JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY
Tan soi than qua da bang duong h§m nho (min^ PCNL);
Nghien cmi tai hai benh vien tuyen tinh
Mini percutaneous nephrolithotomy: Research at two provincial hospitals
Trinrag Thanh Tung*, Le Huy Ngoc**, *Benh vien Da khoa Thanh Hoa Le Ngpc Bang**, H& Trddng Thang** **Benh vien Da khoa Nghe An
Muc tiiu: Danh g i l ket q u i v l dUa ra mpt so nhan xet ve tan s6i qua da bang dudng ham nhd dieu trj s6i than tai hai benh vien tuyIn tinh. £)o/fi/pngvdp/)u'crngp/7dp: Bao gom 45 benh n h i n (tudi trung binh:
50,9 tuoi, nam/nijr: 1,25) dUdc tan sdi qua da bang dudng ham nho dieu tn sdi t h i n tai Bdnh vidn Ba khoa tinh Thanh Hda va Benh vien Da khoa tinh Nghe An t d thang 01 nam 2016 den t h i n g 01 nam 2017. Ket qud: S6i b l t h i n don thuan hay sol b l than ed nhlnh d nhom d l i dddi chiem 82,2%. Kfch thUde sol trung blnh 1,8cm. TJ id thanh cong 95,6%, ty Id sach soi 80%, choc do d l i than dudi hudng d i n cua C-arm 29 trudng hpp, sieu am 16 trudng hpp. Chpe do vao nhdm dai tren 12 trudng hpp, nhom dai gida 8 trudng hpp, nhom d l i dudi 25 trudng hpp. Thdi gian mo trung binh 91,4 phut. Thdi gian nam vidn trung binh 6,4 ngly. Bien chdng sau mo 11,1%. Chuyen mdmd4,4%./fef/uon:Tans6i than qua da b i n g dudng him nh6 la mpt phuong phap d i l u trj sdi than it xam lan, an t o l n , hieu q u i , phu hpp vdi nhCftig trudng hop s6i than
< 2em va eo the ap dung dUdc d cac benh vien tuyen tinh.
Tdkhda: Lay soi than qua da, sol than.
Summary
Objective: Evaluate innitial results and make some remarks on mini-percutaneous nephrolithotomy on renal calculi treatment at two provincial hospital. Subject and method: Included 45 patients (mean age 50.9 years, male/female - 1.25) who were undergone mini-percutaneous nephrolithotomy percutaneous for renal calculi treatment in Thanh Hoa General Hospital and Nghe An General Hospital from January 2016 to January 2017. Result Simple renal pelvis stones or renal pelvis stones with lower calyx stones was 82.2%. Medium stone size was 1.8cm. Success rate was 95.6%, the stone free rate was 80%. Renal access under guidance of C-arm were 29 cases, of ultrasound was 16 cases. Puncture into upper pole were 12 cases, middle were 8 cases, lower pole were 25 cases. The average operative time was 91.4 minutes. The hospitalization was 6.4 days. Complications after surgery was 11.1%. Conversion to open surgery was 4.4%. Conclusion: Percutaneous nephrolithotomy with small tracts (mini-PCNL) was a method of mini-invasive treatment for renal calculi, safe, effective, consistent with the kidney stone cases less than 2cm and could be applied at provincial hospital.
Keywords: percutaneous nephrolithotomy, renal calculi.
