Holmium laser lithotripsy for treatment of complicated ureteral calculi _3433

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Holmium laser lithotripsy for treatment of complicated ureteral calculi
 
 
Of: Dong-Liang Liu, Shi No, Zhou Kaihua, Zhu Shu Xia, Lu Jian, Rong Xia   Abstract Objective To investigate the complexity of ureteral calculi with holmium laser cavity by the efficacy and safety. Methods Retrospective analysis of December 2003 ~ May 2005 were treated by holmium laser treatment of complicated ureteral calculi clinical data of 87 cases. 87 cases were associated with mild to moderate hydronephrosis affected side, 46 cases with stones in distal ureteral stricture, 69 patients with polyps or granulation tissue associated with parcels, 21 patients failed ESWL treatment. Results in 83 patients with 87 cases of a single stone surgery successful, single stone crushing operation and 95.4% (83/87), 2 cases of holmium laser lithotripsy for stones in the process of moving in the calyx, again after ESWL treatment; When 1 case of ureteral perforation into the mirror, 1 case of ureteral mucosal avulsion when the back mirror to open surgery. Conclusion ureteroscopic holmium laser lithotripsy treatment of complicated ureteral calculi is safe and effective, especially for poorly performing extracorporeal shock wave lithotripsy patients. Key words   holmium laser lithotripsy; complicated ureteral calculi   【Abstract】 Objective To evaluate the therapeutic effect and safety of Holmium laser on the endoscopic treatment of ureteral complicated calculi.Methods Investigated the clinical material on Holmium: YAG laser endoscopic treatment of 87 cases with ureteral complicated calculi between December 2003 to May 2005.All 87 cases have hydronephrosis. Among them, 46 cases with ureteral stricture, 69 cases with polypus and 21 cases fail of ESWL . Results 95.4% (83/87) stones were fragmented in one treatment session.Complications were observed in 4.6% (4 / 87) cases mainly perforation and calculi shift.Conclusion Treatment of urinary calculi with this method has been safe, effective and less invasive, especially those failure of ESWL.  】 【Key words holmium: YAG laser lithotripsy; ureteral complicated calculi   since December 2003 ~ May 2005, our hospital by the German Dornier company The 15w holmium laser, combined with rigid ureteroscopy WOLF F8/9.8 treatment of complicated ureteral stones in 87 cases, results were satisfactory, are as follows.   1 Materials and Methods   1.1 General Information of this group 87 patients, 56 males and 31 females; aged 17 to 73 years, average 42.5 years old. Stone Location: right 46, left 37 cases, 4 cases of bilateral ureteral calculi; 46 cases of upper ureteral stones, the middle stone in 7 cases, 34 cases of lower ureteral stones; of which 46 cases of stones in distal ureteral stricture, stricture length was 0.5 2.0cm; polyps or granulation tissue, 69 cases of stones wrapped. Stone size: 0.2cm × 0.4cm ~ 1.8cm × 1.5cm. B ultrasound showed 54 patients with ipsilateral renal pelvis with mild hydrocephalus, 33 cases of moderate water, IVU showed 17 patients suffering from kidney does not develop. ESWL in 21 cases of preoperative treatment of 1 to 7 times, including some crushed stone in 15 cases, no change in 4 cases in situ stone, Stone Street, the formation of 2 cases.   1.2 Diagnostic Criteria (1) stones in the ureter stay> 3 months, diameter> 1cm; (2) intravenous urography contrast agent can not when the stones around the ipsilateral renal pelvis separation> 5.0cm ; (3) distortion of distal ureteral calculi or stenosis; (4) parts of polyp formation or presence of stones impacted stones, and the ureter close adhesion. Meet the above two or more for complex ureteral stones [1].   1.3 treatment by WOLF F8/9.8 Ureteroscopic, MMC pump, WOLF camera system, the German Dornier company 15W holmium laser systems. Epidural anesthesia, patients were Motola lithotomy position. F10 rubber catheter into the bladder is set, the camera system Ureteroscopic under direct vision along the catheter into the bladder through the urethra, along the F4 in the infusion pump directly into the ureter ureteral catheter. Into the mirror To the bottom of a narrow stone associated with polyps or hyperplasia, granulation tissue, the parcel, with 400μm fiber, first holmium laser ablation of polyps or cut a narrow ring (energy 1.5J, frequency 10Hz), then the energy of 0.8 ~ 1.2J, the frequency 5Hz, line holmium laser lithotripsy, the stone crushed to a diameter of less than 2mm. Massive stone walls and adhesive stones in the ureter, the direct use of foreign body forceps removed. Unqualified with fluid discharged stones, some patients self-discharged. Set after double-J tube drainage.     2 results in 87 cases in this group of 63 cases successfully stone the first surgery, a single stone crushing 95.4% (83/87). Stone with polyps or granulation tissue, stenosis and caught the full cut package, gasification to smooth ureteral lumen patency. Stones in 2 patients in this group in the process of holmium laser lithotripsy has been into the calyx, the postoperative treatment of 2 ESWL again completely crushed stone; 1 case ureteroscope into the bladder wall causing ureteral perforation, 1 case in the back mirror avulsion of ureteral mucosa during the middle, were converted to open operation to remove stones in the ureter anastomosis in parallel. An average of 83 cases successfully stone operation time 21min (12 ~ 40min), average hospital stay 2.5 days (2 to 5 days), after double-J tube indwelling time was 14 to 60 days. 62 cases of postoperative gross hematuria, 1 to 4 days after the disappearance, no fever, pyuria and other serious complications. Most stones that basically drained surgery, postoperative abdominal plain film review after 1 week to drain all the stones. Preoperative pelvic separation <5.0cm in 44 patients, hydronephrosis disappeared; the other 43 cases of hydronephrosis was significantly reduced.   3   discussed the complexity of ureteral calculi stones in the ureter as a long residence time, the surrounding tissue can occur in more severe inflammatory response, and thus the formation of polyps or impacted stones,You are not allowed to view links. Register or Login, parcels can be causing ureteral obstruction. The existence of distal ureteral calculi is also easy to cause expansion of the proximal ipsilateral ureter and hydronephrosis. If you do not promptly remove the obstruction, will result in different degrees of ipsilateral renal function. Distal ureteral stricture due to stones or impacted stones, fiber wrapped, ESWL ureteral obstruction in the case of the remote easy to use [2]. The traditional method of rubble stone lower chamber, after the discharge of broken stones are more difficult. Ureteroscopic pneumatic lithotripsy of ureteral mucosa after different degrees of edema, hemorrhage, or mucosal stripping, sometimes stacked stone fragments or the formation of Stone Street, could easily lead to obstruction and secondary infection or affect renal function. Pneumatic lithotripsy also easily lead to gravel site hemorrhage, resulting in blurred surgical field, the operation difficult. Either cold knife, electric cut or Nd: YAG laser in the treatment of ureteral stricture and granulation tissue when the cutting is not very accurate, easy to cut deeper cause of ureteral perforation. Open surgery is not only trauma, surgery time is long, slow recovery after surgery, and postoperative ureteral stricture recurrence is still possible [3]. 

