Y HQC VIET NAM THANG 8 - SO OAC BIET / 2013
DANH GIA KET QUA BUCfC DAU TAN SOI NIEU QUAN B A N G XUNG HOI QUA NQI SOI NGl/OC DONG
TAI BENH VIEN 4 - QUAN KHU IV
Tran Vdn Hien', Nguyen Van Hu-ffng', Le Hai Nam'
T 6 M TAT:
Muc tieu: Nhan xet ve cac trieu chu'ng lam sang, can lam sang chfnh cua sol nieu quan.
Danh gia bu'dc dau ket qua thi/c hien ky thuat tan soi nieu quan qua npi soi nieu quan ngu'dc dong tai Benh vien 4- Quan khu IV.
f>di tu'dng va phu'dng phap: Nghien CLTU tien ciru djnh huicfng tren 35 benh nhan sdi nieu quan, dieu trj bang phu'dng phap tan sdi qua npi soi nieu quan ngu'dc ddng tai Benh vien 4- Quan khu IV, tCr thang 4 nam 2012 den thang 6 ndm 2013.
Ket qua: Trieu chiJTng chfnh: sdi can quang (100%); cd 1 vien sdi (94,29%); dau vung that lutig (100%); kich thu-dc sdi trung binh (12,6±3,7) X (5,5±1,9) m m ; soi 1/3 du'di nieu quan (74,29%) va 1/3 gitte nieu quan (25,71%);
dai buot 42,86%; dai due 2 0 % . Da so soi du'dc xir ly bang tan sol ddn tiiuan (71,43%); ket hdp g§p manh soi (25,71%). Thdi gian xu" ly soi trung binh 42,00 ± 19,27 phut, sau tan sdi cd 31,43%
dat JJ. Tai bien trong thi/c hien ky thuat (8,57%), bien chu'ng sdm (11,43%). ThiTc hien ky thuat thanh cdng 97,14% (tot 91,43%, trung binh 5,71%), that bai 2,86%.
Ket luan: Npi soi ngu'dc ddng vdi dng soi CLTng tan sol nieu quan vi tri 1/3 gliJa, 1/3 du'di bang may tan sdi xung khf nen !a phu'dng phap dieu tri ngoai khoa ft xam hai mang lai ket qua tot an toan cho benh nhan.
Tit khoa: sdi nieu quan, ngi soi tan sdi xung hdi.
' B^nh vi^n 4, Quan khu 4
PhSn bi^n khoa hgc: PGS.TS. Tran Van Hinh
S U M M A R Y
REVIEW I N I T I A L RESULTS OF PNEUMATIC URETEROSCOPIC LITHOTRIPSY AT ^
HOSPITAL - MILITARY ZONE I V Objective: Review of the dinical and subclinical symptoms of ureteral stones, as well as
evaluate the initial results of pneumatic ureterosoopc lithotripsy at 4 Hospitals - Military Zone IV.
Patients & method: A prospective- oriented study was performed on 35 patients with ureteral stones, treated by pneumatic ureteroscopic lithotripsy at 4 Hospital - l^ilitary Zone IV, from April 2012 to June 2013.
Results: The main symptoms: stones photoresist (100%), with 1 stone (94.29%), lumbar pain (100%), the average stone size (12.6±3.7) X (5,5±1.9) mm; gravel thind lower ureter (74.29%) and the third between the ureter (25.71%), acute urinary 42.86%, Diabetes 20%
opaque. The majority of stones treated with lithotripsy alone (71.43%); gripping piece of gravel combined (25.71%). Gravel processing time average 42.00 ± 19.27 minutes, then 31.43% lithotripsy have put JJ-stent. Catastrophe in the making technique (8.57%), early complications (11.43%). Perform technical success 97.14% (91.43% good, average 5.71%), 2.86%
failure.
Conclusion: Endoscopic retrograde probe hardware with ureteral lithotripsy place third middle third lower pulse machine pneumatic
Hpl NSHI KHOA HpC L A N THCTVII, H(?I TigT NigU - TH/jlN HQC V I E T NAM (VUNA) lithotripsy treatments less Invasive surgery gives
good results for patient safety.
Keywords; ureteral stone, pneumatic ureteroscopic lithotripsy.
