VAI TRO Ct A NOI SOI TAN SOI BANG LASER TRONG BIEU TRI SOI NIEU QUAN CHAU KHAM
D6 Lenh Hung', Nguyen Minh Quana' T O M T A T
Mue tieu: Danh gia hieu qua cua noi soi tan sdi bang LASER trong dieu tri soi nieu quan kham doan chau.
Pftwzm^/^Aflp; Nghien cuu mo ta.
Kit qua: Trong thdi gian tir diu thang 03/2008 dSn cudi thang 06/2009, cd 50 benh nhan co sdi nieu quan kham doan chau dugc noi soi tan sdi bang LASER tai benh vien Binh Dan.
Trong do co 14 benh nhan nam, 36 benh nhan nii. Ty le thanh cong 100%. Thdi gian nim vien trung binh 2 ngay. Ty le sach soi 100%. Ty le hep nieu quan theo ddi sau 3 thang 14%.
Kit lugn: Npi soi tan sdi nieu quan bang LASER la 1 phuang phap an toan va hieu qua dt)ng dieu tri sdi nieu quan kham doan chau.
Tit khod: Tdn soi twi soi: Soi nieu qudn khdm; Tdn soi Laser
THE ROLE OF LASER LITHOTRIPSY IN TREATMENT OF IMPACTED DISTAL URETERAL STONE
Purpose: To evaluate the effect of LASER lithotripsy in ueatment of impacted distal ureteral stone.
Method: A prospective study.
Result: From 03/2008 to 06/2009, there were 50 patients performed LASER lithotripsy for impacted distal ureteral stones. 14 male patients and 36 female patients. Success rate was 100%. Mean hospital stay was 2 days. Stone free rate was 100%. Stricture rate following after 3 months was 14%
Conclusion: LASER Uthottipsy is a safe and effective procedure in treatment impacted distal ureteral stones.
Key words: Impacted ureteral stone; Laser lithotripsy MOI BAU
Sdi nieu quan kham (impacted ureteral stone) thudng la sdi n5m cd dinh tai mot vi m' trong NQ, dinh vao thanh NQ gay tdn thuong niem mac NQ, khdng thk di chuyin dugc, inh hudng nang ne cho dudng tiSt nieu tren hon sdi, cho nSn khong th6 di8u tri ndi khoa ddi vdi sdi NQ kham"-°-^'^""'.
Trong nhihig phuang phap dieu tri mod, tan sdi qua noi soi nieu quan ngay cang dugc hoan thien vdi cdc phuang tien phd sdi ben trong ca thS nhu sieu am, xung hoi, thuy dien luc va LASER, cung vdi cac dung cu hd tro dl lay sdi.
Nguyen Minh Quang, Deliveliotis C bing nghien cilu chung minh cho thiy LASER cd kha nang cat cac tdn thuong polyp, pha nk niem mac hoac dao dudng hkm xuyen qua hdn soi ma nang luong tii xung hai khdng thi thuc hien d u g c " " ' . Tac gia Nguyin Van Hoc da khao sat vai trd cua ngi soi tan soi bSng xung hoi trong dilu tri sdi nieu quan chau kham! Ben cjnh nhung thanh cdng cung cdn tdn tai nhung nguyen nhan tliat bai chua thi giii quylt duoc bang nguon nang lugng xung hoi'^".
Tuy mdi dugc pho biln d Viet Nam nhung npi soi nieu quan tan sdi bang LASER thdi gian qua da the Men dugc nhieu uu diem. Tuy vay, phuong tien dilu tri nay cdn mdi va cdn cd them thai gian de tham dinh gia ui ve lau dai*. Ddng thdi, d n cd nhimg nghien cuu sau de tim ra cdc yeu td gidp tan sdi qua npi soi dat duoc kit qua tdi uu.
De CO the ap dung mdt each thich dang cac bien phap dilu tri sdi nieu quan it xam i k not Chung va SOI men quan chau kham ndi rieng, thSy thudc va benh'nhan cin thao luan ky dl ' B?nh vi^n Binh Dan
Dia chi lien lac: BS.Dd Lenh Hiing DT; 0908144628 Email: bsdolenhhung®yahoo.com 458
lua chgn phuong phdp dieu tti phii hgp. Do dd, cdn cd nhirng luan cu dang tin cay, thuyet phyc ve ket qua dieu tri cua cac bien phap nay. Dga tren nhimg ly luan va thuc tien tten, Chung toi thuc hien nghien cuu nham muc tieu: "Danh gia hieu qua cua ndi soi tan sdi bdng LASER ttong dieu tri sdi nieu quan khara doan chau" vdi cac muc tieu cu th8 sau:
1. Khao sat cdc tdn thuang niem mac nieu quan do sdi kham gay ra.
2. Danh gid hieu qua sach sdi cua phttong phap.
3. Xac dinh cac bien chdng va tai biSn cua phuong phap.
DOI TirONG VA PHlTONG PHAP NGHIEN ClTU 2.1. Thiet ke nghien ciru
Nghien cmi tien curu md ta.
2.2. Doi tirong nghien cihi 2.2.1. Tieu chuan chgn benh
Tat ca cac benh nhan dugc chan doan sdi NQ chau khdm, nhap vien vd dieu tti tgi benh vien Btnh Dan trong khoang thdi gian tCr ddu thang 03/2008 den cudi thang 06/2009. Chdn doan xac djnh sdi NQ chau kham dua vdo sir phdi hgp lam sang, cac ddc di8m ttSn KUB, UIV va xdc dinh nhdt la trong luc TSNS.
- KUB: sdi nam d viing chdu.
- Xac dinh sdi nieu quan kham khi: sdi di'nh vao nieu quan, khi ddy hon sdi thi hdn sdi khong di chuy8n, cd ton thuang niem mac NQ nhu: phii nk hinh bdn cdu hoac phi dai hinh polyp.
2.2.2. Tieu chuan loai trij
Cdc trudng hgp khdng dua vdo nghien cuu bao gom:
- Sdi NQ chau kham kem theo vi6m than, b6 than cap, viem dudng ti^t nieu dudi.
- Doi vdi b^nh nhan nam cd budu tuyen tien liet.
- Rdi loan dong mau.
- Neu sau khi dieu tri ndi khoa ma benh nhan van cd nguy ca cao ve tim mach, khdng the ap dung cac hiin phdp vd cam mgt each an toan.
- Cdc trudng hgp cd di dang dudng tiet nieu di kem, vdi sdi NQ da dugc chdn doan trudc (nang NQ, than nieu quan doi, NQ lac chd...).
