NEJM:小的无症状肾结石,该不该手术?

2022-08-14 MedSci原创 MedSci原创

无症状肾结石(asymptomatic renal calculus)是2014年公布的泌尿外科学名词。无症状肾结石就是有肾结石,但是没有表现出任何症状,我们都知道大多数的肾结石患者有不同程度的腰痛。

无症状肾结石(asymptomatic renal calculus)是2014年公布的泌尿外科学名词。无症状肾结石就是有肾结石,但是没有表现出任何症状,我们都知道大多数的肾结石患者有不同程度的腰痛。结石较大,移动度很小,表现为腰部酸胀不适,或在身体活动增加时有隐痛或钝痛。较小结石引发的绞痛,常骤然发生腰腹部刀割样剧烈疼痛,呈阵发性。泌尿系统任何部位均可发生结石但常始发于肾,肾结石形成时多位于肾盂或肾盏,可排入输尿管和膀胱,输尿管结石几乎全部来自肾脏。

临床检查中,在各种影像学研究中通常会发现小的、无症状的肾结石。 当前的美国和欧洲指南是模棱两可的,美国指南建议可以积极监测无症状肾结石,但应为术后有小的残留肾结石碎片的患者提供内镜手术以去除它们。美国和欧洲指南引用了几项研究表明无症状患者肾结石和碎片在术后 5 年内复发的可能性约为 50%。美国或欧洲指南中引用的唯一一项前瞻性研究并未测试内窥镜手术的有效性,而是测试了冲击波碎石术。该研究倾向于观察无症状肾结石而不是手术,因为这两种方法在无肾结石患者数量或 1 年后额外治疗的数量方面没有显着差异。 此后进行的三项回顾性研究也支持对这类患者进行观察。其中一项研究表明,无症状对侧结石的同时治疗与 2 年后手术干预的减少无关。 在另一项研究中,决策分析用于评估手术切除 10 毫米无症状肾结石对生活质量的影响。作者认为主动监测对小型无症状结石而言是首选的管理决策。

因此,外科医生可能会或可能不会选择增加手术时间,并可能增加患者在原发性结石手术期间移除这些无症状或继发性结石的风险。我们将原发性结石定义为位于输尿管或肾脏内并产生症状或被认为具有引起不良临床事件的高风险的结石。继发性结石被定义为位于对侧肾脏(在原发性肾结石的情况下)或位于任一肾脏(在原发性输尿管结石的情况下,具有特定肾在随机化之前确定)。在现代内窥镜和激光出现之前,同时去除原发性和继发性结石是有问题的;然而,该程序目前是相当可行的。 由于缺乏去除无症状小肾结石的指南,因此设计了本试验。本试验中,将患者随机分配接受内窥镜移除其原发性和继发性结石(治疗组)或仅移除主要结石(对照组)。观察两组的复发、手术时间和临床上显著的不良手术事件,以确定去除小结石是否会导致治疗组患者的复发率低于对照组。

这项多中心、前瞻性、研究者发起的、非盲法、随机、对照试验由获得美国国立卫生研究院保密证书的作者设计和实施。本试验由美国国立糖尿病、消化系统疾病和肾脏疾病研究所资助,由美国退伍军人医疗系统提供支持。本试验获得了各参与机构审查委员会批准。

我们筛选了 21 岁或以上的患者,并计划在参与的大型城市三级医疗中心的泌尿外科诊所接受内窥镜手术治疗原发性结石。原发性结石的手术类型——输尿管镜检查或经皮肾镜取石术——是根据每位外科医生的实践偏好做出的临床决定,在试验中没有改变。纳入随机分组前 90 天内能够提供知情同意并在计算机断层扫描 (CT) 上发现一处或多处继发性结石的患者。有已知的全身性疾病或解剖性疾病(如髓质海绵肾、原发性甲状旁腺功能亢进、肾小管酸中毒、结节病和马蹄肾)的患者被排除。

患者以 1:1 的比例随机分配到治疗组或对照组。随机化是根据一个中心计划以 10 人为一组进行的,该计划旨在最大限度地减少招募随着时间的推移可能产生的影响。治疗组患者经输尿管镜取出继发性结石。记录去除原发性和继发性结石的手术时间。

