RU2757531C2 - Method for performing transurethral ureteronephrolithotripsy and ureteronephrolithoextraction with functionally narrowed ureteral lumen - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to urology. While performing transurethral ureteronephrolithotripsy and /or extraction, when the end of endoscope is at the ureteral meatus, supply of rinsing liquid is turned off. The water supply tube is disconnected from endoscope. A syringe filled with drotaverine hydrochloride is connected to liquid supply tap on the endoscope and depending on localization of stone in the ureter, the total volume of drotaverine hydrochloride is changed. With a stone of lower, middle and upper thirds of the ureter the total volume of medicine is 4-5-6 ml / 80-100-120 mg, respectively. Moreover, when an endoscope is installed at ureteral meatus, regardless of stone localization, 2 ml / 40 mg of drotaverine hydrochloride is injected, then after 3-4 minutes the endoscope is carried out behind the meatus into prevesical part of ureter and the remaining part is injected, and if: the stone is localized in the lower third of the ureter, then the volume of drotaverine hydrochloride injection will be 2 ml / 40 mg, the stone is localized in middle third of the ureter - 3 ml / 60 mg, the stone localized in the upper third of the ureter - 4 ml / 80 mg. Then, 3-4 minutes after injection, the syringe with the solution is changed to rinsing liquid supply tube and it is started at half flow and, in presence of already reduced ureter tone, an endoscope is brought to the stone and contact ureteronephrolithotripsy and / or extraction of the stone as a whole is performed.

EFFECT: method allows simultaneously performing transurethral ureteronephrolithoextraction and contact ureteronephrolithotripsy using standard-sized endoscopes with a functionally narrowed lumen of the ureter and its meatus, in any hospital with equipment for endourological operations, to provide adequate urological care to patients with ureteral stones with its functionally narrowed lumen.

1 cl, 3 ex

Description

The invention relates to medicine, to urology, and can be applied for the surgical treatment of urolithiasis in patients of any age and gender, especially with functional narrowness of the ureter, which makes it difficult to access the endoscopic instrument.

There are known techniques for performing ureteroscopy when it is difficult to insert the endoscope into the lumen of the ureter, as well as conducting it along the ureter to the stone (Methodical recommendations No. 5 "Ureteroscopy."

- using a thin ureteroscope;

- expansion of the lumen of the ureter by increasing the hydrostatic pressure by raising the container with the irrigation solution;

- using a syringe or a special irrigation device (in the form of a pedal, pump or "pear");

- turning the ureteroscope by 180 degrees, so that the massive part of the tip passes along the lower surface of the orifice, including when the instrument is moving along the guidewire;

- using a second guide wire, held into the lumen of the ureter, while rotating the ureteroscope should reach such a position that the wires are at an angle of 180 ° with respect to each other and the ureteroscope is passed into the ureter between them;

- if necessary, with a pronounced narrowing of the ureter, it is permissible to overcome the obstacle with an instrument between three strings ("balalaika" technique);

- performing passive dilatation of the ureter, which consists in installing an internal ureteral stent, while a repeated procedure is performed after 3-5 days;

- performing active dilation using ureteral dilators or using balloon dilation under radiological control.

However, all the first 7 techniques are not always possible to apply in view of the pronounced individual functional narrowing of the lumen of the ureter, as well as the impossibility of holding a stent, for passive dilatation of the ureter, in view of abutting with a stent or a guide wire against a stone that completely blocks the lumen of the ureter. It should be noted that when performing delayed endoscopic interventions after passive dilatation of the ureter, the risk of infectious and inflammatory complications from the genitourinary system and complications with repeated anesthesia may increase. In addition, in the modern conditions of insurance medicine, a postponement of surgical treatment and an increase in bed-day are inexpedient from an economic standpoint.

The technique of active dilatation of the ureter also does not allow in some cases to expand the ureter to a diameter that provides adequate access to the stone. The main limiting factor in this case is the high risk of iatrogenic injury to the ureter up to its complete separation from the renal pelvis.

Thus, there is a need for a method that allows both contact ureteronephrolithotripsy and ureteronephrolite extraction with a functionally narrowed ureteral lumen to be performed.

The objective of the invention is to reduce the risk of the likelihood of iatrogenic injury to the ureter and ureteropelvic junction when performing transurethral ureteronephrolithotripsy / extraction in patients with urolithiasis with functionally narrowed ureteral lumen.

