导读 尽管目前科学技术取得了进步,但尿路结石的发病率仍居高不下。欧洲泌尿外科学会(EAU)尿路结石指南专家组制定该指南以帮助泌尿外科医师评价尿路结石的循证诊疗手段,并将诊疗建议与临床实践相结合。该指南涵盖尿路结石的绝大多数方面。有关膀胱结石的处理作为另一部指南单独列出。需要指出的是,尽管临床指南基于专家们所能获得的最佳证据,但遵循指南建议并不一定会取得最佳结果。当对某一患者做出诊疗决策时,指南永远不能取代临床专业知识,同时还应考虑患者的价值观、喜好/个体情况。EAU尿路结石指南于2000年首次发布,2020版对2019版作了部分更新,在2021版更新时将对结石患者的随访做出优化。 1. 简介(略) 2. 方法(略) 3.1 流行病学、分类及复发风险 3.1.1简介: 结石的发病率取决于地理、气候、种族、饮食和遗传因素。复发风险基本上由引起结石形成的疾病或病症决定。尿路结石的患病率为1%到20%不等[8]。在生活水平较高的国家(例如瑞典,加拿大或美国),肾结石患病率显著较高(> 10%)。据报道,有些地区在过去的20年的患病率增加超过了37%[9-11]。越来越多的证据表明肾结石与慢性肾脏疾病的风险有关[12]。 结石可分为以下几类:非感染性结石、感染性结石、遗传相关性结石和药物不良反应(药物结石)(表3.1)。另请参阅第3.2节。 3.1 结石分类:
3.1.2 结石成分: 结石成分是进一步诊断和管理决策的基础。结石通常是由各种物质混合而成的。表3.2列出了临床最相关的物质及其矿物成分。
3.13、结石形成风险因素: 结石形成者的风险状况是一个大家感兴趣的事情,由于它事关结石复发长大的可能性,以及是否需要药物治疗的必要性。 约50%的复发性结石形成者会终生复发[10,14]。高度复发者约占10%(略高于)。结石的类型和疾病的严重程度决定了复发的低风险或高风险(表3.3)[15,16]。 表3.3: 结石形成的高危因素
3.2 结石分类: 尿路结石可根据结石的大小、位置、x线特征、形成的原因、成分及复发的风险等进行分类[10,32 -34]。 3.2.1 结石大小: 结石大小测量通常采用一维或二维的图像层面,根据最大直径可分为5、5-10、10-20和> 20 mm的尺寸。 3.2.2 结石位置 结石按解剖位置可分为:上、中、下肾盏(结石)、肾盂(结石)、输尿管上段(结石)、中段(结石)或下段(结石)和膀胱(结石)。以下指南中没有讨论膀胱结石的治疗。 3.2.3 影像学特征 可以根据普通的X射线外观(KUB)对结石进行分类,不同的矿物成分在X线上表现有所不同[34]。非增强计算机断层扫描(NCCT)可用于根据密度,内部结构和成分对结石进行分类,这对治疗方案有指导作用(第3.3节)[32,34]。 表3.4 影像学特征分类
3.3 诊断评估: 3.3.1 影像学诊断: 最合适的影像学检查根据临床情况而定,具体情况将根据诊断考虑是输尿管结石还是肾结石而有所不同。 标准评估包括详细的病史和体格检查。输尿管结石患者通常会出现腰部疼痛,呕吐,有时发烧,但也可能无症状[35]。对于有发烧或对肾绞痛的诊断有疑问的孤立肾患者,应立即进行评估。超声(US)作为主要的诊断成像工具。不管是否疼痛缓解或出现其他紧急措施,都不应该延迟影像学评估。超声波是安全的(无辐射风险),可重复性强且价格低廉。超声可以判断结石是位于肾盏,或是肾盂,或是UPJ还是UBJ处,同时可以判断上尿路(UUT)扩张的情况。超声对输尿管结石的敏感性为45%,特异性为94%,对肾结石的敏感性为45%,特异性为88%[36,37]。 KUB的敏感性和特异性为44-77%[38]。如果考虑行CT平扫,则不应进行KUB [39]。但是,KUB有助于区分可透X线和不透X线的结石,以利于随访期间的比较。 