Hpl NGHI KHOA HQC LAN THQ VII. H$l T|£T NigU - THAN HQC VI$T NAM (VUNA) phap tdn sol bdng holmium laser tgi B?nh
vi?n Vi?t Du-c". Tgp chi phlu thugt ngi soi va ngi soi Vi?t Nam tap 2- So 2: 75-80.
Nguyen Buu Trieu, Le Nggc Tir, Dwcng Vdn Trung. Ket qua tdn s6i ni^u qudn ngi soi ngugc dong cho 1519 b?nh nhan tgi b?nh
vi?n Buu di?n 1 Hd Ngi. Y Hgc Thirc Hanh, 2004, 141:479-500.
10. Nguyin Minh Tuan va cs (2012) "Danh gia kit qua tan sdi ni?u quan ngi soi bdng laser tgi b?nh vi?n E" Tap chi Y hgc thanh pho Ho Chi Minh chuyen dl than ni?u, ISN 1859-
1779, phy ban tgp 16, so 3 2012.
NGUYEN NHAN THAT BAI TRONG OIEU TRj SOI NIEU QUAN BANG TAN SOI QUA NOI SOI NGl/OC DONG TAI BENH VIEN TRUNG UONG HUE
Nguyen Kim Tuan', Nguyen Van Thuan', Cao Xuan Thanh', Tru-oTig V3n Cin', Hoang Van Tung^ Le Dinh Khanh^, Nguyen Khoa Hung^, Nguyen Du-Vinh'
TOM TAT:
Muc tieu: Khao sat cac nguyen nhan that bai trong npi soi tan sdi ngu'dc ddng dieu tri soi nieu quan.
Doi tu'dng va phu'dng phap nghien cu'u:
Tir thang 8 nam 2006 den thang 4 nam 2013, tai Benh vien Trung u'dng Hue chung toi da thi/c hien tan soi nieu quan npi soi cho 1276 benh nhan (1330 nieu quan). Khao sat va danh gia cac tru'dng hdp that bai.
Ket qua: Ty le tan thanh cong 92,55%
(1231 BN); that bai 7,45% (99 BN), trong do sdi d doan bung that bai 4,66 % (62 BN) va doan tieu khung that bai 2,79% (37 BN). That bai do ddt may la 2,11% (28 tru'dng hdp); sdi chay len than khi tan bang laser 19/1038 tru'dng hdp (1,83%); that bai khi tan sdi bang xung hdi ta 52/212 tru'dng hdp (24,52 %).
Ket lu^n: Tan soi nieu quan qua ndi soi la phu'dng phap dieu trj an toan, hieu qua, it sang
chan. Nguyen nhan that bai chu yeu la sdi nam vi tri cao, kich thu'dc Idn, va than \i nu'dc nang. l/u diem Idn ciia Laser la cd the tan v3 tat ca cac loai sdi va thuan Idi doi vdi cac sdi d cao.
Tii' khoa: npi soi nieu quan, tan sdi ngi soi bang laser, dieu tr| soi nieu quan.
SUMMARY
THE CAUSES OF FAILURES IN URETEROSCOPIC LITHOTRIPSY
Objectives: Assessement of the causes of failures in ureteroscopic lithotripsy.
Material and Methods: From August 2006 to April 2013, in Hue Central Hospital we treated 1276 patients (1330 ureters) with ureteral calculi by ureteroscopic lithotripsy.
Results: The success of ureteroscopy assess to the stones is 97.89%, failure is 2.11%.
The success rate of lithotripsy is 92.55%, failure is 7.45% (for stones of 1/3 upper ureter 4.66%, ' B^nh vien Trung iJcmg Hue
^ Dgi hgc Y Dugc Hue
Phan bi?n khoa hgc: PGS.TS. Tran VSn Hinh
108
Y HQC ViiT NAM THANG 8 - SO OAC BI$T / 2013
and 1/3 lower ureter 2.79%). Failure rate using Laser is 1.83% (stones move into the kidney).
I^ilure rate using pneumatic lithotripsy is 24.52%.