   holmium laser is a high energy solid state laser, the pulse mode emission, the laser pulse time is 0.25ms, the organization is far less than the thermal conduction time (1ms ), so minimal thermal damage to surrounding tissue, tissue penetration depth of less than 0.4mm. Holmium laser in water has a high absorption coefficient, because the organization composed primarily of water, so the main energy concentrated in the surface, the laser with excellent cutting ability and excision capacity for the cutting process in the organization 1mm diameter of blood vessels also can stop the bleeding. Holmium laser lithotripsy has a very good function, through a Combined with endoscopic techniques, for discharge of distal ureteral stone obstruction, or inflammatory polyps narrow package can be used when the holmium laser lithotripsy to be addressed, greatly improving the success rate of a stone treatment. The group of 63 patients in the first 87 cases successfully stone surgery, a single stone crushing 95.4%.   We polyp formation with ureteral stones who first highlighted holmium laser cutting part of the more obvious polyps, exposed stone, after the holmium laser energy to reduce the crushing stones, then cut to adjust to a higher net energy remaining ureteral polyps parietal . Impacted ureteral stones close to the luminal part of the adhesion obstruction, mucosa and stone in between the ablation, energy 1.5J, frequency 10Hz, stone completely dissociated before the energy 0.8 ~ 1.2J, Holmium laser line frequency 5Hz surgery, the stones crushed to a diameter less than 2mm, can be attached to the wall to avoid postoperative residual stone tablets. Polyps of the ureter stones with inclusions and the lumen was completely blocked, should first use of holmium laser lithotripsy fiber side to find the right channel edge ablation polyps later in order to avoid the formation of the first dealing with polyps polyps may result in false passage or perforation of the ureter, also avoid dealing with polyps, bleeding Erzhi blurry vision. The group of holmium laser treatment of ureteral calculi polyps or granulation tissue were wrapped in 49 cases an operation completely remove the obstruction, stone success.   Stenosis of the distal ureteral stones, preoperative need to fully understand the site of ureteral stricture, stricture length. Ureteral stone with a narrow, especially near the ureteropelvic junction obstruction, because in front of a blood vessel adjacent to the ureter, it is generally advised to select the cut in the latter part of the outside [5]. Surgery, under the guidance of the guide wire under direct vision should always be operating in the ureteroscope, through the narrow section of the guide wire insertion, the direction is clear cut, but also to avoid the cut parts of the ureter from the non-wear clothing. Holmium laser cutting along the wire direction of bottom-up, cutting the scope of the stricture should be full or slightly more than a narrow segment, the depth of full-thickness wall of ureter [6]. If you can not ignore the narrow ureter mirror, the use of holmium laser incision of the Ministry of ureter smooth home after more than a mirror, should avoid blindly forced into