RU2316275C1 - Method for treating patients in case of nephrolithiasis with large-sized and stag-horn calculi - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: the present innovation deals with treating patients in case of nephrolithiasis with large-sized and stag-horn calculi due to applying the following technique: through either rigid or semi-rigid ureteroscope one should carry out transurethral contact nephrolithotripsy of a calculus or its part being available for instrumental impact to obtain small-sized fragments. The internal stent should be applied. If necessary, some days later it is important to carry out distance percussion-wave lithotripsy of the remained fragments or parts of calculi. Some time later, it is necessary to remove the stent after complete sanitation of calyx-pelvic renal system or in case of residual fragments of calculi at maximal size being 3 mm, not more. In peculiar case, one should carry out distance percussion-wave lithotripsy with low-energetic percussion-wave impulses, the duration ranged about 0.3-0.6 mcsec. The innovation enables to provide complete renal sanitation against calculi in case of the absence of surgical wound.

EFFECT: higher efficiency of therapy.

1 cl

Description

The invention relates to the field of medical technology and may find application in the treatment of patients with nephrolithiasis with large and coral stones.

A known method of treating patients with nephrolithiasis by means of remote shock wave lithotripsy (DLT) [1]. In this method, the destruction of the stone in the kidney to fragments, the sizes of which are sufficient for their exit from the urinary system in a natural way, is carried out by the action of focused shock waves on the stone. This method is successfully used to treat patients with calculi, the size of which does not exceed 1.5-2 cm. In patients with large and coral stones, the use of this method does not always achieve the desired result.

There is also a method of combination therapy for patients with large and coral stones by combining percussion (through a skin puncture in the lumbar region) nephrolithotomy and remote shock wave lithotripsy [2]. Percussion surgery, both an independent method for removing large and coral-shaped kidney stones, and in combination with remote shock wave lithotripsy, or a combination of open surgery and remote shock wave lithotripsy, are considered the most optimal. However, with the intrarenal location of the pelvis, the coral-shaped stone full of the calyx-pelvis system, as well as with large calculi and the absence of expansion of the pyelocaliceal system, the use of this method is accompanied by significant technical difficulties, high potential trauma and long-term follow-up treatment aimed at complete debridement of the kidney from calculi .

Closest to the claimed method is a method for the treatment of patients with nephrolithiasis with large and coral stones by means of transurethral lithotripsy and remote shock wave lithotripsy [3]. In this method, transurethral lithotripsy uses fibrooptic lithotripsy with the supply of high-power laser radiation to the stone through a thin fiber-optic light guide (diameter 2.6 mm). This allows you to reduce trauma to the urinary tract and, when combined with remote shock wave lithotripsy, achieve complete debridement in most cases of nephrolithiasis with a partial or complete simple coral stone. In the case of nephrolithiasis with a full complex coral stone, complete rehabilitation is achieved only in a limited number of patients. This, apparently, is associated with insufficiently efficient conversion of laser radiation energy into shock wave action inside the stone.

The technical (clinical) result from the use of the invention is to increase the effectiveness and quality of treatment.

The technical result is achieved by the fact that in the method of treating patients with nephrolithiasis with large and coral stones by means of transurethral lithotripsy and remote shock wave lithotripsy, it is proposed to initially conduct transurethral contact nephrolithotripsy of a stone or a part thereof (accessible for instrumental exposure) through finely dispersed fragments to finely dispersed washing them through the working channel of the ureteroscope and installing an internal stent, then, if necessary, Erez 5-7 days to conduct remote shockwave lithotripsy remaining fragments or portions of the stone (1 to 3 sessions) followed by removal of the stent after a complete readjustment pyelocaliceal renal system or the presence of residual stone fragments with a maximum size of not more than 3 mm.

It is also proposed to carry out remote shock wave lithotripsy with low-energy shock wave pulses with a duration in the range of 0.3-0.6 μs.

The essence of the invention lies in the fact that at the first stage of treatment retrograde pyelolithotripsy is performed with the destruction of the pelvic part of the calculus, and, if possible, the upper and middle cups, followed by the maximum removal of fragments of the destroyed stone and the installation of an internal stent. For this purpose, rigid or semi-rigid ureteroscopes are used, which have a wider surgical channel for carrying out various instruments for lithotripsy and lithoextraction of fragments, as well as a wider field of view. For contact lithotripsy, a Lithoclast apparatus with a pneumatic system is used, as the least traumatic, since lithotripsy does not show thermal effects on tissues.

At the second stage of treatment, 5-7 days after the stent is installed, remote shock-wave lithotripsy of the residual stone fragments (1-3 sessions) is performed with shock-wave pulses of the submicrosecond duration range. When conducting remote shock wave lithotripsy, shock wave pulses with a duration of 0.3 to 0.6 μs are preferably used, which allows stones to be broken down into finely divided fractions and significantly reduce the negative impact of shock waves on the kidney tissue.

After achieving a qualitative destruction of the calculus, the patient is discharged from the hospital and continues treatment on an outpatient basis under the supervision of a polyclinic urologist.

At the third stage of treatment, a control examination is carried out after 3-4 weeks and, if necessary, repeated lithotripsy sessions. The stent is removed after complete debridement of the kidney or if the maximum size of the residual fragments is less than 3 mm.

