Abstract
目的
探讨因新型冠状病毒肺炎(corona virus disease 2019, COVID-19)疫情而延迟拔除输尿管支架对泌尿系结石术后患者生活质量(quality of life, QoL) 和心理状态的影响。
方法
选择2019年12月至2020年6月在北京大学人民医院接受上尿路内镜碎石术后留置输尿管支架并返回医院取出支架患者的病例资料进行回顾性分析，收集患者人口学资料、输尿管支架症状问卷(ureteral stent symptoms questionnaire, USSQ)评分、焦虑自评量表(self-rating anxiety scale, SAS)评分和抑郁自评量表(self-rating depression scale, SDS)评分等。USSQ由6个维度(包括排尿症状、躯体疼痛、一般健康状态、工作表现、性功能和支架相关感染)共44个问题组成，量表大部分问题采用李克特(Likert)五级量表，小部分问题采用四级或七级量表量化。SAS和SDS均由20个问题组成, 用于评估患者的焦虑抑郁状态，两个量表采用李克特四级量表，主要统计指标总分(20~80分)。使用标准分(总分乘以1.25取其整数)量化临床焦虑和抑郁程度，并运用矩阵结构分析构建多群组结构方程模型。
结果
共纳入患者71例，输尿管支架中位留置时间对照组32(30, 33) d与延迟组94.5(88, 103) d相比，差异有统计学意义。延迟组患者在USSQ多维度中(包括排尿症状、一般健康状态、工作表现和支架相关感染)得分较高，焦虑和抑郁程度也明显比对照组严重。延长输尿管支架留置时间会加重患者排尿症状、躯体疼痛共同对工作表现的负面影响(P=0.029 < 0.05)，其中，患者较严重的排尿症状导致工作表现欠佳受延长置管时间的影响最显著(CR=2.619>1.96)。新型冠状病毒肺炎疫情期间患者焦虑抑郁程度与支架相关症状严重度呈正相关。
结论
因新型冠状病毒肺炎疫情延迟拔管患者的QoL较差，焦虑和抑郁程度较重；新型冠状病毒肺炎疫情期间患者焦虑抑郁程度越重，支架相关症状会加重。为了提高泌尿系结石术后患者在新型冠状病毒肺炎疫情期间的QoL和心理健康水平，应避免延长支架留置时间或采取相应的干预措施。
Keywords: 延长输尿管支架留置时间, 生活质量(QoL), 焦虑, 抑郁, 新型冠状病毒肺炎
Abstract
Objective
To explore the impacts of delayed ureteral stent removal on the quality of life (QoL) and mental health of urinary calculi postoperative patients due to the corona virus disease 2019(COVID-19) pandemic.
Methods
The demographic and clinical data of patients with ureteral stent placement after urinary endoscopic lithotripsy and returned to Peking University People's Hospital for stent removal from December 2019 to June 2020 were collected. Ureteral stent symptoms questionnaire (USSQ) score and the outcome 20-item self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were collected to estimate the QoL and mental status. The USSQ consisted of 44 questions in 6 domains (including urinary symptom, physical pain, general health, work performance, sexual function, and ureteral stent related infection). For most questions in each domain, its score was a five-point Likert-type scale from 1 to 5, and a small proportion of questions was quantified by 1 to 4 or 1 to 7 scale. SAS and SDS both contained 20 questions used to assess a patient's level of anxiety and depression. Its scoring for each item was on a four-point Likert-type scale from 1 to 4. A total score (ranging from 20 to 80) was the main statistical indicator. The level of clinical anxiety and depression was quantified by using standard scores (total score multiplied by 1.25 to produce integers). And the multi-group structural equation model was constructed by analysis of moment structure (AMOS) analysis.
Results
Overall, 71 patients were enrolled for analysis. It was found that the median duration of ureteral stent time differed significantly between the control and delayed groups for 32 (30, 33) d and 94.5 (88, 103) d, respectively. The delayed group resulted in higher scores in the USSQ multidimensional, which included urinary symptoms, general health, work performance and ureteral stent related infections. Anxiety and depression were also significantly serious in the delayed group than in the control group. A longer indwelling time of a ureteral stent could exacerbate the effects of urinary symptoms and physical pain on work performance (P=0.029 < 0.05). Among them, the patients with severe urinary symptoms leading to poor work performance were most significantly affected by prolonged ureteral stent duration time (CR=2.619>1.96).
