Tnnh Hoang Giang va cdng su Kit qui dieu (n sdi ni$u qu&n bang tan s6i ndi soi nguoc dong Holmium YAG tai...
Ket qua dieu trj soi nieu quan bang tan soi npi soi ngUdc dong Holmium YAG tai Benh vien HQu nghj Viet DQc 2014-2015
Trinh Hoang Giang, Nguyen Quang, Do Tracing Thanh Benh vien HQu nghi Vi§t Dilc
TCr khoa:
Tan s f i n a soi meu quan ngUoc dong
Dja chi lien he:
Tnnh Hoang Giang, Khoa PT Tiit mdu, Benh vi&n HOu nghi Vi&t Bdc, 40 Trang Thi, Hoan Kiem, Ha Npi Oienthoai 0906112 868 Email' [email protected]
Ngay nlian b&i: 01/6/2017, Ngdy duyet: 06/6/2017, Ngay chap nh&n dang:
12/6/2017.
Tom t ^ l
Ddt vdn de: Titfdc dky, nguon nang lUdng thifSng diiOc sii dung trong tan soi nfii soi (TSNS) ngifdc dong 1^ xung hdi hay thuy didn lu'c... Tir khi ilng dung nang lu'Ong laser Hoi: YAG tan soi nidu qudn tai bgnh viSn ViSt Dif c, &6 lifdng ngu'c): benb (NB) tan soi tang hcfn nhilu iin do tdn difdc nhiSu loai s6i vk soi 3 nhieu vi tri cua niSu qukn. Nham d^nh gid hi$u quk cua TSNS laser doi vdi soi ni6u qudn (NQ), chung t6i trinh hky ket qud dieu tri sdm soi nieu quan bang TSNS ngtfdc dbng Holmium: YAG .
Phuong phdp nghiSn ciiu: Tijf 9.2014- 2.2015 , chdng t6i ti^n hSnh nghidn ciJu 116 NB difdc TSNS ngiTdc dong bang laser Hoi: YAG. Soi 6 vi tri doan tha'p ciia nieu qudn (1/3 dirdi) chid'm 37.93% (44 NB), soi nidu qudn dao cao (1/3 giu'a va 1/3 tren) chig'm 62.07% (72 NB). Kich thtfdc soi trung binh 11.99 ± 5.1 mm (5mm -^ 23mm) v^ thffi gian vai trung binh 30.38 ± 10.21 phiit (ISphiit- 56 phiit). Ddnh gid lai ngiffli bdnh sau m^ tif 1 thdng •^ 3 thdng
Kei qua: 100% NB ong soi nieu qudn deu tiep c | n difdc vdi soi 22/116 NB (18.97%) gap khd khan khi diTa ong soi NQ tiep can soi do niem mac che phu hoac do c6 polyp NQ. 10/116 NB (8.62%) trong qud tiinh tdn cd mdnh soi di chuygn ldn be thSn. Trong d6 c6 INB sau ra& 1 thdng phdi tiln hdnh TSNCT de xiJ li manh sdi ton dtf. Ton thu'dng xifdc niSm mac lo NQ gap phai d 66/116 NB (56.90%) va rdch nidm mac nidu quan gap 84/116 NB (72.41%). Chung t6i tien h&nh ddt 6'ng thfing JJ trdn tS^t ck cdc NB sau khi tdn sdi. Hdi chii'ng stent sau TSNS xuat hidn 56/116 NB (48.27%).
Kei ludn: TSNS ngrfdc d6ng Holmium: YAG la mot phtfdng phdp hieu qud vk an todn dd'i vdi soi nieu qudn.