Ngdy nhgn bdi: 17/3/2017. ngdy chdp nhdn ddng-19/4/2017
Ngu&iphdnMi: Trucmg Thanh Titng, Email: [email protected] - Benh vien Da khoa Thanh Hoa
AP CHl Y DL/OC LAM SANG 108 Tap 12-56 5/2017
j . O a t v a n d ^
I Trong hai thap ky gan d l y , nhd sU cai t l l n cCia :ac the he dng npi soi va su phat t r i l n eua eae dang lang Idpng t i n sdi, ma eac phuong p h I p dieu t n sdi :iet nieu ft x l m lan l l n lUpt ra ddi. T i n sdi than qua da (PCNL - percutaneous nephrolithotomy) dupe phat trien de dieu trt eae trUdng hpp sdi than Idn, phufc tap thay cho m d m d [2]. Theo b i o cao eCia c l e trung t i m t i l t nieu Idn tren t h l gidl thi ty Id mo m d Jieu trj sol tiet nieu hien nay ehr khoang 1 - 5,4%, tuy nhidn ty Id n l y d c l e nddc dang p h l t t r i l n van con :ao khoing 14% [7]. Trong hUdng dan eua Hiep hpi tiet nieu Hoa Ky (AUA) n I m 2005, thi t y le sach sdi
;SFR - stone free rate) sau PCNL I I 78%. Cle tai b i i n , Dien chdng cd the gap trong PCNL la: C h l y m l u ; ton thuong ele cd quan l l n can; thuyen tac khf tTnh tiaeh v l nhidm trCing [2]. Be g i l m t h i l u ele tai bien, Dien chdng ed the x l y ra, n h i l u t i e g i l da sd dung :ae loai ong soi cd kieh thUde nhd hon nhU: Mini- KHl 13-20 Fr; micro-PCNL 6-12 Fr.
Tai Viet Nam, cho den nay PCNL mdi ehi duac ing dung tai ele trung t i m tiet nidu Idn nhU: Bdnh /ien Blnh D i n ; Bdnh vidn Trung Udng H u l ; Benh /len Viet Ode, Benh vidn Viet Phap, Benh vien Trung Jang Quan dpi 108, Benh vien 103... Vdi ky t h u l t :ln sdi than qua da bang dUdng ham nhd (mini- 'CNL) thi van dang edn it noi thde hien, d i e biet I I :ac bdnh vidn t u y I n tinh. Benh vien €)a khoa tinh rhanh Hoa va Bdnh vidn Da khoa Nghe An d l dng Jung ky thuat mini-PCNL vao dieu trj sdi than t d iam 2015 - 2016, qua nhdng trUdng hpp d l thUe lien, chung toi tien h l n h nghidn cdu nay vdi muc idu Ddnh gid ket qud vd dUa ra mdt so nhdn xit ve ky hudt mini-PCNL.
I. Doi tdomg va phUdng p h a p
Bao gom 45 bdnh nhan (tuoi trung binh: 50,9 nam, lam/nd: 1,25) dupe t i n sdi qua da bang dUdng ham iho d i l u tn sdi than tai Benh vidn Ba khoa tinh Thanh ioa va Benh vien £)a khoa tinh Nghe An t d t h i n g 01 iam 2016 d i n t h i n g 01 nam 2017. Chan doan sdi than lUa vao lam sang, k i t q u i sieu am, X-quang va CT scan rude md.
Nghidn edu theo phuong phap m d t l cd phan tfch. Thu thap sd lieu theo mau benh an nghien edu ehung. LUa chpn va chuan bj benh nhan theo quy trinh thong nhat. Sddung he thong m I y npi soi eua hang Karl storz, dng soi than mini-PCNL kfch thUdc 13Fr (vd 19Fr) cOa h l n g Lisa. Chpe do dai than dddi hudng dan eua C-arm hoac sidu I m . T i n sdi bang nang lupng laser holmium YAG Sphinx cua Ddc vdi d l y fibre 200-SSOpm.
Hinh 1. Choc dd dai than
Cae budc ky thuat: Sau gay me npi khi q u I n , cle bdnh nhan ddpc sol bang quang ngupc ddng dat catheter nieu q u I n ; dUdi hddng dan cOa C-arm hoac sidu I m , chpe dd dai than bang kim 18 gauge vdi benh n h i n d t u t h l nam sap; nong dudng ham bang bp nong Amplatz; t i n sol bang n l n g ldpng laser, cac m i n h sdi nhd dUpc lay ra ngoai bang rp Dormia kim gap sdi h o l e bom rda.
