RU2829532C2 - Method for percutaneous nephrolitholapaxy under local infiltration anaesthesia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to urology. Patient is prone or supine with turning onto a healthy side under ultrasound control in a hypochondrium or in the eleventh intercostal space along a posterior axillary line under local infiltrative anaesthesia, a renal abdominal system is punctured. Flexible conductor string is installed in it, through which dilators-dilators are successively introduced, starting with N6 and ending with N18 on Charrier scale. Further, a nephroscope is introduced into the cavity system of the kidney, followed by crushing the calculus.

EFFECT: method enables to eliminate complications associated with spinal anaesthesia, including those threatening the patient’s life, reduce the economic costs of the surgical treatment, reducing the length of hospital stay and the postoperative rehabilitation period, thereby reducing the period of incapacity for work, expanding the possibility of percutaneous nephrolitholapaxy in the patients with contraindications for spinal anaesthesia or general anaesthesia.

1 cl, 1 ex

Description

The invention relates to the field of medicine, in particular to urology, and can be used for the surgical treatment of urolithiasis, in particular large kidney stones in patients with contraindications for general and spinal (spinal) anesthesia.

A method of surgical treatment of urolithiasis is known, according to which percutaneous surgical access to the renal cavity system for crushing stones located in it (nephrolitholapaxy) is carried out under spinal anesthesia. This method requires special qualification training of the anesthesiologist and the availability of appropriate equipment and drugs for its implementation. To carry out spinal anesthesia, a syringe with a thin needle and an anesthetic drug are needed. The anesthesiologist, having previously disinfected the patient's skin with an antiseptic solution, inserts a special puncture needle into the patient from the back in the area between the fifth and fourth, less often the third lumbar vertebra. After inserting the needle into the subarachnoid spinal interthecal space, the needle is removed, and instead of it, a special thin plastic catheter is installed in the formed canal, through which an anesthetic drug is introduced into the specified spinal space during the operation. Next, with the patient lying on his side, using ultrasound navigation, a special long puncture needle is used to puncture the renal cavitary system, then a metal guide wire is inserted along the needle, along which the puncture needle is removed, leaving the wire in the renal cavitary system. After this, to form and expand the resulting nephrostomy canal, plastic dilators (dilators) are sequentially inserted along the string, starting with No. 8 and ending with No. 12 on the Charriere scale, then, under visual control, a nephroscope is inserted through the formed canal into the renal cavitary system and subsequent stages of kidney stone crushing are performed (Patent RU 2012110623A) - prototype.

However, the specified method of anesthesia for this operation has a number of disadvantages and complications, which include:

- The need for a qualified anesthesiologist;

- Availability of specialized equipment;

- It is impossible to perform this type of anesthesia in patients with spinal diseases (osteochondrosis, spinal hernias);

- Possible complications: injury to the dura mater of the spinal cord with subsequent temporary or permanent neurological disorders; severe hypotension - acute circulatory disorder, which often requires artificial ventilation of the lungs; purulent and septic complications from the spinal cord - epiduritis, meningitis, requiring active antibiotic therapy and drainage of abscesses; spinal hematomas with vascular injury, especially common in patients with blood clotting disorders, which is fraught with neurological disorders and pain syndrome up to and including patient disability;

- Longer rehabilitation period;

- High economic component of the entire operation as a whole.

The objective of the proposed invention is to reduce trauma with subsequent shortening of the rehabilitation period after surgery, reduce the costs of surgical treatment, and eliminate complications associated with anesthesia.

For this purpose, in the known method of performing percutaneous nephrolitholapaxy, which includes making a skin incision, a puncture under ultrasound control of the renal cystic system with the installation of a flexible guide wire, widening the nephrostomy tract with dilators, inserting an endoscope into the cystic system and crushing the stone, according to the invention, it is proposed to perform all stages of this operation under local infiltrative anesthesia.

Performing percutaneous nephrolitholapaxy (contact crushing of kidney stones) using the described method of local anesthesia allows us to obtain the following technical results:

- To exclude complications associated with spinal anesthesia, including those that threaten the patient’s life;

- reduce economic costs of surgical treatment;

- reduce the patient’s length of stay in hospital and the rehabilitation period after surgery, thereby reducing the period of disability;

- to expand the possibility of performing percutaneous nephrolitholapaxy in patients with contraindications for spinal anesthesia or general anesthesia.

The proposed method is implemented as follows.

