RU2842549C1 - Method for performing fibrocalicolithotripsy of lower calyx of kidney - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to urology, and can be used in treating urolithiasis. That is followed by performing fibrocalicolithotripsy consisting in ureteroscopy with using a ureterorenoscope; a guide wire is inserted into the pelvicalyceal system, and the ureterorenoscope is then removed. A casing is then placed on the guide wire under X-ray control. A fibroureteropyeloscope with a basket comprising a basket control handle, a catheter comprising a guide wire with a basket fixed at its distal end, said basket representing three retractable branches bent at angle of 45 degrees, is inserted into the pelvicalyceal system through the casing. A calculus found in a lower group of renal calyces is grasped with a basket; the calculus is transferred into an upper or middle calyx; the calculus is fragmented into fine particles in a spray mode to suspensions and dust with using a laser fibre of diameter of 200 mcm. Then laser fibre is removed, fibroureteropyeloscope and casing under control of electron-optical converter are removed, internal drainage of kidney is carried out with further drainage of bladder with urethral catheter.

EFFECT: method enables providing more effective gripping and increasing a speed of calculus displacement from the anatomically uncomfortable lower calyx of the kidney into a more convenient middle or upper calyx followed by calculus fragmentation with laser.

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Description

The invention relates to the field of medicine, in particular to urology, and can be used in the treatment of urolithiasis.

Urolithiasis (urolithiasis) is a polyetiological disease that develops under the influence of a complex of exogenous and endogenous factors, characterized by progressive spread, frequent recurrence and high socio-economic losses.

Patients with urolithiasis make up 30-40% of the contingent of urological hospitals and are mostly represented by individuals of the most active working age - 30-55 years (Heers H., Turney B. Trends in urological stone disease: A 5-year update of hospital episode statistics. BJU International. 2016; 118(5): 785-789. doi: 10.1111/bju.13520).

According to localization, stones are most often observed in the kidneys (nephrolithiasis, ICD-10 code N20.0) and ureters (ureterolithiasis, N20.1).

The main modern methods of treating urolithiasis are: remote lithotripsy (crushing stones with a shock wave), contact and percutaneous lithotripsy (using modern, including flexible endoscopes and various methods of destroying stones: laser, ultrasound, pneumatic), and laparoscopy.

The endoscope can be inserted into any part of the kidney, ureter or bladder. The most common approach is transurethral access: a thin endoscope-ureteroscope is inserted through the urethra, then it passes through the bladder to the location of the stone in the ureter or renal pelvis.

After the stone is detected, a probe or laser fiber is passed through the working channel of the endoscope, which destroys the stone. Sometimes large kidney stones are encountered - coral-shaped, their size can reach 5 cm or more. In this case, percutaneous access is used: the stone is fragmented and removed through a centimeter-long incision in the lumbar region. At the same time, an endoscope (nephroscope) is inserted into the kidney through the incision. In order to correctly place it at the desired point in the kidney and control the process of stone destruction, fluoroscopy and ultrasound examination are used.

When using pneumatic and laser lithotripsy, the stone is broken into small fragments under the influence of short shock pulses or laser energy, which are extracted with special grips and baskets. Ultrasonic lithotripsy allows for the simultaneous fragmentation of the stone and the extraction of its smallest fragments.

Anatomically, the kidney has 3 groups of calyces - upper, middle and lower groups.

The most inconvenient is the lower group of renal calyces, since the endoscope has to be strongly bent to perform manipulations.

To capture and move the stone to a more convenient place for subsequent crushing, special baskets are used, consisting of a handle, thin fiber and the basket itself.

But most of them have design flaws that prevent them from fully performing their function. Most often, functional limitations are caused by the design of the distal end of the basket - the part that captures and fixes the stone.

For example, there is a flexible two-channel sensory ureterorenoscope Cobra Richard Wolf, which allows for simultaneous lithotripsy of a calculus in a fixed Dormia basket [https://www.medoborud.ru/gibkiy-dvuhkanalnyy-ureterorenoskop-cobra-richard-wolf]. The disadvantage of the instrument is its high cost and limited dimensions of the working channels (3.3 W each).

In the instrument - the extractor "Capture with channel" the maximum internal diameter of the channel is 1.0 mm, which does not allow a larger diameter probe to be passed through it, which is necessary for effective lithotripsy of dense stones [http://www.xn--80aknjfa0b3g.xn--p1ai/extractors/urological/baskets/extractor-pickup.html].

