RU2776963C1 - Method for percutaneous cystolithotripsy for large stones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to operative urology. A method for percutaneous cystolithotripsy for large bladder calculi, which includes, at the first stage of surgical treatment for patients with cystolithiasis, an ultrasound-guided cystostomy and the installation of a 3-way Foley catheter Ch 20. 3-5 days before the proposed lithotripsy and 3-5 days after it, a complex drug therapy, which includes daily instillation of the combined Coletex-ADL gel in a volume of 20 ml into the bladder, as well as sodium hyaluronate 40 mg in a volume of 50 ml with an exposure of 30 minutes. 3 hours before the operation and 24 hours after the operation, a solution of fosfomycin 3 g is administered orally. After the drug therapy, cystolithotripsy is performed. The Amplatz-shell CH 30 is successively installed along the insurance conductor, then, under the control of the nephroscope, a laparoscopic bag is inserted into the bladder cavity, then the stone is placed in the laparoscopic bag and pneumatic cystolithotripsy is performed, then a basket is passed through the working channel of the nephroscope, with which the stone is captured and crushed stone inside the basket according to the method described above, followed by washing the stone fragments from the bag.

EFFECT: method allows to increase the efficiency of treatment of patients with cystolithiasis with large bladder stones, reduce the risk of damage to the bladder wall during cystolithotripsy, the occurrence of hematuria, postoperative inflammatory process in the bladder, there is no risk of urethral injury, allows the operation to be performed in patients with aggravated anamnesis.

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Description

The invention relates to medicine, namely to a method for performing a urological operation and can be used to treat patients with cystolithiasis with large calculi (from 2 cm) of different density.

Urolithiasis or urolithiasis occupies one of the leading places in the structure of urological diseases in terms of prevalence. Bladder calculi (cystolithiasis) is a form of manifestation of urolithiasis with a prevalence of 5-10% [Nazarov T.Kh., Rychkov I.V., Nikolaev V.A. Historical and modern methods of treatment of patients with bladder stones with benign prostatic hyperplasia. Andrology and Genital Surgery 2021;22(2):13-23. DOI: 10.17650/1726-9784-2021-22-2-13-23]. The relevance of this problem in modern urology is evidenced by a systematic review and meta-analysis conducted in 2019 on the treatment of bladder stones in adults and children by a group of researchers on urolithiasis from the European Association of Urology [Donaldson J.F., Ruhayel Y., Skolarikos A., et al. Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel. EUR Urol. 2019 Sep;76(3):352-367. doi: 10.1016/j.eururo.2019.06.018. Epub 2019 Jul 13. PMID: 31311676]. Bladder stones are etiopathogenetically divided into primary, secondary and migrated. Primary bladder stones usually form in the presence of metabolic disorders in the body and the absence of concomitant pathology of the urinary system. Secondary calculi are formed with infravesical obstruction, foreign bodies, bladder augmentation, etc. [Leslie SW, Sajjad H, Murphy PB. Bladder Stones. 2021 Sep 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. PMID: 28722973]. Among men, bladder stones are more common with a frequency of 10:1 to 4:1 in relation to women. The peak incidence occurs at the age of 3 years in children and 60 years in adults. In adults, more than half are patients suffering from benign prostatic hyperplasia [Wei Huang. Risk factors for bladder calculi in patients with benign prostatic hyperplasia. J.Medicine (Baltimore). 2017 Aug; 96(32)]. Most of the patients in this group are of active working age. Cystolithiasis leads to hematuria, dysuria, pain during exercise, which negatively affects an active daily and working life. An analysis of scientific papers on cystolithiasis shows that this problem has not been studied enough and the question often arises of conducting combined simultaneous operations [Mekke S., Roshani H., van Zanten P., et all. Simultaneous transurethral resection of the prostate and cystolithotripsy: A urological dilemma examined. Can Urol Assoc. 2020. Dec 15. DOI: 10.5489/cuaj.6743. PMID: 33382366]. The question remains about the methods of treatment of such patients, especially in patients with large stones in the bladder. Large bladder calculi make it difficult to choose the optimal tactics for treating patients, especially the elderly, complicate the technique of performing a number of surgical interventions, and increase the risk of postoperative complications. This necessitates the improvement and optimization of treatment methods for patients with bladder calculi [Ivanov V.Yu., Malkhasyan V.A., Semenyakin I.V., Pushkar D.Yu. Bladder stones and their endoscopic treatment. Modern view of the problem. "Experimental and Clinical Urology" 2017; (3), 44-50].

