Hyams Elias S, Shah Ojas
Department of Urology, New York University School of Medicine, New York, New York 10016, USA.
J Urol. 2009 Sep;182(3):1012-7. doi: 10.1016/j.juro.2009.05.021. Epub 2009 Jul 18.
While percutaneous nephrostolithotomy is the standard of care for renal stones greater than 2 cm, recent studies have shown that staged ureteroscopy/holmium laser lithotripsy may be a reasonable option. Stones 2 to 3 cm may be amenable to ureteroscopy as well as to 1-stage treatment based on their intermediate size. We compared clinical outcomes and the estimated cost of percutaneous nephrostolithotomy vs ureteroscopy for 2 to 3 cm renal stones.
We retrospectively identified patients who underwent percutaneous nephrostolithotomy and ureteroscopy at our institution from 2004 to 2008 with a maximal renal stone diameter of 2 to 3 cm. Demographic information, disease characteristics, intraoperative and postoperative data, and complications were recorded. Stone clearance was reported as a residual stone burden of 0 to 2 mm and less than 4 mm. Cost was estimated using local Medicare reimbursements for surgeon, anesthesia, hospital and outpatient services.
A total of 20 patients underwent percutaneous nephrostolithotomy and 19 underwent ureteroscopy for 2 to 3 cm renal stones. The estimated cost of percutaneous nephrostolithotomy was significantly greater than that of ureteroscopy ($19,845 vs $6,675, p <0.0001). There were significantly more second stage procedures among percutaneous nephrostolithotomy cases (11 vs 1, p = 0.003). Stone clearance (0 to 2 mm) was superior for percutaneous nephrostolithotomy vs ureteroscopy (89% vs 47%, p = 0.01). Using a less than 4 mm threshold stone clearance improved to 100% vs 95% (p not significant). Two patients (10.5%) with ureteroscopy required subsequent ipsilateral stone surgery. They were noncompliant with medical/dietary therapy or radiographic surveillance.
While percutaneous nephrostolithotomy achieves superior stone clearance, ureteroscopy achieves acceptable treatment outcomes with a low risk of subsequent stone related events or interventions. The lower relative cost of ureteroscopy in this population may have implications for the development of treatment guidelines.
虽然经皮肾镜取石术是治疗直径大于2cm肾结石的标准治疗方法，但最近的研究表明，分期输尿管镜检查/钬激光碎石术可能是一种合理的选择。2至3cm的结石因其中等大小，既适合输尿管镜检查，也适合一期治疗。我们比较了经皮肾镜取石术与输尿管镜检查治疗2至3cm肾结石的临床结果和估计费用。
我们回顾性确定了2004年至2008年在本机构接受经皮肾镜取石术和输尿管镜检查、最大肾结石直径为2至3cm的患者。记录人口统计学信息、疾病特征、术中及术后数据以及并发症。结石清除情况报告为残余结石负荷0至2mm及小于4mm。费用使用当地医疗保险对外科医生、麻醉、医院和门诊服务的报销费用进行估计。
共有20例患者接受了经皮肾镜取石术治疗2至3cm肾结石，19例接受了输尿管镜检查。经皮肾镜取石术的估计费用显著高于输尿管镜检查（19,845美元对6,675美元，p<0.0001）。经皮肾镜取石术病例中的二期手术明显更多（11例对1例，p = 0.003）。经皮肾镜取石术的结石清除率（0至2mm）优于输尿管镜检查（89%对47%，p = 0.01）。使用小于4mm的结石清除阈值，清除率提高到100%对95%（p无统计学意义）。两名接受输尿管镜检查的患者（10.5%）需要随后进行同侧结石手术。他们不遵守药物/饮食治疗或影像学监测。
虽然经皮肾镜取石术能实现更好的结石清除率，但输尿管镜检查能取得可接受的治疗效果，后续结石相关事件或干预的风险较低。在这一人群中输尿管镜检查相对较低的费用可能对治疗指南的制定有影响。