Conclusions: ureteroscopic lithotripsy is a safe, effective, less traumatic method. The causes of failure are mainly high position, and big size of stones, severe hydronephrosis. The big advantage of the laser is able to break all kinds of stones.
Keywords: ureteroscopic lithotripsy, lasser ureteroscopic lithotripsy.
I- OAT VXN o i
Sdi nieu quan la mgt trong nhiing benh ly thudng gdp cua he tiet nieu. 0 Viet Nam s6i nieu quan chidm ty le 28,27% trong cac b^nh ly ni$u khoa [1],
Soi ni$u qudn thudng gay cac bien chung do tac dudng tiet ni?u, do nhiem khuin. Neu khong dugfc dieu tri kjp thdi thi chiirc nang than bi gidm sut do u nude than, u mii thdn. Dieu tn sdi h? tiet nieu dd cd nhihig thanh tuu dang ke, dsic biet nhu: tan sdi ngoai CO the, tdn soi qua noi soi nieu qudn, phdu thuat ngi soi Idy sdi, phuong phap phdu thuat CO dien da dan han che va thu hep lai. Tan sdi qua npi soi (Endo Uroscopic Lithotrypsy)...
da gidi quyet tdi 90% cdc trudng hgp sdi va phdu thuat Idy sdi chidm khodng 10%. Kk qud dieu tri sdi cd lien quan den nhieu yeu td nhu vi tri, kich thudc, thanh phdn hda hpc cuas6i...[l],[3].
Tai Benh vien Trung ucmg Kuk, nam 2004 phuang phap nay Ian dau tien durgc dp diing. Qud trinh thuc hien ciing da bpc Id cac uu vd nhuac diem ciia phuang phdp dieu tri ndy. Chiing tdi tien hanh de tdi: "Nguyen nhan that bai trong di^u tri soi nieu quan bang tan soi qua noi soi ngvtfc ddng tai Benh vien Trung u-OTig Hu^ " nham khdo sdt nhiing nguySn nhan thdt bai trong dieu trj
sdi nieu qudn bdng tan soi qua ndi soi nieu qudn.
II- D6\ T U O N G VA PHUONG PHAP NGHllN CCrU
1. Doi tu-gng nghien cihi: Gdm 1276 b?nh nhdn (1330 nieu quan) sdi nieu qudn duac nhap vien dieu tri tai khoa Ngoai Tiet ni?u Benh vi?n Trung LTong Hue tir thdng 8/2006 din 4/2013
2. Phu'dng phap nghien cihi.
Thiet ke nghien ciru: md ta cat ngang.
Trang thiet bi
Ong soi nieu qudn cung 7,5 Fr ciia hang Karl- Storz, he thong tdn sdi Laser Holmium YAG va Xung hai cua hang Karl- Storz
Day ddn, Sonde JJ
Thdng cd gid (Sonde Dormia) de gap sdi, Kem gdp sdi
Ky thuat ngi soi tdn sdi (ngirpfc dong).
Tu the benh nhan: tu the san khoa Thao tdc: Sol va ludn day dan vao nieu quan cd sdi qua vi tri sdi len be than, tdn vun sdi bang Laser Holmium YAG hodc Xung hai
Khdo sdt vd ddnh gid cdc nguyen nhan thdt bgL
III- KET QUA NGHIEN cOU 3.1.Ket qua chung:
- Sdi nieu quan ben phai/ trai/ 2 ben:
559/ 663/ 54 (43,81% phai, 51,95% trdi, 4,24
% 2 ben)
Sdi nieu qudn bung/ tieu khung:
671/659 (Ty le 50,45% va 49,55%) - Kich thudc sdi 735 (55,27%) sdi <
10mm, 423 (31,8%) sdi 10,1-15 mm, 99 (7,44%) sdi > 15mm, 73 (5,49%) khdng thdy sdi tren X quang.