Mpt sd tieu ehi can d i n h g i l : Vj tri, kfch thddc v l 50 lupng sdi; tinh trang g i l n eua d l i b l than; tJ' Id sach sdi; t? le thanh cdng (that bai khi khdng t i n dupe sdi hay p h l i chuyen phuong phap mo); thdi gian mo; thdi gian nam vidn; eae tai bien, bien ehdng x l y ra. Xd ly so lieu theo phuong p h I p thong ke y hpc.
3. Ket quS 3.1. Dgc diem sdi
Bdng 1 . V i t r i soi Loai soi
Be than don thuan Bethan + daidadi Oai dadi ddn thuan
S o b e n h n l i d n 20 17 3
TJIe%
44,4 37,8 17,8
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY .12-N''5/20#;
Khdng cd trudng hpp nao sdi san hd than.
Kieh thude soi trung binh 1,8 ± 0,9cm, Idn nhat 3,0cm; nhd nhat l,2em.
Bing 2. Do gian cua than benh ly Dd gian than
B 6 I S o i l
So benh nhan 11 28
T y i i % 24,4 62,2 Cd 6 trudng hpp (TH) gian minh d l i dudl. Khdng CO trudng hpp n I o g i l n than dp HI.
100% eae bdnh nhan ed than bdnh ly tren phim UIV dang cdn t i l t thude tdt.
3.2. Dgc diim kjf thuat Bing 3. Vj tri choc do dai than choc do dai than
Nhom dai tren Nhom dai giCra Nhom dai dudi
So benh nhan 12 8 25
T y l e % 26,7 17,8 55,5 Chpe do nhdm d l i than trdn deu chpe tren sudn 12.100% chpe mpt dudng ham.
Chpe dddi hUdng dan sidu I m 16 TH, d U ^ hudng dan C-arm 29 TH.
Bang 4. Thdi gian mo va thdi gian nam vien Thdi gian md
Trung blnh Thdi gian nam vien Trung binh
X ± SD (phut) 91,4+36,8 X + SD (ngly)
6,4 + 4,2 Thdi gian mo (60 phut -150 phut).
Thdi gian nam vidn (5 ngay - 1 4 ngay).
3.3. Ket qud va tai bien, biin chtifng Bibng 5. Ket qua, tai bien, bl^n chdng
Thanh cong Sach soi Chua sach soi Chuyen mo md Tai bien, bien chiing
So benh nhan
36 7 2 5
T y l e % 80,0 15,6 04,4 11,1
Cd 2 trudng hpp chuyen mo m d do khdng choc:
d d dugc dai than. ' Cac tai b i i n x l y ra trong mo (tdn thuong tang|
l l n can, c h l y mau nhieu trong mo hay r i c h ddt blj than) chua gap trudng hpp nao.
Cd 5 trUdng hpp b i i n chdng sau mo la: 2 trudng hpp tran khi mang phoi nhe sau rut mono-J, 2 trudng hpp chay mau sau mo p h l i truyen mlu, 1 trudng hpp sot sau md phai dung k h I n g sinh manh pho rpng.
4. Ban luan
Bdnh vidn Sa khoa tinh Thanh Hoa va Benh vien Oa khoa Nghe An bat dau trien khai dng dung mini- PCNL v I o dieu trj sdi than t d nam 2015 - 2016. Qua 45 trUdng hpp da thde hien cho thay t f Id thlnh cdng chung I I 95,6%, ty Id sach sdi 80%, day eo the coi la mpt k i t qua ban dau t h u I n Ipi ddi vdi chung tdi. Khi so sanh vdi mpt sd t i e g i l lam PCNL trong v l n g o l i nUde thi khdng t h I y sd khac biet cd y nghia thdng ke gida cae ty le nay: Vu N g u y i n KhIi Ca (2015), nghien edu mini-PCNL tai Benh vidn Viet Dilc eho t h I y tJ- Id sach sdi 86,2% [1]; Kieu Ode Vinh (2015), nghien edu PCNL tai Benh vidn Trung UOng Q u I n dpi 108 eho thay t y Id thanh cdng 97,5%, ty Id sach s6i 62,4% [3]. Trong tong k i t cCia Hiep hpi tiet nieu Hoa Ky (AUA) nam 2005, thi ty Id sach s6i sau PCNL I I 78% [2].