To date, patients with bladder stones undergo surgery to remove these stones. Complications after cystolithotripsy occur in 7.8% of cases. Among the postoperative complications that appear over time, urethral stricture is distinguished [Ankur Bansal, Manoj Kumar, Satyanarayan Sankhwar, Sunny Goel, Madhusudan Patodia et all. Prospective randomized comparison of three endoscopic modalities used in treatment of bladder stones. // Urologia 2016; 83 (2): 87-92 DOI: 10.5301/uro.5000171]. Some studies show that the complication rate for cystolithotripsy is 16% on average. The most common perioperative complications during cystolithotripsy are hematuria, cystitis, pyelonephritis, very rarely bladder perforation [Papatsoris AG, Varkarakis I, Dellis A, Deliveliotis C. Bladder lithiasis: from open surgery to lithotripsy. Urol Res. 2006 Jun; 34(3):163-7. doi: 10.1007/s00240-006-0045-5. Epub 2006 Feb 10. PMID: 16470391].

There are several possible ways to remove stones from the bladder, such as open and endoscopic surgical aids, as well as remote cystolithotripsy.

Among open operations, open cystolithotomy is currently used, usually combined with one-stage transcystic adenomectomy. Of the variations of this operational tool, the most commonly used was suprapubic extraperitoneal cystolithotomy. It is still the option of choice, even in well-equipped facilities, for patients with large stones or prostate volumes greater than 150 cm3.

V. Bhatia et al. back in 1994 pointed out that open cystolithotomy, in comparison with alternative options, is the simplest in technique and with a relatively low risk of complications. This statement is confirmed by the work of Cicione A and co-authors in 2018 [Cicione A, DE Nunzio C, Manno S, Damiano R, Posti A, Lima E, Tubaro A, Balloni F. Bladder stone management: an update. Minerva Urol Nefrol. 2018 Feb;70(1):53-65. doi: 10.23736/S0393-2249.17.02972-1. Epub 2017 Oct 11. PMID: 29022330]. However, this operation may be accompanied by a number of complications. The most common are damage to the pubic-vesical ligament, which takes part in the fixation of the bladder and a low wall incision, at the pubic symphysis. As a result, low drainage installation, which irritates the wall and internal opening of the urethra throughout the entire postoperative period. Insufficient revision of the bladder cavity with damage to the peritoneum is the most dangerous complication, if left unnoticed [Bhatia V, Biyani CS. Vesical lithiasis: open surgery versus cystolithotripsy versus extracorporeal shock wave therapy. Urol. 1994, 151(3): 660-2. DOI: 10.1016/s0022-5347(17)35041-3. PMID: 8308976]. As mentioned, this operation is combined with transvesical adenomectomy, in which case it is important not to damage the urethra intraoperatively. Other complications include:

• formation of vesical fistula;

• urinary stagnation;

• peritonitis, if damage to the peritoneum was missed;

• osteitis of the pubic bones - non-infectious inflammation of the symphysis;

• suppuration of the wound and the divergence of its edges.

Remote cystolithotripsy, in clinical practice, is quite rare and with small stones. The main advantage over open and endoscopic treatment options is low trauma and minimal invasiveness [Ali M, Hashem A, Helmy T, E et al.. Shock wave lithotripsy versus endoscopic cystolitholapaxy in the management of patients presenting with calcular acute urinary retention: a randomized controlled trial. World J Urol. 2019 May;37(5):879-884. doi: 10.1007/s00345-018-2434-0. Epub 2018 Aug 13. PMID: 30105456]. The main disadvantages of the method are [Askarov M.S., Rudenko V.I. Remote cystolithotripsy in patients with benign prostatic hyperplasia. Electronic scientific and educational bulletin "Health and education in the XXI century" No. 1, 2006 (Vol. 8)]:

• excretion of calculi occurs after surgery by the patient himself, which causes risks of injury to the urethra, or acute urinary retention;

• it is inappropriate to use in patients with infravesical obstruction and with a calculus size of more than 2 cm.

