Effect of flexible ureteroscope lithotripsy and percutaneous
nephrolithotomy on the levels of serum inflammatory factors, oxidative
stress and stress hormone in patients with renal calculi
Su-Dong Liang
1, Gao-Fei Lyu
2, Ya-Shi Ruan
1, Ming-Hua Zheng
1, Tian-Li Niu
11. Department of Urology, Taizhou People's Hospital, Jiangsu, Taizhou 225300, China
2. Department of Urology, Yongzhou Central Hospital, Hunan, Yongzhou 425000, China
Journal of Hainan Medical University
http://www.hnykdxxb.com
ARTICLE INFO ABSTRACT
Article history:
Received 11 Oct 2017
Received in revised form 15 Oct 2017 Accepted 18 Oct 2017
Available online 28 Oct 2017
Keywords: Kidney stone
Flexible ureteroscopic lithotripsy Percutaneous nephrolithotomy Inflammatory factors Oxidative stress Stress hormones
Corresponding author: Su-Dong Liang, Department of Urology, Taizhou People's Hospital, Jiangsu, Taizhou 225300, China.
E-mail: liangsudong657@163.com
Fund Project: Science and Technology of Jiangsu Health Department (NO. Y201514).
1. Introduction
Kidney stone is one of the common diseases of the urinary system, the incidence and recurrence rate is higher. China is one of the three major areas of the world's major urinary tract stone, the hospitalization rate ranked first in urology[1]. In addition to pure uric acid stone, in line with the indications are feasible surgical
treatment[2]. Trauma of traditional open surgery is large, with slow recovery, less application, along with the development of endoscopic technology at home and board, minimally invasive laparoscopic surgery is becoming the mainstream treatment. Percutaneous nephrolithotomy (PCNL) and ureteral soft lithotripsy (FURL) are the main treatment regimen, with significant effect, the current clinical research focused on the treatment effect, while ignoring its impact on the body series of stress response[3,4]. Therefore, from the inflammation, stress hormones and oxidative stress, they research is in order to clarify its treatment advantages.
Objective: To investigate the effect of flexible ureteroscope lithotripsy and percutaneous nephrolithotomy on levels of serum inflammatory factors, oxidative stress and stress hormone in patients with renal calculi. Methods: A total of 97 cases of renal calculi patients were chosen as the research objects, based on the random data table, they were divided into the control group (n=49) and the observation group (n=48), patients in the control group underwent percutaneous nephrolithotomy (PCNL) treatment, while the observation group patients were treated with flexible ureteroscope lithotripsy (FURL), before and after 1 d ,the levels of inflammatory factors [interleukin-10 (IL-10), C reactive protein (CRP), white blood cell (WBC)], stress hormone [cortisol (COR), adrenocorticotropic hormone (ACTH), norepinephrine (NE)] and oxidative stress [malondialdehyde (MDA), superoxide dismutase (SOD) ] of the two groups were compared. Results: There were no significant differences in IL-10, CRP, WBC, COR, ACTH, NE, MDA and SOD levels between the two groups preoperative; Compared with the preoperative level in the group, the 1 d post-operation levels of IL-10, CRP, WBC, COR, ACTH, NE and MDA in the two groups were significantly increased, and the level of the observation group was significantly lower than that in the control group; The levels of SOD in the two groups 1 d post-operation were significantly lower
2. Data and method
2.1. Data
A total of 97 patients with renal calculi admitted in Taizhou People's Hospital of Jiangsu Province and Yongzhou Central Hospital of Hunan province from August 2015 to August 2017 were selected as the subjects. All patients were eligible for the selection criteria of this study. The study was accorded with the relevant standards of the hospital ethics committee, approved by the ethics committee of hospital. According to the random data table method, divided into the control group and the observation group (49 cases, 48 cases respectively), in the control group, 33 males, 16 females;
aged 35 to 64 years; the average diameter of stones (1.36 ± 0.27)
cm; 28 cases of single stone, 21 cases of multiple stones. 29 males, 19 females, aged 34 to 65 years in the observation group, average
diameter of stones (1.41 ± 0.22) cm; 30 cases of single stones, 18
cases of multiple stones. There was no significant difference in sex ratio, age, average diameter of stones and number of stones between the two groups (P>0.05).