4.1. Dgc diem soi
Trong 45 TH nghidn edu thi ed d i n 55,6% eo sol be t h i n don thuan hay sdi be than cd nhanh d nhom d l i dudi, chi ed 8 TH sdi d nguyen trong nhom dai dudi than. Kich thude sdi trung binh la 1,8cm (1,2cm - 3,0cm). Trudng hpp soi kieh thUde 1,2em nam hoan t o l n trong nhdm dai dUdi g l y g i l n nhe nhom dai, trudng hpp nay eo dai d l i v l gdc t h o l t cCia true co dai dudi so vdi true b l than be (< 70°) ndn khong chi djnh t i n sdi ngoai co the (ESWL- extracorporal shocl«
wave lithotripsy) ngay t d dau. Tuy nhien, qua mdt st nghidn cdu gan day eho thay ddi vdi sdi nhdm da dudi than cd kfch thude < I e m thi Uu tien sd dyne ESWL va vdi sdi nhdm dai dUdi than ed kfch t h d d c ; Iem thl uu tidn dung PCNL [4], [11].
AP CHi Y DUOC LAM SANG 108 Tap 12-So 5/2017
Mae du vdi PCNL chuan thudng ehi djnh eho nhdng trudng hpp sdi than Idn (> 2cm) va vdi mini- jPCNL eho nhdng trUdng hpp sdi than < 2em [11].
(Nhdng cho den nay, gidi han ve kieh thUde sdi de li/a chpn chi dmh PCNL ehuan hay mini-PCNL van -dang con nhieu quan d l l m : Giusti G (2007) khi nghien edu so s i n h gida PCNL chuan va mini-PCNL trong d i l u t n sdi than cd kfch thude < 2em thay ket , qui khong thuan Ipi doi vdi mini-PCNL [5]; Gouhua Z (2007) qua nghidn edu thay mini-PCNL ed the dieu trj dugc t i t e l cac loai soi san hd Idn vdi n h i l u dudng ham vao than, x^ Id sach sdi t d 72% - 93% [6].
4.2. Dgc diem ky thudt
Chpe dd d l i t h i n sau khi dat catheter nieu q u I n Idn be than la mot khau h i t sdc quan trpng trong PCNL ndi chung, nd q u y l t dinh su thanh cdng eua cupc md. Sharman GR (2015) khuydn ndn sd dung kim chpe dd loai diamond tip ed sd 18 gauge v l ndn chpe qua vom d l i de g i l m thieu ton thuong mach mau, dng dua ra 5 tieu ehuin d i n h g i l dUdng chpe tdt: V I o dudng sau ben; qua nhu md than; vao trung tam eua dai than; hddng v I o trung tam be than; v l khdng nguy hiem den eae mach mau Idn [10]. 45 TH cOa chung tdi dIu duoc sddung kim bevel tip s o l 8 gauge ma khdng gap kho khan, cd 2 TH khdng chpe do ddpc dai than ta do: 1 TH xae ^ n h dp s l u tren C-arm khi chpe ehUci tdt ndn ehUa chpe vao d i n dai than (chpe nhdm d l i dddi);
1 TH sd dung sidu am chpe do d l i than gian dp I (chpe nhdm dai gida). Ca 2 TH n l y ve sau deu p h l i chuyen mdmd.
Chpe dd dai than dddi hudng d i n cOa C-arm chung toi ed 29 TH va dudi hudng dan cua sieu am cd 16 TH. Chung toi ehUa thay ed sU khae nhau d i n g k l nIo v l k i t q u i chpe d d bang hai phuong phap. Tuy nhidn theo Yuhico MP (2008), ehpe do dai than dudi hudng dan eCia sieu am thudng don g i l n hdn, khdng phli chju bdc xa ion hda, cd the x l e ^ n h tdt duac dp slu va nhan biet dugc ele tang l l n can khi choc, choc do dai than dUdi hudng dan cOa C-arm thi thudng 3uoc sd dung hon do tinh bao q u i t eua no ddi vdi toln bd he t i l t nieu trong suot q u i trinh thuc hien ky thult ehpe dd eung nhU nong dudng ham [11]. Choc do dai than dUdi hddng dan cCia C-arm thudng ed 2
<y thuat CO b i n : Ky t h u l t " m I t bd" hay "mat kim"
(bull's eye or eye o f t h e needle) v l ky t h u l t "phep do tam g i l e " (triangulation) [10], ehung toi sd dung ket hpp 2 ky t h u l t di chpe do d l i than.
