| Urinary stones are a widespread disease worldwide,with incidence rates varying by race and region,but the overall incidence is increasing year by year.A range of minimally invasive procedures and devices have been created,developed and are becoming the mainstream choice for the treatment of urinary stones.Early ureteral rigid scopes could only treat ureteral stones below the level of the iliac vessels,but with the advent of ureteral semi-rigid scopes and more flexible ureteral flexible scopes,ureteroscopic lithotripsy can treat kidney stones in any pelvis or calyx.The standard percutaneous nephroscope is 26 Fr or even larger.In order to reduce postoperative complications such as bleeding and infection after percutaneous nephrolithotomy,the diameter of the percutaneous nephroscope has been reduced and newer nephroscopes such as microchannel percutaneous nephroscope and ultramicrochannel percutaneous nephroscope have been developed.At present,international guidelines still recommend percutaneous nephrolithotomy as the first choice for the treatment of stones over 2 cm,because percutaneous nephrolithotomy has the advantage of not being affected by stone load in terms of removal rate.At the same time,with the development of ureteroscopy and its auxiliary devices,the stone removal efficiency of ureteroscopy has increased significantly,and its lithotripsy scope has gradually increased,and more and more doctors and patients are using ureteroscopic lithotripsy as the first choice for large stones over 2 cm.The aim of this study was to compare the efficacy of microchannel percutaneous nephrolithoscopy with ureteral chondroscopy in the treatment of renal stones over 2 cm by controlling preoperative baseline indices in patients with urinary stones through propensity-matched analysis,and to perform subgroup analysis to analyze the differences in the efficacy of these two common minimally invasive lithotripsy procedures in different populations.Objective To compare the safety and efficacy of mini-percutaneous nephrolithotomy(mPCNL)and flexible ureteroscope lithotripsy(f-URS)in the treatment of renal stones more than 2cm,and to explore the specific restrictions by subgroup analysis of stone length and patient age.Methods The clinical data of patients with urinary calculi who underwent minipercutaneous nephrolithotomy or transurethral flexible ureteroscopy lithotripsy for kidney stones larger than 2cm in Qilu Hospital of Shandong University from January 2016 to March 2021 were retrospectively collected,and the preoperative clinical indicators were analyzed by propensity score matching.In order to obtain comparable patients with no significant difference in preoperative clinical baseline data,the postoperative indicators of the two surgical methods were compared.The stone length was stratified with 2.5cm as the dividing line,and the efficacy of mPCNL and transurethral flexible ureteroscope were compared in stones of 2-2.5cm and more than 2.5cm,respectively.At the same time,according to the age of patients,the patients were divided into young,middle and elderly groups,and the performance of the two surgical methods in different age groups was compared.Results A total of 313 patients with large stones who underwent mini-percutaneous nephrolithotomy or flexible ureteroscope lithotripsy were enrolled.According to the different surgical methods,the patients were divided into mPCNL group and f-URS group.There were significant differences in preoperative clinical variables such as gender,stone burden,stone length,and stone location between the two groups.Therefore,propensity score matching analysis was used to match the preoperative clinical data of the patients to obtain comparable patients.A total of 162 patients were included in the study,including 81 patients in the mPCNL group and 81 patients in the f-URS group.There was no significant difference in preoperative clinical data between the two groups.The postoperative hospital stay in the fURS group was significantly shorter than that in the mPCNL group(3,2 days vs 7,2 days,P<0.001),and the postoperative complications in the f-URS group were also less than those in the mPCNL group(9,11.1%vs 25,30.9%,P=0.002).The operative time(100,50 minutes vs 110,60 minutes,P=0.081),immediate stone-free rate(63,77.8%vs 60,74.1%,P=0.714),and 3-month stone-free rate(78,96.3%vs 79,97.5%,P=1.000).In the subgroup analysis of stone length,we found that for stones between 2-2.5cm,the complication rate in the f-URS group was significantly lower than that in the mPCNL group(6,9.8%vs 18,29.5%,P=0.006),and there was no significant difference in operation time and complications.However,when the stone size was larger than 2.5cm,there was no significant difference in complications between the two groups(3,15.0%vs 7,35.0%,P=0.144).The stone clearance rate in the fURS group was lower than that in the mPCNL group,but it was limited by the number of cases.There was no statistically significant difference(9,45.0%vs 14,70.0%,P=0.110).In the subgroup analysis of patients’ age,the postoperative complications of f-URS in the young group(18-39 years old)were significantly lower than those in the mPCNL group(1,5.9%vs 9,37.5%,P=0.028),while there was no significant difference in postoperative complications between the middle and old groups.Conclusion In the treatment of renal stones larger than 2cm,f-URS has shorter postoperative hospital stay and fewer postoperative complications.There is no significant difference in operation time and stone clearance rate between the two groups.When we subdivide the stone length into two groups of 2-2.5cm and>2.5cm,the safety and effectiveness of the two procedures are different.For 2-2.5cm renal stones,patients in the fURS group had fewer complications and shorter postoperative hospital stay,and there was no significant difference in operation time and immediate stone clearance rate between the two groups.When the stone length was more than 2.5cm,the stone clearance rate in the f-URS group was lower than that in the mPCNL group,but there was no significant difference.There was no significant difference in postoperative complications and operation time between the two groups.When we analyzed the subgroup of patients’ age,we found that the incidence of postoperative complications of f-URS in the young group was significantly lower than that in the mPCNL group,while the postoperative complications of f-URS in the middle and old groups increased with the increase of age,so that there was no difference between the postoperative complications of f-URS and mPCNL,suggesting that f-URS may be a better choice for young patients. |
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