2.2 Selection criteria
Inclusion criteria: (1) by abdominal CT, urinary tract X-ray film (KUB plain film) and urinary system color ultrasound and other tests confirmed as single or multiple stones; (2) patients with normal renal
function; (3) stone diameter ≤ 2.0 cm; (4) patients with blood routine,
urine and other laboratory tests were normal; (5) patients and their families are informed and signed informed consent; (6) clinical data after admission was complete. (Ureter, severe ureteral stenosis); (1) Combined with severe heart, liver, lung, kidney and other organ dysfunction; (2) Patients with intolerance (3) Anatomic structural malformation of urinary tract (urethra, severe ureteral stricture) (4) urinary tract infection in acute stage, malignant tumors; (5) with pelvic trauma, surgery and radiotherapy history; (6) mental illness, cannot cooperate with the completion of treatment; (7) clinical data incomplete or do not want to join the researchers.
2.3 Treatment methods
Both groups were given tracheal intubation general anesthesia. The patients in the control group were treated with PCNL: the lithotomy was treated by conventional ureteroscopy, and the F5 ureteral catheter was inserted into the ipsilateral renal pelvis and fixed to the ureter to prevent the catheter from falling off. Termination of catheter connect with normal saline to continue infusion to form "artificial hydronephrosis". Patients to the prone position, adjust the position, use of B-probe to observe the location, number and ipsilateral kidney hydration of stones, to locate the puncture, establishment of percutaneous renal channel, in the axillary line and the twelfth rib margin cross Point (or under 2 cm of cross) to do 1.0-1.5 cm small
incision, puncture the kidney collection system, to be punctured after the successful placement of the zebra guide wire, used fascia dilator along the direction of guide wire expansion channel to F16 - F24, Into the percutaneous nephrolithotomy, inserted the lens, found stones, exited the zebra guide wire. Used ultrasonic crushed stone gravel, the gravel pieces washed out by the lavage, carefully check whether the residual calyces and active bleeding, etc., in the ipsilateral ureteral stayed 5F double J tube, out of the mirror core, And placed a F20 kidney fistula, out of the mirror sheath, suture fixed.
Patients in the observation group were given FURL treatment: routine cystoscopy was performed before 1 to 4 weeks when the stone was taken, and the ipsilateral ureteral F5 double J tube was inserted. After the success of anesthesia, took the lithotomy position, in the ureter under direct vision through the urethra inserted into the ureteroscope to the bladder, removed the F5 double J tube, observed the ureteral opening position, the ipsilateral ureteral catheter inserted into the ureteral catheter along the catheter ureteroscopy, the urethral soft wire (7.5 F STORZ) along the zebra guide wire along the sheath inserted into the renal pelvis, looking for stones after the exit Zebra
guide wire into the 200 μm holmium laser fiber for gravel, carefully
checked whether the residual calculus and active bleeding, etc., removed the holmium laser fiber, ureter soft mirror, etc., 5F double J tube stayed in the ipsilateral ureter , finished surgery after indwelling catheter.
2.4 Indexes observation
5 mL of fasting peripheral venous blood in two groups of patients were extracted before and 1 d after surgery, after centrifugation to take serum, placed in -80 ℃ refrigerator for detection. Observation indexes including (1) serum inflammatory factors: interleukin-10 (IL-10), C-reaction protein (CRP) and white blood cell (WBC). (2) Oxidative stress: malondialdehyde (MDA), superoxide; (3) stress hormone: cortisol (COR), adrenocorticotropic hormone (ACTH), norepinephrine (NE). The levels of IL-10, MDA and SOD were detected by ELISA (ELISA kit was purchased from Shanghai Meilian Biotechnology Co., Ltd.). CRP was measured by immunoturbidimetry. WBC was measured by automatic biochemical analyzer. COR, ACTH and NE were measured by Roche Electrochemiluminescence analyzer, and the method was chemiluminescence. Operation was carried out according to the instructions.