2.2.3. Co- mdu N>30
2.3. Phirong phap nghien cmi
Giai thi'ch cho benh nhan ve ky thuat mo, cac tai bien, bien chung cd the xay ra va kha nang phai chuyen md hd.
2.3.1. Dung cu
- Mdy soi NQ cung hieu Karl Storz, dudng kfnh may 10.5f.
- Ngudn sdng va camera ddng bd cua hang Karl Storz.
- May va sgi phat LASER ciia hang Domier, budc sdng 2080 nm, phat xung thanh nhip 3- 10 hz, nang lugng thay ddi tu 500-1800 mJ.
- Ddy dan dudng.
- Thdng NQ, thdng double-J cd dudng ki'nh 6F, 7F cua cdc hang Urovision®, Boston scientific®, Karl Storz®.
- Ro bdt sdi.
- Dung djch rua khi tan sdi: NaCI 0,9%.
2.3.2. Tiin hanh TSNS
- Gay me ngi khi quan hodc gay te tuy sdng.
- Dat tu th^ cho benh nhan.
- Ddt may soi tir meu dao, bdng quang, qua mieng NQ len den vi tri hdn sdi.
- Tan sdi bdng LASER.
" Trwng luc TSNS, chung tdi quan sdt tdn thuemg niem mac NQ ngay vi tti hdn sdi, quan sat b^ mat hdn sdi neu dugc, khd nang day dung cu len tten hdn sdi, thdi gian tdn sdi, tdn thuang
niem mac NQ sau tan sdi. mdnh sdi vun bam vao thanh NQ.
° Sau TSNS ti^n hanh ddt thdng double-J hoac thdng NQ.
° Hau phlu ghi nhdn ttieu chung dau hdng lung ben TSNS, chay mau, sdt dn lanh. Sd ngay nam vien.
2.3.3. fheo doi sau TSNS
Benh nhdn dugc tdi kham sau mdt thdng, ba thang. Rut thdng double- J sau mgt thang. Ldc tai kham ghi nhan ttieu chung dau hdng lung, sdt dn lanh, sieu am danh gia tinh ttang u nude ciia than, chup UIV danh gia hinh dang NQ va dai ba than, xac djnh vi tn hep NQ.
2.3.4. Xir Iy va phan tich so lieu
Xtr ly va phan ti'ch so lieu bdng phan m^m thong ke SPSS 13.0 for Windows va Excel.
2.4. Mgt so quy irdc ve cac thong so nghien cihi 2.4.1. Kich thirdc sdi
Do chi8u dai true ldn nhat cua vien sdi bdng thudc, tt'nh bdngmm.
2.4.2. Sach sdi
Khi tren phim KUB sau md sdi sach hoan toan.
2.4.3. Thdi gian nam vien Tinh bdng ngay 2.4.4. Thoi gian mo
Tinh ttr liic bdt dau ddt may soi cho den luc k^t thtic dat thdng nieu dao.
KET QUA
Tir ddu thang 03 nam 2008 d^n cuoi thdng 06 nam 2009, chiing tdi da ti^n hdnh TSNS bang LASER cho 50 benh nhdn vdi chdn dodn sdi NQ chau kham tai khoa tiet nieu Benh Vien Binh Dan.
3.1. Cac dac diem ve benh nhan 3.1.1. Tuoi va gidi tinh
- Tuoi benh nhdn: thdp nhdt la 20 tudi vd cao nhat la 81 tudi, trang binh 47,2 tudi ± 14,64. - Sd benh nhan nam la 14 chiem ty le 28% va sd benh nhdn nQ la 36 chi€m ty le 72%.
3.1.2. Ly do nhap vien
Hau bet benh nban cd trieu chung dau hdng lung chiem ty le 90,7%, 1 benh nhdn cd trieu chung sot, 3 benh nhdn cd trieu chung tieu gdt buot va 1 benh nhan cd trieu chung tieu mau.
3.2. Cac dac diem \ e hon sdi 3.2.1. Kich thirdc cua hdn soi
Chung tdi xac dinh kich thudc hdn sdi bdng each do khoang each ldn nhdt cua nd.
- Hdn sdi cd kfch thudc nhd nhat: 5nim.
- Hdn sdi cd kich thudc ldn nhdt: 20mm.
- Phan ldn cac hdn sdi cd kich thudc ttong khoang 0,5cm den 1cm, chiem ty le 52%
3.2.2. Be mat hdn sdi
Danh gid bk mat hdn sdi tren KUB. Tdt ca cac hdn sdi d8u can quang.
- Hdn sdi cd be mat nhin: 15 trudng hgp (30%).
- Hdn sdi cd be mat xu xi: 35 trudng hgp (70%).
Phan bd ciia hdn sdi:
- 22 trudng hgp sdi NQ chdu ben trai (44%).
- 28 Uordng hgp sdi NQ chdu ben phai (56%).
Sd lugng hdn sdi d NQ chau dugc TSNS:
- NQ cd mgt hdn sdi: 43 ttrrdng hgp (86%).
- NQ cd 2 hdn sdi: 5 ttirdng hgp (10%).
- NQ cd 3 hdn soi: 2 ttudng hgp (4%), ba hdn sdi ndm k8 nhau.
Sdi NQ chdu ket hgp vdi sdi d vi tri khac:
^ Bang 1: Sdi NQ chau ket hap vdi sdi d vi tti khac.
[Khdng cd sdi d vj tr^di than ciing ben ~|
460
7(14%) khac
4 3 ( 8 6 % ) ^ ^ ^
3.3. Dac aiem cua than va NQ tren sieu am
Truac khi tien hanh TSNS, cac benh nhan duac sieu am danh gia muc do u nude ciia than va dp gian nd ciia NQ.
- 5() ttudng hgp ddu cd NQ gian nd.
- Sd trudng hop co than u nude dg I la 1 (2%).
- So trudng hgp co than u nude do 2 la 30 (60%).
- Sd tiirdng hgp cd than ir nude do 3 la 19 (38%).
3.4. Chuc nang cua thain
Tat ca cac benh nhdn dugc chup UIV trade khi TSNS.
- Cd 4 trudng hgp than khdng phan tiSt tten UIV (8%).
- 46 tiirdng hgp than cdn phan tik (92%).
Tren UIV, 46 trudng hgp cd dai than be than gian nd. 4 tradng hgp do than khong phan tiet n6n khong the danh gia dugc.
- 43 trudng hgp thudc cdn quang khdng xuong dugc ben dudi hon sdi, chung td da cd su hk tdc hoan toan NQ. 7 tradng hgp thudc can quang cd xudng dugc b6n dudi sdi.
