Y HOC VIET NAM THANG 11 - SO 2/2010
KET QUA BirOTC DAU TAN SOI THAN NOI SOI NGlTOTC DONG
B A N G
NANG LirONG LASER
...;, I Duong Van Trung*
( • ' ; .!«>•!
TOAATAT
Mucdichr. Nhan xet Icet qua bddc dau sit dung ong soi ban cufng va dng soi mem trong tan sdi than ngi soi ngu'dc ddng bang nang lddng laser.
So Ueu va phu'dng phapr. Sd lieu tdng ket tren 45 benh nhan tan sdi than ndi soi ngu'dc dong bang dng soi ban cu'ng va dng soi mem, sii dung nang lu'dng tan sdi Homium: YAG laser. Tir 7/2003 den 7/2006 tai benh vien Bdu dien - Ha npi. Tuoi trung binh 45,63 (tii 27- 68 tud'i), 53,3% nam va 46,7% nu". Vj tri sdi ben phai 57,7%, ben trai 42,3%. Sdi be than 25 benh nhan (55,5%), sdi dai tren 3 benh nhan (6,6%), soi dai giiia 7 benh nhan (15,5%), va sdi dai du'di 10 benh nhan (22,2%). Kich thu'dc sdi t i i 12 mm - 20mm.
Kit qua: Thdi gian tan sdi trung binh 73,50 phut (50-150 phut), thdi gian hau phau trung binh 3,08 ngay (2-5 ngay), sdi tan vun khdng can sir dung phu'dng phap khac 31 benh nhan (68,9%), phdi hdp tan sdi nieu quan ndi soi 5 benh nhan (11,1%), 6 benh nhan ket hdp tan sdi ngoai cd the (13,3%), 3 benh nhan that bai do khong dat dddc dng soi tiep can sdi (6,6%).
Bien chu/ng: Nhiem khuan tiet nieu 4 benh nhan (8,9%), chay mau 3 benh nhan (6,6%), td'n thu'dng be than 1 benh nhan (2,2%).
Ket luan. Ket qua bddc dau sii dung dng soi ban ciing va dng soi mem tan sdi than ndi soi ngu'dc ddng vdi nang lu'dng laser cho ket qua khong cao, tuy nhien la mpt Ida chpn cd the chap nhan dddc khi khdng thiTc hien dddc tan sdi ngoai cd the.
* B^nh vi?n Bmi di?n - Hd Noi
ABSTRACT
Purpose. To remark the initial results of retrograde ureterorenoscopic lithotripsy for renal stones by semirigid and flexible ureterorenoscope with pulsed homium laser.
Materials and method. A total of 45 renal stones patients underwent retrograde semirigid and flexible ureterorenoscopic lithotripsy with pulsed homium:YAG laser, from July 2003 to July 2006 in Postal hospital - Ha noi, Vietnam. The mean age is 45.63 years (range 27 to 67), 53.3%
male and 46.7% female. 57.7% in the right side and 42.3% in the left side . The stones were in the renal pelvis in 25 patients (55.5%), upper calyx in three patients (6.6%), middle calyx in seven patients (15.5%), and lower calyx in 10 patients (22.2%). The stone size from 12 mm to 20 mm.
Results. The mean duration of the procedure is 73.50 minutes (range 50- 150 minutes), the mean post- op hospital stay is 3.08 days (range 2 to 5 days). The stone-free rate 31 patients (68.9%), combination of retrograde ureteroscopic lithotripsy in 5 patients (11.1%), and extracorporeal lithotripsy in 6 patients (13.3%). The ureterorenoscope can not be reached to the stone in three patients (6.6%).
Complications. Urinary infection in four patients (8.9%), haematuria in three patients (6.6%), damage of the pelvis in one patient (2.2%).
Conclusions. The initial results of retrograde ureterorenoscopic lithotripsy for renal stones by semirigid and flexible ureterorenoscope
HOl NGH! KHOA HOC LAN THlf IV • HOl TIET NIEU - THAN HOC VIET NAM with homium laser is not high, but it may be the
accepted option in case the extracorporeal lithotripsy can not be done.
I. OAT VAN o f
Dieu tri benh sdi than cd nhieu phuong phap it xam hai, trong dd phuong phap tan sdi ngoai co the nhe nhang nhat cho benh nhan, tuy nhien mdt sd trudng hgp gap nhieu khd khan nhu: benh nhan beo phi, sdi ciing, than li nudc...