With the patient in the prone position or in the supine position with a slight turn to the healthy side, infiltration anesthesia of the skin is performed until the characteristic "lemon peel" appears at the proposed site of formation of the nephrostomy tract. The puncture is usually performed in the hypochondrium or in the eleventh intercostal space along the posterior axillary line. Any local anesthetic solution (for example, 0.5% Novocaine solution) and a standard injection needle are used to anesthetize the skin. After achieving the required anesthesia, an 8 mm long skin incision is made to pass through it a mini-nephroscope tube of size 18 on the Charriere scale (diameter 6 mm). Next, to anesthetize the nephrostomy tract, a puncture needle with a stylet up to 18 cm long is taken, depending on the patient's obesity and size, and a local anesthetic solution (for example, 0.5% Novocaine solution). Under ultrasound guidance with gradual infiltration of the subcutaneous fat, perirenal tissue, renal capsule and renal parenchyma with anesthetic solution, the above-mentioned needle is advanced up to the section of the renal cavitary system required for puncture. The infiltration of the renal parenchyma performed in this way creates compression of the vessels and prevents bleeding during expansion of the nephrostomy tract. After inserting the needle into the renal cavitary system, the mandrin is removed from the needle. The correct position of the needle is controlled using an ultrasound device. Next, a flexible guidewire is advanced into the renal cavitary system along the lumen of the needle, along which dilators-expanders are alternately inserted to expand the resulting nephrostomy duct, starting with No. 6 and ending with No. 18 on the Charriere scale. A nephroscope tube is installed into the formed nephrostomy channel of sufficient width, into which an endoscope (nephroscope) is inserted under direct visual control, with the help of which the renal cavity system is revised and the calculus is crushed. The operation ends with the installation of a drainage tube-nephrostomy into the renal cavity system, which is removed no later than 2 weeks later, depending on the course of the postoperative period.

According to the proposed method, 18 patients were operated on in the urology department of the State Budgetary Healthcare Institution "City Hospital No. 15" in St. Petersburg. None of the above complications were detected in the postoperative period.

The possibility of performing percutaneous nephrolitholapaxy under local anesthesia is confirmed by a clinical example. Patient Yu., 67 years old. Date of admission to the clinic: 06/06/2020. Diagnosis: Urolithiasis. Left renal pelvis stone. Left-sided renal colic. Chronic pyelonephritis, outside of exacerbation.

According to the results of ultrasound and multispiral computed tomography (MSCT), there is a 15 mm calculus in the pelvis of the left kidney.

On June 10, 2019, surgical treatment was performed using the proposed technique - percutaneous nephrolitholapaxy on the left under local infiltration anesthesia. With the patient in a supine position with a turn to the right side, infiltration anesthesia of the skin was performed in the eleventh intercostal space on the left along the posterior axillary line at the site of the proposed puncture. After achieving the necessary anesthesia of the skin, an 8 mm long incision was made to insert the nephroscope tube No. 18 according to the Charriere scale. Under ultrasound guidance, the subcutaneous fat, capsule and parenchyma of the kidney were infiltrated using a puncture needle, after which the needle was inserted into the middle cup of the cavitary system of the left kidney, and then into the pelvis. The patient did not report pain during these menipulations. A flexible guidewire was passed through the lumen of the needle into the renal pelvis, and dilators were used to sequentially dilate the nephrostomy tract, starting with No. 6 and ending with No. 18 on the Charriere scale. The patient felt slight discomfort at all stages of the nephrostomy tract dilation. Next, a tube was installed into the renal pelvis, and then the nephroscope itself, with which the stone in the renal pelvis was visualized. No bleeding was noted. Laser lithotripsy of the stone was performed. Fragments up to 2 mm in size were removed through an additional branch of the nephroscope tube. No residual stone fragments were found during revision. A tubular nephrostomy drainage No. 12 on the Charriere scale was installed. The patient did not require anesthesia either during or after the operation. She felt satisfactory. She was active 1 hour after the operation. Antibacterial therapy was started based on the preliminary urine culture. The postoperative period was uneventful. The drainage from the kidney was removed on the 1st day after the operation. No signs of exacerbation of pyelonephritis were noted. Laboratory parameters were within the limits of the operation. The patient was discharged on the 2nd day after the operation in a satisfactory condition. Control MSCT did not reveal any stones, there were no signs of urinary leakage.

Claims (1)

A method for performing percutaneous nephrolitholapaxy under local anesthesia, characterized by the fact that the patient in the prone position or in the supine position with a turn to the healthy side under ultrasound control in the hypochondrium or in the eleventh intercostal space along the posterior axillary line under local infiltrative anesthesia is punctured in the renal cavitary system, a flexible guidewire is inserted into it, along which dilators are then alternately inserted, starting with No. 6 and ending with No. 18 on the Charriere scale, then a nephroscope is inserted into the renal cavitary system with subsequent crushing of the calculus.