Treatment results of Ureteroscopy (URS) using Ho:YAG laser lithotripsy in Viet Due University Hospital 2014-2015
Tnnh Hoang Giang, Nguyen Quang, Do Truong Thanh Viet Due University Hospital
Tao chf Dhlu thuat noi soi vk n 31 Viet Nam (2017) So 2 - Tao 7; 5 -
K&t quk diiu tri sdi ni&u qudn bang tdn sdi n&i soi ngupc d&ng Holmium YAG tai... Ttinh Hoang Giang vk c&ng su
Abstract
Introduction: Before the main energy used for ureteroscopy is pneumatic hnpulse or hydro- electric. Since ureteroscopy (URS) using Ho: YAG laser lithotripsy has been applied in Viet Due hospital, the number of patients have been significantly increased because more urinary stones with different types and at different location of the ureter are treated. We will present findings of the treatment method of Ureteroscopy (URS) using Ho:YAG laser lithotripsy in order to assess its effectiveness.
Material and Methods: From September 2014 to February 2015, we perfonned ureteroscopy (URS) using Ho:YAG laser lithotripsy m 116 patients. The stones localized in the distal ureter in 44 patients (37.93%), middle and proximal ureter in 72 patients (62.07%). Average size of stones was from 11.99 ± 5.1 mm (5mm -=- 23nun) and average operation time was 30.38 ± 10.21 minutes (ISminutes -^ 56 minutes). Post-operative follow up with patients after one to three months.
Results: Ureferoscope reached stones in 100% patients. In 116 patients, 22 (18.97%) had some difHculties in finding stones due to the coverage of mucous membrane or due to ureter polype. Pieces of stones moved to renal pelvis of 10/116 patients (8.62%). One patient had been undergone extracorporeal Shockwave lithotripsy to treat remaining pieces of stones. Injury of mucous membrane at the ureteral hole happened in 66 patients (56.90%) and mucous membrane of ureter was torn m 84 patients (72.41%). We place double J drain in all patients after lithotripsy. Stent syndrome after laser lithotripsy occurred 56 out of 116 patients (48.27%).
Conclusion: Ureteroscopy (URS) using Ho:YAG laser lithotripsy is an effective and safe technique m ureteral stones.
Keyword: Ureteroscopy lithotripsy
I. Oat vSn de
N Q I soi tie't nidu du'dc thifc hien l l n d^u tidn bdi Bozzini vdi he thd'ng ong kinh quang hoc ti/ tao vao nam 1806 [1]. Trdi qua hdn mot the ky phat trien, nam 1978, Raney ik ngifSi dau tien cdng b6' tdn soi nidu qudn noi soi bang thuy didn life. Nam 1987, Dretler vk cong sd ik ngU&i d t u tien s^ dung laser tdn soi th&nh cong cho 16 ngu'cfi bdnh (NB) trdn 17 tnrcfng hdp soi nieu qudn doan thl^p. Va cung chinh Dretler vd Cho \k ngtffli d i u tien c6ng bo sii dung he thong 6^ng npi soi ban cu'ng md cho den nay dang siJ dung rpng rai d^ tdn s6i nidu qukn. Trong nhffng nam gan day vdi sif phdt trien cua cdc nguon nang Iifdng laser nhif. Neodymium: YAG, pulsed Dye vk Hoi: YAG da dem Iai ty Id thdnh cong vd an todn cao hdn cho phSu thudt TSNS ngifdc dong [2],[3].
TSNS thu'dng dUdc su" dung cho s6i 1/3 giffa vd 1/3 du'di con TSNCT thifflng difdc suf dung cho soi nieu qudn doan 1/3 tren [4]. Ti le thdnh cong cao ciia TSNS ngu'dc d6ng doi vdi soi niSu qudn doan thd'p da difdc ghi nhdn trong nhieu nghien ctfu. Tuy
nhien, ti le thanh cong cua TSNS ngu'dc ddng vdi soi nieu quan doan cao cdn thay doi khde nhau giu'a cac nghidn ctfu [5],[6],[7],[8].
Nghidn ctfu eiia ehung toi danh gid ket qud phau thuat tdn soi ndi soi soi nidu qudn b i n g laser Hoi:
YAG tai khoa phau thuat tiet nidu, benh vien hffu nghi Vidt Dtfc.
II. Ddi tUdng va phUdng phap nghien ctfu Chung l6i tie'n hdnh nghidn ctfu h6i ctfu tff thang 9.2014- 02.2015, 116 NB soi nieu qudn d nhieu vi tri khde nhau difdc TSNS Hol:YAG.