There are 2 main ways of endoscopic cystolithotripsy [Donaldson JF, Ruhayel Y, Skolarikos A, MacLennan S, Yuan Y, Shepherd R, Thomas K, Seitz C, Petrik A, Türk C, Neisius A. Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel. EUR Urol. 2019 Sep;76(3):352-367. doi: 10.1016/j.eururo.2019.06.018. Epub 2019 Jul 13. PMID: 31311676.]:

1. Transurethral;

2. Percutaneous.

Transurethral cystolithotripsy is traditionally performed in an aquatic environment. This method is most often the option of choice in the presence of instruments for endoscopic urological operations, due to its ease of use and the absence of the need for additional expensive equipment.

There is also a method of transurethral contact cystolithotripsy in a gas (CO2) environment [Patent No. 2532016 "Method of endoscopic cystolithotripsy for large and multiple bladder stones" priority dated 04.12.2013. Glybochko P.V. et al.], which consists in the fact that after passing the cystoscope into the bladder, carbon dioxide is injected into it until the bladder expands, cystoscopy is performed, during which the calculus is visualized and contact cystolithotripsy is performed to small fragments, followed by their washing with saline. EFFECT: method makes it possible to exclude such a side effect as hypermobility (increased mobility) of the calculus, which prevents its rapid destruction and complicates the surgeon's work, and also provides a qualitatively better intraoperative visualization, and reduces the operation time. The considered method does not take into account all the links in the pathogenesis of the development of postoperative complications, and there is also a high risk of developing perioperative complications mentioned above. Even in experienced hands, transurethral cystolithotripsy is fraught with serious urethral complications.

From percutaneous methods of cystolithotripsy, different methods are distinguished.

As a prototype, the method of cystolithotripsy described by Jae Seung Hwang [Jae Seung Hwang, Jeong Hwan Son, Seok Heun Jang, Jae Won Lee, Dae Sung Cho et al. . The Initial Experience of Pneumovesicoscopic Bladder Stone Removal Using a Laparoscopic Entrapment Sac. "Urology" Volume 84, ISSUE 5, P1234-1239, November 01, 2014]. The bladder is filled with CO2 gas up to 15 mm Hg. A prepared laparoscopic bag is inserted through the suprapubic trocar. Transurethral under visual control, the laparoscopic sac is deployed and its opening is expanded using nephroscopic forceps. Bladder stones are placed in a bag using nephroscopic forceps. After confirming that all bladder stones are in the sac, the opening of the sac is retracted extracorporeally with removal of the suprapubic trocar. Then extracorporeal lithotripsy is performed. The air medium is used in this case in connection with the collapse of the laparoscopic bag in a liquid medium.

The disadvantages of this method are:

• the need to inject gas (CO2) into the urinary system;

• the need for transurethral installation of the endoscope, which can cause postoperative complications in the urethra;

• fragmentation of the calculus inside the laparoscopic bag in the air can lead to its damage by sharp fragments of the calculus, which will affect the course of the operation and increase its time.

In the case of the method proposed by us, the laparoscopic bag is used with a string with a memory effect, and the basket, in this case, is a frame for the laparoscopic bag and prevents damage (perforation) of the bag during crushing of the calculus. Pneumatic cystolithotripsy is carried out with a power of 100% (85 mJ), a frequency of 4 Hz and using the Swiss LithoClast Master, EMS device and allows fragmenting the stone for capture in the Khachin basket 4x16 “inflated” (up to 20 mm). Laser cystolithotripsy in the "spray" mode is carried out in a liquid, natural for the bladder, medium. The Khachin basket 4x16 “inflated”, with a diameter of 20 mm, 5 Fr, serving as a frame, does not damage the walls of the bag with calculus fragments, which makes it possible to completely fragment the calculus to small (1-2 mm) fragments, and after crushing, wash and remove all fragments from the bag . Lithotripsy calculus in the bag and basket reduces the risk of damage to the bladder wall in contrast to the prototype.