I- OAT VXN oi
Trong c^c b?nh ly s6i tiet ni^u, s6i ni?u quin chiSm 28-30%, dilng litog thii hai sau s6i th(in. Sdi ni^u quin c6 the 6 bit ky vi tri nio cua ni$u quin, t?ii 1 hay nhieu vj tri, 1 hoic nhieu vien. Soi ni^u quin cin trd luu th6ng nude tieu tir thin xu6ng bing quang, n^u khong dupe xii tri kjp thdi se anh hudng nhanh chdng den chuc ning than vi giy ra nhttag bien chiing ning ni.
Sdi ni^u quin dugic diSu trj bing cic phuong phip npi khoa hoic ngogi khoa kinh difa. Tir nim 1980, cd thi di6u tri sdi ni$u quin bing cae phucmg phip it xim lin nhu tan sdi ngoii co thS, phau thuat npi soi liy sdi, tin sdi npi soi ngupc ddng. Phuong phap tan sdi ni^u quin qua npi soi nieu quan ngupc ddng dupe ap dung tuong ddi phd bien do ky thuat khong qui phiic tap, hau phiu nhe nhang, benh nhin (BN) hdi phyc nhanh; tuy nhien, phuong phip nay cung cd nhimg tai bifa, biSn chiing nhit dinh [1].
Tsii Benh vi?n 4, chung toi ip dung ky thuat tin sdi ni$u quan qim npi soi ngupc ddng tit thing 4/2012. Trong nghien eiiu nay, chung tdi nhan xet vd cic trieu chiing lam sing, cin lam sing chinh va dinh gia kdt qua thvc hi$n ky thuit tin sdi niSu quin qua npi soi nifu quin ngupc ddng.
II- 0 6 l TUONG VA PHUONG PHAP NGHIEN CCru
2.1. Doi tvpng nghien cihi:
Tieu chudn chon bfnh nhdn:
- Nhiing b$nh nhan dupe chin doin li sdi ni$u quin 1 ben hoic 2 ben.
- Kich thudc sdi nhd hon hoac bang 2cm.
Tieu chudn logi tri^:
- B?nh nhan cd cac bpnh ly iToi loan dong mau - Cd thai, viem dudng nieu, nhilm triing - H?p Idng nieu quin, hpp ni$u djo, n bing quang
Benh ly npi khoa cd anh hudng d^n qui trinh gay tS vi phau thuat
- Bpnh nhan ed di tat dudng nipu khdng cd kha ning dit dupe may
- Chiing tdi di chpn 35 BN sdi niSu quin, dupe dieu trj bang phuong phip tin soi qua npi soi nieu quan ngupc ddng tai Benli vien 4, tit thing 4/2012 dSn thing 6/2013.
2.2. Phirong phap nghien ciru:
- Tien ciiu cd dinh hudng.
- Nghien ciiu cac die diem lam sing va can lam sing chinh cua BN sdi nieu quin.
- Chi dinh va chdng chi dinh tin sdi qua ndi soi nieu quan theo Hpi Tilt nieu My [1IJ.
- Th\re hipn ky thuat tin sdi qua npi soi nieu quan bing dng spi ciing [7].
- Dinh gia c i c tai bien, biln chiing cua tin sdi qua npi soi nieu quin.
- Danh gii ket qua thyc hipn ky thuat tan sdi:
* Thanh cdng, gdm 3 mire dp: tdt (soi dupe tin vyn thinh nhitng minh nhd 1-2 mm hoac dupe liy ra hit, khdng cd tai bien, biln chiing); trung binh (sdi dupe tin vun, nhung lay chua hit hojc cd ton thuang xudc niem mac nieu quan hojc chiy miu nhe); kem (tan dupe sdi, cd tai biln nhung khdng phai chuyen phuong phip dilu tri).
•I- That b^i: khdng tilp can dupe dng soi vdi sdi hoic xay ra tai biln ning, khdng thJ tiep tuc th\rc hien ky thuat.
- Xu ly so lieu bing phin mim SPSS 17.0.
2.3. Tien hanh ky thuat - Phuang tien:
+ He thdng ngudn sang.
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Y HQC VigT NAM THANG 8 - s6 DJtC BigT / 2013 + Ong soi nieu quan ciing duang kinh 9
Fr, Diy dan, he thong tuoi nxa, sonde JJ...
+ May tan s6i xung khi nen hi^u Kal Storz cua Due san xuat.