Trong nghidn cihi ciia chung toi c6 55 NB (47.41%) nff vd 61 NB (52.59%) nam. Do tuoi trung binh ciia ngffdi bdnh 49.16 ± 12.57 tuii. Nidu quan (NQ) dffdc chia thdnh 3 doan trdn phim chup XQuang (XQ): N Q 1/3 tren tinh tff b e than tdi bd tren cua khdp cilng chdu, N Q 1/3 giffa nKm trong dien khdp ciing chdu. Soi n^m trong hai doan NQ neu trdn goi Id sdi N Q doan cao. NQ 1/3 dffdi tinh tff bd dffdi eua khdp cffng chdu den l5 NQ do vdo bdng
l i Viel Nam (2017) S5 2 - Tgp 7, 5 - 9
Tn'nh Hoang Giang va cdng sq Ket qud diiu tn s&i ni&u qudn bang tan sdi n&i soi nguoc ddng Holmium YAG tai...
quang. Soi ndm trong doan ndy ggi Id sdi NQ doan thap. Theo phSn loai neu trdn, nghidn ctfu cua chung toi cd 44 NB (37.93%) sdi nkm d NQ doan th^p vd 72 NB (62.07%) sdi nlm d doan cao NQ. Kich thffdc trung binh cua sdi 11.99± 5.1 mm (5 mm-=-23 mm).
Thdi gian phlu thudt trung binh 30.38 ± 10.21 phut (18 -^ 56 phfit). NB dffdc khdm lai tff 1 thdng de'n 3 thdng sau md,
Tidu chu^n danh gid sach sdi, chung toi stf dung theo tieu chuin cua Gupta mo td [9]; 1) Hodn todn sach sdi trong meu qudn trong qud tnnh mi: 2) Sdi dffdc tan nho thdnh nhffng mdnh < 3mm nhffhg khong hodn todn sach trong qua trinh phdu thuat vd sach sdi trong vdng 3 thdng sau phdu thuat.
Chi dinh tdn soi nidu qudn ddt ra khi soi gdy bit tac dffdng nidu qudn hoac soi nidu qudn ed kich thtfdc > 6mm.
TS^t ca NB dffdc gay t6 tuy s^ng va dffdc TSNS bang ong ban ctfng 9.5F ciia Karl-Storz k^t hdp vdi he thd'ng mdy vd sdi phdt laser do hang Accu - Tech sdn xud^t, bffdc sdng 2080 nm, phat xung thdnh nhip 3-10 Hz, nang Iffdng thay doi tff 500 - ISOOmJ.
Sdi NQ dffdc chan dodn dtfa trdn phim XQ, sidu dm vd chup cSt Idp vi tinh he tiet meu (CT).
Thdi gian mo bat diu tff khi dat mdy soi vdo 16 nidu dao va ke't thiic khi dkt xong ti^u. Sau khi dffa ong soi nidu qudn tiep can sdi, sdi dffdc tdn vun dffdi dau dan phat laser Hoi: YAG. Nhffng mdnh soi co kich thffdc ldn hdn 3ram dffdc l^y ra bing kim hodc ro gSp sdi.
Trong vdng 3 thdng dau sau m^ ngffdi benh dffdc
chup XQ hd tiet meu vd sieu dm i bung. Ngffdi bdnh thdnh cong khi chup lai sach sdi theo tidu chuan sach sdi cua Gupta. Thd't bai cua phau thudt khi. sdi di chuyen vdo trong thdn hodc khdng tiep cdn dffdc sdi hodc ed bi^n chtfng Idn phdi cha'm dtft phau thudt hodc khong sach sdi sau phau thudt trong vdng 3 thdng dau.
Phan tfch, xtf li so' Ueu bing chffdng trinh SPSS 15.0.