术后约 90 天使用低剂量 CT 进行术后成像,之后大约每年一次。第一次术后扫描有助于建立新的基线并确定残留碎片​​;此后的年度扫描用于确定试验肾脏中结石的生长和新结石的形成。每 3 个月通过电话或门诊就诊联系患者,记录任何间隔结石事件、急诊科就诊或结石相关手术。随访患者长达 5 年。所有 CT 均由一位不知道分组情况的放射科医师审查。

所有患者都接受了标准的代谢评估和教育,以了解预防结石的适当饮食和液体摄入方案。通过 microCT (SkyScan 1172, Bruker) 和傅里叶变换红外光谱分析回收的结石。

主要结局是各组的复发,复发根据以下三项指标中的任何一项来确定:在随访期间(术后2周至5年),因初始无症状结石的同侧(试验侧)结石而到急诊就诊;在随访期间进行后续手术以取除试验侧结石;或初始继发性结石增大(用CT测量)。一例患者虽然可能有多起复发事件,但只能算作一次复发。

次要结局包括治疗组治疗继发性结石所需的手术时间;术后2周内与手术、支架或结石相关的急诊就诊;以及患者报告的结石排出和新的结石生长情况。结石增大的定义是:根据后续的CT扫描结果,结石一个维度的尺寸增长>1 mm,二个维度的尺寸增长≥1 mm。

该试验于 2015 年 5 月至 2021 年 9 月进行,最后一名患者于 2020 年 5 月入组。共有 75 名患者入组(图 1)。每组一名患者未接受手术,未纳入试验。在随访期间,每组中的一名患者死于与泌尿系统问题无关的原因。由于图 1 所列原因,每组有 3 名患者自愿退出试验。对照组有 1 名患者失访。所有数据都包含在患者死亡、退出或失去联系之前。这些组在基线特征方面是平衡的(表 1),并且代表了通常接受手术切除结石的人群。没有招募单肾患者和西班牙裔患者。没有适当的机制将拒绝参加的患者制成表格,但大多数拒绝参加的患者表示希望避免被随机分配到对照组的可能性,因为他们希望确保无症状的结石会被移除。

主要结果在图 2A 中显示为复发的累积发生率;通过该测量,对照组的复发率高于治疗组(时序检验 P <0.001)。治疗组的限制平均复发时间为 1631.6±72.8 天,对照组为 934.2±121.8 天。与对照组相比,治疗组复发的风险比为 0.18(95% CI,0.07~0.44)。复发事件总结在表 2 中。治疗组 38 名患者中有 6 名(16%)复发,对照组 35 名患者中有 22 名(63%)复发。这一差异(47个百分点)大于统计学功效计算中使用的差异(35个百分点)。

图2:累积事件复发率

表2. 主要有效性结局(复发)

 

图3 试验肾内新结石的累积发生率

由于担心结石生长可能不成比例地导致复发,因此进行了敏感性分析。当排除结石生长作为复发的标志时(图 2B),对照组的复发率仍然较高(通过时序检验 P = 0.002)。治疗组的复发时间比对照组长 36%,治疗组的平均复发时间为 1717.1±51.7 天,对照组为 1262.8±117.7 天。治疗组有 4 名患者 (11%) 和对照组有 15 名患者 (43%) 进行了急诊就诊或手术(复发的两项指标)。在治疗组和对照组中,不计入术后复发时为取除结石进行的访视或操作,急诊就诊或手术(包括支架放置)的总数分别为4(包括2次双侧手术)和23(包括10次手术)。

试验肾中新结石的累积发生率

次要结局中,治疗组 8 例患者(21%)和对照组 10 例患者(29%)观察到患者报告的结石排出(OR,0.67;95% CI,0.23 至 1.94)。这些数据包括每组 4 名患者,无论是患者还是试验人员都无法确定患侧。治疗组 7 名患者和对照组 6 名患者报告无症状结石或碎片排出。此外,通过成像检测到的新结石形成(图 3)和限制平均复发时间(新结石形成时间)相似——治疗组为 1338.8±104.0 天,对照组为 1381.1±100.5 天。治疗组 14 例患者(37%)和对照组 13 例患者(37%)形成新结石(OR,0.99;95% CI,0.38 至 2.56)。