Conclusion
Patients with delayed ureteral stent removal due to the COVID-19 had resulted in worse QoL and mental status. Stents related symptoms are more severe in patients with higher anxiety and depression degree during COVID-19. To improve the QoL and mental health of patients after urinary calculi surgery during COVID-19, it is still not recommended to prolong the stent duration time or corresponding intervention measures should be taken.
Keywords: Prolonged ureteral stent duration time, Quality of life (QoL), Anxiety, Depression, Corona virus disease 2019 (COVID-19)
上尿路结石患者通常需要在内镜碎石术后留置输尿管支架以促进尿液流动，从而减轻梗阻和泌尿系感染[1]。虽然留置输尿管支架对上尿路结石术后患者有益，但也会引起支架相关不适并降低患者的生活质量(quality of life, QoL)。有研究表明，留置输尿管支架不可避免地会引起支架相关排尿症状及躯体疼痛，对患者的一般健康状态、工作表现等均有影响，故应尽量减少支架留置时间[2-3]，然而，仍有很多患者因故不能按时返回医院取出输尿管支架。长时间留置输尿管支架可能会导致支架结壳、碎裂、感染或移位等支架相关并发症，严重时还可引起肾积水导致肾功能损害[4-5]，不仅会增加治疗费用，还会降低患者的QoL[6]。因此，上尿路结石术后留置输尿管支架患者的管理有重要意义。在新型冠状病毒肺炎(corona virus disease 2019, COVID-19)疫情期间，国家和医疗机构采取了一系列措施(包括隔离、跨地区交通限制，以及额外的入院前COVID-19筛查等)遏制COVID-19在院内传播；在此期间，结石术后需要拔除输尿管支架的患者常被归类为非急诊, 可能无法如期入院拔除支架[7]。此外，COVID-19致病性及传染性强，患者于疫情期间就诊也可能会产生焦虑抑郁等负面情绪，从而影响患者的QoL。因此，本研究旨在探讨因COVID-19疫情而延迟拔除输尿管支架对上尿路结石术后患者QoL和心理状态的影响，以期为在类似COVID-19疫情这种突发公共卫生事件期间延迟拔除输尿管支架的患者制定临床管理方案，并为相应的心理干预提供依据。
1. 资料与方法
1.1. 研究对象和方法
选择2019年12月至2020年6月在北京大学人民医院接受上尿路内镜碎石术后留置输尿管支架并返回本院取出支架患者的病例资料进行回顾性分析。排除标准：术前及术中诊断存在嵌顿结石者；泌尿系结石术中可见明显输尿管狭窄者；术后发现存在大于4 mm残余结石者；围术期出现全身感染者；有膀胱过度活动、间质性膀胱炎或神经源性膀胱者；无法配合相应问卷自评者。将入院拔除支架时输尿管支架留置时间超过2个月(>8周)的患者定义为延迟组，其余术后输尿管留置时间不超过2个月(≤8周)的患者作为对照组。所有患者入院拔除支架时均需完成一次问卷自评，分别是根据中文版输尿管支架症状问卷(ureteral stent symptoms questionnaire, USSQ)评估患者的支架相关QoL；通过焦虑自评量表(self-rating anxiety scale, SAS)和抑郁自评量表(self-rating depression scale, SDS) 评估患者的心理状态。本研究开始前获得北京大学人民医院伦理委员会批准(2021PHB004-001)。
1.2. 测量工具
鉴于Zhu等[8]的结果显示中文版USSQ具有良好的判别效度，以及本课题组前期研究结果显示该量表的Cronbach’s α为0.847(另文发表)，因此，采用USSQ。USSQ由6个维度(包含排尿症状、躯体疼痛、一般健康状态、工作表现、性功能和支架相关感染)共44个问题组成，量表大部分问题采用李克特(Likert)五级量表，小部分问题采用四级或七级量表量化。
SAS和SDS均由20个问题组成用于评估患者的焦虑抑郁状态，量表采用李克特四级量表，主要统计指标是总分(20~80分)。使用标准分(总分乘以1.25取其整数)量化临床焦虑和抑郁程度。上述量表在中国参与者中均有良好的效度和信度[9-10]。焦虑水平分为正常(25~49)、轻度(50~59)、中度(60~69)和严重(70及以上), 抑郁水平分为正常(25~52)、轻度(53~62)、中度(63~72)和严重(73及以上)。
1.3. 统计学分析
采用SPSS 22.0软件，符合正态分布的定量资料以x±s表示，两组间差异的比较采用t检验；不符合正态分布的定量资料采用M (P25, P75)表示，组间比较采用Mann-Whitney U秩和检验；非等级计数资料用构成比表示，组间比较采用χ2检验；等级计数资料则采用Mann-Whitney U秩和检验；相关性分析采用Pearson分析；以P＜0.05为差异有统计学意义。运用AMOS 23.0软件构建多群组结构方程模型并进行模型验证，CR≥1.96, P＜0.05为差异有统计学意义。
2. 结果
2.1. 一般情况
共纳入71例患者，其中延迟组36例(50.7%)。两组患者的基线特征包括输尿管支架留置时间、性别、年龄、手术类型、结石位置、工作状态、是否需要卧床及休息时间。对照组32(30, 33) d与延迟组94.5(88, 103) d相比，输尿管支架中位留置时间差异有统计学意义(表 1)。
表 1.