Su ra ddi cua dng soi nieu quan ban Cling va dng soi mem cd the dua dng soi len be than va dai than, cung vdi nang lugng pha sdi bang laser, da giiip cho chiing ta thuc hien phuong phap tan sdi than ndi soi ngugc ddng dugc thuan lgi hon.
Trong bai viet nay chiing tdi neu len mdt sd ket qua va nhiing khd khan budc diu khi thuc hien phuong phap tan sdi than ndi soi ngugc ddng, tai benh vien Buu dien.
II. Sd LIEU VA PHUONG PHAP 1. So lieu:
45 benh nhan dugc tan sdi than ndi soi ngugc ddng bang dng soi ban ciing va ong soi m6m vdi nang lugng laser, tai benh vien Buu dien. Ha ndi. Sd Heu dugc hdi ciiu trong 3 nam (tu thang 7 nam 2003 din thang 7 nam 2006).
2. Phuong phap:
2.1. Chon benh nhan:
- Sdi be than, dai than, kich thudc < 20 mm - Than cdn chiic nang
- Tan sdi ngoai co the that bai hoac khdng cd chi dinh tan sdi ngoai co thi.
2.2. Phuong phap thyc hien - Dung cu:
+ Ong soi ban ciing 6,5 Fr: su dung khi tan sdi be than.
+ Ong soi m6m 7,5Fr/9Fr: su dung nhimg vi tri dng soi ban ciing khdng tilp can
dugc sdi nhu sdi dai than.
+ Nang lugng Homium laser: cd budc sdng laser 2100 nm, sgi day truyen laser 200 pm phil hgp vdi kenh dung cu dng soi mlm va 550 pm dimg cho dng soi ban ciing.
- Qud trinh tdn sdi:
+ Dat dng soi ban ciing ngugc len nieu quan-be than
+ Ong soi mem dugc dua len bl than va dai than theo day dan ludn vao trong dng soi.
+ Sgi day dan truyen laser dat vao kenh boat dpng cua dng soi, tdi vi tri sdi va tiln hanh tan sdi. Tuy theo miic dp sdi ciing hay mem cd the dat cudng dp 1000 mj - 1500 mj va tan sd 1 OHz. Cac manh sdi vun gap hoac bom rira ra ngoai.
+ Dat dng thdng JJ nieu quan-bl than cho tat ca benh nhan sau tan sdi, thdi gian luu dng thdng 2-3 tuSn.
Qua trinh dat dng soi va tan sdi dudi hudng dan cua man tang sang truyen hinh.
- Kiem tra ket qua:
+ Chup phim va sieu am kiem tra ngay sau tan sdi
+ Hen benh nhan kiem tra lai sau I thang in.KETQUA '' ^'
1- So lieu chung:
- Tudi: tudi hung bmh 45,63 (tit 27- 68 tuoi).
- Gidi: 24 nam (53,3%), 21 nii (46,7%).
- Vi tri sdi: sdi be than 25 benh nhan (55,5%)), dai tren 3 benh nhan (6,6%), dai giiia 7 benh nhan (15,5%)), dai dudi 10 benh nhan (22,2%)). Vi tri sdi ben phai 26 benh nhan (57,7%)), ben trai 19 benh nhan (42,3%).
- Kich thudc sdi tir 12 mm - 20 mm.
- Thdi gian tan sdi trung binh 73,50 phiit (50-150 phiit).
- Thdi gian hau phau trung binh 3,08 ngay (2-5 ngay)
Y HOC VIET NAM THANG 11 - 5 0 2/2010
2- Ket qua tan soi:
- Hit sdi 31 benh nhan (chilm ty le 68,9%).
- Sdi vun gay tic nieu quan, phai phdi hgp vdi tan sdi nieu quan ndi soi ngugc ddng: 5 benh nhan (chiem ty le 11,1%).
- Cdn manh sdi tren than phai phdi hgp vdi tan ngoai co the: 6 benh nhan (chiem ty leI3,3%).
- That bai do khdng dat dugc dng soi tiep can sdi: 3 benh nhan (chiem ty le 6,6%).
Bang 1. Tan sdi thanh cdng lien quan den vi tri sdi
Vj tri soi Be than Dai du'di Dai giu'a Dai tren Tong sd
So benh nhan tan soi
25 10 7 3 45
So benh nhan thanh cong
19 6 4 2 31
3- Bien chung:
- Nhiem khuan tiet nieu 4 benh nhan (8,9%).
