Hpl NSH! KHOA HQC LAN THCf VII, HQI TIST NIEU • THAN HpC VigT NAM (VUNA) Pham Nam Vi|t (2005); "Pliau thujit md
nieu quan lay sdi qua nga npi soi sau piiuc m^c; kinh nghi?m ban dau qua 40 trudng hgfp tai Benli vi?n Ho^n Mf: Tgp chi Y hoc Viet nam; Tgp 313 (So dgc bifl): Tr: 144-147.
9. Gaur DD (1992), "Laparoscopic operative retroperitoneoscopy: Use of a new devic"; 3 Urol. 1992:148.1^:206-210.
10. Keeley FX, Gialas I et al (1999);
"Laparoscopic ureterolitliotomy: tlie Edinthburgli experience"; BJU Im 1999:84:765-9.
SO SANH KET QUA BUCiC DAU CUA HAI PHUONG PHAP TAN S6l NIEU QUAN NOI SOI NGUOC DONG
B A N G M A Y T A N LASER VA XUNG HOI
T 6 M T^T:
Muc tieu: Oanii gia ket qua (Jieu tri sdi nieu quan ijang phu'dng piiap tan sdi ngu'dc ddng, nguon tan laser va xung hdi.
Ooi tu'dng va phu'dng phap:Nghlen cud tien cu'u, md ta 144 tru'dng hap tan sdi nieu quan bing npi soi ngu'dc ddng vdi may tan laser va xung hdi tCr thang 06/2012 den thang 06/2013 tai Benh vien Viet Tiep, Hai phdng.
Ket qua: Thdi gian tan sdi laser trung binh 25,5 phut, xung hdi la 36,7 phut. Thdi gian hau phau tan laser trung binh 3,15 ngay, tan xung hai trung binh la 4,8 ngay. Ty le thanh cdng ddi vdi tan laser la 81/84 trudng hdp (96,42%), vdi tan xung hai la 55/60 trddng hdp (91,67%). 1 tru'dng hap phai ket hdp ESWL, 4 tru'dng hap chuyen mc md. Nieu quan 1/3 tren tan thanh cdng bSng laser la 11/12 trifdng hdp.
Ket luan: Viec sir dung nguSn tan laser trong tan sol nieu quan mang lai hieu qua cao, it bien chutig, cd the ap dung tot vdi sdi nieu quan tren cao, kich thudc sol Idn cd mat dp chSc.
Tir khoa: npi sol tan sdi, tan sdi xung hdi, tan sol laser.
' B?nh vien Vi|t Tiep, Hai Phdng
Plian bi?n khoa hpc: PGS.TS. VQ Nguyin KhSi Ca 80
Nguyen Cong Binh', Bui Van Chien'
SUMMARY
COMPARING THE EARLY RESULTS BETWEEN URETEROSCOPIC LITHOTRIPSY BY LASER AND
PNEUMATIC ENERGY Objective: To compare the early results between ureteroscopic lithotripsy by laser and pneumatic energy.
Patients and Method: A total of 84 ureter stone patient underwented laser lithotripsy and 60 ureter stone underwented pneumatic llthptripsy from June 2012 to June 2013 at Viet tiep hospital, Hai Phong.
Results: the mean duration of the procedure when used laser is 25.5 minute and used llthoclast Is 36.7 mins. The mean post-op hospital when used laser is 3,15 days and used llthoclast is 4.8 days. TTie successes in laser energy is 96.42% and pneumatic is 91.67%, combination with ESWL in 1 cases. 4 cases must be treated by open- operation.
Conclusion: The initial result of laser lithotripsy for ureter stone has hight result.
Keywords: endoureteroscopic lithotripsy, pneumatic lithotripsy, laser lithotripsy.
Y HQC VigT NAM THANG 8 - S6 D A C BIET / 2013 I- O A T V A N OE
Soi tiet nieu la benh pho bien nhat trong cac benh ve tiet nieu a Viet Nam. Soi nieu quan da phin la xuat phat tir soi th$n trong qua trinh hinh thanh s6i di chuyen xuong nieu quan, do sir viem phu n8 niem mac khi di chuyen cua soi va kich thuac cua soi ma soi khong troi dugc xuong bang quang va dai ra ngoai. Soi nieu quan la mpt bat thucmg can phai diSu tri vi nieu quan la con duong dpc dao dSn nuoc tieu tu t h ^ xuong bang quang, nku nieu quan bi tSc do soi thi t h ^ s6 dan dan va ijr nude, it mu, th|in bi huy hogi dan den nguy ca suy than va mat chiic nSng than.