The technical result is to increase the effectiveness of treatment of patients with cystolithiasis that has arisen against the background of infravesical obstruction, due to:

• reducing the risk of damage to the bladder wall during cystolithotripsy, which will reduce the risk of hematuria, a postoperative inflammatory process in the bladder;

• no need to immerse the patient in anesthesia or spinal anesthesia, respectively, will be limited to the use of local anesthesia, which allows the proposed surgical aid to be applied to patients with a aggravated anamnesis;

• no need for a second session of cystolithotripsy;

• increasing the efficiency of cystolithotripsy by placing the calculus in a basket and fixing the calculus;

• no risk of injury to the urethra after the operation;

• reducing the risk of urethral stricture and bladder neck sclerosis after surgery;

• reduction of operation time, due to the absence of the need for regular washing of calculus fragments.

The technical result is achieved by the fact that in capable of percutaneous cystolithotripsy in patients with infravesical obstruction in the presence of a calculus with a size of 20 mm, including the sequential introduction of a trocar into the bladder under ultrasound control, the installation of an Amplatz tube along an insurance conductor, then under the control of a nephroscope, holding a laparoscopic bag with subsequent placement of the calculus inside the bag, crushing it and washing the fragments of the stone inside the bag, according to the invention, a laparoscopic bag with a string with a memory effect is used, in which the calculus is placed, and then the bag is pulled up to the Amplatz tube and pneumatic cystolithotripsy is performed through the nephroscope, after which the patient a Khachin basket 4x16 “inflated” is installed and the obtained fragments of the calculus are placed in it, then laser cystolithotripsy is performed in the “spray” mode, in addition, a 3-way Foley cystostomy catheter Ch 20 is installed in the patient before the operation, 3-5 days before before and after surgery, a combined Coletex-ADL gel and sodium hyaluronate are daily instilled into the bladder with an exposure of 30 minutes, and 3 hours before the operation and 24 hours after the operation, a solution of fosfomycin is taken orally. At the same time, pneumatic cystolithotripsy is performed with a power of 100% (85 mJ), a frequency of 4 Hz and using the Swiss LithoClast Master, EMS device, and laser cystolithotripsy with a fiber of 400 μm in diameter in the "spray" mode is performed with energy settings of 2 J, a frequency of 30 Hz and 30 W using a Fiberlase U2, IPG Photonics Corporation.

The use of a basket for capturing a stone and fixing it in a laparoscopic bag during crushing ensures the convenience of performing the method, reducing the risk of rupture of the bag from the sharp edges of stone fragments, which significantly increases the effectiveness of treatment and reduces the number of possible complications. The most preferred option is to use for these purposes the Khachin 4x16 “inflated” baskets. At the same time, due to the impossibility of placing large stones larger than 20 mm in the basket, their initial crushing is carried out inside the bag using pneumatic energy, which excludes the possibility of damaging the bag. Further crushing of the calculus is carried out in the "spray" mode inside the basket. It is this combination that allows the most efficient and safe crushing of large stones.

The method is carried out as follows.

At the first stage of surgical treatment for patients with cystolithiasis, a cystostomy 3-way Foley catheter Ch 20 is installed. 3-5 days before the proposed lithotripsy and 3-5 days after it, complex drug therapy is performed, which includes daily instillation of the combined Coletex-ADL gel into the bladder in a volume of 20 ml, as well as sodium hyaluronate 40 mg in a volume of 50 ml with an exposure of 30 minutes. 3 hours before the operation and 24 hours after the operation, a solution of fosfomycin 3 g is taken orally.