我们的试验表明,与保留继发性结石相比,在输尿管或对侧结石的手术中取除小的无症状肾结石可以减少后续急诊就诊和手术次数,也可以减少结石生长。

原始出处:

Sorensen MD, Harper JD, Borofsky MS, Hameed TA, Smoot KJ, Burke BH, Levchak BJ, Williams JC Jr, Bailey MR, Liu Z, Lingeman JE.Removal of Small, Asymptomatic Kidney Stones and Incidence of Relapse.N Engl J Med  2022 Aug 11;387(6):506-513. doi: 10.1056/NEJMoa2204253

Goldfarb DS.Preemptive Removal of Small, Asymptomatic Kidney Stones.N Engl J Med . 2022 Aug 11;387(6):562-563. doi: 10.1056/NEJMe2208287

 

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    2023-03-04 lifestar 来自上海

    小的无症状#肾结石#,该不该手术?问题有什么药物可治疗?#中药#中的#利尿剂#是否有用,如#海金砂##瞿麦##石韦#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=2117475, encodeId=3faf211e47533, content=小的无症状<a href='/topic/show?id=07058265569' target=_blank style='color:#2F92EE;'>#肾结石#</a>,该不该手术?问题有什么药物可治疗?<a href='/topic/show?id=5c1d22423c8' target=_blank style='color:#2F92EE;'>#中药#</a>中的<a href='/topic/show?id=573332291bd' target=_blank style='color:#2F92EE;'>#利尿剂#</a>是否有用,如<a href='/topic/show?id=ae7710532ea8' target=_blank style='color:#2F92EE;'>#海金砂#</a>,<a href='/topic/show?id=7e3c105328c4' target=_blank style='color:#2F92EE;'>#瞿麦#</a>,<a href='/topic/show?id=c998105329a0' target=_blank style='color:#2F92EE;'>#石韦#</a>?, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82655, encryptionId=07058265569, topicName=肾结石), TopicDto(id=22423, encryptionId=5c1d22423c8, topicName=中药), TopicDto(id=32291, encryptionId=573332291bd, topicName=利尿剂), TopicDto(id=105327, encryptionId=ae7710532ea8, topicName=海金砂), TopicDto(id=105328, encryptionId=7e3c105328c4, topicName=瞿麦), TopicDto(id=105329, encryptionId=c998105329a0, topicName=石韦)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aa0e14, createdName=lifestar, createdTime=Sat Mar 04 13:14:40 CST 2023, time=2023-03-04, status=1, ipAttribution=上海), GetPortalCommentsPageByObjectIdResponse(id=1239458, encodeId=616c1239458d5, content=对于3mm体检发现的肾结石,病人有抢劫处理医院,怎么办了?枸橼酸氢鉀钠会有效果吗?, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 10:18:48 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239432, encodeId=9d421239432a0, content=大于5mm的肾结石还是建议外科干预,体外冲击波处理!, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 09:27:51 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1485293, encodeId=f97d1485293e3, content=<a href='/topic/show?id=4bbe5902ed2' target=_blank style='color:#2F92EE;'>#无症状#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59027, encryptionId=4bbe5902ed2, topicName=无症状)], attachment=null, authenticateStatus=null, createdAvatar=Bioon/avatar/20180429/70baad2aa5a046c5aa2914d262de7d37.jpg, createdBy=bd077990475, createdName=12498da4m34(暂无昵称), createdTime=Mon Aug 15 17:30:54 CST 2022, time=2022-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1238561, encodeId=2ef8123856182, content=好文章,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJlfgys76DEiaNtbYo2re3ibjrUPTRibEXRyFwAB4aAGiave842S0FQDf0wAoaH226NiaSoPPDzhndsf1g/132, createdBy=88b489038, createdName=yangchou, createdTime=Sun Aug 14 08:30:14 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243817, encodeId=960e124381ebe, content=NEJM上果然牛,感谢梅斯更新及时, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=小元, createdTime=Sun Aug 14 05:30:54 CST 2022, time=2022-08-14, status=1, ipAttribution=)]
    2022-08-18 12337380m37(暂无昵称)

    对于3mm体检发现的肾结石,病人有抢劫处理医院,怎么办了?枸橼酸氢鉀钠会有效果吗?