Hien nay, c6 nhieu phuang phap dieu tri hieu qua soi ni^u quan. Theo khuyen cao cua h6i Nieu khoa cua My va Chau Au, tan soi ngoai co the la phuong tipn duoc uu tien lira chpn hang dau trong dieu tri soi nieu quan khong bien chiing.
Tan soi n6i soi ngugc dong dupe chi dinh cho nhung trucmg hop soi ni?u quan doan chau va khong duac khuyen cao cho nhung soi nieu quan doan cao do phau thuat vien kho tiSp cSn dupe soi va soi de chay len th^ dan den cupc mo that bai. Gan day, nha nhirng tien bp ky thuat vai ong soi nho va nhung phuong tien pha soi hieu qua nhimg it gSy ton thuang thanh nieu quan nhu xung hoi va laser, nOi soi nieu quan tan soi dirpc chi dinh rpng rSi hon.
Tren th^rc te cac phuang phap tan nay deu CO nhiing uu diem va han che rieng, vi vay chiing t6i tien hanh nghien ciiu nay nham muc tieu: Bdnh gid ket qud dieu tri ^oi nieu quan bdng phucmg phdp tdn soi npi soi ngugfc dong sA dung xung hai vd laser.
II- Odi TUfjfNG VA PHUONG P H A P NGHIEN CCrU
Tu thdng 06 nam 2012 d^n thang 06 nam 2013, 58 benh nhan soi nieu quan duoc tan s6i npi soi ngupc d6ng bang xung hai v^ 86 BN dugc tan bang laser tai Khoa Ngoai Than Tik Ni?u, Benh vi?n Viet Ti?p Hai Phong.
TiSu chuin citgn benh nhdn:
Soi nieu qudn dugc chan doan d\ra tren sieu am, KUB va UIV .
Khong nhiem khuan tiet nieu.
Than con chiic nang ngam thuoc tren phim chyp nieu do tTnh mach.
Tieu chudn logi trir:
Cac benh ly r6i loan dong mau, lao du6ng nieu, nhiem triing tiet ni?u chua dieu tri on dinh, than mat chiic nang.
- Hep long nieu quan, u phi dai tuyen tien liet, hep nieu dao, viem bang quang, u bang quang.
- Bien dang khop hang, cot song kh6ng nam dupe tu the san khoa.
- Benh toan than nang: Dai thao duong chua on djnh, suy tim nang, suy gan...
III- KET Q O A N G H I E N CLTU
3.1. Bac diem lam sang:
- Tu6i trung binh 38,32 (tir 20 - 73 tu6i).
Gioi: Nam 81 (56,25%), nii 63 (43,75%).
- Trieu chirng khi vao vien: Da so cac benh nhan den kham vi con dau quan than di6n hinh 75 BN (52,08%), 46 TH ( 31,94%) dan kham vi dau that lung, 23 TH (15,98%) sieu am tinh ca phat hien soi.
Hpl NGHI KHOA H(?C IAH THCf VII, Hpl T|6'T NlgU - TH/jlN HgC VigT NAM (VUNA) 3.2. Die diem can lam sang:
- Vi tri s6i:
Vi tri s6i NO 1/3 tren NO 1/3 qlii:a NO 1/3 difdi
l o n g
B i n g l : V i tri s6 Tdn laser
12 27 45 84
Tyle(°/o) 14,28 32,14 53,58 100
Tan xung htil 0 16 44 6 0
TV re CM 0 26,66 72,34 100
- Kich thudc s6i Kich thi/dc soi
<10 mm 10-15 mm
>15mm Tong
Ban Tin laser
11 46 27 84
? 2: Kich thu6c so Ty le ( % )
13,09 54,76 32,15 100
Tdn xung hcfi 17 43 0 60
T y l e f % ) 28,33 71,67 0 100
- Dam dp can quang cua soi so voi c§t s6ng:
Bang 3: Dam do can quang 0am do can quanq cua sol
Lcfn hdn Bang It hdn Khonq thay sol
Tonq
Tan laser 25 36 19 4 84
ciia soi {so vcri cot song) 1 Tv le»/o
29,76 42,85 22,63 4,76 1 100
Tan xung htfi 11 32 15 2 60
Tv le%
18,33 53,33 25 3,34 100 3.3. Ket qua tan soi:
- Thai gian tan soi bing laser trung binh 25,5 phut (17 -70 phiit), thoi gian tan soi bkg xung hai trung binh la 36,7 phiit (25 - 86 phiit).