- Giam dau: Gay te tuy s6ng
Tur the b^nh nhan: Tu th^ sdn khoa, chan bSn nieu quan soi de thdp ciing mSt phing thSn nguai lam cho ni$u q u ^ khong gSp khuc, dl quan sdt man hinh khi thao l^c.
- Thao tac kf thu^t: Soi ki^m tra b^ng quang, ludn day dan v^o ni^u qudn, dua ong soi ni$u quan den sdt voi vien soi, dua que tan d^n vien soi vd tdn v5 s6i vun den < 3 mm, sue rua nieu qudn, dat JJ nieu quan khi CO didy mdu, nhieu sdi vun, con sdi troi thaa
IM- KET Q Q A N G H I E N C Q U
3.1 Gioi: Nam 26 (743%), NG 9 (25,71%).
Co the do dac thCi la Benh vien quan dpi nen ty !e nam Ian han nG. Thao tac noi soi nieu quan nG de hon nam do nieu dso nvc ngdn.
3.2 Tuoi: tuoi trung binh: 49,4 ± 14,88 tu6i, tuoi Idn nhat 74 tuoi, nhd nhat 26 tudi, tudi hay g^p la 30 - 60 tuoi (65,71 %).
3.3 Dac diem 13m sdng -Sot: 2 BN (5,71%),
- Dau vting man suim thdt lung: 35 BN (100,0%), trong dd 12 BN (34,29%) cd can dau qu^n than vd 23 BN (65,71%) dau dm i.
- Ddi due: 7 BN (20,00%).
-Daibudt: 15 BN (42,86%).
- Dai mdu dai thS: 2 BN (5,71%).
- Than to (dau hieu cham than duang tinh): 0 BN.
- Cd 1 benh nhan sdi nieu qudn 2 bSn chung toi npi soi tan sdi cung 1 luc.
3.4. Dac diem tren Xquang va siSu am.
3.4.1. Vi tri soi:
- 1/3 giua nieu qudn: 7 BN (18,7%).
- 1/3 duai nieu qudn: 28 BN (45,3%)
Bang 1. Ket qua tan sdi theo vj tri Vjtri
1/3 tren 1/3 qiuti 1/3 du'di Conq
So lu'dng
0 9 26 35
Ket qua Tot
0 9 (100%) 23 (88,46%) 32 (91,43%)
TB 0 0 2 (7,69) 2 (5,71%)
That bai
1 (3,85) 1 (2,86)
Ty le (%)
0 100 92,31
3.4.2. Kich thuac soi:
- Kich thudfc ngang: 5,5 ± 1,9 mm.
- Kich thudc dgc; 12,6 ±3,7 mm.
3.4.3. So luang soi:
-1 vien: 33 BN (94,29%).
- 2 vien: 2 BN (5,71%).
BSng 2. Dd ngam thuoc tren UIV.
KStqua Tot Trunq binh Kem Conq
Sd Benh nhan 22 10 3 35
Tv le Vo 62,86 28,57 8,57 100
Nhgnxet: Cd 3 BN (10%) chiic nang than kem nhimg van dat ket qui tdt.
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Hpl NGHj KHOA HpC L A N THCT VII, Hpl Tt£'T NifeU - TH<j^N HQC VigT NAM (VUNA)
3.4.4 Ket qua tdn soi theo muc dg u nuoc.
Bang 3. Muc dp than u nude.
Wic d$ th$n H nu'dc Khonq
Odi Bd2 Od3 Conq
Tru'dc t i n sol Sdlu'Ong
0 15 16 4 35
T* 1$ »/o 0 42,86 45,71 11,43 100
Dat ket qua Tot
0 14 (93,33%) 15 (93,75%) 3 (75%) 33 (94,29%)
TB 0 1 (6,66%)
1 (25%) 2 (5,71%)
That bai
1 (6,25%)
3.4.5 TiSn sir can thi?p duang tiet ni^u hen ni^u quan soi.
Bang 4. Tien sir tiet ni?u.
Hinh thirc can thiep Tin sdi than ngoai co the IVId sdi than
Md sdi nieu quin ben tin sdi Khdng cd tien sir can thiep Cong
So l u p n g 3 1 1 30 35
Ty If (%) 8,57 2,86 2,86 85,71 100,0
Nhgn xet: Chi djnh ddi vdi sdi nieu quin hinh thinh sau tin sdi ngoii ca thi la hieu qui 35. Ky thuat npi soi nieu quanxirlysdl
3.5.1. Dal ong soi tiep cgn soi:
- Thanh cdng: 34 BN (97,14%).