The problem is solved by the fact that when performing transurethral ureteronephrolithotripsy / extraction, when the end of the endoscope is in the mouth of the ureter, the irrigation fluid supply is turned off, the water supply tube from the endoscope is disconnected, a syringe filled with drotaverine hydrochloride is connected to the fluid supply valve on the endoscope, and depending on the localization of the stone in the ureter, the total volume of drotaverine hydrochloride is changed: with a stone of the lower, middle and upper third of the ureter, the total volume of the drug is 4-5-6 ml / 80-100-120 mg, and when the endoscope is inserted into the orifice of the ureter, regardless of the localization of the stone, standard 2ml / 40mg drotaverine hydrochloride, then after 3-4 minutes the endoscope is passed by the orifice into the prevesical ureter and the remainder is slowly introduced, and if:

- the stone is localized in the lower third of the ureter, then the volume of injected drotaverine hydrochloride will be 2 ml / 40 mg,

- the stone is localized in the middle third of the ureter - 3 ml / 60 mg,

- the stone is localized in the upper third of the ureter - 4 ml / 80 mg,

then, 3-4 minutes after the injection, the syringe with the solution is changed to the irrigation fluid supply tube and it is started at half inflow and, against the background of the already reduced ureteral tone, the endoscope is slowly brought to the stone and contact ureteronephrolithotripsy or whole stone extraction is performed.

An essential feature of the invention is the drug-induced expansion of the ureter through intraoperative instillation into the lumen of the ureter of the myotropic antispasmodic drug drotaverine hydrochloride (ATX CODE A03AD02 (Drotaverine)), which provides a temporary decrease in the tone of the muscular layer of the ureter wall and the ureteropelvic ureterocerebral segment ureter, with a functional narrowed lumen of the ureter and the pelvic-ureteric segment.

The proposed technique for intraoperative medical expansion of the ureter allows access to the stone without significant time costs and increasing the risk of ureteral injury.

The method is carried out as follows.

In the patient's position, an endoscope is inserted into the bladder to perform endoscopic interventions (standart lithotomy). The end of the endoscope is inserted into the orifice of the ureter along a pre-wound guide wire, after which the guide wire is removed, the irrigation fluid supply is turned off, the water supply tube from the endoscope is disconnected, a syringe filled with drotaverine hydrochloride is connected to the fluid supply valve on the endoscope. Depending on the localization of the stone in the ureter, the total volume of drotavern-hydrochloride is changed. With a stone of the lower, middle and upper third of the ureter, the total volume of the above drug will be 4-5-6 ml / 80-100-120 mg. When the endoscope is inserted into the orifice of the ureter, regardless of the localization of the stone, the standard 2ml / 40mg of drotaverine hydrochloride is injected, then after 3-4 minutes the endoscope is passed behind the orifice into the prevesical section of the ureter and the remainder is slowly introduced, namely 2 ml / 40 mg if the stone is localized in the lower third of the ureter, 3 ml / 60 mg if in the middle third of the ureter and, accordingly, 4 ml / 80 mg of drotaverine hydrochloride if the stone is localized in the upper third of the ureter. On average, 3-4 minutes after the introduction of the remaining part of drotaverine hydrochloride, the syringe with the solution is changed to a tube for supplying irrigation fluid and it is started at half inflow, and against the background of a decreasing ureteral tone, the endoscope is slowly brought to the stone. If ureteral bends are encountered along the path of the endoscope, guidewires can be reapplied to help traverse these bends. When the endoscope reaches the stone, contact ureteronephrolithotripsy is performed or, if the ureteral lumen is open, the entire ureterolitho-extraction is performed.

In the case when the endoscope with an insufficient spasmolytic effect of drotaverine hydrochloride due to the pronounced functional narrowing of the ureteral lumen, it is still impossible to bring an internal ureteral stent to the stone for the purpose of passive dilatation of the ureter. The need for drainage of the upper urinary tract after surgery by internal stenting with ureteral stents is decided individually, taking into account the peculiarities of the operation, as well as the presence / absence of inflammation of the upper urinary tract.

Clinical examples

Example # 1. Stone of the upper third of the right ureter

Patient N., 42 years old. A long standing, dense (1300 HU units) stone of the upper third of the right ureter, 1.5 × 0.7 cm in size, disrupting the outflow of urine from the right kidney and not amenable to distance shock wave lithotripsy was diagnosed. The results of excretory urography suggested that the patient had a narrowed lumen of the ureter below the stone, but there were no signs of anatomical narrowing (cicatricial stricture) of the ureter. The patient was shown to perform transurethral contact ureterolithotripsy.

The endoscope is inserted into the bladder. The mouth of the ureter is punctate. The endoscope was passed along the guidewire into the mouth. Endoscopic imaging revealed a narrowing of the ureteral lumen. Endoscopic instillation along the ureter was carried out from the bottom up with a solution of drotaverine hydrochloride in a volume of 6 ml / 120 mg according to the above technique (2 ml / 40 mg in the ureteral orifice and 4 ml / 80 mg in the prevesical section). At the same time, an increase in the lumen of the ureter from the orifice to the prevesical section of the ureter was noted 4 minutes after the first injection of the drug, and after 4 minutes after the second injection, the muscle tone of the ureter from the prevesical section to the stone was weakened and the endoscope was freely passed to the stone. Standard contact ureterolithotripsy and ureterolitho-extraction of all fragments were performed. Part of the fragments migrated into the renal cavity system during the operation. On the next day after the operation, all fragments of the previously destroyed stone had come off, which was confirmed by ultrasound and survey urography. Due to the long-term presence of the stone in the ureter, the operation was completed with internal stenting of the right kidney. Thus, complete contact ureterolithotripsy and ureteronephrolite extraction were performed. The patient was discharged on the 2nd day of the operation with the achieved stone free rate effect.