Under local infiltration anesthesia, a cystostomy 3-way Foley catheter Ch 20 is removed and an Amplatz sheath Ch 30 is installed into the bladder cavity along the fistulous tract along the insurance guide, a silicone valve is installed on it, then a laparoscopic bag with the effect is inserted into the bladder under the control of a nephroscope. memory (see figure 1). The calculus is placed in a laparoscopic bag using a nephroscope tube (see Fig. 2) and pulled up to the Amplatz sheath, thereby ensuring the isolation of the stone in the bag (see Fig. 3). In the center of the stone, a short session of lithotripsy is performed using pneumatic energy in order to obtain 2-3 fragments (see Fig. 4). Through the working channel of the Ch 14.5 nephroscope, a Khachin basket 4x16 "inflated" is carried out, with the help of which the bladder stone is captured, thereby isolating the stone in the basket and the laparoscopic bag (see Fig. 5). A laser fiber with a diameter of 400 μm is passed along the working channel of the nephroscope and laser cystolithotripsy is performed in the “spray” mode with a power of 30 W (Fiberlase U2 Apparatus) over a fixed stone in a basket. The operation is completed by sequential removal of the basket, washing of the stone fragments from the bag, followed by removal of the bag and Amplatz sheath, installation of a 3-way Foley catheter Ch 20 through the cystostomy hole to continue instillation of the bladder for 3-5 days. The patient is discharged from the hospital under the outpatient supervision of the urologist of the polyclinic with recommendations. The cystostomy catheter is removed after a planned operation to eliminate the infravesical obstruction.

In the proposed scheme, the complex preparation Coletex-ADL consists of dioxidine, lidocaine, sodium alginate. Dioxidine as an antibacterial drug to eliminate the pathogen and prevent infectious complications before and after surgery; Lidocaine as a local anesthetic to relieve pain and pollakiuria; Sodium alginate to enhance adhesion to the urothelium, as a result, providing a long-term effect of dioxidine and lidocaine.

Sodium hyaluronate, as a viscoelastic protector of the intercellular substance of the bladder urothelium, creates a viscoelastic film on the surface of the mucous membrane, protecting it from the negative effects of calculi, and accelerates the recovery of the bladder in the postoperative period.

Fosfomycin, as an antibacterial drug, is used to eliminate the pathogen and prevent infectious complications before and after surgery.

Due to the percutaneous installation of the Amplatz membrane into the cavity of the bladder through a previously performed cystostomy, trauma to the urethra is excluded. The need to inject carbon dioxide into the bladder is also eliminated, since a bag with a string with a memory effect is used.

The use of the Khachin 4x16 “inflated” basket provides the best protection against bag rupture compared to similar devices. At the same time, this basket is quite reliable, including due to the special interweaving of strings, which makes it possible to fix the stone with maximum radial force and conduct lithotripsy without the risk of breaking the strings of the basket. The parachute-type basket shape excludes perforation of the laparoscopic sac when the basket is inserted, unlike other types of baskets that have an external stop at the distal end of the basket [Patent No. Khachin V.N. et al.].

Using the Fiberlase U2 machine with the above parameters ensures maximum stone fragmentation and atomization in a short period of time.

The claimed invention is illustrated by examples.

Clinical example No. 1.

Patient K., 68 years old, came to the clinic with complaints of blockage of the urine stream during urination, occasional admixture of blood in the urine after active physical exertion, frequent and difficult urination in small portions. When performing ultrasound of the organs of the urinary system, it was revealed that the bladder is of a normal shape, the walls are thickened, there are single pseudodiverticula of the wall; in the cavity of the bladder, a calculus with dimensions of 3.3x4.2 cm is located. The prostate gland is enlarged up to 88 cm ³ . Objectively, on palpation in the projection area of the bladder, there is slight pain. Urination is frequent, difficult, in small portions, there is a symptom of laying a stream of urine. Urine is cloudy, without visible pathological impurities, the color is yellow.