- Cd 12 dirdng hgp NQ gian nd va gap gdc tten hdn sdi (24%).
- Co 34 tiirdng hop NQ gian nd va khdng gap gdc tten hdn sdi (68%). Do cd 4 ttixdng hgp than khdng phan tiet tten UIV (8%) nen khdng danh gia dugc tinh ttang gap gdc nieu qudn tten UIV Clia 4 trudng hgp nay.
3.5. TSNS 3.5.1. Vo cam
Tat ca 50 benh nhdn d8u dugc vo cam bdng gdy te ttiy song (100%).
3.5.2. D^c diem ton thuxmg niem mac d vi tri hon sdi
- So tradng hgp ni€m mac NQ phu ne hinh ban cdu: 17 trudng hgp (34%).
- NiSm mac NQ phi dai hinh polyp: 33 trudng hgp (66%).
Khi dua may soi den vi tti hdn sdi, 43 tradng hgp khdng the dua day dan dudng vd may soi NQ vugt qua khdi hdn sdi, 7 tradng hgp cd the dua dugc day dan dudng vugt qua khdi sdi nhung mdy soi NQ thi khdng. Khi ddy hdn sdi bdng thdng NQ, tat ca hdn sdi deu khdng di chuydn.
- 35 trudng hgp (70%) hdn sdi bi niem mac phii ne hoac polyp che khuat nhung van cdn quan sat dugc mgt phan cua hon sdi.
-15 trudng hgp hdn sdi bj niSm mac phii ne hoac polyp che khuat hoan toan (30%).
3.5.3. Kha nang tiep can sdi trong khi TSNS - 49 tiirdng hgp cd the tiep cdn dugc sdi ttong khi TSNS.
- I trudng hgp ban ddu khdng thi tiep can dugc sdi do NQ dan, gap gdc, doan NQ cd sdi di chuyen qua hudng khac khi mdy soi gdn tiep can. Nhung sau dd cd the tiep can dugc de TSNS khi dp dung thu thuat ndng than len ve phia ddu lam thdng va cd dinh NQ.
3.6. Ton thirong NQ sau TSNS va each xix tri 3.6.1. T6n thu-ong NQ
° Mdt nigm mac NQ: 12 ttirdng hgp (32,4%).
° Tray sudt niem mac NQ (mucosal tear): 21 ttirdng hgp (56,8%).
° Manh sdi vun ndm trong thanh NQ: 1 tradng hgp (2,7%).
° NQ bi xudt huy^t: 1 tradng hgp (2,7%).
° Hai mrdng hop thiing NQ (5,4%).
[|
461Bilu d6 1: T6n thuong NQ u-ong khi TSNS.
3.6.2. Xir tri sau TSNS
Sau khi TSNS, tiiy theo tinh trang tin thuang niem mac NQ, chiing toi tiln hinh dat thdng NQ hoac thong double-J.
- 2 uuong hop dugc dat thong NQ (4%).
- 48 benh nhan dugc dat thong double-J (96%).
3.7. Ket qua 3.7.1. Thoi gian tan soi
- Ngan nhat la 10 phiit.
- Dai nhat la 60 phut.
Trung binh 28,6 phut ± 13,7.
3.7.2. Ty le thanh cdng va that bai Tat ca 50 truang hgp diu thanh cong (100%).
3.7.3. Ty le sach soi
Benh nhan dugc chup KUB kilm tra trudc xuat vien:
- C6 48 tnrang hgp sach soi, chilm ty Ie 96%.
- C6 2 tnrang hgp con vun soi nho tren than, chiem ty le 4%.
D sach so
• cdn s6i
^ ^ ^ ^ ^ K.i sau TSNS.
3.8. Dien tien sau TSNS " ' '
- Thong NQ nit sau khi 48 gio. HSu hit benh nhan co tilu mau sau TSNS, thuang khoi sau vai ngay dieu ui. Nlu benh nhan dugc dat thong NQ thi chung toi theo doi so luang va mau sac nuoc tieu t i thong NQ va tir thong nieu dao rieng biet.
- Co 5 trudng hap dau hong ben TSNS, chilm ty le 10%.
- Co 2^tnrong hgp sot dm lanh, dau hong lung cung ben tan soi, chilm ty le 4%, dugc tien hanh cay nuoc tieu, 2 uucrng hgp nay kit qua cly nuac tilu diu am tinh.
- Thai gian nam vien: ngan nhat: 2 ngay. dai nhat: 7 ngay. Trung binh- 3 68 naav ± 1 3 3.9. Theo do! sau TSNS
- Sau 4 tuin benh nhan dugc tai khSm nit thong double-J.
- Sau ba thang, benh nhan dugc sieu am danh gia tinh trang u nuac than.
So sanh voi sieu am tnroc khi TSNS chung toi co:
° S6 ttuong hop giam do: 20 ttuong hgp (40%).
° Khong thay doi 5 mrong hgp (10%).
° Hit u nugc 25 ttuong hgp (50%).
- Danh gia hep NQ qua UIV sau 3 thang, co 7 tnrang bj hep NQ o vi tri cua hdn soi (14%).
Bieu do 3: Hep NQ sau 3 thang BAN L U ^
4.1. Dac diem nhom benh nhan 4.1.1. Tu6i
NghiSn ciru ghi nhan benh nhan cd tudi thdp nhdt la 20 tudi va cao nhdt la 81 tudi, trung binh 47,2 tudi ± 14,64, cung tuang dong vdi kit qua ghi nhan dugc qua nghien cuu cua cac tac gia khac''^'^*'"-^-^^'. Di^u nay cho thdy benh sdi nieu thudng gap d dd tudi lao dong.
4.1.2. Gid-i tinh
Theo Tran Vdn Sang va Menon M, sdi tilt nieu thudn^ gap d nam gidi nhilu han so vdi nir gidi'^''**, nghien ciru ciia chiing tdi thi ghi nhan nu nhieu ban nam vdi 14 nam (28%) va 36_nii (72%), ^ le nam/nii' la 1:2,6, tuong ddng vdi ket qua nghian ciiii sdi kham cua Nguyin Van Hgc* ^', Day khong phai la ty Ie mdc benh that su, dai dien cho dan sd cd sdi nieu ndi chung, can cd nghien cun vdi cd raau ldn han d l cd thi danh gid ty le radc benh that su.