III. Ket qui
Thdi gian phlu thuat trung bmh 30.38 ± 10.21 phut (ISphiit -=- 56 phtft). 100% NB ong soi NQ tiep can dffdc sdi. 22/116 NB (18.97%) gdp khd khan khi dffa ong soi NQ tie'p can sdi do nidm mac che phu hodc do ed polyp NQ hodc do 16 NQ phu ni vi sdi d doan trong thdnh bang quang. Cdc trffdng hdp neu tren thffdng do sdi NQ phdt hien lau ngdy nhffhg chffa xtf tri hodc do sdi gam chdt vdo nidm mac mdu qudn. Chtfng tdi da tie'n hdnh dffng laser cdt bd phan nidm mae ehe phu, polyp 15/116 NB (12.93%) de tid'p cdn sdi.
10/116 NB (8.62%) trong qua trinh tdn cd mdnh sdi di ehuyen Ien be than. Trong dd cd INB sau mo 1 thang phdi tie'n hdnh TSNCT d^ xtf li mdnh sdi ton dff.
Trong vdng 3 thdng diu tien sau md,ti Id thdnh cdng ciia phdu thudt tuy theo tffng vi tri ciia sdi dtfde tdm tdt trong Bdng 1. Ti Id sach sdi ngay trong md do'i vdi sdi nidu qudn doan cao 87.5% vd vdi sdi nidu qudn doan thS^p 97.92 %. Ti le sach sdi chung trong md dd'i vdi tat cd cdc vi tri 91.37%.
g 1: Ket quk t^n sdi nOi soi ngiiOc d6ng bSng Hoi: YAG tren nhi6u vi Irl
Tl le sach sdi trong mo T? le thanh cong
1/3 tr§n 1/3 giOa NQ dogn cao +
1/3diJdi-(NQthap)
S6NB 38(6) 25(3) 63
43(1) 97,72
91 37
Tan rh\ nhSu thuat n6i soi vk nOi soi Vi#t Nam (2017) 3 6 2 - Tfip 7; 5 -
Kit qui di&u tn s&l ni&u qudn bang tan s6i n&i sol nguoc dong Holmium YAG tai ... Trjnh Hoang Giang vd c&ng si
Nghien etfu cfla chiing toi khdng phdt hidn trffdng hdp nao cd bien chtfng nang, trim trong. 66 NB (56.9%) xffdc 16 nieu qudn vd 84NB (72.41%) rdch niem mac NQ deu dtfdc xff li bang cdch ddt o'ng thong JJ vd cdc NB neu trdn deu khdng cd bid'n chtfng sau rdt JJ. Chdy mdu sau mi gap trong 110/116 NB (94.82%) nhu^g deu Id cde ehay mdu nhe khong ctn truydn mdu hay phau thudt lai. Hpi chtfng stent sau md gap trong 56/116 NB (48.27%).
Bang 2: Cac bien chting g^p phSi
Bien chffng So NB Tl le (%) Xudc 16 meu quan
R^ch niem mac ni#u qukn Niidc tieu d6 HOi chiing stent sau m6
72 41 94 82 48 27
IV. Ban luan
Chpn Itfa phtfdng phdp thich hdp dieu tri cho sdi nieu qudn vdn Id vd'n de ctn thdo ludn. Ddi vdi sdi trong thdn vd sdi nidu qudn ndm d doan cao khi khdng tff ddo thdi, tdn sdi ngodi ed the (TSNCT) Id stf Iffa chpn ffu tien do Id mot can thiep it sang chan vd cd ti Id ttf vong thap [10], Ti Id sach sdi khi TSNCT dd'i vdi sdi NQ doan cao dtfdc ghi nhdn khodng 78.2%.
Ti Id sach sdi Idn tdi 89.1 % khi dtfdc dat dng thong JJ trtfdc khi TSNCT vd 95.5% khi di chuyen Idn tdi be than [11]. Do vdy, TSNCT td't nhd't dtfdc thtfc hidn eho sdi nieu qudn 1/3 tren cd dffdng kinh dffdi 10mm[12].