入组患者的基线特征资料
Baseline characteristics of enrolled patients
| Items | Control group | Delayed ureteral sent removal group | P |
| PCNL, percutaneous nephrostolithotomy; RIRS, retrograde intrarenalsurgery; URL, ureteroscopic lithotomy. | |||
| Number of patients, n(%) | 35 (49.3) | 36 (50.7) | |
| Duration ureteric stent time/d, M (P25, P75) | 32 (30, 33) | 94.5 (88, 103) | < 0.001 |
| Gender, n(%) | 0.144 | ||
| Male | 27 (77.1) | 22 (61.1) | |
| Female | 8 (22.9) | 14 (38.9) | |
| Age，n(%) | 0.552 | ||
| <40 | 12 (34.3) | 8 (22.2) | |
| 40-60 | 12 (34.3) | 17 (47.2) | |
| >60 | 11 (31.4) | 11 (30.6) | |
| Surgery type, n(%) | 0.017 | ||
| PCNL | 2 (5.7) | 11 (30.6) | |
| RIRS | 23 (65.7) | 20 (55.6) | |
| URL | 10 (28.6) | 5 (13.9) | |
| Stone location, n(%) | 0.275 | ||
| Left | 13 (37.1) | 18 (50.0) | |
| Right | 22 (62.9) | 18 (50.0) | |
| Working status, n(%) | 0.002 | ||
| Full time | 16 (45.7) | 9 (25.0) | |
| Not working or unemployed | 0 (0) | 10 (27.8) | |
| Retirement | 19 (54.3) | 17 (47.2) | |
| Bed rest, n(%) | 0.005 | ||
| No | 35 (100.0) | 28 (77.8) | |
| Yes | 0 (0) | 8 (22.2) | |
| Rest time, n(%) | 0.317 | ||
| None | 20 (57.1) | 25 (69.4) | |
| Half a day | 10 (28.6) | 5 (13.9) | |
| Two half a day | 5 (14.3) | 6 (16.7) | |
2.2. 输尿管支架相关症状评分
对照组19(18, 22)分与延迟组26(24, 27)分相比，中位排尿症状总分差异有统计学意义(P < 0.001，表 2)；延迟组的U1(尿频)、U3(尿急)、U4(急迫性尿失禁)、U6(尿不尽感)、U10(总体排尿不适的影响)和U11(长期留置支架的意向)分项中位评分均显著高于对照组(表 3)。总体而言，延迟组的排尿症状明显比对照组严重。
表 2.
入组患者输尿管支架相关症状评分
Results of USSQ score of the patients
| Items | Control group (n=35) | Delayed ureteral sent removal group (n=36) | P |
| USSQ, ureteral stent symptom questionnaire; SPDS, subjective pain degree score. | |||
| USSQ urinary symptom score (U1－U11), M (P25, P75) | 19 (18, 22) | 26 (25, 27) | < 0.001 |
| USSQ physical pain score (P4－P9), M (P25, P75) | 9 (7, 9) | 7 (6, 11) | 0.024 |
| Overall pain score (SPDS), x±s | 0.34±1.03 | 1.22±2.26 | 0.039 |
| Number of pain sites, x±s | 0.11±0.32 | 0.39±0.69 | 0.035 |
| USSQ general health score (G1－G6), M (P25, P75) | 10 (8, 11) | 15 (14, 16) | < 0.001 |
| USSQ work performance score (W5－W7), M (P25, P75) | 4 (3, 5) | 7 (7, 8) | < 0.001 |
| USSQ sexual function score (S4+S5), x±s | 1.34±1.95 | 1.08±1.96 | 0.578 |
| Sent related sexual abstinence/%, n (%) | 23 (65.7) | 28 (77.8) | 0.259 |
| USSQ ureteral stent related infection (I1－I5), M (P25, P75) | 7 (7, 8) | 10 (9, 11) | < 0.001 |
| Total USSQ score, M (P25, P75) | 52 (48, 53) | 68 (65, 72) | < 0.001 |
表 3.
