According to incomplete statistics, the incidence of urinary stones in China accounts for 15% of the population, and stone disease can cause other pathologies, such as hydronephrosis, renal failure and uremia, which seriously threaten people’s health and life. In today’s “lithotripter era”, open surgery for stone extraction is a thing of the past. Pneumatic ballistic lithotripsy is a new lithotripsy technology for urinary stone treatment, which uses the energy of high-pressure gas to push the special steel beads to produce pulsed vibration, and under the surveillance of endoscope, this vibration is transmitted to the stone surface by a special vibration rod to break the stone, so the efficiency of lithotripsy is very high, known as the “invisible air gun It is called “invisible air gun”. Because of its minimally invasive, safe and efficient characteristics, this technique is now widely used abroad for the treatment of ureteral stones, bladder stones, urethral stones and kidney stones.
I. Treatment of urinary stones
The treatment of urinary tract stones is divided into general treatment and lithotripsy treatment. General treatment means that the patient’s symptoms of renal colic should be relieved first, and then non-surgical or surgical treatment should be decided according to the size and location of the stones. For stones less than 0.8cm in diameter, the treatment can be combined with atropine, belladonna and other antispasmodic drugs by taking Chinese medicine stone draining flush, while drinking a lot of water and moderate activity.
The combination of Chinese and Western medicine can eliminate small stones from the body.
Although extracorporeal shock wave lithotripsy has become the first treatment for upper urinary tract stones, surgery is still an essential treatment for lower urinary tract stones, ureteral impaction stones, giant kidney stones, stones that are difficult to locate or treat with shock wave lithotripsy (swL), and severe stone streets after shock wave lithotripsy.
Open surgery is the traditional method for treating urinary stones, and this method has problems such as high trauma, bleeding, high rate of residual stones, slow recovery and complications. With the continuous development of various endoluminal urological techniques, the proportion of open surgical treatment has decreased significantly. Transurethral ureteroscopic lithotripsy is performed by using a tiny ureteroscope to enter the bladder through the urethra and perform bladder lithotripsy for stone removal under direct view of a TV screen, or by inserting a ureteroscope along the ureter for lithotripsy and stone removal. This procedure is a safe and effective way to save patients from the pain of “open surgery” and has the advantages of less complications, faster recovery and shorter hospital stay, and is currently the preferred treatment for bladder stones and stones in the middle and lower ureter. Minimally invasive percutaneous nephrolithotomy is performed under x-ray or B-ultrasound positioning, through the skin puncture of the lumbar back into the kidney to establish a small channel, using the nephrolithoscope under the direct view of the TV screen to break up the stone and remove it.
Second, the classification of lithotripter
Lithotripter is an indispensable surgical instrument for endoluminal urology surgery. With the improvement of endoluminal equipment and operation technology of urology, lithotripter has also made great development.
Lithotripters are special instruments used to perform in vivo lithotripsy, including mechanical, electrohydraulic, ultrasonic, laser and pneumatic lithotripters. According to the lithotripter lithotripsy mechanism, it can be divided into two major categories: mechanical and shock wave type. The former crushes stones with mechanical energy, and the lithotripter and stones are in direct contact, while the latter converts other energy into shock waves to crush stones, mechanical lithotripters include manual lithotripters, ultrasonic lithotripters and pneumatic lithotripters, and shock wave lithotripters include liquid electric and various types of laser lithotripters.
Overview of pneumatic ballistic lithotripsy
Pneumatic ballistic lithotripsy is a new type of lithotripsy, which was firstly developed in Lausanne, Switzerland in 1990, and thus named as SwissLithoclast. The principle of operation is the same as that of an industrial pneumatic hammer. The pneumatic ballistic lithotripter is available in different pressure settings up to 300 kPa and has a variety of stainless steel lithotripter probes that can break up various stones including calcium oxalate monohydrate and cystine stones. A group of in vitro experiments using standard stone models compared the lithotripsy efficiency of ultrasound, electrohydraulic, laser and pneumatic ballistic lithotriptors, with the pneumatic ballistic lithotriptor being the most efficient. Like the ultrasonic lithotripter, the pneumatic lithotripter probe cannot be bent and can only be used for rigid and semi-rigid endoscopy, but without the thermogenic effect of the ultrasonic lithotripter probe. The disadvantage of the pneumatic ballistic lithotripter is that the probe tends to push the stone, which should be noted during ureteral lithotripsy because the stone moving proximally will increase the difficulty of lithotripsy, and the stone should be fixed with a lithotripsy basket first if necessary. In addition, the stone fragments after lithotripsy with the pneumatic ballistic lithotripter are coarse and often require the use of other instruments such as stone extraction forceps. Recently, an improved pneumatic lithotripter, the Bmwne pneumatic lithotripter, has been evaluated experimentally and is expected to be used clinically in the near future. Its nickel-titanium alloy probe can be bent at will within 90. Therefore, it can be used for soft ureteroscopy, and its lithotripting efficiency is not worse than that of the rigid probe.