Hpl NGHI KHOA H(?C LAN THg VII, Hpl TIET NigU - THAN HOC VigT NAM (VUNA) - Miic d0 li nude cua than: Khong ir - Phuong ti$n tan s6i: Laser: 79,72%
nuoc /Dp 1/ dp 2/ dg 3: 128/ 499/ 532/171 (1038); Xung hoi: 20,28% (264) (9,62%; 37,52%; 40,01%; 12,85%) - DSt Sonde JJ sau tin: 85,48% (1137)
3.2. Cilc nguyen nhan that b^i:
Thanh cong: 92,55% (1231); That b?i: 7,45% (99) Bang 1: Ket qua theo vi tri soi
^ ~ ~ ^ ^ ^ - _ _ ^ ^ Vi Iri Ket qua ' ^ , Thanh conq
That bai Tonq
Ti^u l<hung n 622
37 659
»/o 46,76
2,79 49,55
Bung n 609
62 671
»/o 45,79 4,66 50,45
Tong n 1231
99 1330
»/o 92,55 7,45 100
Nhgn xet: That bai ddi vdi sdi nieu qudn doan bung cao han doan tieu khung cd y nghTa thdng ke (p<0,05).
Bang 2: Ket qud theo kich thudc sdi
^^-.Jtich thu'dc (mm) Ket qua ^~~""--^
Thanh cong
That bai Tong
< 10 n
(%)
724 (54,43)
11 0,84
735 (55,27)
>10-15 n
(%)
382 (28,72)
41 (3,08)
423 (31,8)
>15 n
(%)
52 (3,91)
47 (3,54)
99 (7,45)
Khonq thay n
(%)
73 (5,49)
0 (0)
73 (5,49)
Tonq n
(%)
1231 (92,55)
99 (7,45)
1330 (100) Nhdn xet: Kich thudc sdi < 10mm cd ti le that bai thdp hon cd y nghTa so vdi sdi Idn (p<0,05).
Bang 3: Ket qud theo dp ir nude tren Sieu dm
^ ^ - ^ Sieu am Ket qua ^ ^ ^ Thanh cong
That bgi Tong
Binh thu'dng n
(%)
126 (9,47)
2 (0,15)
128 (9,62)
S o l n
(%)
488 (36,68)
11 (0,84)
499 (37,52)
So 2 n
(%)
497 (37,37)
35 (2,64)
532 (40,01)
B6 3 n
(%)
120 (9,03)
51 (3,82)
171 (12,85)
Tong n
(%)
1231 (92,55)
99 (7,45)
1330 (100)
110
Y Hpc VIJT NAM THANG 8 - S6' PAC Blgl / 2013 Bang 4: K6t qua theo phuang ti?n phd v5 sdi (n = 1302)
^ ^ ^ " " - ^ ^ ^ P h i r d n g tien Ket qua —-~~-~^
Thanh conq T h a t bai
Tonq
Laser n 1019
19 1038
»/o 78,26
1,46 79,72
Xung hcri n 212
5 2 264
«/o 16,29 3 , 9 9 20,28
TSng n 1231
7 1 1302
»/o 94,55 5,45 100
Nhdn xet: Six dyng Laser de tdn cd 19 trudng hprp (1,46 %) sdi chay len than.
B a n g 5: N h o m that bgi
^ ^ - ^ ^ Vi tri ThSt b«i ^ ^ ~ ~ - - - - ~ - _ _ Khonq tiep can du'dc soi Soi chay len than
Tonq
Tieu i<hung n 5 23 28
%
5,04 23,24 28,28
Bung
"T
23 48 71
%
23,24 48,48 71,72
Tong n 28 71 99
%
28,28 71,72 100
B a n g 6 : Cac tai bien k h i tan soi Tai bi§n
Chay mau Thunq nieu quan Sol chay len than Khonq
Tonq
n 82 27 71 1150 1330
»/o 6,17 2,02 5,34 86,47
100
IV- BAN LUAN
Npi soi nieu quan dieu tri sdi nieu qudn Id mpt trong nhimg phuang phdp it xdm nhap dupe six dung cd hieu qua cao. Day Id mot phucmg phdp ddi hdi trang thiet bi khdng qua ddt va de duac trang bi ban. Trong vai nam I?i day, mpt sd ca sd Idn bdt dau su dung ngudn ndng lucrng Laser. Laser duac sir dung cho thdy cd nhieu uu diem hem so vdi xung hoi, tuy nhien cung cd nhiing nhuac diem nhdt dinh. Qua nghien cuu chung tdi cd mdt s6 nhihig vdn dk bdn luan.