入组患者输尿管支架相关症状分项评分
Results of ureteral stent symptoms questionnaire (USSQ) sub-score of the patients
| Items | Control Group | Delayed ureteral sent removal group | P |
| USSQ urinary symptom score | |||
| U1-daytime frequency, M(P25, P75) | 2 (1, 2) | 3 (2, 3) | < 0.001 |
| U2-nocturia, x±s | 2.23±0.88 | 2.33±0.59 | 0.555 |
| U3-urgency, M(P25, P75) | 1 (1, 2) | 2 (1, 2) | 0.001 |
| U4-straining to start, M(P25, P75) | 1 (1, 2) | 2 (1, 2) | 0.002 |
| U5-urge incontinence, x±s | 1.20±0.41 | 1.33±0.48 | 0.209 |
| U6-residual urine sense, M(P25, P75) | 2 (1, 2) | 3 (3, 4) | < 0.001 |
| U7-dysuria, x±s | 2.03±0.71 | 2.31±0.62 | 0.084 |
| U8-hematuria rate, M(P25, P75) | 2 (1, 2) | 2 (2, 3) | 0.016 |
| U9-hematuria amount, M(P25, P75) | 2 (1, 2) | 2 (2, 2) | 0.034 |
| U10-total symptom, M(P25, P75) | 1 (1, 2) | 2 (2, 3) | < 0.001 |
| U11-intention of long-term indwelling stent, M(P25, P75) | 3 (3, 3) | 4 (3, 4) | < 0.001 |
| USSQ physical pain score | |||
| P1-presence of pain, n(%) | 4 (11.4) | 10 (27.8) | 0.083 |
| P2-presence of upper abdominal pain, n(%) | 0 (0) | 0 (0) | - |
| P3-SPDS of upper abdominal pain | 0 | 0 | - |
| P2-presence of lower abdominal pain, n(%) | 0 (0) | 5 (13.9) | 0.054 |
| P3-SPDS of lower abdominal pain | 0 | 0.39±1.05 | 0.033 |
| P2-presence of suprapubic pain, n(%) | 0 (0) | 0 (0) | - |
| P3-SPDS of suprapubic pain | 0 | 0 | - |
| P2-presence of back pain, n(%) | 3 (8.6) | 9 (25) | 0.065 |
| P3-SPDS of back pain, x±s | 0.23±0.81 | 0.83±1.54 | 0.042 |
| P2-presence of penis pain, n(%) | 1 (2.9) | 0 (0) | 0.493 |
| P3-SPDS of penis pain, x±s | 0.11±0.68 | 0 | 0.324 |
| P4-physical activity, x±s | 1.20±0.41 | 1.47±0.81 | 0.078 |
| P5-sleep difficulty, M(P25, P75) | 1 (1, 1) | 1 (1, 2) | 0.024 |
| P6-pain during voiding, M(P25, P75) | 2 (2, 3) | 1 (1, 2) | 0.002 |
| P7-flank pain during voiding, x±s | 1.51±0.51 | 1.44±0.50 | 0.562 |
| P8-analgesics, x±s | 1.20±0.41 | 1.31±0.58 | 0.377 |
| P9-effects of stent-related pain, x±s | 1.40±0.55 | 1.61±1.13 | 0.319 |
| USSQ general health score | |||
| G1-light physical activities | 1 | 1 | - |
| G2-heavy physical activities, M(P25, P75) | 3 (2, 3) | 4 (3, 4) | < 0.001 |
| G3-tiredness and fatigue, M(P25, P75) | 1 (1, 2) | 2 (2, 2) | < 0.001 |
| G4-calm and tranquility, M(P25, P75) | 1 (1, 2) | 3 (3, 4) | < 0.001 |
| G5-social activities, M(P25, P75) | 1 (1, 2) | 4 (3, 4) | < 0.001 |
| G6-extra help from relatives and friends, x±s | 1.60±0.50 | 1.72±0.45 | 0.284 |