Vdi stf phdt trien eua dng noi soi mem vd cdc dng ngi soi bdn cffng cd kfch thffdc nhd, TSNS ngtfde ddng cd the dem Iai ty Ie thdnh cdng cao vdi bid'n chtfng tha'p hdn. Trong nhilu nghien ctfu trffdc ddy da chi ra rang, TSNS cd ti Id thdnh cong tffdng tff vd cao hdn TSNCT do ldm sdi bdi xu^it nhanh hdn vd gidi thodt ngay Idp tffc stf tac nghen [10]. Ti Id thdnh cdng cua TSNS ngffdc ddng vdi sdi nieu qudn doan thd'p dtfdc ghi nhdn tff 94%- 99% [13]. Trong nghien ctfu cua chffng toi, ti le thdnh cdng chung cua TSNS la 99.13 % trdn tat ed cdc vi tri vd ti Id
thdnh cdng vdi sdi NQ dotin cao 98.61%, sdi NQ doan thd'p 100%.
Laser Hoi: YAG cd ffu diem vffdt trdi Id cd the tan vd dffdc tS^t ca cdc loai sdi. So vdi cdc ngudn ndng Iffdng khde. Hoi: YAG cd khd ndng Idm vd sdi thdnh nhi^u mdnh nhd nhff cdt vd It gdy tdn thffdng nieu quan. Nhieu nghien cffu cdng bd ti 1# sach sdi trong md Id 100% [14]. Trong nghidn ctfu cua chiing tdi ti le saeh sdi trong mo 91.37 % cho td't cd edc vi tri vd 87.5% ddi vdi sdi nidu qudn doan cao, 97.72%
vdi sdi meu qudn doan thap. Trong vdng 3 thdng dau tien hau hd't ngffdi bdnh dd hoan todn sach sdi.
Ket qud neu tren cung tffdng tff nhff cdc tdc gid khac da cdng bd trdn thd' gidi.
Tinh an todn ciia laser Hoi: YAG vin cdn dang dffde thao ludn trong nhieu nghien ctfu giffa cdc tdc gid khde nhau. Tuy nhidn h^u h^t y kien chung deu thl^y r^ng laser ed bid'n chtfng it hdn vd bien chtfng mudn nhtf hep nieu qudn Id thlip hdn so vdi edc ngudn ndng Iffdng khde diing dd tan sdi khde [15].
Ddc bidt khi stf dung laser Hoi; YAG vdi cdc dng soi cd nhd hodc dng soi nidu qudn mim tl Id hep nieu qudn sau md chi con khodng 0.7% [14]. Chung toi ehffa gdp trffdng hdp hep nieu qudn sau md do thdi gian theo doi sau md chtfa dii ddi. Trong cdc nghien ctfu khde cd de cap den ti Id thung nidu qudn tff 4 %- 9%[15].Hlu he't cde tdn thffdng deu Id thiing nidu qudn nhe vd chi can ddt d'ng thdng JJ dd su'a chffa thtfdng tdn. Sdi di chuyen vdo trong thdn khdng ndn xem Id mdt bi^n chtfng vi dieu nay cd the xdy ra vd cd die xtf Ii bKng phffdng phdp TSNCT. Ddy dffde xem nhff mpt thd't bai ciia TSNS vd dtfdc ghi nhdn tff 5%- 18% tiiy theo cdc bdo cao da cdng bd. Thd't bai chung cua TSNS cd thd gap phdi 5%- 25% [16].
V. K^t luan
TSNS ngtfdc ddng Holmium: YAG Id mdt phtfdng phdp hieu qud vd an todn dd'i vdi sdi nieu qudn.
Tai lieu tham khao
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Tgp chl p h i u thu?lt nSi soi vk ngi sol Vi§t Nam (2017) SdS 2 - TSp 7; 5 - •
Tn'nh Hodng Giang vk c&ng su Kit qud diiu trj soi ni&u quin bing (dn s6i n&i soi ngUQc d&ng Holmium YAG t^i..
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Tap chl Y diTdc hoc quan sU, 2008 so'4, tr 105-109.
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'\ RK ? - T S D 7. 5 -