- ThM gian hju phau trung binh sau tan laser la 3,15 (2-5 ngay), d6i vai tan xung hoi la 4,8 (2-8 ngay).
- Tan sdi thanh cong:
Vi tri sol NO 1/3 tren NO 1/3 qiOS NO 1/3 dudi
Tonq so '
B a n s 4: l a n s BN tan Laser
12 27 45 8 4
01 thanh cong lien Thanh conq
11 27 43 81
quan den vi tri soi.
BN tan xunq hdi 0 16 44 60
0 14 41 55
82
Y HQC VI$T NAM T H A N G 8 - s 6 OJ^C BigT / 2013
3.4. Bien chirng:
- Nhiem khu4n ni?u: voi tdn laser c6 6 BN (7,14%), t ^ xung hoi c6 10 BN (16,67%).
Ton thuong niSm mac nieu quan doi voi tan Laser la 26%, tan xung hoi la 35%.
- Ddi mau: sau tan laser c6 4/84 BN (7,14 %), tdn xung hoi la 7/60 BN (11,67%).
IV- BAN LUAN
Hi$n nay, ciing voi sir phdt trien cua phau thugt npi soi va cac dung cy npi soi hi^n dai, b?nh nhan soi ni?u qudn co rat nhieu su chpn lya trong vi|c dieu trj, rat it truang hpp phai mo ma lay soi. Phuang phap chii yeu hien t^ la su d\ing npi soi nguoc dong voi cac thS hp mdy tdn xung hoi hodc laser mang lEii hipu qud cao, day deu Id nhiing phuong phap dieu tri it xam Ian, it ton thuong nieu quan.
Phuong phdp tan xung hoi dd dupe trang bi cho nhieu benh vien co uu diem gid thanh thap, chi phi dau tu it ton kem, tuy nhien viec su dung ong soi ciing han che hieu qua trong viec tan soi a vi tri nieu qudn 1/3 tren, cung voi do nguon tdn xung hoi se gap kho khan doi vdi nhihig soi co kich thuoc Ion va mat dp ran chdc.
Trong nghien ciiu cua chiing toi, viec sii dung nguon tan laser da khdc phuc duoc nhung nhupc diem tren.
Lira chgn kich thuac s6i de tan laser trong nhien ciiu ndy khong gap nhiku kho khan, v6i 27 trudng hap soi co kich thuoc
>15mm (32,15%), day Id kich thuoc soi ma hi?u qud tan soi sS khong cao n^u tdn bdng mdy tdn xung hai, chiing toi chi gap 1 truang hpp that bai nhung nguyen nhan chu ySu khong phai do kich thuac soi to ma do soi nam sdt lo ni^u qudn, khong ddt dupe mdy soi ISn de tan soi.
Tdn soi bdng nguon tan laser hipu qua doi vdi cd nhthig soi co m^t dp ran chdc, trong nghien ciiu ndy co tai 72,61% s6i c6 m$t dp bdng ho^c Idn hon cdn quang ciia cpt song. Ket qud ndy phu hpp vdi nhieu nghien cuu cua Duong vdn Trung [2], Grasso M, ChalikY[3].
Ve thdi gian tdn soi, trung binh ciia tan laser Id 25,5 phiit nhanh hon so vdi tan xung hai. Thdi gian Idu nhat khi chiing toi tdn sdi bang laser la 70 phiit, cdn tdn xung hoi la 86 phiit. Qud trinh tdn sdi laser trong nghien ciiu cua chiing toi thudng chi g$p khd khan trong viec ddt mdy soi len nieu qudn do h?p l5 nieu qudn, do sdi sdt 16 nieu qudn, nguyen nhan ndy 1dm cho thdi gian tdn sdi keo ddi. Nhiing trudng hgp sdi ciing chiing tdi tan bdng nang luang laser rat de dang, nhimg khi tan bang xung hoi gap rat nhieu khd khan, lam cho thdi gian tan keo dai hem rat nhieu.