| USSQ work performance score, M(P25, P75) | |||
| W5-shorten working hours | 1 (1, 1) | 2 (2, 2) | < 0.001 |
| W6-change the usual job | 1 (1, 2) | 2 (1, 2) | 0.002 |
| W7-working hours | 2 (1, 3) | 4 (3.75, 4) | < 0.001 |
| USSQ sexual function score, x±s | |||
| S4-dyspareunia | 1.23±0.43 | 1.17±0.38 | 0.519 |
| S5-sexual life | 2.74±0.51 | 2.94±0.23 | 0.037 |
| USSQ ureteral stent related infection score | |||
| I1-urinary tract infection frequency, M(P25, P75) | 1 (1, 2) | 2 (2, 3) | < 0.001 |
| I2-antibiotic use, M(P25, P75) | 1 (1, 1) | 1 (1, 2) | < 0.001 |
| I3-extra help from medical staff, x±s | 1.14±0.36 | 1.25±0.44 | 0.262 |
| I4-seek medical attention, M(P25, P75) | 1 (1, 1) | 1 (1, 1) | 0.006 |
| I5-intention to indwell the second stent on the opposite side, M(P25, P75) | 3 (3, 4) | 4 (4, 4) | < 0.001 |
延迟组疼痛部位数量(0.11±0.32 vs. 0.39±0.69, P < 0.05，表 2)和主观疼痛程度评分(subjective pain degree score, SPDS)(0.34±1.03 vs. 1.22±2.26, P < 0.05，表 2)均显著高于对照组。其中，延迟组下腹痛SPDS(0.39±1.05)和背痛SPDS(0.83±1.54)显著高于对照组(P < 0.05，表 3)。
延迟组患者的一般健康状态评分[10(8, 11) vs. 15(14, 16), P < 0.001，表 2]和工作表现评分[4(3, 5) vs. 7(7, 8), P < 0.001，表 2]均低于对照组。与对照组相比，延迟组中位支架相关感染评分更高[7(7, 8) vs. 10(9, 11.25), P < 0.001，表 2]，延迟组患者发生尿路感染的频率更高(表 3)。延迟组的中位USSQ总分显著高于对照组[52(48, 53) vs. 68(65, 72), P < 0.001，表 2]，表明COVID-19疫情期间延迟组患者的支架相关症状更严重，QoL更差。
2.3. 延长输尿管支架留置时间的调节作用
根据Pearson相关性分析提示除了躯体疼痛、性功能外，其余各维度间均有显著相关性(表 4)，构建延长输尿管支架留置时间(后简称：置管时间)作用于USSQ多维度的理论模型(图 1)，利用AMOS 23.0对理论模型进行假设检验，发现患者排尿症状越严重，其一般健康状态越差(非标准化回归系数=0.637>0，P < 0.05，表 5)，但延长置管时间并不会加重上述影响(P=0.574>0.05，表 5)。尽管患者输尿管支架相关感染越严重，排尿症状越严重，一般健康状态和工作表现越差(非标准化回归系数=0.623 vs. 0.572 vs. 0.565>0，P < 0.05，表 5)，但是延长置管时间同样不会加重此影响(P=0.351>0.05，表 5)。此外，患者排尿症状和躯体疼痛对工作表现的影响显示排尿症状与工作表现呈负相关(P < 0.05，表 5)，并且进一步对理论模型中该路径的变量进行效应分解，发现延长置管时间可以显著加重患者较差的排尿症状对工作表现的负面影响(P=0.029 < 0.05，表 5；CR=2.619>1.96)。
表 4.
USSQ各维度间相关性分析
Correlation analysis among ureteral stent symptoms questionnaire (USSQ) dimensions
| Items | Urinary symptom | Physical pain | General health | Work performance | Sexual function | Ureteral stent related infection |
| *P < 0.05，#P < 0.001. | ||||||
| Urinary symptom | 1 | |||||
| Physical pain | -0.120 | 1 | ||||
| General health | 0.626# | 0.035 | 1 | |||
| Work performance | 0.578# | 0.007 | 0.779# | 1 | ||
| Sexual function | 0.243* | -0.114 | 0.065 | 0.064 | 1 | |
| Ureteral stent related infection | 0.617# | -0.063 | 0.558# | 0.547# | 0.099 | 1 |
图 1.
