Martov A G, Ergakov D V, Andronov A S, Dutov S V, Takhaev R A, Kil'chukov Z I, Moskalenko S A
Department of Urology and Andrology, A.I. Burnazyan SSC Federal Medical Biophysical Center of FMBA of Russia, Moscow, Russia.
D.D. Pletnev City Clinical Hospital, Moscow Health Department, Moscow, Russia.
Urologiia. 2017 Jun(2):28-35. doi: 10.18565/urol.2017.2.28-35.
The choice of treatment for the stones of the lower renal calyx is one of the challenging issues of modern urology. The aim of this retrospective and prospective study was to investigate the clinical effectiveness and safety of 3 modern minimally invasive techniques for treating renal stones: percutaneous (PNL) and transurethral (TNL) nephrolithotripsy and extracorporeal shock wave lithotripsy (ESWL) in patients with solitary lower calyx stones sized from 10 to 15 mm.
The study included 136 patients with symptomatic stones of the lower calyces, who underwent ESWL, PNL and TNL from November 2010 to the present day. The criteria for inclusion in the study were: the presence of a solitary stone of the lower calyx, the stone size of 10 mm to 15 mm, the performance of the classical (standard) PNL in the prone position (puncture access 28-30 Fr) and the follow-up examination at 3 months after the operation. Forty-six patients underwent ESWL, 49 - PNL, and 41 - TNL. Postoperative follow-up was done at 3 months and included a plain radiography, ultrasound and non-contrast-enhanced computed tomography. The stone free rate (SFR) was used as a criterion for the effectiveness of the intervention, where the stone size of 3 mm was taken as the upper limit for the possible presence of fragments. Besides, the rate of repeat interventions, complications and subjective assessment of patients treatment satisfaction (0 to 10) by using visual analogue scale (VAS) were investigated.
The effectiveness analysis of the three methods for treating the lower calyx stones sized 10-15 mm showed that PNL was no more effective than TNL (SFR 95.9% and 85.4%, respectively), but both methods were significantly more effective than ESWL (SFR 69.5%). 29.3% of patients who underwent TNL required repeat interventions (TNL or ESWL), while among those treated with ESWL, 45.6% required repeat ESWL sessions. PNL resulted in stone clearance in one stage. Postoperative inflammatory complications were most prevalent among patients who underwent TNL (26.8%). Bleeding requiring hemotransfusion was observed only after PNL (14.3%). Obstructive complications were observed in all study groups. For them, internal stenting was most often performed after ESWL (10.9%), puncture nephrostomy - after TNL (7.3%). Statistically significantly higher VAS measured quality of life was found after ESWL (7.9) and PNL (7.0) compared with THL (4.8).
All three methods (PNL, TNL and ESWL) for treating lower calyceal stones sized from 10 to 15 mm are quite effective. Using them separately or in combination allows most patients to safely achieve a stone-free state.
下肾盏结石的治疗选择是现代泌尿外科面临的具有挑战性的问题之一。这项回顾性和前瞻性研究的目的是调查三种现代微创技术治疗肾结石的临床有效性和安全性：经皮肾镜取石术（PNL）、经尿道肾镜碎石术（TNL）和体外冲击波碎石术（ESWL），用于治疗直径为10至15毫米的孤立性下肾盏结石患者。
该研究纳入了136例有症状的下肾盏结石患者，他们在2010年11月至目前接受了ESWL、PNL和TNL治疗。纳入研究的标准为：存在孤立的下肾盏结石，结石大小为10毫米至15毫米，采用经典（标准）俯卧位PNL（穿刺通道28-30F）并在术后3个月进行随访检查。46例患者接受了ESWL，49例接受了PNL，41例接受了TNL。术后3个月进行随访，包括腹部平片、超声和非增强计算机断层扫描。结石清除率（SFR）用作干预有效性的标准，其中3毫米的结石大小被视为可能存在碎片的上限。此外，还调查了重复干预率、并发症以及使用视觉模拟量表（VAS）对患者治疗满意度（0至10）的主观评估。
对三种治疗10-15毫米下肾盏结石方法的有效性分析表明，PNL并不比TNL更有效（SFR分别为95.9%和85.4%），但这两种方法均明显比ESWL更有效（SFR为69.5%）。接受TNL治疗的患者中有29.3%需要重复干预（TNL或ESWL），而接受ESWL治疗的患者中有45.6%需要重复进行ESWL治疗。PNL一期实现了结石清除。术后炎症并发症在接受TNL治疗的患者中最为普遍（26.8%）。仅在PNL后观察到需要输血的出血（14.3%）。所有研究组均观察到梗阻性并发症。对于这些并发症，ESWL后最常进行内支架置入（10.9%），TNL后进行穿刺肾造瘘（7.3%）。与TNL（4.8）相比，ESWL（7.9）和PNL（7.0）后测量的生活质量VAS在统计学上显著更高。
所有三种治疗10至15毫米下肾盏结石的方法（PNL、TNL和ESWL）都相当有效。单独或联合使用这些方法可使大多数患者安全地达到无结石状态。