2.5 statistical analyses
SPSS 17.0 statistical software was used to analyze the data. The levels of inflammatory factors, stress hormones and oxidative stress were normal distribution, and the expression was conformed to
normal distribution, presented by Mean ± SD, comparison intergroup
3. Results
3.1 Comparison of inflammatory factors in both groups
There was no significant difference in IL-10, CRP and WBC between the two groups (P>0.05). 1 d after surgery, the levels of IL-10, CRP and WBC in the two groups were significantly higher than those in the preoperative group (P<0.05), and the level of
the observation group [(15.91 ± 5.65) ng/L, (21.54 ± 2.67) mg/L, (25.62 ± 5.49) ng/L, (12.23±1.29)×109/L] were significantly lower
than control group [(25.62±5.49) ng/L, (29.61±3.22) mg/L and (16.63±1.07)×109/L], The difference was significant (P<0.05) (see
Table 1).
3.2 Comparison of oxidative stress levels in both groups
There was no significant difference in the levels of MDA and SOD between the two groups (P>0.05). 1 d after surgery, comparison of
MDA level, control group (6.58±0.64) mmol/L and the observation group (6.12±0.58) mmol/L were significantly higher than those
in the preoperative group (P<0.05), and the control group was significantly higher than the observation group (P<0.05); 1 d after surgery SOD level in control group and observation group were
(85.65±9.95) U/mL and (94.71±7.63) U/mL respectively, which
were lower than those in the preoperative (P<0.05), moreover control group was significantly lower than observation group, the difference was significant (P<0.05) (see Table 2).
3.3 Comparison of stress levels in both groups
There was no significant difference in COR, ACTH and NE between the two groups (P>0.05). The levels of COR, ACTH and NE 1d after surgery in the control group and the observation group were significantly higher than those in preoperative group, the difference was significant (P<0.05). Compared with COR, ACTH and NE level in the control group1d after surgery, the levels of COR, ACTH and
NE in observation group (33.74±13.96) nmol/L, (35.76±4.65) ng/ L and (239.77±25.42) ng/mL, respectively, and the difference was
significant (P<0.05) (see Table 3 ).
4. Discussion
According to incomplete statistics, the incidence of kidney stones in China was 1% to 5%, the annual increased incidence
of 15 to 20 cases/million, and showed an increasing trend[4]. The formation of kidney stone is mainly due to excessive intake of diet can form stone, clinical symptoms mainly were paroxysmal severe pain, hematuria,etc, can cause urinary tract obstruction and hydronephrosis, increase risk of urinary tract cancer, seriously affected the quality of life of patients[5,6]. Clinical treatment included antispasmodic, analgesic, anti-inflammatory and traditional Chinese medicine and other symptomatic treatment, removing calculus and surgical treatment, which is mainly surgical treatment[7]. In
Table 1.
Comparison of inflammatory factors in both groups.
Group n Treatment time IL-10 (ng/L) CRP (mg/L) WBC (×109/L)
Control group 49 Before operation 4.70±0.87 5.39±1.21 5.42±0.93
1 d after operation 25.62±5.49* 29.61±3.22* 16.63±1.07*
Observation group 48 Before operation 4.57±1.06 5.34±1.39 5.38±1.05 1 d after operation 15.91±5.65*# 21.54±2.67*# 12.23±1.29*#
Note: *compared with the preoperative level, P<0.05; #compared with the control group 1 d after operation, P<0.05.
Table 2.
Comparison of oxidative stress levels before and after treatment.
Group n Treatment time MDA (mmol/L) SOD (U/mL)
Control group 49 Before operation 6.04±0.69 99.45±9.64
1 d after operation 6.58±0.64* 85.65±9.95*
Observation group 48 Before operation 5.84±0.79 101.55±9.08
1 d after operation 6.12±0.58*# 94.71±7.63*#
Note: *compared with the preoperative level, P<0.05; #compared with the control group 1 d after operation, P<0.05.
Table 3.
