输尿管镜钬激光碎石术后早期并发症的Clavien-Dindo分级及影响因素分析

Clavien-Dindo classification system and influencing factors analysis of early complications after ureteroscope lithotripsy with holmium laser

摘要:

目的 应用Clavien-Dindo分级系统（CDCS）对经尿道输尿管镜钬激光碎石术（URL）治疗输尿管结石所致的早期并发症按严重程度进行分级，并探讨术后早期并发症的影响因素。方法 回顾性分析2013年1月—2019年9月宜昌市第一人民医院泌尿外科行URL治疗的1 142例输尿管结石患者的临床资料，按术后是否出现并发症分为并发症组144例和无并发症组998例。应用CDCS对术后早期并发症进行统计分析，采用Logistic回归模型分析术后早期并发症发生的影响因素，建立URL术后早期并发症预测模型。结果 术后出现并发症144例，发生率12.6%。CDCS分析结果显示，Ⅰ级并发症76例（52.8%）、Ⅱ级37例（25.7%）、Ⅲa级15例（10.4%）、Ⅲb级9例（6.3%）、Ⅳa级1例（0.7%）、Ⅳb级6例（4.2%）、Ⅴ级并发症0例（0.0%）。单因素分析结果显示，结石负荷、结石位置、手术时间、合并糖尿病、术前发热、术前降钙素原、术前尿培养、重度肾积水、合并输尿管狭窄、病程、术者熟练程度是URL术后发生早期并发症的影响因素（P <0.05）。多因素Logistic回归分析显示，结石负荷≥ 45 mm²［O^R=1.039（95% CI：1.010，1.070）］、结石位于输尿管上段［O^R=1.734（95% CI：1.211，2.482］、手术时间≥ 60 min ［O^R=1.032（95% CI：1.006，1.058）］、合并糖尿病［O^R=1.832（95% CI：1.040，3.227）］、术前尿培养阳性［O^R=3.163（95% CI：1.195，8.373）］、合并输尿管狭窄［O^R=2.010（95% CI：1.102，3.669）］和术者为低年资医师［O^R=2.213（95% CI：1.414，3.463）］是URL术后早期并发症发生的独立影响因素（P <0.05）。根据这7个因素建立的URL术后早期并发症预测模型的受试者工作特征曲线下面积为0.791（95% CI：0.756，0.826），敏感性为77.1%（95% CI：0.696，0.832），特异性为65.1%（95% CI：0.621，0.680）。结论 URL术后早期并发症分级主要为Clavien-Dindo分级Ⅰ级、Ⅱ级。结石负荷≥ 45 mm²、结石位于输尿管上段、手术时间≥ 60 min、术前尿培养阳性、合并糖尿病、合并输尿管狭窄和低年资医师实施手术可能会增加URL术后早期并发症。

Abstract:

Objective To analysis early complications of rigid ureteroscope lithotripsy (URL) with holmium laser by using the Clavien-Dindo classification system (CDCS), and to investigate influencing factors associated with the complications.Methods This retrospective study included 1,142 patients with ureteral calculi who underwent URL in our hospital from January 2013 to September 2019. The patients were divided into complications group (144 cases) and no complications group (998 cases) according to whether or not there were postoperative complications. Early complications after URL were analyzed according to the CDCS，and influencing factors of the postoperative early complications were evaluated with the logistic regression model，with which the predictive model for complications was established.Results Early complications occurred in 12.6% of patients. According to the CDCS of early complications, grade Ⅰ complications occurred in 76 patients (52.8%), grade Ⅱ in 37 patients (25.7%), grade Ⅲa in 15 patients (10.4%), grade Ⅲb in 9 patients (6.3%), grade Ⅳa in one patient (0.7%), grade Ⅳb in 6 patients (4.2%), and grade Ⅴ in none. The one-way analysis of variance showed that stone surface area, location of stone, surgery time, diabetes mellitus, preoperative fever, serum procalcitonin, positive culture from preoperative urine, severe hydronephrosis, ureteral stricture, course of disease, and skill level of the surgeon were associated with an increased risk of early complications after URL (P < 0.05). Furthermore, a multivariate analysis revealed that stone surface area ≥ 45 mm² [O^R = 1.039 (95% CI: 1.010, 1.070) ], upper ureteral calculi [O^R = 1.734 (95% CI: 1.211, 2.482) ], surgery time ≥ 60 min [O^R = 1.032 (95% CI: 1.006, 1.058) ], diabetes mellitus [O^R = 1.832 (95% CI: 1.040, 3.227) ], ureteral stricture [O^R = 2.010 (95% CI: 1.102, 3.669) ], positive culture from preoperative urine [O^R = 3.163 (95% CI: 1.195, 8.373) ], and the junior surgeon as operator [O^R= 2.213 (95% CI: 1.414, 3.463) were identified as independent predictive factors for postoperative early complications (P < 0.05)．The predictive model for early complications after URL constructed based on the above 7 factors. The ROC curve analysis showed that the AUC was 0.791 (95% CI: 0.756, 0.826), the sensitivity and specificity were 77.1% (95% CI: 69.6%, 83.2%) and 65.1% (95% CI: 62.1%, 68.0%).Conclusions Early complications after URL are mainly in grade Ⅰ and grade Ⅱ of CDCS. Stone surface area ≥ 45 mm², upper ureteral calculi, surgery time ≥ 60 min, diabetes mellitus, ureteral stricture, positive culture from preoperative urine, and the operation was performed by a junior surgeon have high risk of early complications after URL.