背景:在美国,小儿尿路结石以每年4-10%的速度增加,尤其是在青少年和女性中。相当多的患者将需要对他们的结石进行手术管理。与冲击波碎石术相比,原发性输尿管镜检查(URS)提供了在单一麻醉药下治疗结石的机会,其再治疗率或解剖学和结石特征限制较低。以前评估主要URS的研究在很大程度上能力不足,受到石头位置的限制,和/或不代表美国的石头人口。
目的:主要研究结果是主要URS的成功和与成功相关的患者特征。次要结局是无石率(SFR),30天急诊科(ED)访视,再入院30天,和并发症。
方法:我们对2011年至2023年年龄小于18岁且接受原发性URS的患者进行了回顾性队列研究。如果在URS或进行诊断性URS之前放置输尿管支架,则排除患者。如果获得了对输尿管的访问并且完成了结石的治疗,则认为主要URS是成功的。在失败的主URS中,我们放置了输尿管支架进行分阶段管理.
结果:共纳入196例患者,对224个肾单位进行或尝试进行原发性URS。中位年龄为15.8(IQR13.4-16.9)岁,中位随访时间为8.4(IQR1.1-24.6)个月。主要URS的成功率为79%。基于以下因素,成功的主要URS没有明显的特征:总体年龄,<14vs>14岁,性别,身体质量指数,石头的历史,内在逻辑过程的历史,术前α阻滞,石头的位置,多块石头,URS的类型,或急性治疗。在成功的主URS中,SFR为88%,结石大小(p=0.0001)是结石残留的唯一预测因子.30天ED率为21.4%,30天计划外再入院率为12.5%,并发症发生率为7.5%。没有长期并发症得到重视。
结论:我们的主要URS的成功与以前发表的文献相比是有利的。我们的SFR率,30天ED访问,30天计划外再入院,并发症发生率与其他研究相似。这项研究的局限性在于其回顾性设计,选择偏差,和中间跟进。
结论:在大多数没有任何与成功相关的患者特征的儿科患者中,初级URS可以安全地完成。由于出色的SFR和在单一麻醉剂下治疗结石的潜力,我们主张在可能的情况下进行原发性URS。
Pediatric urolithiasis has been increasing at rate of 4-10 % annually in the United States, most notably within adolescents and females. A significant number of patients will require surgical management of their stones. Primary ureteroscopy (URS) affords the opportunity to treat stones under a single anesthetic with lower re-treatment rates or anatomical and stone characteristic limitations compared to shockwave lithotripsy. Previous studies evaluating primary URS have been largely underpowered, are limited by stone location, and/or are not representative of the stone population in the United States.
Primary study outcomes were the success of primary URS and patient characteristics associated with success. Secondary outcomes were the stone-free rate (SFR), 30-day emergency department (ED) visits, 30-day readmissions, and complications.
We performed a retrospective cohort study of patients less than 18 years of age from 2011 to 2023 who underwent primary URS. Patients were excluded if a ureteral stent was placed prior to URS or diagnostic URS was performed. A successful primary URS was considered if access to the ureter was obtained and treatment of the stone(s) completed. In failed primary URS, a ureteral stent was placed for staged management.
A total of 196 patients were included and primary URS was performed or attempted on 224 renal units. The median age was 15.8 (IQR 13.4-16.9) years and median follow up 8.4 (IQR 1.1-24.6) months. The success rate of primary URS was 79 %. No significant characteristics were appreciated for successful primary URS based on: overall age, <14 vs > 14 years of age, sex, body mass index, history of stones, history of endourologic procedures, preoperative alpha blockade, location of stone(s), multiple stones, type of URS, or acute treatment. In successful primary URS, the SFR was 88 % with stone size (p = 0.0001) the only predictor of having residual stones. The 30-day ED rate was 21.4 %, 30-day unplanned readmission rate was 12.5 %, and complication rate was 7.5 %. No long-term complications were appreciated.
Our success of primary URS compares favorably to previously published literature. Our SFR rate, 30-day ED visits, 30-day unplanned readmission, and complication rates are similar to other studies. Limitations of the study are its retrospective design, selection bias, and intermediate follow-up.
Primary URS can be completed safely in the majority of pediatric patients without any patient characteristics associated with success. We advocate for primary URS when possible due to the excellent SFR and potential of treating stones under a single anesthetic.