4.2. Chan doan sdi NQ chau kham 4.2.1. Dira vao thcri gian
Chiing tdi khdng cd benh nhdn dugc theo doi bdng KUB dl bilt rd thdi gian cd sdi NQ kham, viec theo doi se mat nhieu thdi gian, chi phi va ddi hdi cd su hgp tdc giiia benh nhan va thay thudc. Do dd, chiing tdi khdng dua vao thdi gian cd sdi de chan doan tinh ttang kham cua sdi. Chung toi xac dinh sdi NQ khdm dya vao hdi benh sii, danh gia hinh dang dai than, b l th^n va NQ tren UIV va quan trong nhat la dac diem ciia sdi va cua niem mac NQ quan sat ttong Itic ndi soi.
4.2.2. Du-a vao Iam sang va cac xet nghiem hinh anh hoc
Benh nhan ciia chiing tdi din kham benh da phdn vi dau hdng limg am i keo dai nhieu thang (90,7%), chi cd mgt benh nhdn vac vien vi dan thuan cd tieu mau dai thi keo dai, qua ngi soi NQ chan doan thi phdt hien nguyen nhan tieu mdu do sdi NQ kham. Tat cd ttudng hgp deu dugc sieu dm thdy NQ gian nd, 60% cd than u nude do 2, 38% cd than u nude do 3, chung td nhu ddng cua dudng tiet nieu tren hdn sdi da giam dang ke. Neu chi dya vao yeu to thdi gian cua trieu churng dau hdng lung de ggi y chan doan sdi NQ khara thi cd the khdng chinh xac vi trieu chung dau la trieu chiing chu quan ciia ngudi benh. Yaraaguchi K nhdn xet la khong the biet chdc chan thdi gian cua sdi NQ kham va chan doan chinh xac nhat la quan sat ttong liic noi soi NQ ket hop vdi dac diem cua NQ tten UIV'""'. Mugiya S ciing nhan thdy rdt khd de xdc dinh thdi gian cua sdi NQ kham. Do vay, hg chan doan xdc dinh sdi NQ kham dya vao cac tdn thuemg niSm mac NQ liic ngi soi'^^'.
KUB: giiip danh gia kich thudc, vi tri, sd lugng va tinh chat cua hdn sdi.
Nghien cuu ghi nh|n:
° Tdt ca cdc hdn sdi deu can quang.
° Vi tri vd so lugng sdi ttxmg NQ: cd 22 tradng hgp sdi NQ chau ben trai, 28 tradng hgp sdi NQ chau ben phai. Ket qua nay cung tuang ddng vdi nghien cuu ciia Nguyen Van Hgc'^^*.
463
° Kich thuoc h5n s6i: chiing toi do kfch thuoc hon soi bang each lay ki'ch thuoc lon nhat cua hon soi. ki'ch thuoc nho nhiria Smm va 1cm nhit la 20mm, phan lon soi co kich thuoc tir 5min din 10mm (52%). Kupeli B nhan thay soi NQ co kich thuoc tten 10mm thuang la soi NQ kham"" Yamaguchi K ghi nhan kich thuac trang binh cua soi NQ kham la ICemm™.
Roberts WW: 10,3mm'=", Mugiya S: 15mm°", Nguyin Van Hgc: 10,83mm'- '. Nhu vay c6 thi noi lang da so soi NQ kham thuang co ki'ch thudc tten 10mm. Tuy nhien kha nSng soi NQ khara khong phu thugc vao kich thuac cua no, cd nhitng hon soi co ki'ch thuac l-2mm van khong thi dl chuyin tir NQ vao bang quang"'"', nghiSn cilu cua chung toi 60% soi NQ kham CO kich thuac duai 10mm. Su biln thien nhu vay cd thi giai thi'ch la do ki'ch thudc soi khong ddng vai ttd chi'nh ttong su kham vao NQ ciia soi ma b l mat xa xi, gai goc cua soi mdi la yeu to quan ttgng lam sdi dinh vao thanh NQ, khong di chuyin xudng dugc va lau ngay kham vao thanh NQ.
Chiing toi danh gia bl mat hdn soi tten KUB va quan sat ttong luc TSNS, nhanthay cd 35 uirdng hgp (70%) cd bl mat xu xi, nhilu gai, 15 truang hgp (30%) cd bl mat nhin. Kit qua nay cung tuong ddng vdi nghien cuu ciia Nguyin Van Hgc'^ '. Theo Ngo Gia Hy, neu hdn soi cd gai thi dl ket lai ttong NQ hon so vdi hdn sdi cd be mat nhin'^'*'. Trin Van Sang ket luan khi chup phim ttieo ddi diln tiln hon sdi di chuyin trong NQ, nlu thiy hdn sdi c6 gai va tten UrV cd hinh anh thudc can quang khong xudng dugc bdn dudi hdn sdi thi hdn sdi khdng thi tong xuat ra ngoai dugc"''. Chung toi cd thi tien doan sdi NQ kham dua vao nhCrng dac diem tren.
UrV: 4 trudng hgp (8%) than cung ben vdi soi NQ khdng phan tilt, 46 tnrdng hgp (92%) cdn lai than phan tilt binh thuemg. Kit qua nay cung tuong ddng vdi nghien ciiu ciia Nguyen Van Hgc'^^'. 86% cac tmdng hgp thudc can quang khdng xudng dugc phia dudi hdn sdi, chirng td hdn sdi gay be t5c hoan toan, chi cd 7 orudng hgp ghi nhan cd it thuoc can quan^
xuong dugc dudi sdi, cd the la do nhiJng tnrdng hgp nay sdi kham vao thanh NQ nhtmg be mSt sdi xCi xi nen tao nen khe nhd va thudc cd the xudng dugc it. Theo Mugiya S va Yamaguchi K, hinh anh UIV thudng gap d benh nhan sdi NQ kham la gian nd dai than, be than va NQ ttdn hdn sdi'^'-""'. Nghien cihi cua chung tdi cd 12 tnrdng hgp (24%) NQ tren hdn sdi gian nd va gap gdc, gay khd khan khi soi len doan NQ ben tren cung nhu khi dua day din dudng len tten de dat thong JJ. Day chinh la nguyen nhan cd the dan den tai bien thung NQ khi cd gang soi len tten.
4.3. Cac ton thinmg niem mac NQ do sdi khiim
Trong liic TSNS, chiing tdi quan sat niem mac ciia NQ ngay vi trf cua hdn sdi nhan thay hau het cd tdn thuong niem mac NQ, cac tdn thuang nay che phu hon sdi mdt phan hay hoan toan, gay nhieu khd khan cho thao tac tan sdi. Dua theo phan Ioai cua Yamaguchi K, nghidn ciju ghi nhan:
- Tdn thuang niem mac NQ loai I: niem mac NQ phli nl dang ban cau (edematous hemispheric lesion): 17 tnrdng hgp (34%), cung tuong ddng vdi kit qua ciia Nguyin Van Hoc (33,3%)*- '. Ton thuang Ioai nay thudng che phu mdt phin hdn sdi, niem mac NQ che phii bam len tten be mat va giira cac ranh cua hdn sdi. Gurbuz ZG va cdng sit nhan thiy ttong sdi NQ kham cd hien tugng phu ne niem mac hinh ban ciu phia tten va phia dudi hdn sdi, phu ne lam hep long NQ va lam cho TSNS gap nhilu khd khan"".