Thdi gian hdu phau trung binh la 3,15 ngay ddi vdi tan laser, 4,8 ngdy ddi voi xung hoi. Do khi tdn bdng xung hoi thdi gian tan keo ddi hon, ton thuong niem mac nieu qudn, nhiem khuan nipu tdng cao Idm cho thdi gian hau phau keo dai hon.
Ket qua tdn sdi birdc dau cua chiing toi thanh cdng 82/84 trudng hpp (97,61%) khi tdn laser, 55/64 trudng hgp (85,94%) d6i vdi- tdn xung hoi, cung tuong tu vdi cac tac gia khac nhu Duong Van Trung [2], Mulvaney W.P,BeckC. W. [4].
Chiing tdi nhdn thay ty le thdnh cdng cao nhat la nhiing sdi nieu quan 1/3 giiia, soi nieu quan 1/3 tren cd 2 tnrdng hgp that bai (2,38
% ), day la nhung trudng hpp sdi di chuyen vdo trong cdc ddi than chiing tdi that bai do CO ddi than hep khdng tiep can duac sdi da phai ket hgp tan sdi ngodi co the. Vdi sdi nieu quan 1/3 dudi cd 4 tnidng hpp chiing tdi phai chuyen md md do sdi nam sat bang
83
Hpl NGHj KHOA HQC L A N THCf VII, Hpl TlgT NigU - THJlN HQC V I E T NAM (VUNA)
quang gay hep lo ni?u qudn khong dat dugc ong soi ni§u qudn. Nhihig trudng hpfp ndy co the xdc dinh trudc d\ra tren phim chyp ni?u do tinh mgch.
Qud trinh tan s6i bdng laser d6i h6i dg chinh xdc cao, ciing v6i vi^c lya chpn cudng dp laser hgp ly giiip cho vipc tdn s6i hi?u qud vd trdnh dupe cdc biSn chimg nhu r6 ni?u qudn, chdy mdu nieu qudn...Nghien cuu ciia chiing toi c6 4 trudng hpp (7,14%) c6 biSn chiing ddi mdu, day la nhihig trudng hpp sdi vi6m dinh, mjt dp chdc, vi$c tan sdi gay tdn thuang thdnh ni?u qudn. khi tdn xung hoi chiing tdi chi dieu chinh dupe cudng dp tdn, ban che dupe khdng nhi^u tai bidn nay nen ti 1? ddi mdu cdn khd cao 11,67%.
V- KiT LUAN
Viec sir dung ngudn tdn xung hcri vd laser trong tdn sdi niju qudn mang lai hieu qua cao, it hiin chiing, rieng ngudn tdn laser cd the dp dyng tdt vdi sdi nieu quan tren cao.
kich thudc sdi Idn cd mat do chdc, day la mpt sy lya chpn tdt trong vi?c diiu tri sdi nieu qudn.
TAI UEU THAM KHAO
1. Trjn Qudn Anh (2001), "sdi nieu quin", Benh hpc ngoai khoa tap 2, Nha xudt ban Y hpc Ha npi, tr 140-145.
2. Duong v a n Trung (2010) " Budc dau tSn sdi than npi soi ngupc dong bdng nang ltri;mg Laser, Y hpc Viet Nam thang 11/2010, tr 577-581.
3. Graso M, Chalik V. principles and aplications of laser lithotripsi: Experience with the holmium laser lithotrite. J Clin laser IVIedSur 1998; 16:3-7
4. Mulvaney.W.P.and Beck,C.W. The laser beam in urology. J Urol I968;99:l 12.
5. Watson GIW, Smith N.A. Comparison of tlie pulsed dye and holmium lasers for slone fragmentation: In vitro smdies and clinical experience. SPIE vol. 1879 laser in Urology, Gynaecology and general Surgery 1993: 139- 142.