Chpn Ida chpe d d nhdm d l i dUdi hay trdn phu thudc vao hinh thai v l vj t r i sdi, eung nhd sU hieu biet v l g i l i phau cCia cau true than. Sampaio FJ (2000) nghien edu g i l i phau cho thay: Cue trdn than ed 98,6% ehi ed mdt nhdm dai than d gida; cdc dddi than cd 58% ed hai nhdm d l i v l phan gida than eo 96% ed hai nhdm dai [9]. Theo Vu V I n Ty (2015), ddi vdi choc dd nhdm dai dddi thi nguy co c h l y m l u v l t o n thuong mang phdi it hpn, edn vdi nhdm dai tren thi thudng tiep can ddpc hau het dUdng tiet nieu trdn giup x d trf dupc cac trudng hpp sdi san hd, sdi dai trdn, sdi nidu q u I n tren hay hep khue ndi be than nieu q u I n [2].
Trong nghien cdu nay, chpe d d v I o nhdm dai t r d n e d 12TH, nhdm d l i gida 8TH v l nhdm dai dddi 25 TH la ehpe dd nhdm dai dudi. Trong sd trudng hpp chpe d d v I o nhdm d l i trdn cd:
2 TH ed c h l y mau nhe trong mo va sau mo c h l y m l u nhieu p h l i truyen m l u , trUdng hpp n l y ed Id do luc ehpe cham vao mach gian thuy (interlobal vessel).
2 TH ve sau ed bien ehdng t r i n khi m I n g phdi sau rut mono-J, nguyen n h i n la do chpn d l l m chpe tren xuong sudn 12 ma khdng t u i n t h u nguydn t i e tranh 1/2 trong ddi vdi xUOng sUdn 12 v l 3/4 trong ddi vdi xuong sudn 11.
Bleu n l y eho t h I y chi dmh choc dd nhom dai trdn can can nhac ky de t r i n h c l e tai bien, b i i n ehdng ed the x l y ra. Cd le doi vdi each ehpe d d nay ehi ndn I p dung khi lam PCNL vdi ele dng vd sidu nhd (micro). Celik H (2015), qua tdng k i t ve PCNL cho thay ty' Id e h l y mau mach gian thuy trong chpe do nhdm dai tren la 67% v l nhdm dai dUdi la 13%, b i i n chdng mang phdi thudng gap trong ehpe do qua xuong sudn vdi ty Id < 2% [4].
Do c l e benh nhan trong nhdm nghien edu n l y ed sdi than vdi tinh chat khdng qua phdc tap v l kich thudc khdng q u i Idn ndn tat ca d I u dupe t i n v l l l y sdi bang mdt dUdng ham vdi n l n g ldpng laserholmium YAG. Mac du nang lupng t i n sdi sd dung trong PCNL cd nhieu lua chon, nhUng qua nghien edu Celik H (2015) cho thay n l n g luong t i n
108 - CLINICAL MEDICINE AND PHARMACY Vol.l2-N''5/2017
sdi phii hpp vdi mini-PCNL v l micro-PCNL nhat la laserholmium YAG [4]. Yuhico MP (2008) eho rang laser holmium YAG co the tan v d dupe tat ea ele loai sdi vdi dp an toan eao, tuy nhidn no khdng thde su hieu qua vdi nhdng trudng hpp sdi co kich thddc Idn h p n 2 e m [ l l ] .