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=2117475, encodeId=3faf211e47533, content=小的无症状<a href='/topic/show?id=07058265569' target=_blank style='color:#2F92EE;'>#肾结石#</a>,该不该手术?问题有什么药物可治疗?<a href='/topic/show?id=5c1d22423c8' target=_blank style='color:#2F92EE;'>#中药#</a>中的<a href='/topic/show?id=573332291bd' target=_blank style='color:#2F92EE;'>#利尿剂#</a>是否有用,如<a href='/topic/show?id=ae7710532ea8' target=_blank style='color:#2F92EE;'>#海金砂#</a>,<a href='/topic/show?id=7e3c105328c4' target=_blank style='color:#2F92EE;'>#瞿麦#</a>,<a href='/topic/show?id=c998105329a0' target=_blank style='color:#2F92EE;'>#石韦#</a>?, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82655, encryptionId=07058265569, topicName=肾结石), TopicDto(id=22423, encryptionId=5c1d22423c8, topicName=中药), TopicDto(id=32291, encryptionId=573332291bd, topicName=利尿剂), TopicDto(id=105327, encryptionId=ae7710532ea8, topicName=海金砂), TopicDto(id=105328, encryptionId=7e3c105328c4, topicName=瞿麦), TopicDto(id=105329, encryptionId=c998105329a0, topicName=石韦)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aa0e14, createdName=lifestar, createdTime=Sat Mar 04 13:14:40 CST 2023, time=2023-03-04, status=1, ipAttribution=上海), GetPortalCommentsPageByObjectIdResponse(id=1239458, encodeId=616c1239458d5, content=对于3mm体检发现的肾结石,病人有抢劫处理医院,怎么办了?枸橼酸氢鉀钠会有效果吗?, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 10:18:48 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239432, encodeId=9d421239432a0, content=大于5mm的肾结石还是建议外科干预,体外冲击波处理!, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 09:27:51 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1485293, encodeId=f97d1485293e3, content=<a href='/topic/show?id=4bbe5902ed2' target=_blank style='color:#2F92EE;'>#无症状#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59027, encryptionId=4bbe5902ed2, topicName=无症状)], attachment=null, authenticateStatus=null, createdAvatar=Bioon/avatar/20180429/70baad2aa5a046c5aa2914d262de7d37.jpg, createdBy=bd077990475, createdName=12498da4m34(暂无昵称), createdTime=Mon Aug 15 17:30:54 CST 2022, time=2022-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1238561, encodeId=2ef8123856182, content=好文章,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJlfgys76DEiaNtbYo2re3ibjrUPTRibEXRyFwAB4aAGiave842S0FQDf0wAoaH226NiaSoPPDzhndsf1g/132, createdBy=88b489038, createdName=yangchou, createdTime=Sun Aug 14 08:30:14 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243817, encodeId=960e124381ebe, content=NEJM上果然牛,感谢梅斯更新及时, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=小元, createdTime=Sun Aug 14 05:30:54 CST 2022, time=2022-08-14, status=1, ipAttribution=)]
    2022-08-18 12337380m37(暂无昵称)

    大于5mm的肾结石还是建议外科干预,体外冲击波处理!