According to laboratory blood tests, azotemia was detected (increased creatinine level up to 130 µmol/l, urea 9.2). A urine culture was taken for microflora with the determination of sensitivity to antibiotics, showing the correct choice of an antibacterial drug. On the day of hospitalization, a cystostomy was installed to eliminate the symptoms of CRF. Trocar cystostomy was performed under local anesthesia, under ultrasound guidance, a 3-way Foley catheter Ch 20 was installed. To reduce bladder inflammation, the patient underwent antibiotic therapy with fosfomycin 3g No. 2 3 hours before surgery and 24 hours after surgery, before surgery, daily instillation into the bladder of the combined gel Coletex-ADL in a volume of 20 ml, as well as sodium hyaluronate 40 mg in a volume of 50 ml with an exposure of 30 minutes for 3 days.

1. Surgery was performed under local infiltration anesthesia. Ch 30 Amplatz sheath was installed percutaneously along the safety guidewire, then a silicone valve was installed on it, through which a nephroscope with a working channel of 14.5 Ch was passed. Under the control of a nephroscope, a laparoscopic bag with a string with a memory effect of 750 ml was inserted into the bladder. With the help of it, a calculus is captured. The laparoscopic bag was pulled up to the Amplatz tube, which led to the isolation of the stone in the bag. A pneumatic probe was passed along the working channel of the nephroscope and a session of pneumatic cystolithotripsy was performed with a power of 100% (85 mJ), a frequency of 4 Hz and using the Swiss LithoClast Master, EMS device, the calculus was fragmented into 2 smaller fragments without damaging the laparoscopic sac. Then, the basket of Khachin 4x16 "inflated" was inserted into the latter, with the help of which the first fragment of the bladder calculus 18 mm in size was captured. Then, using a laser fiber in the “spray” mode with a power of 30 W, laser cystolithotripsy was performed on a fixed stone in a basket (using the Fiberlase U2 device, IPG Photonics Corporation). The same procedure was carried out with the second fragment of the calculus. The crushed stone fragments were washed out of the laparoscopic bag. The operation was completed by placing a 3-way Foley catheter Ch 20 through the cystostomy hole. Postoperative period without complications. In the postoperative period, bladder instillation of the combined Coletex-ADL gel in a volume of 20 ml and sodium hyaluronate 40 mg in a volume of 50 ml was continued for 3 days with an exposure of 30 minutes. Cystostomy drainage was retained until the issue of infravesical obstruction was resolved. The patient was discharged on the 4th day after the operation under the supervision of a polyclinic urologist . A month later, the patient underwent a planned transurethral resection of prostatic hyperplasia without complications, the patient urinates satisfactorily on his own. On the control ultrasound of the bladder - no features. Control clinical and biochemical blood and urine tests were within normal limits. The patient is under the supervision of a polyclinic urologist.

Clinical example No. 2.

Patient O., 80 years old, came to the clinic with complaints of difficulty urinating, periodic admixture of blood in the urine, and weakness. He considers himself ill for more than 5 years, when the above complaints first appeared. An objective examination per rectum shows that the prostate is significantly enlarged in size, has a densely elastic consistency, the interlobar sulcus is smoothed, painless on palpation. External genital organs of the male type, without features. From the anamnesis it is known that the patient suffered a myocardial infarction with stenting of the left coronary artery a year ago, and has been suffering from type 2 diabetes mellitus for 30 years, receiving hypoglycemic therapy. The patient underwent TRUS of the prostate and bladder, which determined the enlarged prostate due to hyperplasia of the transient zone, the volume of the prostate is 105 cm ³ . The contents of the bladder are heterogeneous, a hyperechoic inclusion with an acoustic shadow (calculus) is determined, 4.7 * 3.9 cm in size, displaced when the body position changes. Urination is frequent, difficult, there is a symptom of laying a stream of urine. Urine cloudy, yellow. According to the results of a biochemical blood test, there is an increase in creatinine to 196 µmol/l, urea 10.2 mmol/l. During hospitalization, urine culture was performed on the flora with the determination of sensitivity to antibacterial drugs, E. coli was detected at a concentration of 1 * 10 ⁶ , sensitive to fosfomycin, after which a cystostomy was installed in order to eliminate the symptoms of CRF. Trocar cystostomy was performed under local anesthesia, under ultrasound guidance, a 3-way Foley catheter Ch No. 20 was installed. The patient was recommended to take antibiotic therapy with fosfomycin 3g to reduce inflammation of the bladder. No. 2 3 hours before surgery and 24 hours after surgery, before surgery, daily instillation into the bladder of the combined Coletex-ADL gel in a volume of 20 ml, as well as sodium hyaluronate 40 mg in a volume of 50 ml. with an exposure of 30 minutes for 5 days.

