摘要目的 比较输尿管软镜碎石术(RIRS)与微创经皮肾镜碎石术(MPCNL)治疗儿童≥1.5 cm肾结石的疗效及安全性.方法 回顾性分析2011年3月至2016年3月收治的97例肾结石患儿的病例资料,患儿均有≥1枚直径≥1.5 cm的结石.根据手术方式分为RIRS组和MPCNL组,手术均由同一组手术医师进行.RIRS组40例,男29例,女11例;年龄(7.3±3.9)岁,范围1.4～14.8岁;结石直径(1.9 ±0.4) cm,范围1.5 ～3.0 cm;鹿角形结石3例;≥1.5 cm结石44枚,其中33枚位于肾盂及上中盏,11枚位于下盏;多发结石30例,单发结石10例;7例有同侧碎石手术史,3例术前尿培养阳性.MPCNL组57例,男45例,女12例;年龄(5.9±2.9)岁,范围1.3 ～12.3岁;结石直径(2.1 ±0.5)cm,范围1.5～3.5 cm;鹿角形结石7例;≥1.5 cm结石60枚,其中56枚位于肾盂及上中盏,4枚位于下盏;多发结石41例,单发结石16例;4例有同侧碎石手术史,2例术前尿培养阳性.两组的性别、年龄、结石直径、鹿角形结石例数,下盏结石数量,单发结石与多发结石比例、同侧碎石手术史、术前尿培养阳性率比较差异均无统计学意义(P＞0.05).RIRS组患儿术前均留置双J管4周,RIRS组置管前尿常规白细胞数量(31.1个/μl)与MPCNL组术前白细胞数量(23.8个/μl)比较差异无统计学意义(P＞0.05).结果 RIRS组手术时间(90.2±17.8)min;术后血红蛋白下降值(7.9 ±7.9)g/L;术后并发症发生率为7.5％ (3/40);术后住院时间(5.0±2.3)d;一期结石清除率72.5％(29/40),经过分期手术,最终清石率为90.0％(36/40);住院费用(42 994.1±9 747.8)元.MPCNL组手术时间(77.8±15.6) min;术后血红蛋白下降值(10.0±7.1)g/L;术后并发症发生率为24.6％(14/57);术后住院时间(8.0±2.5)d;一期结石清除率82.5％(47/57),经过分期手术,最终清石率为94.7％(54/57);住院费用(24626.3±6 324.7)元.两组的一期清石率、最终清石率、血红蛋白下降值比较差异无统计学意义(P＞0.05),手术时间、术后并发症发生率、术后住院时间、住院费用比较差异有统计学意义(P＜0.05).结论 RIRS和MPCNL均是治疗儿童≥1.5 cm肾结石安全、可行的术式,两者清石率无显著差异.RIRS的术后住院时间短、并发症少,MPCNL的手术时间短、住院费用低、术前无需常规留置双J管.

abstractsObjective To evaluate the safety and efficacy of retrograde intrarenal surgery (RIRS)and minimally invasive percutaneous nephrolithotripsy (MPCNL)for the pediatric renal calculi (≥ 1.5 cm).Methods In the retrospective study,97 patients with renal calculi (≥ 1.5 cm) underwent operation which is conducted by the same operative team from March 2011 to March 2016.Among them,40 patients were treated with RIRS,including 29 male and 11 female patients.57 patients were treated with minimally invasive percutaneous nephrolithotripsy,including 45 males and 12 female patients.The mean stone size was (1.9 ± 0.4) cm (ranging 1.5-3.0 cm) in the RIRS group and (2.1 ± 0.5) cm(ranging 1.5-3.5 cm) in the MPCNL group.In RIRS group,3 stones were stag-horn calculi.The diameter in 44 stones was more than 1.5 cm.Among them,33 stones located in the renal pelvis and upper middle calyces.11 stones located in the lower calyces.Multiple stones were found in 30 cases and single stone was found in 10 cases.7 cases had the history of unilateral urolithiasis.3 cases had the positive results of urine culture before operation.In MPCNL group,7 stones were stag-horn calculi.The diameter in 60 stones was more than 1.5 cm.Among them,56 stones located in the renal pelvis and upper middle calyces.4 stones located in the lower calyces.Multiple stones were found in 41 cases and single stone was found in 16 cases.4 cases had the history of unilateral urolithiasis.2 cases had the positive results of urine culture before operation.The mean stone size in MPCNL was larger,but the difference was not statistically significant (P ＞ 0.05).No statistical significance was found between the two groups in sex,age,preoperative urine,positive culture,patients with renal staghorn calculi,percentage of multiple calculi,stones in lower calyx and operation history of the same side(P ＞ 0.05).The urine white blood cells between the two groups were statistically significant (P ＜0.01),but the urine white blood cells in RIRS before placing double J stent had no significant difference with those in MPCNL.Results In RIRS group,The mean operative time was(90.2 ± 17.8) minutes.The mean hemoglobin deficit was (7.9 ± 7.9)g/L.The complication rate was 7.5％ (3/40).The postoperative hospital stay was (5.0 ± 2.3) days.The hospitalization cost was (42 994.1 ± 9 747.8) yuan.Stone-free rates after one session was 72.5％ (29/40).After second procedure,stone-free rates were up to 90.0％ (36/40).In MPCNL group,the mean operative time was (77.8 ± 15.6) min.The mean hemoglobin deficit was (10.0 ± 7.1) g/L.The complication rate was 24.6％ (14/57).The postoperative hospital stay was (8.0 ±2.5) days.The hospitalization cost was (24 626.3 ± 6 324.7) yuan.The stone-free rate after one session was 82.5％ (47/57).After second procedure,stone-free rates were up to 94.7％ (54/57).In statistics,there was no significant difference in hemoglobin drop,the stone-free rate on one session and the final stone-free rates(P ＞ 0.05).But significant difference existed in operative time,complications rate,postoperative hospitalization time and hospitalization cost (P ＜ 0.05).Conclusion Both RIRS and MPCNL are feasible,safe and minimally invasive way to treat renal calculi(≥ 1.5 cm) in pediatric patients.The stone-free rates between the two groups are comparable.RIRS has an advantage in postoperative hospitalization time and postoperative complications.MPCNL takes the advantage of operation time,hospitalization cost and needn't routinely places the double-J ureteral stent.