4.3. Ket qud vd tai bien
Ket q u i nghien cdu eho thay: Thdi gian mo trung binh 91,4 ± 36,8 p h u t ; thdi gian nam vidn trung binh 6,4 ± 4,2 ngay; t y le t h l n h cdng dat 95,6%; va tJ' le sach sdi 80%. Ket q u i nay khae biet khong co y nghTa thdng ke so vdi: Vu Nguyen k h I i Ca (2015) nghien cdu ve mini-PCNL, thdi gian mo 89,87 phut, ty Id sach sdi 86,2% [1]; Kieu Ode Vinh (2015) nghien cdu ve PCNL, thdi gian mo 100 ± 42 phut, thdi gian nam vidn 6,6 ± 3 n g l y [3].
Cac tai b i i n ton thuong tang lan can, c h l y m l u nhieu trong md hay r i c h ddt be than, ehung tdi ehua gap trudng hpp nao. Co 5 TH (11,1%) bien chdng sau md v l cleh xd tri cu t h l nhd sau:
2 TH sau rut mono-J benh nhan thay khd t h d va tdc nguc cung bdn mo, nghe phdi g i l m ri rao p h i nang, chup X-quang ed t r i n khi mang phdi mde dp nhe. Trudng hop nay ehiing tdi theo ddi vai ngay bdnh n h i n dn djnh eho xuat vidn.
2 TH sau md chay m l u n h i l u qua mono-J cd l l n m l u cue p h l i truyen m l u . 2 trudng hop nay sau vai ngay d i l u t n nddc t i l u trong dan va dn djnh.
1 TH sdt sau md p h l i dung k h I n g sinh manh phd rpng. Theo Celik H. (2015), ty le sot sau m d thudng c h i l m khoang 2,8% - 32,1% vdi ty Id nhiem khuan huyet khdng cao, nhung dng khuyen ndn lam xet nghiem nude t i l u va eau khuan nieu trudc khi lam PCNL [4].
5. Ket luan
Qua nghidn edu ehung tdi thay t i n sdi than qua da bang dudng ham nhd (mini-PCNL) I I mdt phuong p h I p dieu tri sdi than it xam lan, an toan, hieu qua, phu hpp vdi nhdng trddng hpp sdi than <
2em va cd the ap dung dupc ddi vdi c l e bdnh vien ,„
tuyen tinh. Tuy nhien, vdi nhdng trUdng hpp s6i than cd kfch thude Idn hon c l n ed phau t h u l t vien ^ ^ n h i l u kinh n g h i e m v l ed day du trang thiet bj.
Tai lieu tham khao
Vu Nguyen KhIi Ca va CS (2015) Tdn sdi thdn qiM'"
da bdng dudng hdm nhd dudi hudng ddn cua $i& ""
dm. Y hoc TP. Hd Chi Minh, 19(4), tr. 277-281.
Vu Van Ty (2015) Lay sdi than qua da. Y hpc TP. Ho L*
Chf Minh, 19(4), tr. 7-15.
Kilu Ode Vinh va CS (2015) Ket qud phau thudt lay \ sdi than qua da tai Binh viin 108. Y hpc TP. Ho Chi - Minh,19(4),tr.111-116.
Celik H et al (2015) An overview of percutaneous nephrolithotomy. EMJ.iJrology 30):46-52.
Giusti G et al (2007) Minlperc? No, thank you! Eur.
Urol 51:810-814.
Guohua Z et al (2007) Minimally invasive percutaneous nephrolithotomy for staghom calculi: A novel single session approach via multiple 14-18Fr tracts. Surg laparose Endose pereutan tech 17:124-128.
Khalaf ES et al (2013) The outcome of open renal stone surgery calls for limitation of its use: A single institution experience. African journal of urology
19:58-65. , Miller NL et al (2007) Techniques for fluoroscopic
percutaneous renal access. The journal of urol 178:
15-23.
Sampaio FJ (2000) Renal anatomy. Endourologic considerations. Urol. Clin. North Am 27:585-607.
10. Sharma GR et al (2015) Fluoroscopy guided percutaneous renal access in prone position. World journal of clinical cases 3(3): 245-264.
11. Yuhico MP, Ko R (2008) The current status of percutaneous nephrolithotomy in the management of kidney stones. Minerva urologiea e nefrologica 60(3): 159-175.
9.
