May M, Schönthaler M, Gilfrich C, Wolff I, Peter J, Miernik A, Fritsche H-M, Burger M, Schostak M, Lebentrau S
Urologische Kliniken, St. Elisabeth-Klinikum Straubing, St.-Elisabeth-Str. 23, 94315, Straubing, Deutschland.
Urologische Kliniken, Universitätsklinikum Freiburg, Freiburg, Deutschland.
Urologe A. 2018 Feb;57(2):172-180. doi: 10.1007/s00120-017-0565-3.
The Post-ureteroscopic Lesion Scale (PULS) was designed as a standardized classification system for ureteral lesions after uretero(reno)scopy (URS). This study evaluates its routine use and a possible clinical impact based on a representative patient cohort.
Data of 307 patients in 14 German centers within the BUSTER project were used to test 3 hypotheses (H): PULS score shows a high interrater reliability (IRR) after independent assessment by urologic surgeon and assistance personnel (H1); PULS score is correlated with the frequency of postoperative complications during hospital stay (H2); post-URS stenting of the ureter is associated with higher PULS scores (H3).
Median age of patients was 54.4 years (interquartile range [IQR] 44.4-65.8; 65.5% male). Median diameter of index stones was 6 mm (IQR 4-8) with 117 (38.4%) pyelo-caliceal and 188 (61.6%) ureteral stones. Overall, 70 and 82.4% of patients had pre-stenting and post-URS stenting, respectively. Stone-free status was achieved in 68.7% after one URS procedure with a complication rate of 10.8% (mostly grade 1-2 according to Clavien-Dindo). PULS scores 0, 1, 2 and 3 were assessed in 40%, 52.1%, 6.9% and 1% of patients, respectively, when estimated by urologic surgeons. PULS score showed a high IRR between the urologic surgeon and assistance personnel (κ = 0.883, p < 0.001), but was not significantly correlated with complications (ρ = 0.09, p = 0.881). In contrast, a significant positive correlation was found between PULS score and post-URS stenting (ρ = 0.287, p < 0.001). A PULS score of 1 multiplied the likelihood of post-URS stenting by 3.24 (95% confidence interval 1.43-7.34; p = 0.005) as opposed to PULS score 0.
Removal of upper urinary tract stones using URS is safe and efficacious. Real-world data provided by this study confirm a high IRR of the PULS score and its clinical impact on the indication for post-URS stenting. A future prospective randomized trial should evaluate a possible standardization of post-URS stenting based on PULS score assessment.
输尿管镜检查后病变量表（PULS）被设计为输尿管（肾）镜检查（URS）后输尿管病变的标准化分类系统。本研究基于一个具有代表性的患者队列评估其常规应用及可能的临床影响。
在BUSTER项目中，德国14个中心的307例患者的数据用于检验3个假设（H）：泌尿外科医生和辅助人员独立评估后，PULS评分显示出较高的评分者间信度（IRR）（H1）；PULS评分与住院期间术后并发症的发生率相关（H2）；输尿管URS术后支架置入与较高的PULS评分相关（H3）。
患者的中位年龄为54.4岁（四分位间距[IQR]44.4 - 65.8；65.5%为男性）。索引结石的中位直径为6mm（IQR 4 - 8），其中肾盂-肾盏结石117例（38.4%），输尿管结石188例（61.6%）。总体而言，分别有70%和82.4%的患者进行了术前支架置入和URS术后支架置入。一次URS手术后结石清除率为68.7%，并发症发生率为10.8%（根据Clavien-Dindo分级大多为1 - 2级）。泌尿外科医生评估时，分别有40%、52.1%、6.9%和1%的患者PULS评分为0、1、2和3。PULS评分在泌尿外科医生和辅助人员之间显示出较高的IRR（κ = 0.883，p < 0.001），但与并发症无显著相关性（ρ = 0.09，p = 0.881）。相比之下，PULS评分与URS术后支架置入之间存在显著正相关（ρ = 0.287，p < 0.001）。与PULS评分为0相比，PULS评分为1使URS术后支架置入的可能性增加3.24倍（95%置信区间1.43 - 7.34；p = 0.005）。
使用URS清除上尿路结石安全有效。本研究提供的真实世界数据证实了PULS评分的高IRR及其对URS术后支架置入指征的临床影响。未来的前瞻性随机试验应基于PULS评分评估来评估URS术后支架置入的可能标准化。
