Department of Urology, University Medical Centre Freiburg, Freiburg, Germany.
J Endourol. 2012 Nov;26(11):1425-30. doi: 10.1089/end.2012.0227. Epub 2012 Aug 27.
Objective parameters for the classification of ureteral injuries and resulting indications for ureteral stent placement after ureteroscopy are lacking. We hereby present a new classification system including proof of interrater reliability and validation of recommendations for postoperative ureteral stent placement.
The Postureteroscopic Lesion Scale (PULS) was applied in 435 patients undergoing ureteroscopy. Interrater reliability between three surgeons (junior resident, senior resident, and specialist) was evaluated in 112 patients. Postoperative ureteral stent placement was performed according to PULS. For follow-up with ultrasonography, we assumed hydronephrosis to be an indirect sign for significant postoperative ureteral obstruction.
No ureteral lesion was seen in 46.2% of patients (grade 0). A grade 1, 2, or 3 lesion was seen in 30.8%, 19.1%, and 3.9% of patients, respectively. No grade 4 or 5 lesions were observed in our series. Interrater reliability was high (Kendall W=0.91; mean Spearman Rho=0.86). This was particularly true between senior resident and specialist (Rho=0.95), compared with junior resident and senior resident or specialist (Rho=0.83, Rho=0.79, respectively). All patients with documented lesions had a Double-J stent placed. Indwelling time varied according to PULS. Results of a postoperative ultrasonographic follow-up could be obtained in 95.6% of cases. No patient showed clinical or sonographic signs of upper urinary tract obstruction.
According to these preliminary data for the clinical application of PULS, interrater reliability is high. Standardized empiric recommendations for the use and duration of postoperative stent placement after ureteroscopy might be useful in guiding urologists in this conversely discussed issue, ultimately preventing ureteral strictures as a late complication of ureteroscopy. These will have to be confirmed, however, by controlled trials in the future.
目前缺乏经输尿管镜检查后输尿管损伤分类的客观参数和由此导致的输尿管支架置入适应证。本研究提出了一种新的分类系统，包括对三位术者（住院医师、高年住院医师和专家）之间的组内一致性的评估和术后输尿管支架置入适应证的验证。
435 例行输尿管镜检查的患者应用 Postureteroscopic Lesion Scale（PULS）。对 112 例患者评估了三位术者（住院医师、高年住院医师和专家）之间的组内一致性。根据 PULS 行术后输尿管支架置入。行超声检查随访时，假设积水为输尿管梗阻的间接征象。
46.2%（0 级）的患者未见输尿管损伤，30.8%（1 级）、19.1%（2 级）和 3.9%（3 级）的患者分别存在 1 级、2 级或 3 级损伤，本研究中未见 4 级或 5 级损伤。组内一致性较高（Kendall W=0.91；平均 Spearman Rho=0.86）。高年住院医师与专家之间（Rho=0.95）的一致性显著高于住院医师与高年住院医师或专家之间（Rho=0.83，Rho=0.79）。所有有记录的损伤患者均留置了双 J 支架。留置时间根据 PULS 而定。95.6%的病例可获得术后超声随访结果。无患者出现上尿路梗阻的临床或超声征象。
根据 PULS 在临床应用中的初步数据，组内一致性较高。标准化的术后支架留置使用和留置时间经验性推荐可能有助于指导泌尿科医生解决这一存在争议的问题，最终防止输尿管镜检查的晚期并发症——输尿管狭窄。但未来仍需要进行对照试验来证实这一点。