2. Surgery was performed under local infiltration anesthesia. Ch 30 Amplatz sheath was installed percutaneously along the safety guidewire, then a silicone valve was installed on it, through which a nephroscope with a working channel of 14.5 Ch was passed. Under the control of a nephroscope, a laparoscopic bag with a string with a memory effect with a volume of 750 ml was inserted into the bladder. With the help of it, a calculus is captured. The laparoscopic bag was pulled up to the Amplatz tube, which led to the isolation of the stone in the bag. A pneumatic probe was passed along the working channel of the nephroscope and a session of pneumatic cystolithotripsy was performed with a power of 100% (85 mJ), a frequency of 4 Hz and using the Swiss LithoClast Master, EMS device, the calculus was fragmented into 3 smaller fragments without damaging the laparoscopic sac. Then the basket of Khachin 4x16 "inflated" was inserted into the latter, with the help of which the first fragment of the bladder calculus 17 mm in size was captured. Then, using a laser fiber in the “spray” mode with a power of 30 W, laser cystolithotripsy was performed on a fixed stone in a basket (using the Fiberlase U2 device, IPG Photonics Corporation). The same procedure was carried out with the second and third stone fragments. The operation was completed by placing a 3-way Foley catheter Ch 20 through the cystostomy hole. Postoperative period without complications. In the postoperative period, the instillation of the bladder of the combined Coletex-ADL gel in a volume of 20 ml, as well as sodium hyaluronate 40 mg in a volume of 50 ml, was continued. with an exposure of 30 minutes for 5 days The patient was discharged on the 6th day after the operation under the supervision of a polyclinic urologist. A month later, the patient underwent a planned transurethral resection of prostatic hyperplasia without complications, he urinates satisfactorily on his own. On the control ultrasound of the bladder - no features. Control clinical and biochemical blood and urine tests were within normal limits. The patient is under the supervision of a urologist at the polyclinic.

The results of treatment of 32 patients aged 30 to 82 years old, in whom the proposed method for the treatment of patients with large bladder stones was tested, were studied. All operations were completed without complications, and the proposed method provided effective treatment of patients with cystolithiasis.

Claims (1)

A method for percutaneous cystolithotripsy in patients with infravesical obstruction in the presence of a calculus larger than 20 mm, including sequential introduction of a trocar into the bladder under ultrasound control, installation of an Amplatz tube along an insurance conductor, then, under the control of a nephroscope, a laparoscopic bag, followed by placing a calculus inside the bag, its crushing and washing of stone fragments inside the bag, characterized in that a laparoscopic bag with a string with a memory effect is used, in which the stone is placed, and then the bag is pulled up to the Amplatz tube and pneumatic cystolithotripsy is performed through the nephroscope with a power of 85 mJ, a frequency of 4 Hz and using the Swiss LithoClast Master, EMS apparatus, after which the Khachin basket 4x16 “inflated” is installed in the patient and the obtained fragments of the calculus are placed in it, then laser cystolithotripsy is performed with a fiber with a diameter of 400 μm in the “spray” mode with energy settings of 2 J, h frequency of 30 Hz and power of 30 W, using the device Fiberlase U2, IPG, in addition, before the operation, the patient is fitted with a 3-way Foley cystostomy catheter Ch 20, 3-5 days before and after surgery, a combined gel is instilled into the bladder daily Coletex-ADL and sodium hyaluronate with an exposure of 30 minutes, and 3 hours before the operation and 24 hours after the operation, a solution of fosfomycin is taken orally.

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