- Tdn thuang niem mac NQ loai 2; mem mac phi dai dang polyp (polypoid): 33 tnrdng hgp (66%), cung nrong ddng vdi nghien cuu ciia Nguyin Van Hgc (66,7%)°". Cd thi cd mdt hoSc nhieu polyp, chieu dai thay ddi va lo liing ttong long NQ, can ttd quS ttinh tilp can vdi hon sdi. Cac polyp nay che phii mdt phin hay hoan toan hdn sdi iam cho khdng quan sat thiy sdi trong Mc TSNS, gay khd khan va de cd tai biln trong qua ttinh TSNS. Cdc polyp nay hinh thanh la do hdn sdi ki'ch thich niem mac man ti'nh din din tinh ttang tang sinh va phi dai niem mac" '.
Cac nghien cuu ciia tac gia khac cung ghi nhan loai tdn thuang nidm mac phi dai dang 464
polyp: Nguyen Minh Quang: 6 tmdng hgp'"^'. Mugiya S: 51 ttudng hgp'"". Dang Nggc Anh:
4 trudng hop'"', Duong Van Trang: 20%'ttirdng hgp'^*, Chau Quy Thuan, Trdn Nggc Sinh: 13 trudng hgp sdi NQ kham cd polyp'^', Vu Hdng Thinh: 30 tradng hgp'^". Tdt ca diu cd nhdn dinh chung la sdi kham vdi polyp gay khd khan nhilu cho thao tac tan sdi, nhung thuan lgi la khong sg hdn sdi di chuyin len than.
Ddi vdi loai tdn thuong niem mac phu nl dang ban cdu: nghien cim ciia Mugiya S ghi nhan 28 trudng hgp. Su phii ne niem mac gdy hep Idng NQ lam cho viec tiep can vdi hdn sdi vo ciing khd khan, de gay thiing NQ va hep NQ vl sau'"". Khi TSNS, chiing tdi nhdn thdy 15 tradng hgp (30%) hdn sdi hi tdn thuang niem mac phii ne hodc polyp che khuat hoan toan, 35 tradng hgp (70%) hdn sdi bi che khuat mgt phdn. Cac hdn sdi cd be mat xii xi tan dl va hem so vdi hon sdi cd be mat nhdn va nlu hdn sdi khdng bi niem mac NQ che khuat hoan toan thi TSNS de han so vdi trudng hgp hdn sdi bi che khudt hoan toan vi nhd nhin thdy hdn sdi chiing toi CO the dinh hudng true ciia nieu quan d ben tten, dat ddu day tan chinh xac len sdi, giup ban chl cdc tai biln cd thi cd do khdng quan sat thdy sdi.
4.4. Ky thuat TSNS sdi nieu quan chau kham
KJ thuat TSNS diing nhat la tiirdc khi tan sdi phai nhin thdy rd hdn sdi"**. Nhutig tnrdng hgp sdi NQ kham co polyp che kin khdng cdn nhin thdy hdn sdi se rat de gay ra tai bien trong khi TSNS. Ngudn nang Iugng LASER td ro uu thi d dac dilm nay vi cd thi dot teo cac sang thuong polyp, giup quan sat dugc sdi ttong qua trinh tdn sdi, giiip ban chl tai biln cd the cd md ngudn ndng lugng xung hai khdng cd dugc'^'^"^'*.
Trong ldc TSNS, bam nude cd cam giac gap luc can do hdn sdi bit kin phia tren vd cac bui sdi khi tdn se lam md quang tradng gay khd khan cho viec quan sat khi tan. Khi cd su thdng thuong giiia NQ ben dudi vd ben tren hdn sdi thi viec bam nude khong cdn cam gidc gap luc can nvta va cac vun sdi cd dudng thoat nen quang trudng se ro rang giup cho viec tdn sdi dugc an toan va chfnh xac.
Do vay, ky thuat TSNS sdi NQ chau kham bang LASER ciia chiing tdi nhu sau:
Neu nhu quan sdt thdy cd cac sang thuang polyp gay che khuat sdi, chiing tdi se diing day tan LASER cdt cac polyp nay, lam lg ro ra bl mat sdi. Sau dd, chung tdi diing ddu day tdn sdi tan va sdi d thanh ben sdi, tao ra mgt kenh thong thuang giiJa NQ ben tren vd dudi sdi giiip cho viec bam nude trd nen nhe nhang va de dang han, cac bui sdi cd dudng thoat lam cho quang tradng rd rang. Ddng thdi qua k6nh nay chiing toi day day dan dudng len vugt ^ua hdn sdi va de lai tai chd ttong NQ cd tac dung giiip dinh vi ttong liic thao tac vd lam thang NQ. Cong viec tiep theo la nit may soi ra ngodi va ddt lai may soi vao ttong NQ, ldn ddt mdy nay d l ddng ban so vdi ldn ddu, may dugc ddt vdo NQ d ben ngoai day dan dudng, tiep tuc tan sdi, nlu hdn sdi van con kham vao thdnh NQ thi cd the tan sdi ma khdng can diing dung cu bdt sdi, thinh thoang cd the lam bong cdc sdi vun bdng dau may tdn sdi.
Nang lugng diing trong TSNS: chiing tdi su dung nguon ndng lugng tan sdi la Holmium LASER. Deliveliotis C nhdn thdy TSNS bdng laser la mgt phuong phap tiiich hgp ttong dieu tti sdi NQ kham'^*. Mugiya S va cgng s\i diing LASER de cat bd polyp de tiep can vdi hdn sdi, thao tdc tan sdi de dang ban vd cdt bd phdn polyp nhd vao long NQ giiip ttanh tao mo seo cho niem mac vl sau'^^*. Theo Nguyin Minh Quang, tdn sdi bdng LASER con gidp dao dudng hdm xuyen qua sdi sau dd tan cho sdi vd vun tir tir* '. Theo Yagisawa, TSNS sdi NQ kham bdng LASER cdn cd uu diem la tao ra cac mdnh sdi vun cd kich thudc nhd han va hdn sdi khdng di chuyen len than'''"*. Nguon ndng lugng xung hai khdng cd dugc cac uu diem tren.