Example # 2. Stone of the middle third of the left ureter

Patient O., 48 years old. A calculus of the middle third of the left ureter (1100 HU units), 0.8 × 0.6 cm in size, did not disturb the outflow of urine from the left kidney, but did not respond well to external shock wave lithotripsy and lithokinetic therapy. The results of CT imaging with contrast enhancement revealed in the patient a narrowed lumen of the ureter below the stone. The patient was shown to perform transurethral contact ureterolithotripsy.

During the operation, the assumption about the narrowness of the ureter of functional genesis was confirmed. The endoscope was inserted along the guidewire at the orifice of the ureter, after which the guidewire was removed. Through the endoscope tube, endoscopic instillation along the ureter was carried out from the bottom up with a solution of drotaverine hydrochloride with a total volume of 5 ml / 100 mg according to the above technique (2 ml / 40 mg in the ureteral orifice and 3 ml / 60 mg in the prevesical section). 4 minutes after the first injection of the drug and 4 minutes after the repeated administration of the drug, there was a weakening of the muscle tone of the ureter up to the stone and the endoscope was freely passed to the site of localization of the ureteral stone. Contact ureterolithotripsy and ureterolithotripsy were performed. Moreover, one of the large fragments was displaced into the cavity kidney, which was also freely removed by an extractor of the Dormia basket type (nephrolithic extraction). The postoperative period was unremarkable. The patient was discharged on the 2nd day after the operation with the achieved "stone free rate" effect.

Example No. 3. Stone of the lower third of the left ureter

Patient B., 59 years old. A calculus was diagnosed in the lower third of the left ureter (projection of the ilio-sacral joint), 0.5 × 0.6 cm in size, significantly impairing the outflow of urine from the left kidney, poorly amenable to conservative lithokinetic therapy. Remote shock wave lithotripsy was not possible due to the difficulty of targeting the stone. The patient was shown to urgently perform transurethral contact ureterolithotripsy / extraction or drainage of the upper urinary tract.

During the operation, the punctate orifice of the ureter was revealed. Through the endoscope tube, endoscopic instillation along the ureter was carried out from the bottom up with a solution of drotaverine hydrochloride with a total volume of 4 ml / 80 mg according to the above method (2 ml / 40 mg at the ureteral orifice and 2 ml / 60 mg in the prevesical section). 4 minutes after the first injection of the drug and 3 minutes after the repeated injection, the muscle tone of the ureter weakened and the endoscope was freely passed to the ureteral stone. Ureterolithoextraction was performed with a Dormia basket. The operation was completed with internal stenting of the left kidney. The patient was discharged on the 3rd day after the operation with the achieved "stone free rate" effect.

The proposed method makes it possible to quite freely bring the endoscope to the stone; perform lithotripsy or extract the whole stone with its small size; to accelerate the passage of residual (remaining) fragments of the destroyed stone after endoscopic surgery.

The use of the proposed method in clinical practice makes it possible to achieve several technical (therapeutic) results:

- simultaneously perform transurethral ureteronephrolite extraction and contact ureteronephrolithotripsy using endoscopes of standard size with functionally narrowed lumen of the ureter and its orifice;

- in any hospital with equipment for endourological operations, provide adequate urological care for patients with ureteral stones with its functionally narrowed lumen.

Claims (4)

A method of performing transurethral ureteronephrolithotripsy and / or ureteronephrolite extraction with a functionally narrowed lumen of the ureter, including placing an endoscope into the lumen of the ureter, characterized in that when performing transurethral ureteronephrolithotripsy and / or extraction, when the end of the endoscope is at the mouth of the ureter disconnect from the endoscope, connect a syringe filled with drotaverine hydrochloride to the fluid supply valve on the endoscope and, depending on the localization of the stone in the ureter, change the total volume of drotaverine hydrochloride: with stone in the lower, middle and upper thirds of the ureter, the total volume of the drug is 4-5 -6 ml / 80-100-120 mg, respectively, and when the endoscope is inserted into the orifice of the ureter, regardless of the localization of the stone, 2 ml / 40 mg of drotaverine hydrochloride is injected, then after 3-4 minutes the endoscope is passed behind the mouth into the prevesical ureter and introduce the remainder, and eu whether: - the stone is localized in the lower third of the ureter, then the volume of injected drotaverine hydrochloride will be 2 ml / 40 mg, - the stone is localized in the middle third of the ureter - 3 ml / 60 mg, - the stone is localized in the upper third of the ureter - 4 ml / 80 mg, then, 3-4 minutes after the injection, the syringe with the solution is changed to a tube for supplying irrigation fluid and it is launched on a half inflow and, against the background of an already reduced tone of the ureter, the endoscope is brought in to the stone and perform contact ureteronephrolithotripsy and / or extraction of the whole stone.