Arustamov L D, Katibov M I, Merinov D S, Gurbanov Sh Sh, Artemov A V, Epishov V A
N.A. Lopatkin Scientific Research Institute of Urology and Interventional Radiology branch of the NMRRC of Minzdrav of Russia, Moscow, Russia.
Urologiia. 2017 Dec(6):65-71.
Management of patients with large and staghorn stones of a solitary kidney is widely debated among urologists and has not been sufficiently investigated, which determined the relevance of this study.
The study comprised 80 patients with large (>20 mm) and staghorn stones of an anatomically or functionally solitary kidney. Of them, 58 patients underwent percutaneous nephrolithotripsy (PNL), and 22 had open surgery. The criterion of the treatment effectiveness was the complete stone clearance or small residual fragments sized less than 3 mm. The safety criterion was the absence of intra- and postoperative complications, according to Clavien-Dindo grading system. The study analyzed the following factors influencing the effectiveness and safety of PNL: the number of accesses; nephroscope diameter; use of a nephroscope sheath; type of lithotripter; size, density, type and composition of the stone.
Percutaneous nephrolithotripsy demonstrated statistically significantly better safety results compared with open surgery with comparable effectiveness. Long-term stone recurrence rate after PNL and open surgery was 10.4 and 18.2%, respectively. PNL resulted in a statistically significant improvement in the kidney function while it worsened after open surgery. The effectiveness of PNL depends on the stone type and size and the kind of lithotripter. It was 7.5 times greater for a large stone than for staghorn calculi and 4.6 times higher for stones sized less or equal 45 mm than for those sized > 45 mm. Ultrasonic lithotripter was 2.2 times more effective than another type of lithotripter. The safety of PNL depends on the nephroscope diameter, of a sheath, the number of accesses, the type of lithotripter and the type of stone. Using a 24-Ch nephroscope was 3.6 times safer than that with a diameter greater than 24-Ch; not using a sheath was 3.2 times safer than using it; one access was 3 times safer than at multiple ones; using an ultrasound lithotripter was 2.7 times safer than with another type of lithotripter; treating a large stone was 2.1 times safer than a staghorn stone.
The study findings can be used to optimize the treatment of patients with large and staghorn stones of a solitary kidney.
孤立肾大结石和鹿角形结石患者的管理在泌尿外科医生中存在广泛争议，且尚未得到充分研究，这决定了本研究的相关性。
本研究纳入80例解剖学或功能上孤立肾的大结石（>20 mm）和鹿角形结石患者。其中，58例患者接受经皮肾镜取石术（PNL），22例接受开放手术。治疗效果的标准是结石完全清除或残留小于3 mm的小碎片。安全标准是根据Clavien-Dindo分级系统，术中及术后无并发症。本研究分析了以下影响PNL有效性和安全性的因素：穿刺通道数量；肾镜直径；是否使用肾镜鞘；碎石器类型；结石大小、密度、类型和成分。
与开放手术相比，经皮肾镜取石术在有效性相当的情况下，安全性在统计学上显著更好。PNL和开放手术后的长期结石复发率分别为10.4%和18.2%。PNL使肾功能在统计学上有显著改善，而开放手术后肾功能恶化。PNL的有效性取决于结石类型和大小以及碎石器类型。大结石的有效性比鹿角形结石高7.5倍，直径小于或等于45 mm的结石比直径>45 mm的结石高4.6倍。超声碎石器的有效性比另一种类型的碎石器高2.2倍。PNL的安全性取决于肾镜直径、是否使用鞘、穿刺通道数量、碎石器类型和结石类型。使用24F肾镜比直径大于24F的肾镜安全3.6倍；不使用鞘比使用鞘安全3.2倍；单通道比多通道安全3倍；使用超声碎石器比另一种类型的碎石器安全2.7倍；治疗大结石比治疗鹿角形结石安全2.1倍。
本研究结果可用于优化孤立肾大结石和鹿角形结石患者的治疗。