Ddt ong ndi soi vao nieu qudn tiep can dupe soi theo chiing tdi Id da thdnh cdng dirpc 97,89% (1302/1330 nieu quan). Do do d$t mdy ddng vai trd quan trpng nhat. Nd phu thupc vao vi tri sdi, sdi thap dat mdy dl vd
khi len cao thi khd do ni?u quan gap khuc hoac ddi hudng khi di qua cdc d o ^ ca the.
Ket qud cua chung tdi: sdi d doan bung that bai 4,66 % vd doan ti^u khung thdt bai 2,79%
(Bdng I). Theo Joseph W. Segura sdi nieu quan d o ^ bung tan thanh cdng 70%, doan ti^u khung 89%
Han nOa sdi doan tren dat mdy khd cdn do mirc dp u nude cua than, neu than u nude nhieu se day lech nieu qudn 1dm cho dat may cdng khd khdn, chinh vi vay sdi doan tren neu than ix nude nhieu thi can nhac khi tan sdi ndi soi ngupc ddng. Ket qua than ix nude dp 3 cd 51/171 trudng hpp that bai (Bang 3)
Mpt sd trudng hop sdi nieu qudn dudi nhung rat khd ddt may vi hep Id nieu quan
Hpl NGHj KHOA HQC L A N THCT VII, HOI TIET NIEU - THAN HOC VIET NAM (VUNA)
hodc hep ni?u quan doan thdnh bdng quang, ddc bi?t Id sdi ndm ngay doan thanh bdng quang ma chua thd xuong bdng quang. Nhieu khi sdi 1dm xod di n6p lo ni?u qudn 1dm rat kho tim lo ni?u qudn, khong dua dupe day dan len ni?u qudn, luc nay rdt th^n trpng vi cd the gdy thung ni?u qudn vd l?ch dudng.
vk kich thudc sdi chung tdi nh^n thdy sdi cang Idn thi ty le that bai cang cao. k^t qud cOa chung tdi cd 47/99 trudng hprp sdi >
15mm that bai do sdi to dinh chdc vdo niem mac ni?u qudn vd lam cho ni?u qudn gap khuc kliong ti6p can dupe sdi (Bdng 2). Ben canh dd, do sdi Idn nen vi$c phd v5 sdi cGng khd khdn han.
Theo k6t qua ciia chung tdi that bai ddt dng soi ni?u qudn Id 2,11% (28 trudng ht^p).
Cd nhieu nguyen nhdn khien cho viec ddt mdy that bsii, tuc khdng the dua dng npi soi vdo nieu qudn, hoac dua duac vao Id nieu qudn nhung khdng the tiep can dupe sdi. Hai nguyen nhan thudng gap la Id nieu quan hep khdng the dua dng soi vdo dupe, nguyen nhdn khdc cung thudng gap la tinh trang phii nen niem mac dudi sdi, tao nen nhung polyp ddi khi che lap hodn toan nieu qudn do dd
khong (he dua ong ndi soi tiep can sdi ductc.
Doi vdi trudng hgp polyp, sir dung laser to ra cd nhiC'u uu diem do chiing toi cd the dot true tiep Icii polyp de tao dudng tiep can soi.
Sail khi tiep can duac soi viec tan soi cfiiig lilt khd vi neu sdi tan khong het lam cho niiu quan tac hon do phii ne, hoac soibi chay len than, nhat Id sdi cao va nieu quan gian. Chiing tdi gap 71 Iruimg hop (5,34%) hi IC-n tlnin mdt phan hoac hoan toan. trong dd 48,48% SOI nieu quan bung. 23.24% ti^u killing (Bang 4).