Comparison of stress levels before and after treatment.
Group n Treatment time COR (nmol/L) ACTH (ng/L) NE (ng/mL)
Control group 49 Before operation 96.47±12.79 25.76±3.61 203.42±21.79 1 d after operation 167.29±20.91* 53.60±6.17* 302.71±33.67*
ObservationGroup 48 Before operation 95.82±12.02 25.92±3.89 204.28±20.35 1 d after operation 118.74±13.96*# 35.76±4.65*# 239.77±25.42*#
recent years, with the development of micro-cavity technology, the emergence of new treatment methods, such as PCNL, FURL and extracorporeal shock wave lithotripsy (ESWL), etc. Relevant studies have pointed out that minimally invasive surgery can effectively reduce the chronic inflammation caused by surgical trauma, reduce the body damage, more conducive to improving the quality of life of patients, better meet the modern concept of urological minimally invasive treatment[8-10].
PCNL had] visual operation, small surgical trauma, rapid postoperative recovery and high security advantages, has become the first choice for most of the treatment of kidney stones[11]. FURL as a new type of endoscopic technique, without the need for renal puncture, can directly enter to renal pelvis through the natural cavity, less damage to patients, patients with less pain, more conducive to recovery and shorten the hospital stay[12]. Although the two programs have definite curative effects on kidney stones, there was still a lot of controversy about the treatment of stones less than 2 cm in diameter[13]. The aim of this study was to clarify the advantages of both treatments for diameters less than 2 cm in kidney stones, from inflammatory factors, oxidative stress and stress hormone and other serum indexes.
A large number of clinical studies have confirmed that under the stimuli of surgery and other injury factors the defense system of body was activated and caused inflammatory response, but the release of inflammatory factors would lead to further damage to the
body[14,15]. WBC levels were significantly increased after surgery,
CRP was an acute phase response protein synthesized by the liver when the body was damaged or had chronic inflammation. The level of CRP was positively correlated with inflammatory response, infection and injury. WBC and CRP were sensitive indexes of injury and inflammation[16]. IL-10 as a multi-functional anti-inflammatory factor, with a strong immune suppression and immune regulation effect, on the one hand to inhibit proinflammatory factor overexpression, on the other hand to control the inflammatory response caused by body damage, but its level over-expression can inhibit immune function, thereby increasing the condition[17]. The results of this study showed that the levels of WBC, CRP and IL-10 were significantly increased in both patients after treatment, which indicated that surgical treatment could lead to chronic inflammatory reaction, and the increase of inflammatory factor level after FURL treatment was significantly lower than that of PCNL, indicating that FURL was less invasive in patients, the body produced less inflammatory stress, the results of the study was consistent with the previously reported content[18,19].
In addition to WBC, CRP and IL-10 and other inflammatory factors, hormones and oxidation and antioxidant function also played an important role in surgical stress. Surgical stress can promote the genesis of active oxygen free radicals, active nitrogen
free radicals and other highly active molecules, thereby resulting in body oxidation and anti-oxidation imbalance[20]. MDA and SOD were oxidized products and antioxidants respectively, both of which were clinically more commonly used to reflect the level of oxidative stress[21]. Adrenal, hypothalamic-pituitary-adrenal cortical axis system activation was an important manifestation of stress response in the body, after surgery, COR, ACTH levels were significantly increased, COR increased more obvious, can be used as an important measurement index of body stress response[22]. The results showed that the levels of COR, ACTH, NE and MDA were significantly increased and the levels of SOD were significantly decreased after treatment in the two regimens, and the effect of FURL on the indexes of patients was significantly lower than that of PCNL. The results of this study showed that FURL surgery on the patient's stress response was less, more conducive to the recovery of the disease. The reason may be related to FURL surgery without renal puncture, reducing its damage to the kidney and kidney around the organization.
In summary, in the treatment of kidney stones that diameter less than 2 cm, compared with PCNL surgery, FURL surgical treatment of patients with less trauma, mainly presented as little inflammatory stress response, oxidative stress and hormone levels and had important clinical value.
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