Examples of the use of the proposed method for the treatment of patients with large and coral stones, conducted by the author at the Federal State Institution “7 Central Military Clinical Aviation Hospital”, are given below.

1. Large stones, "dense" stones of the pelvis of the intrarenal type.

The pelvis of the intrarenal type, in which it is located inside the sinus and is completely closed by the renal parenchyma, occurs in 33% of the population. As a rule, the formed stone completely fills the entire pelvis, while the expansion of the pyelocaliceal system of the kidney is insignificant or absent, and radiological signs of its narrowing are often observed in the pelvic-ureteric segment. Performing an open nephrolithotomy or percutaneous nephrolitholapaxia in such a situation is technically difficult, the risk of complications is high. The use of remote lithotripsy for the destruction of large stones of large "density" is limited by the amount of use of high-energy impulses, the risk of obtaining coarse fragmentation with the threat of obstructive complications. We have investigated the possibility of using the method of transurethral contact pyelolithotripsy in the treatment of patients with this pathology.

37 patients with "dense" stones from 2 to 3 cm in size (22 men and 15 women) aged 36 to 72 years were examined and treated. In 23 patients, the density of calculi was 1000-1100 (N, units on the Hounsfield scale), in 14 - more than 1200. Transurethral contact pyelolithotripsy was performed using the Litoclast pneumatic lithotripter (EML, Switzerland), of which the conical ureterorenoscope is a component (the smaller size is 8, the largest - 9.8 on the Charrier scale). Under the control of vision, finely dispersed destruction of the stone and washing of its fragments was carried out. The operation ended with internal drainage of the J-J kidney by stent No. 7 or 8 on the Charlier scale, which was removed on an outpatient basis for 14-21 days. There were no complications during the operation. In 7 cases, DLT fragments were migrated that migrated during the operation to the lower group of calyxes. The postoperative period was 3-6 days.

Thus, the treatment of large "dense" stones of the pelvis of the intrarenal type using the method of transurethral contact pyelolithotripsy can be an alternative to open surgery, percutaneous surgery and ineffective in this case, DLT.

2. Coral stones.

When the coral stone is completely or partially performed by the unexpanded pyelocaliceal system of the kidney, as well as with high strength of the calculus (more than 1200 units on the Hounsfield scale), the use of percussion surgery as an independent method of calculus removal, and in combination with DLT, is often accompanied by complications and prolonged subsequent treatment . This category of patients requires the most gentle methods of removing coral stones.

The results of treatment of 31 patients with coral nephrolithiasis aged 25 to 67 years (average 51.4 years), in whom tubular secretion deficiency did not exceed 70%, and chronic pyelonephritis were in the latent phase, were studied. In 10 patients, the intrarenal type of the pelvis was observed, in 15 - more than 1/3 of the volume of the coral calculus was stone mass with a density of more than 1200 units on the Hounsfield scale. Against the background of antibiotic therapy, transurethral contact pyelolithotripsy was performed primarily with the Lithoclast apparatus, the maximal sanitation of the pyelocaliceal system of the kidney from fragments, and internal drainage of the kidney with a JJ stent No. 7 or 8 on the Charlier scale. There were no complications during the operation. If necessary, on the 5-7th day after the operation, DLT was performed. In 9 cases, exacerbation of chronic pyelonephritis was noted, stopped conservatively. They did not resort to open surgery. The postoperative period averaged 8.8 days, patients started work early. Before discharge, residual fragments occurred in 49% of patients who subsequently received 1-3 sessions of DLT on an outpatient basis. In the long-term follow-up period (3-6 months), 62% of those examined showed improvement in renal function. Residual fragments of coral-like stones were observed in 3 (8%) cases; DLT was performed.

Treatment of coral nephrolithiasis in patients using transurethral contact pyelolithotripsy has several advantages over classical nephrolithotomy and percutaneous nephrolithotripsy: there is no surgical trauma to the parenchyma, a shorter rehabilitation period, the method is psychologically acceptable for patients.

Information sources

1. RF patent No. 2177354, class. A61B 17/22, priority 2001.12.25.

2. Bianchi G., Malossini G., Beltrami P. et all. / Arch. Exp. Urol. Apr., 51 (3), 306-309, 1998.

3. Magiya S., Suzuki K., Ushiyama T. et all. / Int. J. Urol. Mar., 5 (2), 129-133, 1998.

Claims (2)

1. A method of treating patients with nephrolithiasis with large or coral stones by means of transurethral lithotripsy and remote shock wave lithotripsy, characterized in that initially transurethral contact nephrolithotripsy of the stone or its part, accessible for instrumental exposure, to fine-grained particles is performed through a rigid or semi-rigid ureteroscope washing them through the working channel of the ureteroscope and installing an internal stent, then, if necessary, after a few days remote shock-wave lithotripsy of the remaining fragments or parts of the stone is carried out, followed by removal of the stent after complete rehabilitation of the pyelocaliceal system of the kidney or in the presence of residual fragments of stone with a maximum size of not more than 3 mm. 2. The method according to claim 1, characterized in that the remote shock wave lithotripsy is carried out by low-energy shock wave pulses with a duration in the range of 0.3-0.6 μs.