Su dung tan sdi Laser, sdi it di chuyen se han che soi len than tuy nhicn trong 1038 benh nhdn tan sdi bang laser chimg toi gap 19 benh nhdn (1,83%) sdi chay len than doi hoi dp chinh xac rat cao neu khdng de gay nen bong nieu quan la ngu\en nhan hep nieu quan s.iii na_\
Su dung tan soi bang xung hai 212 gap 52 irirdng hpp (24.52 % ) . Mpt van de ciing lam rat kho chiu la khi sdi nieu quan lau ngay gay nen vicm nhiem va niem mac nieu quan sal dirdi sdi tang sinh gay nen hinh anh polip nieu quan ga\ khd khan khi tiep can soi.
Bang 7. Nguyen nhan that bai so \ di eiie Uic gia khac.
Nguyen nhan Khonq tiep can soi Chay len than
Du'dng van Trung (2004)
7,43%
1,73%
Nguyen Vu Phi/Ong (2008)
1,5%
9
Chung toi (2013)
2,11 5,34 Ddt Sonde JJ ni?u qudn sau khi tdn sdi
cung cdn bdn cdi, theo chung tdi neu sdi nhd lay het sdi md trong qua trinh tdn khdng gay tdn thuang ni?u quan thi khdng cdn ddt stent (1). Cdn neu nieu quan bi tdn thuang hodc sdi to, sau tan sdi cdn nhi^u manh vun thi nen
tial \ a thdi gian dat tuy thudc vao mirc do Ion thuang nieu quan cd the tir 7- 30 ngay hoac hon nira (2,3)
Chiing tdi dat Sonde .U sau tan: 85,48%
(1137). khong dat: 14.52% (193).
112
Y HOC VIET NAM THANG 8 - s 6 D A C BIET / 2013
Bang 8. Ty 1? tai bi^n so vdi cac tdc gia khac.
Cac tai bien Chav mau Thunq NQ Chay len than Lon long
Younei M 2 0 0 1
4,3 0,13
0 0
Du'dng Van Trung 2000
9 0,4
0 0
Chung toi 2013
6,17 2,02 5,34 0 p < 0,05
IV- KET LUAN
Tdn sdi ni$u qudn qua npi soi la phuang phap dieu tri an toan, hieu qud, it sang chdn.
Nguyen nhan thdt bai chCi yeu la sdi ndm vi tri cao, kich thudc Idn, va thdi gian mac benh ddi gay cho than li nude nang. Uu diem Idn cua Laser la cd the tdn va tat ca cac loai sdi va thulln Ipi doi vdi cac sdi d cao.
TAI UEU THAM K H A O
1. Trhn Qudn Anh (2001),"Sdi nieu quan", Benh hpc ngoai khoa, Nha xuat ban Y hpc Ha Npi, Tr. 140-145
2. Du-ong Van Trung, Le Ngoc Tur, Nguyen Bihi Trieu (2004), "KSt qud tdn sdi ni6u quan ndi soi ngupc ddng cho 1519 benh nhan tai Benh vien Buu dien I Ha Ndi", Y hpc thuc hanh, Hpi nghi Ngo^i khoa toan qudc, (491), Tr.497- 500.
3. Chan KY, Zulkifli MZ, Nazri MJ, Rashid MO (2005), "A review ofday
care ureteroscopy of a teaching hospital in Malaysia", Med J Malaysia, 60(1), pp.
5-9.
EL-Khader K, EL-Fassi J, Tazi K, Ibenattya. A, Hachimi M, Lakrissa A (1997), "Place de L'Urei'teiroscopie dans le traitement de la lithiase de L'ureteire pelvien. A propos de 52 cas", Ann Urol, 31, p.89-91.
Joseph W. Segura, "The Management of Ureteral Stones", American Urological Association, Inc. © 1997, p.4-5
Jefrry L. Huffman. (1992) Ureteroscopy. In: Patrick C. Walsh' Campbell's urology, 6 th Ed.
Philadelphia, Pennsylvania; 1992: 2195- 2227.
Turk TMT and Jenkins AD (1999). A comparison of ureteroscopy to in situ extracorporeal Shockwave lithotripsy for the treatment of distal ureteral calculi;
Joural of Uro, 1999, 161: 45-47.
