重力震動排石療法對於下端腎結石經震波碎石術後廓清之影響

Abstract

背景與目標： 下端腎結石接受震波碎石後，其結石因重力沈積之故不易排出體外。臨床上有許多治療可以增進結石之廓清；例如倒立、給予利尿以及利用敲擊震動之方式。本研究目標為下端腎結石經過震波碎石術後，給予重力震動排石治療是否可增加其結石之廓清率並減少剩餘結石之面積。同時並找出可能影響結石廓清率之預測因子。 方法： 本研究為回溯性世代研究。114人因下端腎結石而接受體外震波碎石治療。其中58人僅接受震波碎石術，另外56人在震波碎石術後同時接受每週一次，為期一個月（至多4次）的重力震動排石治療。重力震動排石治療過程為：病人飲用500ml清水並接受利尿劑注射。30分鐘後面朝下平躺且上半身向下傾斜45°，並在結石患側綁上震動器實行10分鐘之震動治療。術後一個月及三個月分別接受X光檢查來確認結石廓清率以及剩餘結石之大小。 結果： 兩組患者之年齡、性別、體質比、結石之患側、結石長度、結石面積、腎盞長度、腎盞寬度、腎盞高度、腎盞腎盂夾角、腎盞輸尿管夾角、腎盞脊椎夾角、最大震波強度、震波次數以及震波碎石時間等各變數均無明顯之差異。震動排石治療組與控制組相比，在術後一個月（35.7% vs 19.0%, p=0.045）及術後三個月（46.4% vs 24.1%, p=0.013）之結石廓清率均有顯著增加。另外在結石面積減少之比率方面，震動排石治療組亦明顯大於控制組（術後一個月：68.7% vs 23.4%, p<0.001；術後三個月:82.5% vs 27.9%, p<0.001）。此外除了震動排石治療以外，術後一個月結石廓清之預測因子為結石面積（OR=0.95, 95%CI 0.91－0.99）以及腎盞腎盂夾角（OR=1.07, 95%CI 1.01－1.15）。而術後三個月結石廓清之預測因子為結石面積（OR=0.95, 95%CI 0.92－0.99）、腎盞寬度（OR=2.50, 95%CI 1.32－4.75）以及腎盞腎盂夾角（OR=1.07, 95%CI 1.01－1.13）。 結論： 下端腎結石之患者經震波碎石術後給予重力震動排石治療，可顯著增加術後一個月以及三個月之結石廓清率。

Background and Objectives: Treating lower pole renal stones with shockwave lithotripsy can result in incomplete stone clearance due to poor drainage of residual stone fragments, leading to recurrent stone formation. Clinically we can use the adjunct treatments, such as diuresis, gravity therapy or percussion to facilitate the stone passage. The objectives of this study is to determine whether percussion, diuresis and inversion (PDI) therapy can improve the clearance rate of lower pole renal stone after shockwave lithotripsy. Methods: 114 patients with lower pole renal stone who received shockwave lithotripsy were arranged into two groups. One group (n=58) received shockwave treatment alone, and the other group (n=56) received shockwave lithotripsy followed by weekly PDI therapy (range 1 to 4). PDI therapy was performed as follows. Patient drank 500ml water and received 20mg Furosemide injection. After 30 minutes, they lay in prone position with upper trunk 45°downward to the ground. A vibrator was applied over the flank and subjects received vibration therapy for 10 minutes. Patients received follow up one month and three months after the shockwave lithotripsy. Stone clearance and residual stone characteristics were documented with plain abdominal radiography. Result: There were no significant differences in both groups while comparing demographics, total stone diameter, radiological features (infundibular neck diameter, infundibular length, caliceal height, infundibular-pelvic angles, infundibular-ureteral angles, infundibular-vertebral angles, cortical thickness) and shockwave parameters (shockwave intensity and duration). The radiologically documented complete stone clearance rates were significantly different in one months (control vs PDI: 19.0% vs 35.7%, p=0.045) and three months (control vs PDI: 24.1% vs 48.2%, p=0.006). There was also significant difference in change of stone area between two groups in one month (23.4% v.s. 68.7%, p<0.001) and three months (27.9% v.s. 82.5%, p<0.001). The predictors for one month stone clearance were initial stone area (OR=0.95, 95% CI 0.91－0.99) and infundibular-pelvic angle (OR=1.07, 95% CI 1.01－1.15). The predictors for three month stone clearance were initial stone area (OR=0.95, 95% CI 0.92－0.99), infundibular neck diameter (OR=2.50, 95% CI 1.32－4.75) and infundibular-pelvic angle (OR=1.07, 95% CI 1.01－1.13). Conclusion: Percussion, diuresis and inversion therapy is effective in assisting the clearance of lower pole renal stone after shockwave lithotripsy.