A method for breaking a calculus in a body into smaller pieces and extracting the pieces from the body using a special device comprising an expansion sheath, a lithotripsy probe, a tubular element and an extraction basket is known from the prior art, and comprises the following sequence of operations: (a) inserting said medical device with the basket closed through an endoscope into said body near the calculus; (b) manipulating the tubular element and the expansion sheath to open the extraction basket, catching the calculus in the extraction basket and closing the basket around the calculus; (c) manipulating said lithotripsy probe to extend it from the lumen in the tubular element and approach the calculus caught in the extraction basket; (d) supplying energy to said lithotripsy probe to dismember the calculus into smaller fragments; and (e) removing the medical device from the body together with at least one fragment of the calculus retained within the basket [patent for invention RU 2489105 C2. Application No. 2010125712/14 dated 11/17/2008, published: 08/10/2013 in Bulletin No. 22]. A disadvantage of this invention is the impossibility of guaranteed access to calculi located in hard-to-reach parts of the kidney for subsequent crushing.

The closest to the proposed invention is a method for minimally invasive surgical treatment of nephrolithiasis in adults, in which two approaches to the kidney are performed simultaneously. Access to the renal pelvis is performed under ultrasound and X-ray guidance by puncturing the calyx vault with a needle, located in the avascular zone of Bredl and coinciding in direction with the location of the main volume of the stone. Then, a guidewire is passed through the needle into the renal pelvis-calyx system and a second puncture of the kidney is performed through the calyx located in the direction of the stone from the first approach. Then, a guidewire is also installed through the needle into the renal pelvis and bougienage of the main approach is performed with a telescopic set with the installation of the external tube of a standard nephroscope 24 Charriere and simultaneous bougienage of the additional approach is performed with the introduction of the tube of a mininephroscope 16.5 Charriere. Then, through the created accesses, the kidney stones are removed by performing contact lithotripsy through the main access with an ultrasonic probe with simultaneous lapaxy of small fragments and performing contact holmium laser lithotripsy through an additional mini-access with instrumental movement of stones into the working area of the standard nephroscope, and stone fragments comparable in diameter to the tube are extracted outward with a lithoextractor. After complete removal of the stones, an endoscopic examination is performed under fluoroscopic control. After which the mini-nephroscope tube is removed leaving a safety guide wire in place to monitor bleeding from the access and, if there is none, drainage is performed through the main percutaneous tract using an 18 Charriere balloon nephrostomy with a balloon filling of 3 ml. Next, under fluoroscopic control, the adequacy of the drainage position is determined by performing antegrade pyeloureterography, the operation is completed by suturing the skin incision with temporary installation of a balloon nephrostomy drainage along the percutaneous tract, fixing it to the skin incision with a separate interrupted suture [patent for invention RU 2689853 C2. Application No. 2018137712 dated 10/25/2018, published: : 05/29/2019 in Bulletin No. 16]. The disadvantages of this method are access by puncturing the skin of the lumbar region, the risk of intra- and postoperative bleeding, as well as the need to perform the operation under endotracheal anesthesia, which limits the use of this method in patients with concomitant pathology.

The technical result of the proposed method consists in increasing the efficiency of capture and increasing the speed of movement of stones from the anatomically inconvenient lower calyx of the kidney to the more convenient middle or upper calyx, followed by crushing the stone with a laser.

The technical result is achieved in that the method for performing fibrocalicolithotripsy, consisting in performing ureteroscopy using a ureterorenoscope, installing a guidewire in the renal pelvis-calyceal system with subsequent extraction of the ureterorenoscope, then installing a casing along the guidewire under fluoroscopic control, characterized in that a fibroureteropyeloscope with a basket is inserted through the casing into the renal pelvis-calyceal system, including a handle for controlling the basket, a catheter in which there is a string, at the distal end of which a basket is fixed, which is three retractable branches bent at an angle of 45 degrees, the basket captures a calculus located in the lower group of renal calices, transfers the basket with the calculus to the upper or middle calyx of the kidney, followed by fragmentation of the calculus into small particles in the spray mode to suspension and dust using a laser fiber with a diameter of 200 microns, then the laser the fiber is removed, the fibroureteropyeloscope and casing are removed under the control of an electron-optical converter, internal drainage of the kidney is performed, followed by drainage of the urinary bladder with a urethral catheter.

Internal drainage of the kidney can be accomplished using a stent or a ureteral catheter.

The design of the basket is shown in Figure 1, where 1 is the handle for controlling the basket, 2 is the catheter, 3 is the basket.

Clinical trials of the proposed method were conducted in the urology departments of the Russian Railways Medicine in Kirov and Barnaul. A total of 40 patients were operated on using the proposed method, including 16 women and 24 men aged 25 to 68 years. The average operation time was from 22 to 40 minutes. The average stay of patients in the hospital was 5 days, the urethral catheter was removed on the first day after surgery, followed by a stage of recovery and dynamic observation of these patients in the amount of ultrasound, MSCT of the urinary system, as well as a control outpatient visit 1 month after surgery with a urological assessment according to the same criteria.

An example of implementing the proposed method.