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=2117475, encodeId=3faf211e47533, content=小的无症状<a href='/topic/show?id=07058265569' target=_blank style='color:#2F92EE;'>#肾结石#</a>,该不该手术?问题有什么药物可治疗?<a href='/topic/show?id=5c1d22423c8' target=_blank style='color:#2F92EE;'>#中药#</a>中的<a href='/topic/show?id=573332291bd' target=_blank style='color:#2F92EE;'>#利尿剂#</a>是否有用,如<a href='/topic/show?id=ae7710532ea8' target=_blank style='color:#2F92EE;'>#海金砂#</a>,<a href='/topic/show?id=7e3c105328c4' target=_blank style='color:#2F92EE;'>#瞿麦#</a>,<a href='/topic/show?id=c998105329a0' target=_blank style='color:#2F92EE;'>#石韦#</a>?, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82655, encryptionId=07058265569, topicName=肾结石), TopicDto(id=22423, encryptionId=5c1d22423c8, topicName=中药), TopicDto(id=32291, encryptionId=573332291bd, topicName=利尿剂), TopicDto(id=105327, encryptionId=ae7710532ea8, topicName=海金砂), TopicDto(id=105328, encryptionId=7e3c105328c4, topicName=瞿麦), TopicDto(id=105329, encryptionId=c998105329a0, topicName=石韦)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aa0e14, createdName=lifestar, createdTime=Sat Mar 04 13:14:40 CST 2023, time=2023-03-04, status=1, ipAttribution=上海), GetPortalCommentsPageByObjectIdResponse(id=1239458, encodeId=616c1239458d5, content=对于3mm体检发现的肾结石,病人有抢劫处理医院,怎么办了?枸橼酸氢鉀钠会有效果吗?, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 10:18:48 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239432, encodeId=9d421239432a0, content=大于5mm的肾结石还是建议外科干预,体外冲击波处理!, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 09:27:51 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1485293, encodeId=f97d1485293e3, content=<a href='/topic/show?id=4bbe5902ed2' target=_blank style='color:#2F92EE;'>#无症状#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59027, encryptionId=4bbe5902ed2, topicName=无症状)], attachment=null, authenticateStatus=null, createdAvatar=Bioon/avatar/20180429/70baad2aa5a046c5aa2914d262de7d37.jpg, createdBy=bd077990475, createdName=12498da4m34(暂无昵称), createdTime=Mon Aug 15 17:30:54 CST 2022, time=2022-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1238561, encodeId=2ef8123856182, content=好文章,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJlfgys76DEiaNtbYo2re3ibjrUPTRibEXRyFwAB4aAGiave842S0FQDf0wAoaH226NiaSoPPDzhndsf1g/132, createdBy=88b489038, createdName=yangchou, createdTime=Sun Aug 14 08:30:14 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243817, encodeId=960e124381ebe, content=NEJM上果然牛,感谢梅斯更新及时, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=小元, createdTime=Sun Aug 14 05:30:54 CST 2022, time=2022-08-14, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=2117475, encodeId=3faf211e47533, content=小的无症状<a href='/topic/show?id=07058265569' target=_blank style='color:#2F92EE;'>#肾结石#</a>,该不该手术?问题有什么药物可治疗?<a href='/topic/show?id=5c1d22423c8' target=_blank style='color:#2F92EE;'>#中药#</a>中的<a href='/topic/show?id=573332291bd' target=_blank style='color:#2F92EE;'>#利尿剂#</a>是否有用,如<a href='/topic/show?id=ae7710532ea8' target=_blank style='color:#2F92EE;'>#海金砂#</a>,<a href='/topic/show?id=7e3c105328c4' target=_blank style='color:#2F92EE;'>#瞿麦#</a>,<a href='/topic/show?id=c998105329a0' target=_blank style='color:#2F92EE;'>#石韦#</a>?, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82655, encryptionId=07058265569, topicName=肾结石), TopicDto(id=22423, encryptionId=5c1d22423c8, topicName=中药), TopicDto(id=32291, encryptionId=573332291bd, topicName=利尿剂), TopicDto(id=105327, encryptionId=ae7710532ea8, topicName=海金砂), TopicDto(id=105328, encryptionId=7e3c105328c4, topicName=瞿麦), TopicDto(id=105329, encryptionId=c998105329a0, topicName=石韦)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aa0e14, createdName=lifestar, createdTime=Sat Mar 04 13:14:40 CST 2023, time=2023-03-04, status=1, ipAttribution=上海), GetPortalCommentsPageByObjectIdResponse(id=1239458, encodeId=616c1239458d5, content=对于3mm体检发现的肾结石,病人有抢劫处理医院,怎么办了?枸橼酸氢鉀钠会有效果吗?, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 10:18:48 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239432, encodeId=9d421239432a0, content=大于5mm的肾结石还是建议外科干预,体外冲击波处理!, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 09:27:51 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1485293, encodeId=f97d1485293e3, content=<a href='/topic/show?id=4bbe5902ed2' target=_blank style='color:#2F92EE;'>#无症状#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59027, encryptionId=4bbe5902ed2, topicName=无症状)], attachment=null, authenticateStatus=null, createdAvatar=Bioon/avatar/20180429/70baad2aa5a046c5aa2914d262de7d37.jpg, createdBy=bd077990475, createdName=12498da4m34(暂无昵称), createdTime=Mon Aug 15 17:30:54 CST 2022, time=2022-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1238561, encodeId=2ef8123856182, content=好文章,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJlfgys76DEiaNtbYo2re3ibjrUPTRibEXRyFwAB4aAGiave842S0FQDf0wAoaH226NiaSoPPDzhndsf1g/132, createdBy=88b489038, createdName=yangchou, createdTime=Sun Aug 14 08:30:14 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243817, encodeId=960e124381ebe, content=NEJM上果然牛,感谢梅斯更新及时, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=小元, createdTime=Sun Aug 14 05:30:54 CST 2022, time=2022-08-14, status=1, ipAttribution=)]
    2022-08-14 yangchou