Fourth, traditional lithotripsy are difficult to achieve the desired effect
1, drug lithotripsy: If the stone mass is small and the number is small, this conservative treatment method can be used, but because it is difficult for the drug to form a real destructive force on the stone. It is easy to recur and cause more damage due to incomplete treatment.
2, open surgery to remove stones, this is the most traditional surgical treatment for stones, which is very damaging to patients, painful and has many post-operative complications. At present, it is basically eliminated by regular hospitals.
3, extracorporeal shock wave lithotripsy under the monitor, can accurately break the stone. Recovery after surgery is faster, but the effect of extracorporeal shock wave lithotripsy is less obvious for stubborn stones and huge stones. If stones are stuck in the ureter for a long time, causing ureteral inflammation, edema, hyperplasia and adhesion, the application of extracorporeal shock wave lithotripsy is completely ineffective, and then, we have to rely on laser intracorporeal lithotripsy or even surgery to solve the problem.
Five, pneumatic ballistic lithotripsy technology to create a new era of lithotripsy
Pneumatic ballistic lithotripsy is recognized as the most advanced technology for the treatment of urinary stones, and is regarded as a revolutionary leap in the diagnosis and treatment of urinary stones, which is revolutionary in that it does not require an incision and can completely crush stones at once.
Fast stone crushing, one time cure
The pneumatic ballistic lithotripter makes the examination and treatment of the urethra, bladder and ureter more clear, intuitive, convenient and fast through the ureteroscope with an all-round view. It operates through ureteroscope, lithotripsy and stone retrieval under direct vision, one-time cure, high success rate of treatment for stones in all ureteral segments, no damage to surrounding tissues, no bleeding and no pain. It makes up for the shortage of extracorporeal shock wave lithotripsy, and is especially suitable for rescuing urological emergencies such as uremia, renal colic and lower urinary tract stone obstruction.
Quick stone extraction and immediate discharge
Pneumatic ballistic lithotripsy can not only “crush” the stone, but also remove the stone completely at one time without damaging the kidney. The endoscope is inserted directly into the stone through the urethra, and the stone is crushed by the pneumatic ballistic lithotripter, and then the stone is removed by a special clamp. It makes the patient’s wish of removing stones without surgery a reality.
Percutaneous nephrolithotomy system is like “opening a mountain to break a stone”
As we all know, surgery to remove stones is very damaging, with many complications and certain risks, while drug treatment often has low stone removal rate and long treatment time. In contrast, percutaneous nephrolithotomy system (PCNL) and medication with the treatment method are effective, less complications, no pain, and short treatment time.
Percutaneous nephrolithotomy is commonly known as “lithotripsy”, in which a hole is dug to break the stone and then taken out, and the urologist is the “plumber”. This system is actually a minimally invasive “hole-punching” procedure, mainly used for the treatment of large multiple kidney stones.
Break each one into pieces
The percutaneous nephrolithotomy system involves making a small cut through the skin to enter the kidney and then crushing the stone with a lithotripter, which immediately reduces the size of the large stone and then suctioning it out. Although this method is complicated to operate, it is particularly effective for large and multiple kidney stones.
Minimally invasive technology, no more incisions
Pneumatic ballistic lithotripsy is precise, safe, non-invasive and precise, while avoiding complications. Nowadays, patients who cure urinary lithotripsy without incision, after they have relieved themselves of the pain that has plagued them for years without pain and without realizing it, have opened a small chopstick-thick opening and sucked out all the stones, which is said to be a minor surgery, but solves a big problem that has plagued them for years. The real authority of medicine lies not only in its ability to relieve patients of their diseases, but also in its ability to reduce the level of pain to zero in the process of treatment.”
VI. Scope of application of pneumatic ballistic lithotripsy
Pneumatic ballistic lithotripsy can be used for percutaneous nephrolithotripsy, ureteroscopic lithotripsy and cystoscopic lithotripsy. The size of the probe can be changed, so it can be used in most of the rigid lumpectomies for ureteral stones, renal pelvis stones, calcium stones, bladder stones, urethral stones, etc.
7.Pneumatic ballistic lithotripsy procedure
1.Pre-operative preparation
1.1, psychological preparation Patients generally have the psychological fear of surgery, worrying about the pain brought by surgery and the unknown success of surgery. They can learn from the doctors and nurses that pneumatic ballast lithotripsy is a minimally invasive surgery, without incision, with the advantages of small trauma, fast recovery, less complications, less bleeding and fast postoperative recovery, so that they can build up confidence and actively cooperate with the treatment.
1.2 Pre-operative preparation 1. Cooperate with doctors to do routine blood and various blood biochemical and coagulation tests, chest X-ray and ECG, ultrasound and pyelogram; 2. Improve various pre-existing disease conditions of patients to improve the tolerance of surgery, advise them to quit smoking and drinking, and instruct them to do deep breathing, coughing, sputum and other ability exercises; 3. Do a good job of skin cleaning in the surgical field; 4. Preoperatively, the patient should be instructed to eat lightly, drink more water, and prevent from catching cold; 5. Fasting and drinking in the evening before surgery and clean enema in the morning of surgery to empty the intestine, routine preoperative intramuscular injection of preoperative drugs and take abdominal plain film again to determine the location of the stone.