- Dai mau: 3 benh nhan (6,6%)).
- Tdn thucmg be than: I benh nhan
( 2 , 2 % ) . >.sn.K. ^i.n...: ,.,.,.'„ , ! •
IV. BAN LUAN
Dilu tri benh sdi than cho din nay cd nhilu lira chpn, dua tren mdt sd ylu td lien quan nhu: kich thudc sdi, vi tri sdi, miic dp anh hudng cua sdi than gay nen, dieu kien y tl, va ylu to kinh tl cua benh nhan, tir dd bac sT lira chpn phuong phap dilu tri phu hgp ddi vdi timg benh nhan.
Phuong phap tan sdi ngoai co the dugc ling dung tren lam sang tir nhiing 80 cua the ky birdc, da nhanh chdng trd thanh phuong phap chilm uu the dilu tri benh sdi than. Tuy nhien, mdt sd benh nhan gap khd khan nhu beo phi, sdi bam dinh... khdng thuc hien dugc tan sdi ngoai co thi, trong trudng hgp dd tdt hon la sti dung ky thuat ndi soi nhu:
l^y sdi than qua da, tan sdi ndi soi ngugc ddng, hoac md md.
Nhd sir phat trien cua cdng nghe thilt bi ndi soi, dng soi cd dudng kinh nhd, dng soi ban Cling va dng soi mem, cd the dua dng soi len be than va dai than de dang hon. Dac biet vdi su ddng gdp cua cdng nghe tan sdi laser, l&i dkx tien nam 1968, Mulvaney va Beck da tan sdi bang ruby laser, sau do den pulsed dye laser budc sdng 504 nm, va holmium:
YAG laser cd budc sdng 2100 nm cd the tan dugc mpi loai sdi. Cudng dp pha sdi cua laser tuy theo cdu tao timg loai sdi, ddi vdi sdi struvit la 2,8 J/mg, sdi acid uric 4,8J/mg, sdi cystine 5,8J/mg, sdi monohydrate 6J/mg.
Khi tan sdi, nang lugng laser dugc hap thu bdi nudc d ben trong va tren be mat vien sdi, lam cho mgi loai sdi deu tan, tao thanh nhiing manh sdi nhd hoac bui sdl [7], [8].
Tan sdi than ngugc ddng bang dng soi mlm dugc Fuchs & Fuchs (1990) da bao cao tren 208 benh nhan cd kich thudc sdi < 20 mm [5]. Sau dd Grasso & Chalik (1998) sir dung ong soi mem tan sdi than ngugc ddng vdi nang lugng Holmium laser [6].
Chaussy va Bergsdorf nhan thay ty le het sdi tuong tu giiia tan sdi ngoai co the va tan
HOI NGH! KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
sdi than ndi soi ngugc ddng, nhung tan sdi ngoai CO thi dugc lua chgn uu tien hon vi la phuong phap khdng xam hai, thdi gian nam vien ngan hon so vdi tan ndi soi [2]. Chinh vi vay trong nghien ciiu nay, chiing tdi chpn benh nhan tan ndi soi khi khdng thuc hien dugc tan sdi ngoai co the.
Lira chpn kich thudc tan sdi than ndi soi ngugc ddng tiiy theo timg tac gia, theo Grasso va cdng su nen chpn kich thudc < 20 mm, ddi vdi sdi cd kich thudc > 20 mm, ty le tan sdi thanh cdng chi dat 45%. Nghien ciiu cua Anany va cdng su (2001) da thuc hien tan sdi cho 30 benh nhan cd kich thudc sdi >
20 mm ty le thanh cdng 11% [I]. Trudc dd, Dretler (1994) bao cao tan ndi soi ngugc ddng va ket hgp vdi tan sdi ngoai co the cho 8 benh nhan sdi than san hd [3]. Vi budc dau thuc hien cho nen chiing tdi chpn kich thudc sdi < 20 mm.
Chpn dng soi va sir dung nang lugng laser: Chiing tdi nhan thay sgi dan nang luge laser 550 pm cudng do pha sdi nhanh hon nhieu loai 200 pm, chinh vi vay ddi vdi sdi be than, chiing tdi sir dung dng soi ban ciing cd kenh boat ddng rpng vira vdi sgi din nang lugng 550 pm giiip cho qua trinh dat dng soi va tan sdi nhanh, chi sii dung dng soi mlm khi dng soi ban ciing khdng tiep can dugc sdi.