3.3.1.1对急性腰痛/疑似输尿管结石患者的(影像学)评估 非增强计算机断层扫描(NCCT)已成为诊断急性腰痛的标准,基本取代了静脉泌尿造影(IVU)。NCCT可以确定结石的直径和密度。如果检查没有结石,应辨别腹痛的原因。对于可疑的急性尿石症患者时,NCCT的准确性明显高于IVU [40]。 非增强CT可以检测出透X光的尿酸和黄嘌呤结石,但茚地那韦结石则仍检查不出[41]。非增强CT可以确定结石密度,结石内部结构,皮肤到结石的距离以及周围的解剖结构,这些信息都会影响治疗方式的选择[34,42-44]。非造影成像的优势必须与肾功能和集合系统解剖信息缺失相平衡,放射剂量亦是如此[45-48]。 低剂量CT可以降低放射风险,但是,在标准临床工作中可能很难考虑放射风险[49-51]。在体重指数(BMI)<30的患者中,低剂量CT对<3 mm的输尿管结石的敏感性为86%,对于结石> 3 mm的结石的敏感性为100%[52]。一项有关前瞻性研究的META分析 [51]显示,低剂量CT诊断出的尿路结石症的总敏感性为93.1%(95%CI:91.5-94.4),特异性为96.6%(95%CI:95.1-97.7%)。双能CT可以区分含尿酸的结石和含钙的结石[53]。 3.3.1.2 对肾结石患者影像学评估 静脉尿路造影(IVU)可以提供肾功能,集合系统结构和尿路梗阻程度的信息,而CT可以快速获取3D数据,包括有关结石大小和密度,皮肤到结石的距离以及周围解剖结构的信息,但是会增加辐射暴露的成本。除了在肥胖患者中结石或非常小的结石外,低剂量和超低剂量方案似乎可以产生与标准剂量方案相当的结果[51,52,54,55]。 一项小型随机研究显示,与IVU相比,在行仰卧位经皮肾镜检(PNL)中,使用CT进行术前计划可简化手术操作并缩短手术时间[56]。 如果拟行手术碎石取石术,则需要进行增强扫描评估肾脏集合系统[57]。 3.3.1.3 诊断影像的证据和指南摘要
3.3.2 代谢相关性诊断 除了影像学检查,每一位尿结石急症患者除了影像学检查外,还需要对尿液和血液进行简单的生化检查。在这一点上,结石形成的高危和低危患者一视同仁。 3.3.2.1 基础实验室检查分析-非急症尿石症患者 所有结石患者的生化检查相似。但是,如果没有计划的干预措施,则可以省略钠,钾,C反应蛋白(CRP)和凝血时间等检查。 只有对结石高复发风险的患者才应接受更具体的分析程序[16]。结石特异性代谢评估在第4章中进行了描述。 诊断结石的最简单方法是使用经过验证的方法(第3.3.2.3节中列出)对排出的结石进行分析。一旦知道了矿物成分,就可以确定潜在的代谢紊乱。 3.3.2.2 结石成分分析 首次结石患者都应进行结石成分分析。 在临床实践中,对于以下情况需要重复结石分析:
指导患者过滤尿液,以提取待分析的结石。确认结石的排出和肾功能的恢复。 首选的分析方法是红外光谱(IRS)或x射线衍射(XRD)[60-62]。用偏光显微镜可以得到相同的结果。化学分析(湿化学)通常被认为是过时的[60,63]。
3.3.3特殊群体和情况下的诊断: 3.3.3.1 妊娠期影像学诊断 在孕妇中,辐射暴露可能引起非随机(致畸)或随机(致癌,诱变)效应。致畸作用随着剂量的增加而累积,且要一定的阈剂量(<50 mGy被认为是安全的),并取决于胎龄(8周之前和23周之后的最低风险)。致癌作用(甚至<10 mGy的剂量也有危险)和诱变作用(需要500-1000 mGy的剂量,远远超过普通放射学研究中的剂量)随着剂量的增加而恶化,但它们不需要剂量阈值,并且不依赖 在胎龄上[65]。 孕妇不应该常规接受重复的影像学检查。当US[66]、X线成像[67,68]和MRI[69,70]被用于诊断评估时,科学团体和组织要一致认为诊断评估是安全的。