Source: Journal of Modern Urology Author: Liu Jiuhua, Zhang Wei, Liu Xuejun, Yao Dongwei 2008-12-27
[Abstract] Objective To investigate the clinical efficacy of transurethral ureteroscopy with pneumatic ballast plus ultrasonic lithotripsy in the treatment of ureteral stones. Methods From June 2006 to June 2007, 40 cases of ureteral stones were treated by transurethral ureteroscopy with pneumatic ballast plus ultrasonic lithotripsy. Results The one-time stone crushing rate was 97.5% (39/40), the one-time stone removal rate was 87.5% (35/40), the average unilateral operation time was about 30 min, the average postoperative hospital stay was 4 d, and there were no significant complications. Conclusion Transurethral ureteroscopy with pneumatic ballast plus ultrasonic lithotripsy is effective in the treatment of ureteral calculi, with the advantages of safety, less injury and good results. Liu Jihua, Department of Urology, Lianyungang Second People’s Hospital
【Key words】 Ureteral stones, ureteroscopy, pneumatic ballast lithotripsy, ultrasonic lithotripsy
From June 2006 to June 2007, 40 cases of ureteral stones were treated by transurethral ureteroscopy with pneumatic ballast plus ultrasonic lithotripsy with satisfactory results, which are reported below.
1 Data and methods
1.1 General data There were 40 cases in this group, 28 males and 12 females, aged 19-71 years, average 43 years, stone diameter 0.7-2.0 cm, average 1.1 cm; 7 cases of upper ureteral stones, 11 cases of middle ureteral stones, 22 cases of lower ureteral stones; 37 cases unilateral, 3 cases bilateral (including 1 case of bilateral ureteral stones combined with acute renal failure); 9 cases with history of extracorporeal shock wave lithotripsy. All patients underwent ultrasound, abdominal plain film, intravenous urography and CT examination before surgery.
1.2 Methods Epidural anesthesia was used, and the lithotomy position was adopted. A German Wolf 8.0/9.0 F rigid ureteroscope was used to enter the bladder through the urethra under direct vision, find the ureteral opening on the affected side, insert the ureteral guidewire, and insert the ureteroscope into the ureteral lumen by rotating the lateral entry method under the guidance of the guidewire, and slowly advance the ureteroscope along the guidewire under direct vision. When a stone is found, the water inflow rate of the perfusion pump is slowed down and the size of the stone, the relationship with the ureteral mucosa, the presence of polyps around the stone, and whether the stone floats with the water are observed. Smaller stones can be removed slowly with a foreign body clamp; larger stones must be lithotripped. During lithotripsy, a pneumatic ballistic lithotripsy probe is inserted through the ureteroscopic channel and the stone is pressed against the lateral wall of the ureter with continuous pulses to break up the stone. Then the pneumatic ballistic probe was replaced with an ultrasonic lithotripsy hollow probe, and the stone was gently touched, and the stone was sucked by the first gear, followed by the second gear for ultrasonic lithotripsy, and the lithotripsy particles were sucked into the collection bottle by negative pressure. After the operation, a double “J” tube was placed to drain the stone, and the stone was removed after the abdominal plain film was reviewed 4 weeks after the operation to confirm that no stone remained.
2 Results
The one-time stone crushing rate was 97.5% (39/40) in all 40 patients, and one case was converted to open surgery because the lower part of the stone was severely blocked by inflammatory polyps and the lumen could not be seen clearly by the microscope. The one-time stone extraction rate was 87.5% (35/40), and 4 cases of residual stone crushing were discharged by themselves within 1 month. The average unilateral operation time was about 30 min. The average postoperative hospital stay was 4 d. Except for a few cases of mucosal abrasion of the ureteral opening and ureteral wall, no serious complications such as hemorrhage and perforation occurred in this group. A few patients developed mild hematuria, which improved 1 to 2 d after surgery and required no special treatment. 6 patients with postoperative fever were relieved by anti-inflammatory and symptomatic treatment.