Patient R., 51 years old, was admitted to the clinic with the diagnosis: Urolithiasis. Stones in the left kidney. Chronic pyelonephritis outside of exacerbation. CRF 0. According to computed tomography, 2 stones in the left kidney were verified. In the middle group of calyces 0.8x0.9 mm and in the lower group of calyces 1.1x0.8 mm with a density of 530 HU. The anamnesis includes remote lithotripsy in 2011 and percutaneous nephrolithotripsy on the left in 2019. The operation was performed using the proposed method. Under spinal anesthesia after treating the external genitalia with Cathejel lubricant. Ureteroscopy was performed with a rigid Karl Storz 8-13 Charriere ureterorenoscope. Under visual control, a Zebra TM guidewire was inserted into the renal pelvis-calyceal system (RPS) with subsequent extraction of the ureterorenoscope. Then, under fluoroscopic control, an Amplatz 12-14 Charriere casing was inserted along the guidewire to the ureteropelvic segment. An Innovex fibroureteropyeloscope was inserted into the RPS along the casing under visual control (see Figure 2). An optical revision of the RPS was performed. Two stones were detected, one in the middle calyx and the other in the lower calyx. At the first stage, the stone located in the middle calyx was crushed to make it more convenient for lithotripsy. The stone was fragmented into small particles in the spray mode to a suspension and dust using a FiberLase U2 thulium laser with a 200-micron diameter laser fiber. The suspension was simultaneously washed away with a flow of physiological solution created through the working channel of the fibroureteropyeloscope. After the lithotripsy, the fibroureteropyeloscope was moved to the lower calyx, the calculus was captured by the original basket and moved under visual and fluoroscopic control to the middle calyx. The calculus was crushed using the same technique. Then the laser fiber was removed. An optical revision of all calyces was performed for residual calculi. The fibroureteropyeloscope was removed together with the casing under visual optical control. A 4.0 Charriere ureteral catheter was inserted into the renal cavity system. The urinary bladder was drained with a Foley 18 Charriere urethral catheter. The postoperative period was uneventful. The urethral catheter was removed together with the ureteral catheter the next day. An ultrasound examination was performed: no calculi or dilation of the renal pelvic system were detected. Control ultrasound on day 3 showed no dilation of the renal pelvis, clinical blood tests were within normal limits, and the patient's health was satisfactory. The patient was followed up in the follow-up period for up to 6 months. No complications or recurrence of nephrolithiasis were noted in the late postoperative period.

The use of the proposed method allowed to significantly reduce the operation time, on average by 25%, allowing to perform lithotripsy of stones previously moved from hard-to-reach sections of the renal pelvis to the middle or upper calyx. Thus, there is no additional damage to the intrarenal structures of the lower group of calyces, which reduces the likelihood of developing hemorrhagic and infectious-inflammatory complications by 1.5 times, compared to the standard approach.

The above conclusions are confirmed by the data presented in the comparative table of parameters characterizing the efficiency of basket capture and the increase in the speed of stone movement when moving the stone to a more convenient cup.

The proposed method converts the above advantages into increased clinical effectiveness (frequency of complete release from clinically significant stone fragments as a result of one operation) for large multiple stones up to 92%, which significantly exceeds the similar indicator for the standard approach with crushing the stone directly in the lower calyx. Good results in both clinical effectiveness and safety for the patient allow us to consider the proposed method of operation as the method of choice in the treatment of multiple large calyceal kidney stones.

Table

Parameter Stone size
from 5-6 mm Stone size
from 10 to 12 mm Time of crushing of a concrement in the lower calyx without displacement 32 min 56 min Time of crushing of the concrement in the calyx with movement to the middle or upper calyx 21 min 38 min

Claims (2)

1. A method for performing fibrocalicolithotripsy, which consists of performing ureteroscopy using a ureterorenoscope, installing a guidewire in the renal pelvis-calyceal system, then removing the ureterorenoscope, then installing a casing over the guidewire under fluoroscopic control, characterized in that a fibroureteropyeloscope with a basket is inserted through the casing into the renal pelvis-calyceal system, including a handle for controlling the basket, a catheter containing a string, at the distal end of which a basket is fixed, which is three retractable branches bent at an angle of 45 degrees, the calculus located in the lower group of renal calyces is captured with a basket, the basket with the calculus is transferred to the upper or middle calyx of the kidney, followed by fragmentation of the calculus into small particles in the spray mode into suspension and dust using a 200 micron diameter laser fiber, then the laser fiber is removed, the fiber ureteropyeloscope and casing are removed under the control of an electron-optical converter, internal drainage of the kidney is performed followed by drainage of the bladder using a urethral catheter. 2. The method according to item 1, characterized in that internal drainage of the kidney can be carried out using a stent or a ureteral catheter.