延长输尿管支架留置时间作用于USSQ多维度的理论模型
Theoretical model of prolonging the indwelling time of ureteral stent on multidimensional ureteral stent symptoms questionnaire (USSQ)
表 5.
延长置管时间作用于USSQ多维度理论模型的路径分析
Path analysis of ureteral stent symptoms questionnaire (USSQ) multidimensional theoretical model by extending the duration time of the stent
| Hypothesis model | Estimate | CR | P | Label | Chidist | |
| General health | Urinary symptom | 0.637 | 6.995 | < 0.05 | Relationship exist | 0.574 |
| Physical pain | 0.113 | 1.241 | 0.215 | No relationship | ||
| Work performance | Urinary symptom | 0.588 | 6.114 | < 0.05 | Relationship exist | 0.029 |
| Physical pain | 0.079 | 0.821 | 0.412 | No relationship | ||
| Urinary symptom | Ureteral stent related infection | 0.623 | 6.664 | < 0.05 | Relationship exist | 0.351 |
| Physical pain | Ureteral stent related infection | -0.057 | -0.474 | 0.636 | No relationship | |
| General health | Ureteral stent related infection | 0.572 | 5.835 | < 0.05 | Relationship exist | |
| Work performance | Ureteral stent related infection | 0.565 | 5.725 | < 0.05 | Relationship exist | |
2.4. 新冠疫情期间患者心理状态对输尿管支架相关症状的影响
延迟组患者的焦虑和抑郁程度显著高于对照组(P < 0.001，表 6)，其中延迟组36例(100%)患者表现出轻度至中度焦虑；33例(91.7%)患者表现出轻度至中度抑郁。构建新型冠状病毒肺炎疫情期间患者心理状态和USSQ多维度的理论模型(图 2)，结果表明患者的焦虑、抑郁程度越严重，一般健康状态和工作表现越差，输尿管支架相关感染也越严重(P < 0.05，表 7), 并且，患者的抑郁程度与排尿症状严重程度呈正相关(P < 0.05，表 7)。
表 6.
入组患者SAS和SDS评分
Results of patients' SAS and SDS
| Group | SAS | SDS | |||||||||
| Normal | Mild | Moderate | Severe | P | Normal | Low | Moderate | Severe | P | ||
| SAS, self-rating anxiety scale; SDS, self-rating depression scale. | |||||||||||
| Control, n(%) | 19 (100) | 14 (33.3) | 2 (20) | - | < 0.001 | 19 (86.4) | 14 (40) | 2 (14.3) | - | < 0.001 | |
| Delayed group, n(%) | 0 (0) | 28 (66.7) | 8 (80) | - | 3 (13.6) | 21 (60) | 12 (85.7) | - | - | ||
图 2.
新冠疫情期间患者心理状态和USSQ多维度的理论模型
Theoretical model of patients' mental status and USSQ multidimensional assessment during the COVID-19 pandemic
表 7.
新型冠状病毒肺炎疫情期间患者心理状态和USSQ多维度理论模型的路径分析
Path analysis of patients' mental status and USSQ multidimensional theoretical model during COVID-19 pandemic
| Path diagram | Estimate | CR | P | Label |
| USSQ, ureteral stent symptoms questionnaire; SAS, self-rating anxiety scale; SDS, self-rating depression scale. | ||||
| SAS | ||||
| Urinary symptom | 0.186 | 1.671 | 0.095 | No relationship |
