目的：采用meta分析经皮肾镜碎石术（percutaneous nephrolithotomy，PCNL）与经输尿管镜碎石术（ureteroscopic lithotripsy，URSL）治疗近端输尿管结石（≥10mm）的有效性、安全性和潜在并发症。方法：采用PubMed、Web of Science、Cochrane Library进行系统文献检索，2024年4月前符合条件的比较PCNL与URSL治疗近端输尿管结石的文献均被纳入。采用Review Manager 5.4软件进行统计分析与显著性检验。结果：共纳入文献13篇，共涉及患者1102例，PCNL540例，URSL562例，其中随机对照试验（randomized controlled trial，RCT） 7篇，非RCT6篇。PCNL手术时间[加权均数差（weighted mean difference，WMD） =20.46，95%CI  1.32~39.60，P=0.04]、总住院时间 （WMD=2.31，95%CI  0.57~4.05，P<0.01）、术后住院时间 （WMD=2.83，95%CI  1.93~3.73，P<0.01）均长于URSL，初始结石清除率[优势比（odds ratio，OR） =5.50，95%CI  2.04~14.85，P<0.01]和最终结石清除率（OR=5.55，95%CI 3.48~8.87，P<0.01）高于URSL。PCNL与URSL并发症发生率比较，差异无统计学意义（OR=0.96，95%CI  0.62~1.50，P=0.86）；PCNL术后发热发生率（OR=1.85，95%CI  1.13~3.04，P=0.02）和输血率（OR=6.90，95%CI 1.77~26.89，P<0.01）均高于URSL。结论：与URSL比较，PCNL治疗较大的近端输尿管结石更有效，但其危险性较高，具有更高的结石清除率、术后发热率和输血率。

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王贵林,景锁世,骆作喜,等.经皮肾镜碎石术与经输尿管镜碎石术治疗≥10mm近端输尿管结石疗效与并发症的meta分析[J].泌尿外科杂志(电子版),2024,16(03):1-7.DOI:10.20020/j.CNKI.1674-7410.2024.03.01

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近年来，泌尿系结石发病率在世界范围内呈上升趋势^[1]。输尿管结石能否自发排出很大程度上取决于其大小和位置，直径≥10mm的近端输尿管结石自发排出的可能性较小^[2]。当较大的近端输尿管结石出现嵌顿时，可能引起肾积水、继发感染、输尿管息肉、输尿管狭窄等^[3]。目前，较大的近端输尿管结石的主要治疗手段包括体外冲击波碎石术（extracorporeal shock wave lithotripsy，ESWL）、经输尿管镜碎石术（ureteroscopic lithotripsy，URSL）、经皮肾镜碎石术（percutaneous nephrolithotripsy，PCNL）和腹腔镜输尿管碎石术（laparoscopic ureterolithotomy，LU），由于治疗效果、手术并发症、经济负担和患者意愿等存在差异，其最佳选择方案仍存在争议^[4-6]。由于纳入研究的证据水平和文献数量不同，不同的文献综述和meta分析得出的结果也存在差异。例如在一项URSL、PCNL及LU治疗输尿管近端大结石（直径>10mm）的系统综述和meta分析中，研究人员推荐URSL作为治疗较大近端输尿管结石的标准疗法^[4]。而另一项meta分析最终推荐PCNL，并建议进一步研究微创PCNL^[3]。基于此，为提供更加详细的信息、更高水平的证据，本研究进行meta分析，比较PCNL与URSL治疗近端输尿管结石的疗效与并发症。

1. 资料与方法

1.1 检索策略

1.2 纳入与排除标准

1.3 数据提取及质量评估

1.4 统计学处理 

2. 结果

2.1 文献特征

2.2 患者基线特征

2.3 疗效评估

2.4 手术并发症

3. 讨论

近端输尿管结石手术治疗方案的选择主要取决于结石大小、肾积水、感染状况、费用、可用器械和患者意愿等^[21]。对于<10mm的近端输尿管结石，ESWL自20世纪80年代引入以来一直是首选治疗方案。在某些情况下，URSL具有更好的疗效和更低的费用，或将取代ESWL成为<10mm的近端输尿管结石的一线选择^[1,22]。根据欧洲泌尿外科协会泌尿系结石治疗指南的建议，ESWL已经失去作为大多数肾结石和输尿管结石一线治疗方案的地位，目前推荐URSL和PCNL等内腔镜手术作为一线治疗方案^[23]。对于≥10mm的近端输尿管结石，ESWL、URSL、PCNL和LU均为可供选择的治疗方案。PCNL、LU均比URSL、ESWL更有效，同时并发症发生率也相对较高^[5,11]。考虑到不同术式的不同特点、术者经验、可用器械和患者意愿等，≥10mm的近端输尿管结石的首选推荐治疗方案尚未形成统一共识。本研究纳入的13篇文献报告了年龄、性别和结石位置（左/右）的相似性，而结石大小存在统计学差异。然而，在具体每项研究中，结石大小均不存在统计学差异，因此，本课题组认为该差异可能是由于不同文献的临床异质性和方法学异质性造成的。本研究结果显示，PCNL初始结石清除率和最终结石清除率均高于URSL，但只有4篇文献报告了初始结石清除率。需要指出的是，各文献用于判断结石清除率的随访时间不完全一致。11篇文献的随访时间超过1个月，2篇文献随访时间不足1月。上述结果表明，与URSL相比，PCNL清除大的近端输尿管结石更加有效。近端输尿管碎石的相关并发症是限制手术治疗方案选择的关键因素之一。多数文献均报告了并发症，但是每项研究重点关注的并发症类型存在差异。其中，术后≥38℃的发热和输血是大多数研究均关注的重要并发症。汇总分析显示，与URSL相比，PCNL手术时间和住院时间更长，说明PCNL可能更复杂、并发症更严重。只有5篇文献报告了总并发症，meta分析并未发现PCNL与URSL的并发症发生率存在统计学差异。虽然两者并发症发生率是相似的，但是与URSL相比，PCNL术后发热和输血率更高。5篇文献未报告术后发热，并不清楚未报告的具体原因。输血的患者均来自PCNL组，URSL组未报告需输血的情况，说明PCNL可能存在危及生命的出血。由于50%的研究为回顾性分析，这限制了结果的质量。此外，近年来内腔镜手术的技术和理念得到了较大发展，不同时期行PCNL和URSL在技术上可能存在差异，一定程度上也限制了结果的质量。发热和输血是报告最多的并发症，而其他并发症在部分研究中未见报道。对于多数研究未见报道的并发症，本课题组并未对其进行进一步的统计分析。综上所述，与URSL比较，PCNL治疗较大的近端输尿管结石更有效，但其危险性较高，具有更高的结石清除率、术后发热率和输血率。

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