- Thit bai: 1 BN (2,86%) do khdng tim thiy 15 nieu quin.
3.5.2. Phucmg phap xu ly soi (n = 35):
- Tin sdi, gip sdi: 9 BN (25,71%).
- Gip sdi don thuin: 1 BN (2,86%).
- Tin sdi dem thuin: 24 BN (68,57%).
- Khdng xii ly dupe (dp khdng tilp can dupe sdi): 1 BN (2,86%).
Sau xir tri, cd 11 BN (31,43%) phii da JJ-stent.
3.5.3. Thai gian noi soi xu ly soi:
Bang 5, Thdi gian npi soi xii ly sdi.
Thdi qian ( p h u t )
<30
Cong
SS ItfOnq
18
T y le °/o
51,43 45,71
2,86
mgn xet: Co 34 trudng hpp miy soi tilp can dupe sdi, 1 benh nhan khdng tim thiy 16 mpu quan do mem mac bing quang viem njng, phu nl. Thdi gian tin sdi trung binh: 42,00 ± 19,27 phut, thai gian dii nhat la 75 phut, ngin nhit li 12 phiit
Y Hpc VI$T NAM T H A N G 8 - S6 OAC BIET / 2013
3.5.4 Ket qud thuc hien ky thugt (n = 35):
Bang 6. Thdi gian thuc hien ky thu^t.
Soi ni^u quan Thinh cdng That bai, chuyen md md Cong
So Ivong 34
1 35
Tv le % 97,14
2,86 100
Nhdn xet: Cd 34 BN thanh cdng, 1 trudrng hgfp that bai do bang quang viem phii ne che lap kin Id nieu qudn khdng ti6p can dugc sdi...
- Thdnh cdng: 34 BN (97,14%), trong dd:
+ T6t: 32 BN (91,43%).
+ Trung binh: 2 BN (5,71%).
- Thdt bai: 1 BN (2,86%).
3.5.5. Tai bien va bien chungsam:
- Tai bien (tdn thuang niem mac): 3 BN (8,57%), trong do:
+ Tai biSn 6 BN sdi 1/3 giua nieu quan:
1/9 BN (11,11%).
+ Tai bien d BN sdi 1/3 dudi nieu qudn:
2/26 BN (7,69%).
- Bien chung som (dau qudn than, nhiem khudnnieu, dai mdu): 4 BN (11,43%), gdm:
+ Bien chiing d BN sdi 1/3 giQa nieu quan: 1/9 BN (11,11%).
+ Bien chung d BN sdi 1/3 dudi nieu quan: 4/26 BN (15,38%).
IV- BAN LUAN
4.1. Trieu chirng lam sang:
Trieu chung chu y6u khien BN di kham benh la dau vimg man suan thdt iung (100%), trong dd 34,29% cd con dau qudn than dien hinh; 65,71% dau dm i viing hd than ben cd sdi. Theo Ngd Gia Hy vd Tran Quan Anh, dau vimg man suon thdt lung Id trieu chihig chinh cua sdi nieu quan, con dau quJin than dien hinh xudt hien khi sdi di chuyen hoac cd viem phii ne, tac nieu quan cap tinh [5], [2]. Cdc trieu chung khac nhu dai budt (42,86%), ddi dye (20,0%), sdt (5,71%), dai mdu dai thi (5,71%).
4.2. Trieu chirng X quang:
Vj tri sdi trong nieu quan: chiing toi gdp 74,29% BN sdi 1/3 dudi va 25,71% sdi 1/3 giita. Tran Quan Anh lua chpn 70-75%
sdi nieu qudn 1/3 dudi, 25-30% d 1/3 giGa vd 1/3 tren [2]. Khi mdi ung dung kj thuat ndi soi nieu quan tan sdi, ngudi ta thudng chi dinh cho sdi nieu quan 1/3 dudi, sau do dan md rpng cho sdi d 1/3 giita vd 1/3 tren.
Chung tdi img dung ky thuat nay trong dilu kien ky thuat chua hoan thien nen khdng chpn sdi 1/3 tren nieu quan.