3 DISCUSSION
The rapid development of luminal urology technology has provided a broad prospect for the treatment of ureteral stones, and lumpectoscopic techniques have gradually replaced traditional surgical methods, and currently 95% to 98% of patients with ureteral stones do not require open surgical treatment [13]. Ureteroscopic pneumatic ballistic lithotripsy is a new technique of intracavitary lithotripsy used in clinical practice since the 1990s, which is based on the principle that compressed air drives the bullet body in the handle of the lithotripter to impulse the stone under direct view of the ureteroscope [35], thereby breaking up the stone, which is safe, efficient, simple to operate, more effective in lithotripsy, and has fewer complications. Ultrasonic lithotripsy system includes ultrasonic generator, transducer, ultrasonic probe rod, negative pressure suction device and foot switch. It can make lithotripsy and stone removal simultaneously. The third generation of pneumatic ballistic combined ultrasonic lithotripsy system is an all-in-one machine combining two methods. For large stones or hard stones, the stones are first broken by pneumatic ballistic, and then small stones are crushed and sucked out by ultrasonic lithotripsy, without changing ureteroscope during the whole lithotripsy process, thus reducing the chance of damage to the ureteral opening and ureter. Lithotripsy and lithotripsy are performed simultaneously to reduce the upward movement of lithotripsy particles, shorten the operation time and reduce the occurrence of complications.
The key to the success of the procedure is to insert the ureteroscope to the stone site and to see the stone. The ureteroscope is inserted into the bladder cavity under television surveillance and the ureteral opening is observed. If the opening is normal, a guidewire is placed first, the perfusion rate is increased to open the opening slightly, a zebra guidewire is inserted for guidance, the ureteroscope is rotated 180° in the orthostatic position, the lower lip of the ureter is compressed with the protruding part of the front of the sheath, and the mirror is rotated to the normal position after entering the wall segment, the bladder should not be filled too much at this time to avoid excessive force, which can cause injury [6]. If the ureteral opening is narrow and it is difficult to pass the ureteroscope, the “additional tube method” can be used. The specific operation is as follows: insert the guidewire first, then insert the ureteral catheter to enlarge the opening, and the ureteroscope can follow it into the narrow opening, then remove the catheter and continue to advance the ureter upward under continuous hydraulic perfusion and guidewire guidance. During the process of entering the mirror, always keep the field of view clear, avoid blindly entering the mirror with unclear field of view and rough force, if the ureter is twisted, it can be overcome by adjusting the position, increasing the perfusion pressure and rotating the mirror. While maintaining a clear field of view after entering the mirror, the perfusion pressure should be reduced as much as possible to avoid pushing the stone to the renal pelvis and causing renal parenchymal reflux, which may cause intraoperative chills and postoperative fever.
If a polyp is formed under the stone and the scope is inaccessible, the stone can be exposed under direct vision after treatment of the granulation tissue or polyp with biopsy forceps. After seeing the stone, first observe the stone activity, if the stone is large, first use the probe to fix the stone against the pressure on the ureteral wall and start continuous pulsed pneumatic ballistic lithotripsy, then use ultrasonic lithotripsy to crush the small stone and aspirate it, for smaller and more active stones, use the head low hip high position, change to low pressure intermittent perfusion, pull the stone to a relatively stable place with the lithotripter to fix it, and the probe to fix the stone at the canal wall Lithotripsy, which reduces the upward migration of stones, and direct ultrasonic lithotripsy or combined lithotripsy whenever possible. The upper segment of the stone is more mobile, and the ureteroscope can easily damage the ureter by entering the distance, which is not easy to operate. Therefore, transurethral ureteroscopic pneumatic ballistics with ultrasound lithotripsy is especially suitable for middle and lower ureteral stones.
After lithotripsy, the mucosa of ureter has different degrees of edema, bleeding or mucosal exfoliation, and sometimes stone fragments accumulate together or form “stone streets”, causing obstruction and affecting kidney function and secondary infection, so double “J” tubes should be routinely left in place after surgery. There were only 6 cases of postoperative lumbar pain and fever in this group of patients, which were cured by anti-infection treatment, and there was no one case of abscess kidney. The double “J” tube can play the role of drainage and support, and small stones can also slide down the double “J” tube, which helps to discharge the stones. For patients who need to undergo ESWL treatment after surgery, it is even more necessary to keep the double “J” tube in place.
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Authors: 1. Department of Urology, Lianyungang Second People’s Hospital, Lianyungang, Jiangsu 222023, China; 2. Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China