Effects of RIRS and Mini-PCNL on liver and kidney function,endocrine changes and trauma in

44Journal of Hainan Medical University 2019; 25(3): 44-47Journal of Hainan Medical University☒Corresponding author: Hong-Xin Liu, Department of Urology, Chongming Branch,Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 202150, China.Fund Project:Chongming County Science and Technology Development Fund Project. Project No: CKY2015-07.1. IntroductionThe upper ureteral calculi belong to the urinary system diseases.The main manifestations are bladder irritation, frequent and urgent urination and hydronephrosis [1]. Some patients have complicated infection and urinary tract obstruction [2]. In patients with severeconditions, the stones need to be removed by surgery. Common surgical procedures for the treatment of urinary calculi include percutaneous nephrolithotomy (PCNL) and combined ureteroscopy (RIRS)[3,4]. Minimally invasive PCNL (Mini-PCNL) can reduce surgical trauma, but it is easy to cause intraoperative massive hemorrhage and kidney damage [5,6]. The efficacy of RIRS is better, and it can exceed 90% of stone removal rate in the first stage [7,8]. However, there are few reports on the differences in liver and kidney function and endothelium changes and trauma between RIRS and Mini-PCNL in the treatment of upper ureteral calculi. This study compared the therapeutic effects of the two surgical methods and reported the following.Jin-Cheng Yin et al./ Journal of Hainan Medical University 2019; 25(3): 44-47452. Materials and methods 2.1 Clinical data100 patients with upper ureteral calculi who were treated in our hospital from March 2016 to February 2018 were randomly divided into observation group and control group. Among them, 50 patients in the observation group (RIRS group) included 35 males and 15 females, aged 36-60 years, with an average diameter of calculus (1.19±0.23) cm. The degree of hydronephrosis was mild in 24 cases and moderate in 26 cases. The course of disease was 3 months to 5 years; the other 50 cases as the control group (Mini-PCNL group), including 33 males and 17 females, aged 35-58 years, with an average diameter of calculus (1.20±0.25) cm, the degree of hydronephrosis was mild in 26 cases, moderate in 24 cases, duration of disease from 3.5 months to 5 years. There were no differences in the general data of gender, age, stone diameter and hydronephrosis between the two groups. There was no statistical difference (P >0.05), which could be compared and analyzed. The study was approved by the hospital ethics committee, and patients or their families were informed and signed consent forms.Inclusion criteria: (1) patients were in line with the clinical diagnostic criteria for upper ureteral calculi [9]; (2) patients were diagnosed by abdominal vertical position radiograph and CT and met the corresponding surgical lithotripsy indications. Exclusion criteria: (1) patients with a history of urinary calculi surgery; (2) patients with severe heart, liver, renal insufficiency, coagulopathy, urinary tract infection, spinal deformity; (3) patients with clinical data missing.2.2 MethodsThe RIRS group used a combined ureteroscopy technique, as follows: The patient was given general anesthesia and the stone position was intercepted. In order to explore the ureteral condition of the affected side, place the ureter hard endoscope into it and observe whether there is a narrow distortion along the way. It is best to extend the hard endoscope to the position of the ureteral stone to determine the specific condition of the stone. Then insert the zebra guidewire along the hard endoscope, withdraw the endoscope after placing it. Subsequently, insert the catheter with the soft-sleeve sheath along the zebra guide wire until the position of the calculi, remove the inner core of the guide wire, and then insert the ureteral hose along the soft-lens sheath, and look straightly and conduct the holmium laser lithotripsy. The Mini-PCNL group was treated withminimally invasive percutaneous nephrolithotomy. The specific operation was as follows: the patient chose general anesthesia, supine position, and the percutaneous renal dilatation channel was established by means of ultrasound. After the sheath was placed, the holmium laser lithotripsy was performed. Both groups were given routine anti-infective treatment after surgery, and double "J" tubes were placed for 1-4 weeks.2.3 Indicators observation3 to 5 mL of the venous blood of the two groups was collected before and after surgery, and the supernatant was separated by centrifugation. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-transpeptidase (γ-GT), urea nitrogen (BUN) and serum creatinine (Scr) using an automated biochemical analyzer Horizontal detection; application of enzyme-linked immunosorbent assay for adrenocorticotropic hormone (ACTH), cortisol (Cor), norepinephrine (NE) and serum soluble vascular cell adhesion molecule-1 (sVCAM-1) levels; Western blot was used to detect sedimentation (ESR) level.2.4 Statistical methodsThe data were analyzed by SPSS 19.0 statistical software. The measurement data were expressed by mean ± standard deviation ( x±s). The two groups were compared by independent sample t test. When P <0.05, the difference was considered statistically significant.3. Results3.1 Liver function factors of both groupsThere were no significant differences in liver function factor levels (including ALT, AST, and γ-GT) between the RIRS group and the Mini-PCNL group before and after surgery, and there was no significant change between the two groups after surgery (P >0.05), see Table 1.3.2 Renal function factors of both groupsThere were no significant differences in renal function factor levels (including BUN and Scr) between the RIRS group and the Mini-PCNL group before and after surgery, and there was no significant difference between the two groups (P >0.05). See Table 2.Table 2.Comparison of renal function factors between the two groups.Table 1.Comparison of liver function factors between the two groups (U/L).Jin-Cheng Yin et al./ Journal of Hainan Medical University 2019; 25(3): 44-47 463.3 Endocrine change factor levels of both groupsThere were no significant differences in endocrine change factor levels (including ACTH, Cor and NE) between the two groups (P>0.05). After surgery, the levels of endocrine change factors in the two groups were significantly increased than those before surgery (P<0.05). And the levels of endocrine change factors in the RIRS group [ACTH was (27.37±3.29) pg/mL; Cor was (150.09±18.47) ng/mL; NE was (165.48±26.74) μg/L] and the Mini-PCNL group [ACTH was (38.42±4.33) pg/mL; Cor was (222.37±28.70) ng/ mL; NE was (287.26±25.29) μg/L], the difference was statistically significant (P<0.05), see table 3.3.4 Body trauma factor levels of both groupsThere was no significant difference in sVCAM-1 level and ESR level between the two groups before operation (P>0.05). After operation, the levels of sVCAM-1 in the two groups were significantly increased than those before operation (P<0.05). ESR level was obviously decreased (P<0.05), and the sVCAM-1 level in the RIRS group [(596.55±56.24) ng/mL] was significantly higher than that in the Mini-PCNL group [(820.62±72.89) ng/mL]. The ESR level of patients in the RIRS group [(8.29±0.63) mm/h] was significantly higher than that in the Mini-PCNL group [(7.16±0.68) mm/h], and the difference was statistically significant (P<0.05). Table 4.4. DiscussionThe upper ureteral calculi are a urological disease with multiple incidences and high incidence, which has a serious impact on the physical and mental health and quality of life of patients. In the case of diet regulation or drug treatment cannot achieve the desired effect, in order to solve the cause and prevent disease recurrence, surgical treatment is often used[10]. Clinically, there are many surgical methods for the treatment of upper ureteral calculi. Extracorporeal shock wave lithotripsy (ESWL) was once the preferred method, but the effect of lithotripsy will be affected by many factors, and some of the crushed calculi are not easily discharged. It has gradually been replaced by Mini-PCNL and RIRS surgical methods[11,12]. Operation of Mini-PCNL is achieved by establishing a percutaneous renal dilatation channel. The calculi removal effect is obvious, and the degree of trauma caused by operation can be reduced[13-15], but it is not effective to treat some calculi that are local, large, and stay for long time then leading to secondary mucosal pathological changes or ureteral stricture and distortion[16]. The RIRS's lithotripsy operation is achieved by a combined flexible ureteroscope. The components can be assembled and disassembled without disinfection[17]. The stone removal rate is high, with low complication rate, and short hospital stay, and the operation's trauma is little and able to avoid ureteroscopy damage to the urethra, high safety[18,19]. In addition, RIRS can also be used as a good choice for extracorporeal shock wave lithotripsy or secondary surgery for patients after percutaneous nephrolithotomy[20]. The two surgical methods, RIRS and Mini-PCNL, have received much attention, but there are few reports on the differences in liver and kidney function and endogenous secretion changes and trauma between the two types of surgery.The local operation of urinary surgery has a certain influence on the renal function of the patient, and the trauma caused during the operation will also cause liver function damage to some extent. ALT, AST and γ-GT are commonly used indicators to reflect liver cell damage. ALT is found in tissues such as heart, brain, kidney and skeletal muscle. It is not specific, but its high level can still indicate that liver cells are in damage state; AST was first discovered in hepatocytes and has a high specificity for liver disease[21]. Scr and BUN are often used to reflect renal function damage. When the glomerular filtration rate decreases, both levels are increased. Scr is the most commonly used clinical indicator. When the glomerular filtration rate drops to 50% of normal, its level will begin to rise rapidly, and it indicates that kidney function is already in a state of damage[22]. The results of this study showed that there was no significant difference in the levels of ALT, AST, γ-GT, BUN and Scr between two groups (P>0.05), suggesting that the effects of RIRS and Mini-PCNL on liver and kidney function were comparable.Trauma caused by surgical procedures (including intraoperative surgical procedures, postoperative indwelling catheters, etc.) is an important source of stress, not only damages liver and kidney function, but also activates stress response, releasing and increasing various endocrine hormones content[23,24]. Increased secretion of the adrenal cortex is an important endocrine change that occurs during stress. After stimulation by the hypothalamic hormone, the pituitary will release ACTH and act on the adrenal cortex, and the Cor secretion increases[3]. Cor and NE are the main stress hormones, as the body's stress state changing, its content will change, which can reflect the degree of trauma caused by surgery and predict the quality of postoperative rehabilitation[25-27]. The results of this study showed that after treatment, the levels of ACTH, Cor and NE in the RIRS group were significantly lower than those in the Mini-PCNLTable 3.Comparison of levels of endocrine change factors between the two groups.P P Table 4.Comparison of body trauma factor levels of two groups.P PJin-Cheng Yin et al./ Journal of Hainan Medical University 2019; 25(3): 44-4747group (P <0.05), suggesting that RIRS can better relieve the stress state of patients with upper ureteral calculi after surgery.The degree of surgical trauma is one of the important factors affecting the prognosis of patients. It not only stimulates the stress response, but also triggers inflammation, changes blood rheology, increases blood viscosity, causes blood stasis, etc., which is unfavorable to the body's microcirculation [28]. sVCAM-1 is a common cell adhesion molecule, and its expression level is related to body trauma. In the early stage of trauma, sVCAM-1 content will increase abnormally; ESR is an important indicator for blood rheology [29]. The results of this study showed that compared with the Mini-PCNL group, the sVCAM-1 level in the RIRS group was significantly decreased (P <0.05) and the ESR level was significantly increased (P <0.05), suggesting that the impact of RIRS procedure on the body trauma and blood viscosity is smaller.In summary, RIRS and Mini-PCNL have a similar effect on liver and kidney function in patients with upper ureteral calculi, and RIRS can better reduce postoperative stress, reduce trauma and influence on blood viscosity.References[1] N a YQ, Ye ZQ, Sun G. 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