Qua trinh tan sdi bang laser ddi hdi do chinh xac cao, khdng de sgi dan laser tilp xiic true tiep vao td chiic vi se gay tdn thuong va chay mau. Tia laser cd thi xuyen thung sdi tao thanh I Id sang mat sau vien sdi, neu khdng quan sat tdt, nguy co tdn thuong td chiic mat sau vien sdi. Chinh vi vay, chiing tdi pha sdi timg phdn mpt, cho den khi tan het vien sdi.
Bui sdi va chay mau la nguyen nhan gay khd quan sat vien sdi, vi vay sii dung nudc
mudi dang truong bom rira de nhin rd vien sdi. Theo Anany va cdng su (2001) nen dat dng thdng 5- 6 F ngugc len nieu quan - dai be than trong qua trinh tan sdi se giiip cho bom rira dugc rd hon [I].
Ket qua tan sdi budc dau cua chiing toi dat 68,9% ciing tuong tu nhu cac tac gia khac (Grasso, 1998; Anany, 2001) [6], [1], trong dd sdi be than thanh cdng cao nhat, soi dai dudi ty le thanh cdng thap nhat (bang I).
Tuy nhien, Elashry va cpng su bao cao ty le thanh cdng la 92%i [4], tac gia dl cap din kinh nghiem lien quan den ty le thanh cdng.
Su phdi hgp vdi tan sdi ngoai co the va ldy sdi nieu quan ndi soi ngugc ddng lan 2 giiip cho ty le thanh cdng cao 93%. Grasso tan soi
> 2 cm lan dau chi dat 45%), sau lan thii 2 thanh cdng dat 91%). Chiing tdi that bai khdng dat dugc dng soi tiep can sdi (3 benh nhan) deu gap sdi dai dudi do cd dai hep.
Vi tri sdi dai dudi thanh cdng lien quan den cau tao giai phau: gdc dai- be than > 90 dp, dudng kinh cd dai rdng > 5 mm va chieu dai dai than < 3 cm, nhiing dac diem nay c6 j the nhan biet qua phim chup nieu do tinh mach. J, n/u'ti
Ty le bien chung theo cac tac gia ndi chimg la thap, quan sat rd vien sdi trong qua trinh tan sdi giiip giam nhieu bien chiing.
Trong nghien ciiu chiing tdi gap I benh nhan tdn thuong be than vi sdi bam dinh, tia laser tilp can td chiic nhieu, trudng hgp nay chiing tdi phai lim dng thdng JJ nieu quan 4 tuan.
V. KET LUAN
Kit qua budc dau sir dung dng soi ban Cling va dng soi mem tan sdi'than npi soi ngugc ddng vdi nang lugng laser cho ket qua khdng cao, tuy nhien la mdt lira chpn cd thi
Y HOC VIET NAM THANG 11 - SO 2/2010
chap nhan dugc khi khdng thuc hien dugc tan sdi ngoai co thi.
TAI UEU THAM KHAO OSlv Cc , 1. Anany F.G, Hammouda H.M, Maghraby
H.A, and Elakkad M.A. Retrorograde ureteropyeloscopic holmium laser lithotripsy for large renal calculi. BJU international 2001,88,850-853
2. Chaussy C, Bergsdof T. Extracorporeal Shockwave lithotripsy for lower pole calculi smaller than one centimeter. Indian J Urol, 2008,24:517-20.
3. Dretler SP. Ureteroscopic fragmentation followered by extra-corporeal shock wave lithotripsy: a treatment alternative for selected large or staghom calculi. J Urol
1994; 151: 842.
4. Elashry OM, Eibahnasy AM, Rao GS, Nakada SY, Clayman RV. Flexible
7.
ureteroscopy. Washington University experience with the 9.3F and 7.5F flexible ureteroscopes. y f/ro/ 1997; 157: 2074
Fuchs AM, Fuchs GJ. Retrograde intrarenal surgery for calculus disease:
new minimally invasive treatment approach. J Endourol 1990; 4: 337
Grasso M, Chalik Y. Principles and applications of laser lithotripsy:
Experience with the holmium laser lithotrite. J Clin Laser Med Sur 1998; 16:
3-7
Mulvaney, W. P. and Beck, C.W. The laser beam in urology. J. Urol 1968; 99:112 Watson GM, Smith N. A. Comparison of the pulsed dye and holmium lasers for stone fragmentation: in vitro studies and clinical experience. SPIE vol. 1879 laser in Urology, Gynaecology and general Surgery 1993:
139-42
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