4.5. K i t qua 4.5.1. Thdi gian tan soi
Nghien ciru ghi nhan thdi gian tan sdi nhanh nhat la 10 phiit, dai nhat Id 60 phiit, tmng binh 28,6 phiit ± 13,7, thdi gian cd ngdn hon so vdi nghien cuu cua Nguyin Van Hgc'^^', cung tan sdi NQ chdu kham nhung ngudn ndng lugng la xung hai. Tuy nhien, d& cd su ddnh gia
465
chinh xac, cdn tiln hanh nghien cihi bdt cap, so sanh, vdi sir tuomg ddng ve nhdm nghien cmi.
Dil vay, nghien cuu ciia Nguyen Minh Quang cun^ ghi nhan rang thdi gian tan sdi bdng LASER nhanh ban thdi gian tan sdi bdng xung hai|^ *. Trong tan sdi xung hoi, hdn sdi vo ra thanh cac manh to, phdi ldy ra bdng gid nen mat nhieu thdi gian hom, ban niia d nhirng Ioai soi qua rdn, nang lugng xung hoi khdng thi pha sdi vd dugc, phai mat rat nhieu thdi gian, con tdn sdi bdng LASER sdi thudng vd vun ra nhu cam, va chay theo ddng nude tudi rira xudng bang quang. Quan ttgng la thdi gian tan sdi khdng phu thugc vao kfch thudc sdi ma phu thugc vao do cung cua sdi va cdch vien sdi vd ra. Ngudn ndrig lugng LASER cd the pha dugc cac loEti sdi ban chdt khde nhau, giup sdi va nhanh ban va de thoat ra ngoai ban.
4.5.2. Ty I? thanh cong va sach soi
Chiing tdi danh gia phau thuat thanh cong khi tan sdi vd nat, dugc lay ra hoan toan hay chi cdn nhimg mdnh vun nhd, cd thi tu ra dugc. Nghien ciru ghi nhan ty le thdnh cong la 100%. Hdu hit cac tradng hgp chup KUB kiem tta diu sach sdi (96%), chi cd 2 ttirdng hgp cdn vun sdi nhd chay len than ttong qua trinh tan soi, nhung kfch thudc vun sdi nhd, dieu tn ngi klioa cd thi tu ra ngoai dugc, khdng cdn tan sdi ngoai co thi bd sung. Kit qua nay cung tuang dong vdi nghien cim ciia Changgeng Yi Xue Za (100%)*^\ Nguyin Minh Quang (98%)'^^'Sofer (100%)*"*.
Trong nghien ciru cua Nguyin Van Hgc*^^*, cac tradng hgp that bai khi tan sdi NQ chau kham vdi ngudn nang lugng xung hoi Id do sdi khong vd hay do polyp che kin hoan toan sdi thi nhung nguyen nhan nay diu cd Uil khde phuc va giai quyet bdng ngudn nang lugng LASER.
Sdi dl vd hay khdng phu thugc chu yeu vao thanh phan tinh the vd ket cdu ciia cdc tinh thi cdu tao nfin hdn sdi. Ddng thdi cung cdn phu thudc mgt phan vao phuong tien diing de tan soi"'^'. Trong nghien cuu ctia chiing toi, bang ngudn ndng lugng LASER, khdng cd soi nao khdng vd, cung tuang ddng vdi nhan xet ciia Nguyen Minh Quang* ^\
Neu nieu quan cd nhilu polype d dudi sdi, cac polype nay se che lap hdn sdi Iam cho viec tiep can hdn sdi gap khd khan. Tmdng hgp nieu quan cd nhieu poplyp hoac cd hep nieu qudn, Devarajan, Sofer vd Fried cho rang tan sdi bdng laser cd im diem la cd the diing laser cdt cdc cho hep hodc cdt cdc polype nay dl tan sdi thuan tien hon'^^'^'^°*.
4.5.3. Tai bien va bien chirng
Nghien ciiu ghi nhan da phdn tin thuong NQ trong ldc TSNS la trdy xudt niem mac NQ: 21 ttirdng hgp (56,8%), mat niem mac niem mac NQ: 12 tmdng hgp (32,4%). Nghien ctru ciia Nguyen Van Hgc cung ghi nhan cd 21 tradng hgp niem mac NQ bi bong ttdc mat lop niem mac. Day Id loai tdn thuong niem mac ndng va can mgt dng thong ttong NQ dl giup cho qud ttinh lanh seo niem mac NQ'^^*. Akhtar MS va cgng sy TSNS nhan thay ngay vi tri soi kham thudng cd tinh trang phii ne va tdn thuang trong qua trinh thao tac, cho nen dat thong ttong NQ sau TSNS la cdn thiet'". Theo Harmon, sau tan sdi nieu quan ngi soi, viec ddt thdng nieu quan nhdm muc dich gidm dau, ngan ngira cac biln chung tdc nghen do phu nl niem mac nieu qudn va cdc bien chung do qua trinh tan sdi gay ra"^'. Hoskin lai cho rdng muc dfch cua thdng nieu quan sau tan sdi la dl lam giam ty Ie hep nieu quan, bao ve chuc ndng than va giup giam dau sau md. Dat thdng nieu quan luu con giiip benh nhan ttanh dugc can dau bao than sau tdn sdi do manh sdi vun rdt xudng hodc phu nl nieu mac gdy tdc nghSn. Ddng thdi, do cd ong thong ben ttong, nieu quan mat nhu dgng dan ra mdt each thu dgng tao dieu kien cho nhirn| manh vun sdi nhd cdn sdt lai ttong nieu quan cd thi lu ttdi ra ngoai theo ddng nude tieu ". Vl vay, sau tan sdi, chung tdi xem xet lai tinh hinh nieu mac d vi tti vi8n soi va xii tri sau dd tuy thudc vao danh gia nay. Nghien ciru cua chung toi cd 48 benh nhan dugc dat thong double- J (96%) va 2 ttudng hgp dugc ddt thdng NQ (4%). Chiing tdi chi ddt thong NQ cho nhung trudng hgp sdi kham nhe, niem mac NQ ft bj tdn thuong, cdn hdu hit eae tradng hop chiing tdi deu ddt thdng double- J vi doi vdi sdi NQ kham, hau hit diu anh hudng dudng tiet nieu tten hdn sdi vd cd mdt ty le hep NQ tir 0,5% din 24%, sdi kham cang lau thi nguy co hep 466
NQ cang cao. Vi^c dat thong double- J giiip lam giam be tdc NQ, phdng ngira can dau bao th?n, giup thiic ddy qud ttinh liln seo va giam ty le hep NQ v l sau' '. Cd nhung tmdng hgp vien soi bam dinh vao nieu mac, ttong liic tan sdi, ldy sdi ra ngoai se gay nhilu sang chdn cho ni?u inac.^Cac tmdng hgp nay, sau khi lay sdi ra ngoai, quan sat se thay nieu mac chd cd sdi X ^ '"^^;^t^^y xudc, thdm chf cd thi bong ttdc hdn Idp nieu mac. Liic nay, nlu khong cd tmgt ong thdng ddt ttong nieu quan ttx)ng mgt thai ^ian tW ttong qua ttinh lanh seo, 2 thanh ciia nieu quan cd the dinh lai gay hep nieu quan vl sau. Thdng double- J cd un dilm la tha vao ttong ldng bang quang n6n khdng gay anh hudng din sinh hoat cua benh nhan, sau khi ddt thong, benh nhan CO the xudt vien va mang thdng vl trong mgt thdi gian nhdt dinh.