如果已明确需要接受放射线检查,且这些(检查)将影响其医疗护理,孕妇则不应拒绝接受放射线检查。 一般而言,对胎儿辐射剂量大于0.5mGy的检查需要有正当理由。 超声(必要时,使用肾阻力指数的变化和经阴道/经腹超声膀胱充盈)已成为评估疑似肾绞痛孕妇的主要放射诊断工具。然而,妊娠期正常的生理变化可模拟输尿管梗阻[73-75]。 磁共振成像可以作为一种二线检查手段 [71],可以用来确定尿路梗阻的程度,结石表现为一种充盈缺损[69]。由于3T MRI尚未在妊娠期进行评估,目前建议使用1.5T [72,77]。为了避免对胚胎的毒性作用,妊娠期不推荐使用钆[73]。 对于妊娠期尿路结石的检查,与MRI(80%)和US(77%)相比,低剂量CT的阳性率更高(95.8%)。根据怀特等研究提示,低剂量CT可提高诊断准确性,避免输尿管镜检查等负面干预措施[78]。尽管低剂量CT方案可减少放射线照射,但目前仍建议孕妇慎用,作为最后的选择[73]。 3.3.3.1.1 妊娠期影像学诊断的证据和指南总结
儿童尿路结石有很高的复发风险,因此,对高危患者应采用标准的诊断程序,包括有效的结石分析(第3.1.3节和第4章)。最常见的促进结石形成的非代谢性疾病为膀胱输尿管返流(VUR)、UP梗阻、神经源性膀胱和其他的排尿困难[79]。 在选择诊断程序以确定儿童尿石症时,应记住这些患者可能不合作,需要麻醉,并且可能对电离辐射敏感。再次强调,应当遵循ALARA原则(As Low As Reasonably Achievable)[80-82]。 超声波 超声是儿童主要的影像学检查手段[83]。对于儿童,它的优点是没有辐射,不需要麻醉。影像学检查应包括充盈的膀胱和输尿管上段[84-88]。彩色多普勒超声可显示输尿管(尿液)喷出[85]和双肾弓状动脉阻力指数的差异,提示梗阻级别[86]。然而,US未能识别40%的儿童结石[87-90],且提供有限的肾功能信息。 腹平片(KUB) KUB有助于鉴别结石及其透光度,便于随访。 静脉尿路造影术 IVU的放射剂量与膀胱尿道造影的放射剂量相当(0.33mSV)[91]。然而,需要注射造影剂是一个主要的缺点。 螺旋计算机断层扫描 最新低剂量CT方案已被证明可以显著减少辐射暴露[48,55,92]。在儿童中,只有5%的结石“逃脱”NCCT的检测[85,92,93]。现代高速CT设备很少需要镇静或麻醉。 磁共振尿路成像术 磁共振尿路造影(MRU)不能用于检测尿结石。然而,它可能提供关于集合系统、输尿管梗阻或狭窄的位置以及肾实质形态的详细解剖学信息[94]。 表3.3.3.2.1儿童影像学诊断的证据和指南摘要
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Leppert, A., et al. Impact of magnetic resonance urography on preoperative diagnostic workup in children affected by hydronephrosis: should IVU be replaced? J Pediatr Surg, 2002. 37: 1441. https://www.ncbi.nlm./pubmed/12378450 (未完待续~~) 原文链接:https:///guideline/urolithiasis/ 译者简介 声明 内容仅供参考,转载请后台联系授权,侵权必究! 编译:徐煜宇(广州医科大学第五附属医院) 编辑:榭小仙 校对:王冬 |
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