顯差異,并且具有縮短住院及手術(shù)時(shí)間,減輕患者的術(shù)后疼痛感的優(yōu)勢(shì),是安全有效的手術(shù)方式、值得推廣應(yīng)用。
[Abstract]:BACKGROUND AND OBJECTIVE BACKGROUND: With the development of society, the incidence of urinary calculi is on the rise. China is a country with high incidence of urinary calculi. PCNL has become the first choice for the treatment of renal calculi and upper ureteral calculi, and PCNL placement of renal fistula and ureteral stent was once a routine procedure. Doctor's concern. An operation method of tubeless PCNL has been proposed and proved to be safe and effective by a certain number of clinical practices. However, it has not yet been recognized that tubeless PCNL, evidence-based medicine evidence and large sample randomized controlled clinical trials are insufficient, especially under the tense doctor-patient relationship in China. Objective: To explore the safety and effectiveness of the clinical application of tubeless percutaneous nephrolithotomy (PCNL) and to guide the practice through a meta-analysis of the clinical comparative study between tubeless and traditional PCNL. CENTRAL and other databases and manually assisted searches of the Chinese Journal of Urology and the Journal of Modern Urology were conducted from 2006 to 2016. Literatures on the clinical comparison between non-tubular PCNL and traditional PCNL were screened strictly according to inclusion and exclusion criteria, and 13 literatures were obtained. The Jadad scoring method was used to study the literatures. After evaluating and analyzing the quality of the study, RevMan 5.3 software was used to collect the data of hospitalization time, operation time, stone clearance rate, postoperative hemoglobin decrease, postoperative blood transfusion, postoperative pain VAS score, postoperative analgesic drug demand, postoperative urinary extravasation, postoperative fever and postoperative recovery time of normal activity. Results: The sample size of 13 articles included 602 cases in the experimental group and 590 cases in the control group; hospitalization time: 10 articles were statistically analyzed. The results showed that the average hospitalization time of the experimental group was 1.45 days, 95% CI was - 1.45 [- 1.91, - 0.99], Z = 6.22 (P 0.00001); operation time: 10 articles. Statistical results showed that the average operative time of PCNL in the experimental group was 0.3 minutes shorter than that in the control group; 95% CI was - 0.30 [- 0.44, - 0.16], Z = 4.29 (P 0.0001). Stone clearance rate: 7 papers were reported, 95% CI was 1.07 [0.69, 1.66], Z = 0.30 (P = 0.76) showed no significant difference between the two groups. Postoperative blood transfusion: There was no significant difference in postoperative hemoglobin loss between the two groups. Postoperative blood transfusion: Nine literatures analyzed postoperative blood transfusion, 95% CI 0.69 [0.44,1.08], Z = 1.62 (P = 0.10) showed no statistical difference in postoperative blood transfusion between the two groups. VAS pain score, 95% CI was - 2.67 [- 4.38, - 0.97], indicating that the experimental group than the control group decreased by an average of 2.63; Z = 3.07 (P = 0.002). Postoperative analgesic drug requirements: 5 research data Meta analysis showed that 95% CI was - 0.97 [- 1.42, - 0.52], the experimental group compared with the control group using analgesic drugs significantly decreased, Z = 4.21 (P 0.0001). Surgical complications: postoperative urinary tract. There was no significant difference between the two groups (Z = 0.48 P = 0.63) and postoperative fever (Z = 1.96 P = 0.05). Conclusion: There is no significant difference in stone clearance rate, blood transfusion, postoperative urinary extravasation, postoperative fever and postoperative pain between PCNL and traditional PCNL, and it is a safe and effective surgical method.
【學(xué)位授予單位】：南昌大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R699

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