Nghien ciru ciia chiing tdi cd 2 ttirdng hgp thung NQ xay ra sau khi da tan vd sdi thanh cong, soi len tten de ddnh gia tinh tt^ng NQ ben tten sdi va dl dua ddy ddn dudng len than d§t thong double- J vi day dan khdng vugt qua chd NQ gap gdc dugc dii da ddi sang day dan mem loai hydrophilic nhung do NQ gian ldn, gap gdc nhieu, NQ liep ben dudi vi tti cd sdi, tt-ong luc cd gdng ed Idin thiing NQ. Tuy nhien sau dd dp dung thu thuat nang giu than I6n Iren lam thdng NQ thi cd thi dua day dan dudng len tten dugc dl dat thdng double- J. Theo y v3n cung ghi nhan, biln chung dugc ghi nhan nhilu nhat ttong qua trinh tan sdi la thung nieu quan, thay doi tir 0,3% din 6,1% tren cdc y van da cdng bd tir ndm 1984 din nam 1992'^^*.
Vdi nhieu cai tien ve may soi va cac phuang tien tan sdi, biln chung nay giam xudng cdn 0%-
lugng 0,5 Joule/ nhip phat xung va tdn so 10 Hz, Holmium LASER gay thiing sau 2 gidy dp sdt vdo niem mac nieu quan. Tuy nhien, Santa-Cmz lai khdng chii y rdng tren lam sang, ngoai nguon phdt xung ciia cdc phuang tien tdn sdi, nieu quan cdn chiu tdc dgng eua hdn sdi da eg sdt vdo nigm mac tir Idu gdy nhieu bien ddi vl mo hgc. Thung nieu quan khi tan sdi bdng xung hai Id do nieu quan da cd diem yeu tir trade, nay cd mgt luc tac dgng ttr hdn sdi do xung hoi ttuyen vao hdn sdi gay thiing. Khi tdn sdi bdng LASER, nieu quan chi bi thung nlu ap sat que tdn sdi vdo nigra mac nieu quan, Vi vdy, de tranh biln chiing nay, cdn chu y ddt vi tri que tdn sdi vdo ngay gitra hdn sdi, tranh va eh^m true tiep vao nieu quan. Nghien ciru ctia chiing tdi khdng ed ttirdng hgp nao thiing NQ la do tan bdng LASER vdo thanh NQ.
Mgt tmdng hgp khac cd xudt huyet niem mac NQ ngay vi trf hdn sdi, xudt huyet xay ra khi cd gang tan sdi va gap eae manh sdi vun, niem mac NQ xudt huyet gay can trd eho viec quan sat, chiing tdi dat thong double- J cho tradng hgp nay, hdu phdu nude tieu lot dan. Nhieu tac gia nhdn thay niSm mac NQ tai vj trf hdn sdi khara rat dl bi tdn thuong, xuat huylt do nai day cd tinh trang vi8m man tinh. 1 tradng hgp mdnh sdi vun bam sau vao thanh NQ, ehung tdi diing kem gap ra vd dat thdng double- J.
Cac bien chiing sau md dugc ghi nhdn la hdu bet benh nhan cd tieu mdu sau TSNS, thudng khdi sau vai ngay dieu tri, 5 tmdng hgp dau hdng ben TSNS, chiem ty le 10%., 2 trudng hgp sdt dn lanh, dau hong lung cung ben tdn sdi, ehiem ty le 4%, duge tiln hanh cay nude tieu, 2 tradng hgp nay ket qua cay nude tieu deu am tinh.
Tdc gia Nguyin Vdn Hgc TSNS cho cac sdi NQ ehau kham bang xung hoi cung ghi nhdn ty Ie tai bien ttong liic TSNS Id: mdt niem mac NQ: 21 tmdng hgp (41,2%), trdy sudt niem mac NQ: 27 tmdng hgp (52,9%), manh sdi vun ndm ttong thanh NQ: 1 tmdng hgp (2%), NQ bi xuat huyet: 1 ttirang hgp (2%), mgt tradng hgp day dan dudng xuyen thanh NQ (1.96%)'^^'. Qua dd ed thi thdy rdng ty le tai biln va biln chimg khi tan sdi NQ ehau kham Ichong khac nhau giira ngudn nang Iugng LASER va xung hoi. Tuy nhien, de ed dugc nhdn djnh dung va chfnh xdc hon, can tien hanh nghien cuu vdi ea mdu ldn ban va thilt ke nghien cuu phii hgp.
4.5. Theo doi sau TSNS
Sau TSNS, benh nhan dugc hen tdi kham lai sau 1 thdng dl rut thdng double-J, sau 3 thang chup UIV kiem tta. Cdc trieu chiing ciia benh nhan cd the co khi mang thdng double-J 467
la dau bung, ulu rat. tilu nhilu lln. sdt, tilu dem, thong NQ ddng sdi, dau hdng lung khi tilu do ngugc ddng bang quang NQ. DIU dudi cua thdng di chuyen len cao vao NQ, diu tten ciia thdng di chuyin xudng dudi ra khdi bl than. Nlu thong luu qua lau cd the bi dirt Iam nhilu doan"". Trong nghien cihi cua chiing toi cac benh nhan than philn chu ylu khi dang mang thdng double-J la ttlu rat, tieu lit nhat, tilu ra mau, khong cd benh nhan than dau hdng khi ran tilu, khdng cd benh nhan bj nhilm ttning dudng tieu b i n , khong gap flnh hudng thdng double- J di chuyen.