- Sd luang sdi: chung tdi gap da sd BN cd sdi 1 vien (94,29%), tuang duang vai ket qud cua Nguyen Quang vd Duong Van Trung [7], [8], cd 2 benh nhdn sdi 2 vien. Chung tdi it chpn sdi nhieu vien vi trong qud trinh tdn vien sdi d thdp, cac vien sdi d doan tren de trdi ngugc len than va day dugc coi la mot tai bien.
- Dp can quang ciia sdi: 100% BN cd sdi can quang. Dac diem thd nhuong khu vuc miin trung cd the cd anh huong den chat lugng ngudn nude, tir do lien quan den dam do can quang ciia sdi.
4.3. Ky thuat noi soi nieu quan nguoc ddng xuly soi:
- Dat dng soi tiep can sdi thanh cong la budc quylt dinh su thanh cong cua ky thu^t.
Nhilu truong hgp khdng tim dugc lo nieu quan tir bang quang hoac khdng the dua dng soi vao nieu quan do Id nieu qudn hep nen
89
Hpl NGHj KHOA HQC LAN THtf Vlt. Hpl TI^T NigU - THAN HQC VigT NAM (VUNA) phai chuyen phuong phdp dieu trj khdc.
Trong nghien curu ndy, cd 1 BN (2,86%) khdng d^t dugc ong soi vi khdng tim thay lo ni?u qudn do dang viem bdng quang cap tinh mu:c dp ndng (mpt trong s6 chong chi dinh ciia ky thuat, chung tdi coi day Id m^t that bai trong vi?c chi djnh).
Trong npi soi ni?u qudn tan sdi, cd 3 phuang phap xir ly sdi co bdn: tan sdi thdnh nhthig mdnh nhd (1-2 mm) dl sdi tu ddo thai ra ngoai, gdp nhtJ-ng vien sdi cd kich thudc nhd ra ngodi, tdn nhd vien sdi vd gdp nhiJng mdnh sdi vun ra ngoai. Co 9 BN chung tdi ap dyng phuong phdp tan sdi ket hgp gdp sdi (25,71%) do phuang phap ndy cd thdi gian tan sdi ngdn, vi trong thyic te de tan vien sdi thanh nhihig manh 1 -2 mm ddi hdi nhieu thdi gian; han nira cung khdng the gap vien sdi cd kich thudc Idn hon dudng kinh cua nieu qudn ra ngoai mpt each dan thuan, neu cd se gay ra nhiing tai bien, bien chung nang, cd thi gay hep nieu quan sau nay. Chiing tdi gap sdi don thuan cho 1 BN (2,68%) cd sdi nhd doan nieu quan thanh bang quang.
- Sau tdn sdi nieu quan qua npi soi nieu qudn nguoc ddng, 11 BN (31,43%) dugc ddt JJ-stent, 8 BN (22,86%) khdng dat ndng nieu qudn. Theo Hpi Tiet nieu My, chi dinh ddt ndng nieu qudn sau ndi soi tdn sdi ngugc ddng bao gdm: ton thuong ni?u qudn, hep nieu qudn, than dan dgc, suy than va sdt mdnh sdi Idn [9]. Nhilu tdc gia dua ra ly do d^t ndng ni?u qudn sau tan sdi la tdn thuang thdnh ni?u qudn (do sdi bam dinh hoac do tac ddng CO hpc cua que tdn, thoi gian tan sdi dai), con sdi v\in nhilu. Tuy nhien, cd mdt s6 quan diem cho rdng vi?c ddt ndng nieu quan hodc JJ-stent nen chi dinh chdt che vi ngodi van de chi phi cdn gay ra mpt s6 bdt Igi.
Cung cd quan diem ting hp viec dat ndng nieu quan thudng quy se giup gidm ti le hep
ni?u qudn, gidm ir nude th$n va giam dau.
Theo chung toi, nhiJng BN sdi nhd, sdi cliua gay tdn thuong nieu quan, tan sdi ho|c gip sdi thu^n Igi, thdi gian thuc hien ky thu|t ngdn, niem m?c nieu quan binh thudng sau tdn sdi thi khong can phdi ddt ndng ni?u qudn.