| Physical pain | -0.145 | -1.226 | 0.220 | No relationship |
| General health | 0.336 | 3.389 | < 0.05 | Relationship exist |
| Work performance | 0.433 | 4.500 | < 0.05 | Relationship exist |
| Ureteral stent related infection | 0.284 | 2.694 | 0.007 | Relationship exist |
| SDS | ||||
| Urinary symptom | 0.313 | 2.814 | 0.005 | Relationship exist |
| Physical pain | 0.056 | 0.470 | 0.638 | No relationship |
| General health | 0.446 | 4.496 | < 0.05 | Relationship exist |
| Work performance | 0.405 | 4.210 | < 0.05 | Relationship exist |
| Ureteral stent related infection | 0.376 | 3.571 | < 0.05 | Relationship exist |
3. 讨论
本研究发现因COVID-19疫情上尿路结石术后延迟取出输尿管支架患者的QoL较差，焦虑和抑郁程度较重, 并且延迟组患者焦虑抑郁程度与支架相关症状呈正相关。此外，延长输尿管支架留置时间会加重患者排尿症状和躯体疼痛共同对工作表现的负面影响，其中，患者排尿症状对工作表现的负面影响受延长置管时间的影响最显著。
延迟组患者USSQ总分增加与排尿症状和支架相关感染加重显著相关，也与一般健康状态和工作表现欠佳显著相关。以往的研究指出，输尿管支架留置于患者体内，由于支架本身的物理特性不可避免的频繁刺激膀胱引起支架相关排尿症状和躯体疼痛[11]。此外，长期留置支架影响了膀胱输尿管抗反流机制，导致膀胱内的尿液沿着支架管反流至上尿路，患者短期可并发腰部疼痛、肾盂肾炎，长期可引起肾积水导致肾功能损害，势必导致患者一般健康状态和工作表现下降[12-13]。遗憾的是，支架本身的物理特性导致的不适尚未有可靠的解决办法。值得注意的是，本研究延迟组较对照组患者出现更显著的下腹部或背部SPDS，并伴有支架相关躯体疼痛引起的睡眠障碍，这与Kuehhas等[14]的研究结果一致。本课题组推测除了支架本身的物理性质与支架走行区域产生的异物刺激疼痛外，也可能是支架留置时间延长导致尿液反流所致，长时间的躯体疼痛对于无法耐受的患者可能影响其睡眠，进而导致患者一般健康状态和工作表现欠佳。
本研究还发现延迟组支架相关感染分数增加主要与更频繁的尿路感染和抗生素使用有关。研究表明延长置管时间与细菌定植水平呈正相关，置管时间超过3个月，细菌定植率可达75.1%[4, 15-16]；类似地，支架结壳率也随着置管时间延长增高[17]。输尿管植入体内后，支架表面即可为生物膜沉积和细菌定植提供环境，延长置管时间不可避免地提高了细菌定植率和支架结壳率[18]，此外，生物膜本身可抵抗细菌受机体免疫系统识别和抗生素的抗炎作用，并且多种细菌定植于生物膜常导致单一抗生素治疗无效或疗程延长[18-19]。
多群组结构方程模型验证了延长置管时间对USSQ多维度影响的调节作用。本研究发现患者排尿症状和躯体疼痛共同对工作表现的负面影响可随着置管时间延长加重，其中患者较重的排尿症状导致工作表现欠佳受延长置管时间的影响更显著，然而，支架相关感染症状对患者排尿症状、一般健康状态和工作表现的影响并没有因置管时间延长而加重，因此，置管时间延长是导致患者工作表现欠佳的因素之一，避免置管时间延长可以减轻患者排尿症状对工作表现的负面影响。
延长置管时间的患者除了支架相关并发症会影响总体QoL，本研究还发现COVID-19期间患者的焦虑和抑郁程度越重可导致支架相关不适症状加重，从而降低QoL，并且，延迟组患者更容易出现轻中度焦虑抑郁。COVID-19背景下患者因故延迟拔管，与泌尿外科的资源分配变化(包括推迟非急诊手术、跨区域就诊的隔离限制和额外的入院筛查)有关，会导致情绪应激压力和许多负面的心理反应，包括抑郁、焦虑、担忧、感觉无助等。大多数人面对COVID-19都有负面情绪[20]，本课题组推测延迟组患者的主要心理压力源可能是拔管计划不确定以及置管时间延长引起的支架相关不适症状反复出现和加重。鉴于促进患者心理健康可能改善个人QoL[21]，为了保护泌尿系结石术后患者在COVID-19期间的身心健康，应避免延长支架留置时间。
综上所述，延迟组患者总体QoL下降，焦虑和抑郁程度较重，并且COVID-19期间患者的焦虑和抑郁程度较重可导致支架相关不适症状加重。根据多群组结构方程模型验证结果，置管时间延长是导致患者工作表现欠佳的因素之一，避免置管时间延长可能减轻患者排尿症状对工作表现的负面影响。考虑到泌尿系结石术后患者COVID-19期间身心健康与支架相关QoL, 应避免延长患者支架留置时间，或采取相应的干预措施。希望本研究得出的结果，能够为在类似COVID-19疫情这种突发公共卫生事件期间的医务人员提供理论和实践依据，以更好地对上尿路结石术后因故置管时间延长患者进行管理。
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