Sau 3 thang chung tdi tiln hanh sieu am cho benh nhan de danh gia tinh trang li nude ciia than. Kit qua cd 20 trudng hgp giam do li nude (40%), 5 trudng hgp khong thay ddi do li nude (10%) va 25 mrdng hop hit ir nude (50%). Theo Stoller ML, dat thdng double-I giiip din luu nude ttlu tir than xudng bang quang nhung sau TSNS sdi NQ cd dat thdng double-J, tinh ttang is nude cua than cd the khdng cai thien
Tren UIV, cd 7 ttudng hgp (14%) hep NQ ngay vi tti ciia hon sdi (hinh 4.19). Chiing tdi xac djnh hep NQ dua theo dinh nghTa: hep NQ sau TSNS sdi NQ kham la hep tai vi tri cua hdn sdi, cac dai than, b l than va NQ tten vi tti nay gian nd dang ke tten UTV hoac xac dinh vi tti hep bang UPR nlu UIV khdng danh gia dugc'^^'*". Hep NQ sau TSNS diln tiln rit am thim, thudng khdng bilu hien trieu chiing. Thdi dilm chiing tdi chup UTV cho benh nhan dl xac djnh biln chimg hep NQ la 3 thang sau TSNS nhu cac tac gia khac'^'-^'"'*".
Nghien ciru cua cac tac gia khac cung ghi nhan flnh trang hep NQ theo doi sau TSNS.
Roberts WW: 24% theo doi sau 7 thang™, Yagisawa T: 27%'™, DeliveliotisC: 6%, cic nghien ciJru khac 17%'". NguySn Van Hoc: I2,5_%'^".
Neu so sanh vdi nghien cuu cua Nguyin Van Hgc thi ty le hep NQ sau TSNS cua nhdm chung tdi cao hon. Tuy nhien. Mugiya cho ring sdi kham thudng ket hgp vdi hep NQ va polyp'"". Khao sat md hoc cho thay cd hien tugng viem man, xa hoa md ke va tang sinh meu mac tai vi tri sdi, do vay sdi kham cd the ki'ch thich hien tugng viem gay ra hep NQ va polyp'^". Sofer nhan thiy ty Ie hep nieu quan mdi mac sau tan sdi la 1%, cd tuong quan thuan vdi tinh ttang nieu quan phii ne nhieu polype va sdi dinh chat vao nidm mac nieu quan. Cung theo Sofer, ilolmium LASER khdng gSy anh hucrng gi tdi viec hep nieu quan sau tan sdi'^^'.
Va de danh gia hep NQ sau TSNS sdi NQ kham thi can thdi gian theo doi lau hon.
KETLUAN
Qua 50 ttirdng hgp sdi NQ chau kham dugc TSNS bang LASER, chiing tdi nhan thSy ring:
Sdi kham gay ra cac tdn thuang cho niem mac NQ, anh hudng din dai hk than va NQ tten hdn sdi la mdt ttong nhirng loai sdi khd dilu tri. Hai dang tdn thuang niem mac la phii nl niem mac NQ dang ban cau gay hep NQ va phi dai niem mac NQ dang polyp lam cho viec tilp can vdi sdi hay tan sdi gap nhilu khd khan va dl gay tai bien khi TSNS.
Tdn thuong thudng gap nhat khi TSNS la ttiy xudt niem mac, mit niem mac NQ.
Thiing NQ va xuit huylt niem mac NQ la nhiing tai bien cd thi cd nhung it xay ra. Thao tac ti mi. dat day tan LASER chinh xac len sdi, khdng dl diu day tan ap true tilp vao niem mac se giup ttanh dugc tai biln thung NQ ciing nhu han che thuong tdn cho niem mac NQ vdn da bj finh trang kham cua NQ lam tdn thuang. Cd ging lly hit cac manh sdi vun bam tai vi tri cua hdn sdi dl phdng ngira phan iing tao md hat Iam giam ty Ie hep NQ. Sau TSNS, ttiy thudc vao mure dd tdn thuong niem mac se quylt dinh dat thdng NQ hoac thdng double-J giup giai quylt finh ttang li nude ciia than va NQ, tao thuan lgi cho vun sdi di chuyin ra ngoai va giup phdng ngira, han che bien chimg hep NQ vl sau vi cac ttirdng hgp TSNS sdi NQ chau kham cd mdt ty le hep NQ nhat dinh do sdi kham liu ngay Iam thay ddi cau ttiic niem mac tai vi ui ciia hdn sdi.
Ty le thanh cdng khi tan sdi NQ chau kham bSng LASER dat din 100%. Hieu qua sach sdi den 96% va khdng can TSNCT bd sung. Ngudn nang lugng LASER cd uu dilm hon xung hoi d hieu qua pha vd sdi, cd thi pha vd mpi loai sdi, iam sdi va vun ra thanh cac manh 468
rat nho cd the tu thoat ra dugc, giiip nit ngdn thdi gian tan sdi, hon nua cdn cd the gitip eat cac sang thuang polyp Jam cho viee tiep can va tan sdi d l dang ban ma ngudn ndng lugng xung hcri kh6n^ lam duge. Va tdn thuong niem mac do tan sdi bdng LASER khdng dang kl nen ed the noi rdng TSNS bdng LASER la phuang thuc dilu tri an toan va hieu qua cho sdi NQ chau kham.
Cudi ciing, qua d l tai nay, chiing tdi kiln nghi hai vdn dl:
- Thu nhat: ^sau khi TSNS soi NQ kham phai theo ddi Idu dai bdng UIV hodc UPR dl phdt hi?n som bien ehung hep NQ neu cd de ed hudng gidi quyet kip thdi nhdm bao ve chiic ndng than.
- Thu hai: can tien hanh nghien cun vdi ed mau ldn hem, thdi gian theo doi ddi ban va thiet ke nghien cim phti hgp, bdt cap so sdnh vdi nhdm sdi NQ kham dugc TSNS bdng xung hoi, la ngudn ndng lugng dugc ttang bi d hdu hit d cdc benh vien cd chuyen khoa Nieu hien nay tai nude ta. Tir do, cd sir so sanh chfnh xac, dai dien cho qudn thi sdi NQ kham chung, giiip fch cho viec lira chgn phuong thirc TSNS phii hgp cho cac tradng hgp sdi NQ kham.
TAI LIEU THAM KHAO
1. Akhtar MS and Akhtar FK (2003). "Utility of the lithodast in the tteatment of upper, middle and lower ttact calculi". Edinb Irel, pp. 144-148.
2. Changgeng Yi Xue Za Zhi (1999). "Application of the holmium yttrium-aluminum- gamet laser for complicated impacted ureteral stones: a preliminary report". J Endourol;22(2), pp. 259-64.
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