    好文章,谢谢分享。

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=2117475, encodeId=3faf211e47533, content=小的无症状<a href='/topic/show?id=07058265569' target=_blank style='color:#2F92EE;'>#肾结石#</a>,该不该手术?问题有什么药物可治疗?<a href='/topic/show?id=5c1d22423c8' target=_blank style='color:#2F92EE;'>#中药#</a>中的<a href='/topic/show?id=573332291bd' target=_blank style='color:#2F92EE;'>#利尿剂#</a>是否有用,如<a href='/topic/show?id=ae7710532ea8' target=_blank style='color:#2F92EE;'>#海金砂#</a>,<a href='/topic/show?id=7e3c105328c4' target=_blank style='color:#2F92EE;'>#瞿麦#</a>,<a href='/topic/show?id=c998105329a0' target=_blank style='color:#2F92EE;'>#石韦#</a>?, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82655, encryptionId=07058265569, topicName=肾结石), TopicDto(id=22423, encryptionId=5c1d22423c8, topicName=中药), TopicDto(id=32291, encryptionId=573332291bd, topicName=利尿剂), TopicDto(id=105327, encryptionId=ae7710532ea8, topicName=海金砂), TopicDto(id=105328, encryptionId=7e3c105328c4, topicName=瞿麦), TopicDto(id=105329, encryptionId=c998105329a0, topicName=石韦)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aa0e14, createdName=lifestar, createdTime=Sat Mar 04 13:14:40 CST 2023, time=2023-03-04, status=1, ipAttribution=上海), GetPortalCommentsPageByObjectIdResponse(id=1239458, encodeId=616c1239458d5, content=对于3mm体检发现的肾结石,病人有抢劫处理医院,怎么办了?枸橼酸氢鉀钠会有效果吗?, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 10:18:48 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239432, encodeId=9d421239432a0, content=大于5mm的肾结石还是建议外科干预,体外冲击波处理!, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220815/ed1dc7a7138b4385a751b9e022e11a76/4abdfbe1d4da4c6f89dcd27185d4b93c.jpg, createdBy=25772392215, createdName=12337380m37(暂无昵称), createdTime=Thu Aug 18 09:27:51 CST 2022, time=2022-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1485293, encodeId=f97d1485293e3, content=<a href='/topic/show?id=4bbe5902ed2' target=_blank style='color:#2F92EE;'>#无症状#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=59027, encryptionId=4bbe5902ed2, topicName=无症状)], attachment=null, authenticateStatus=null, createdAvatar=Bioon/avatar/20180429/70baad2aa5a046c5aa2914d262de7d37.jpg, createdBy=bd077990475, createdName=12498da4m34(暂无昵称), createdTime=Mon Aug 15 17:30:54 CST 2022, time=2022-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1238561, encodeId=2ef8123856182, content=好文章,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJlfgys76DEiaNtbYo2re3ibjrUPTRibEXRyFwAB4aAGiave842S0FQDf0wAoaH226NiaSoPPDzhndsf1g/132, createdBy=88b489038, createdName=yangchou, createdTime=Sun Aug 14 08:30:14 CST 2022, time=2022-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1243817, encodeId=960e124381ebe, content=NEJM上果然牛,感谢梅斯更新及时, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=小元, createdTime=Sun Aug 14 05:30:54 CST 2022, time=2022-08-14, status=1, ipAttribution=)]
    2022-08-14 小元

    NEJM上果然牛,感谢梅斯更新及时

    0

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