- Thdi gian xu ly sdi cua chiing tdi trung binh 42,00 ± 19,27 phut, dai han so vdi cac tdc gia khdc cd ciing ca che tdn sdi. Dilu ndy c6 the do chung tdi mdi triln khai kj thu|t nen ky thuat chua thanh thuc, hon nita chiiiig tdi van sir dyng ndng lugng tan sdi co hpc c6 kha ndng phd sdi han che.
4.4. Ket qua thirc hifn ky thuat:
Chung tdi thuc hien tdn sdi thanh cong 97,14%, trong do cd 94,29% tdt, 5,71%trung binh va 2,86% that bai. Ti 1? thanh cong nay tuong duang vdi mpt sd tac gia khac cd cung cache tdn sdi [7], [10],
Trong nghien cuu cua chiing tdi, cdc BN sdi d 1/3 giiJa cd ty le tai bien va bien chm^
cao hon sdi 1/3 dudi nieu qudn nhung khong cd y nghTa thdng ke do sd lugng thuc hi?n kj thuat cdn il.
V- KET LUAN
Nghien cuu 35 BN sdi nieu qudn, dilu trj bdng tan sdi qua ndi soi nieu quan ngugc ddng tai Benh vien 4, chung tdi nit ra ket luan:
100% la sdi cdn quang; 94,29% co 1 vien sdi vd 100% cd dau vimg thdt lung. Sol nieu quan cd kich thudc trung binh 12,6 ± 3,7 mm theo chilu dgc va 5,5 ± 1,9 mm theo chieu ngang; sdi 1/3 giiia nieu qudn chilm 25,71% vd 1/3 dudi nieu quan chilm 74,29%. Tuy nhien ty 1? nay mpt phdn do s\f lira chpn cua phau thuat vien (trdnh nhiing trudng hgp khd nhu sdi kich thudc Idn hay sdi d doan ni^u quan cao).
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Y HOC VigT NAM T H A N G 8 - S6 PAC BI$T / 2013
- Ddt ong soi vao nieu quan tilp c$n sdi thanh cdng 97,14%; xir ly sdi bdng phuang phdp gdp sdi don thuan 2,86%, tdn sdi ket hop gdp manh sdi 25,71%, tan sdi dan thudn 86,57%. Sau tdn sdi cd 31,43% BN dugc d^t JJ-stent, thdi gian xii ly sdi trung binh 42 ± 19,27 phut. Ti 1? tai bien trong thyc hi?n ky thu|it la 8,57% (do tdn thucmg niem mac nieu quan vd hdi chung npi soi). bien chiing sdm (dau viing ho than 7,7%, nhiem khuan nieu 7,7% vd dai mdu 3,8%), gap cd d BN sdi 1/3 giiia va dudi nieu qudn. Thuc hien ky thuat npi soi nifu qudn tdn sdi thdnh cdng 97,14%
(tdt 91,43%, trung binh 5,71%,) vd thdt bai 2,86%.
TAI UEU THAM K H A O
1. Dang Ngoc Anh va CS (2004), "Nhan xet ket qua tan sdi bang phuang phap npi soi tai Khoa Ngoai, Bpnh vien 198", Tap chi Y hpc thuc hanh, sd 491, tr. 555-558.
2. Tran Quan Anh (2002), "Sdi nieu qudn", Benh hpc ngoai khoa, tap 2, Nha xudt bdn Y hoe. Ha Ndi, tr. 140-145.
Tran Cac va CS (2009), "Ket qud npi soi tan soi nieu quan bang xung hoi d 235 BN sdi nieu qudn". Tap ehi Y dugc lam sang 108,4 (3), tr. 75-7
Tran Van Hinh (2013) Cdc phuong phdp chdn dodn vd dieu trt sdi tiet nieu.
tr327-329
Ngo Gia Hy (1985), "Sinh ly va sinh ly b?nh nieu quan", Nieu hpc, tap 3, Nhd xudt bdn Y hpc, Hd Ndi, tr. 20-82.
Nguyen Quang va CS (2004), "Mot sd nhdn xet ve tinh hinh dieu tri sdi nieu qudn ngugc ddng va tdn sdi bang Llthoclast tai Khoa Tiet nieu Benh vien Viet Diic", Tap chi Y hpc thuc hdnh, sd 491, tr. 501-504.
American Urological Sssociation (2007), Guideline for the Management of ureteral Calculi, Baltimore, USA.
American Ulorogical Association (2007), Guideline for the Management of Ureteral Calculi, Baltimore, USA.