2.Intraoperative treatment methods
2.1. Sacral anesthesia is used for urethral and bladder stones. The ureteroscope is inserted into the urethra or into the bladder via the urethra, and the stone is broken with a 2 mm lithotripsy rod by clicking or even striking. Residual bladder stones with a diameter of 5-10 mm are crushed with a bladder lithotripter, and the stones can be expelled by themselves or flushed out with an Arik flush, and a catheter is left in place depending on the urethral injury.
2.2. Patients with middle and lower ureteral stones are placed in the lithotomy position with epidural anesthesia. The WOLF 8.9-11.5F ureteroscope was inserted into the ureter via the urethra, and a 0.8-1.0 mm lithotripsy rod with an air compression pump attached was inserted from the working channel of the ureteroscope after seeing the stone, and after aligning the stone, the air pressure pump was activated to break the stone to less than 3 mm with a single or continuous pulse, and the slightly larger ones could be removed with alligator forceps. Postoperatively, a double J tube is routinely placed and drained for 15 days to 1 month.
2.3 For kidney stones and upper ureteral stones, minimally invasive percutaneous nephrolithotomy, which is known as “perforation lithotripsy”, is often used. Minimally invasive percutaneous nephrolithotomy is performed with a channel less than or equal to 6 mm in diameter. A percutaneous renal access is established through an X-ray C-arm or ultrasound-guided puncture, and the stone is entered into the kidney through the renal access and removed by a lithotriptic rod. Postoperative fistula and double J-tube were routinely placed to facilitate future treatment of residual stones.
3 .Postoperative care
3.1. Closely observe the changes in condition According to the routine care of urology and routine care after holding hard anesthesia, closely observe the changes in vital signs. At the same time, monitor urine volume and renal function at 1 hour, 2 hours, 12 hours and 24 hours after surgery according to medical advice.
3.2. Position and diet The patient can be changed to semi-sitting position after lying down for 4-6 hours to facilitate drainage and prevent urine reflux. After fasting for 4-6 hours after surgery, semi-liquid can be introduced, without abdominal distension, abdominal pain and other discomfort can be gradually changed to general diet, drink more water, up to 2500ml or more per day to achieve the purpose of physiological flushing of the urinary tract, do not eat animal liver, nuts and other foods containing high cholesterol to prevent stone regeneration.
3.3. Care of indwelling double J tube Postoperative are indwelling double J tube for 4-6 weeks, the placement of double ding tube in ureter is good for drainage, can prevent blood clots or debris particles from blocking ureter, encourage patients should drink more water during the placement, do not do strenuous exercise, avoid doing some actions that increase abdominal pressure, such as coughing, laughing, forceful defecation, prevent double J tube displacement, cause bleeding, urine reflux.
3.4. Care of indwelling catheter After surgery, the indwelling catheter should be kept unobstructed, avoid folding and pulling when turning and moving, pay attention to the color, quality and quantity of urine, generally the time of indwelling urine after surgery is 24 hours, if there is hematuria and deepening of color, the time of extubation can be extended appropriately, when it is found that the flow of urine is not smooth, according to the situation, timely suction while flushing with saline or 20ml syringe, during the indwelling catheterization the urethral opening should be The urethral opening should be scrubbed with iodophor twice a day to prevent infection.
4.Discharge instruction
4.1 Drink more water, up to 2500ml per day, so that the daily urine volume is kept above 2000ml.
4.2, according to the analysis of stone composition, guide the diet, such as oxalate stones, can eat less oxalic acid-rich food such as spinach; phosphate stones should eat low phosphorus, low calcium food, avoid drinking a lot of milk; uric acid stones should not eat high purine food such as animal viscera.
4.3, During the period of double J tube placement, take proper rest and avoid strenuous activities, especially avoid doing simultaneous stretching of limbs and abdomen, avoid sudden squatting and heavy physical labor, and pay attention to keep the bowels unobstructed to prevent constipation.
4.4 Come to the hospital for regular review as instructed, self-monitor the color, quality and quantity of urine according to the doctor’s instruction, return to the hospital for timely follow-up if abnormalities are found, recheck KUB and renal function and remove the double J tube 4-6 weeks after surgery, and recheck ultrasound regularly to check for recurrence of stones.
IX. Safety of pneumatic ballistic lithotripsy
Urinary tract injury usually occurs during endoscopic or ureteroscopic search for stones, and smaller endoscopes usually reduce urinary tract injury. The degree of safety is related to the user and his or her experience. The principle of pneumatic ballistic lithotripsy is that the energy generated by compressed gas is used to drive a bullet body in the handle of the lithotripter, which pulses to break up the stones, causing light damage to the mucosa because of its high lithotripsy efficiency and little heat production. A group of animal experiments compared the degree of damage to the bladder and ureter by these four lithotripters and found that the pneumatic ballistic lithotripter and ultrasonic lithotripter were lighter, with only mild epithelial detachment, whereas the liquid electric and laser lithotripters caused total epithelial tearing and necrosis. Therefore, pneumatic ballistic lithotripsy is a safe and efficient lithotripsy technique.