percutaneous nephroscopic ultrasonographic lithotripsy

Percutaneous nephrolithotomy has become an important part of urinary tract surgery. It has expanded the clinical value of urologic surgery and changed many traditional concepts related to the diagnosis and treatment of upper urinary tract diseases, and improved the level of diagnosis and treatment. The nephroscope currently used has a metal hard kidney mirror and a fiber variable nephroscope. The former has a multi-functional nephroscope, a direct-viewing nephroscope, a right angle nephroscope and a 30° side-viewing nephroscope, the latter being common with choledochoscopy. The direction of the conversion field can be adjusted at will, the operation is convenient, and the observation is clear. A variety of kidney mirrors and accessories are available. If the kidney stone is too large to be directly removed by the nephroscope by the above method, the stone should be crushed before being taken out. Percutaneous nephrolithotomy is a popular method (UL) for safety and reliability. Curing disease: Indication Percutaneous nephrolithotomy is applicable to: If the kidney stone is too large, it can not be directly removed by the nephroscope. Contraindications 1. The following conditions are absolute contraindications (1) A bleeding disorder that is not corrected or impossible to correct. (2) Uncontrollable hypertension. (3) Untreated urinary tract infection. (4) The stone is in the left kidney, the position is high, and there is splenomegaly; or in the right kidney, the position is high and there is hepatomegaly. (5) The patient is extremely obese, from the waist skin to the kidneys over 20cm. (6) Kidney tuberculosis. (7) The ipsilateral upper urinary tract has undergone partial resection or transurethral electrocautery. (8) Allergic to venous contrast agents. (9) Isolated kidney. (10) Those whose spirits are abnormal or unable to cooperate. 2. The following conditions are relative contraindications (1) The kidney is in a high position and the approach needs to be above the 12th rib. (2) The coagulation mechanism is not completely normal or azotemia. (3) The intrarenal collecting system is small or has a fork in the kidney. (4) There is severe posterior scoliosis. (5) Congenital abnormalities, such as horseshoe kidney or pelvic ectopic kidney. (6) The range of kidney activity is large. (7) Incarcerated ureteral stones. (8) There are branched or staghorn stones, especially if the collection system is not enlarged or the stones develop into multiple renal pelvis, and the stones are incarcerated in the narrow funnel. Preoperative preparation 1. Before the percutaneous nephrolithotomy, you must take a plain X-ray film to verify the size and location of the stone. 2. Venous urography. If you have taken it within 2 to 6 months before surgery, you do not have to repeat it. 3. The following experimental data must be obtained before surgery. Blood sodium, potassium, chlorine, carbon dioxide combined with carbon binding, blood sugar, blood urea nitrogen, creatinine, urine routine, urine culture, hemoglobin, whole blood count, platelet count, blood coagulation Primitive time and activity, urinary calcium, phosphorus, uric acid, blood type, chest X-ray film and electrocardiogram. 4. Antibiotics are given before surgery. For those with bacteriuria, antibiotics should be given intravenously. 5. Before percutaneous nephrostomy, intravenous infusion (200ml / 20min or 150 ~ 200ml / h), diuretic (administered intravenous mannitol 6 ~ 12g or furosemide 10 ~ 20mg), in order to make the renal pelvis dilated. 6. Determine preoperative medication based on the type of anesthesia used. 7. Before the percutaneous nephrostomy, when the ureteral catheter (with or without sac) is placed through the urethra, the contrast agent should be prevented from flowing down the ureter. The balloon ureteral catheter used as a occlusion should be placed in the proximal end of the ureter. 8. Preoperative preparation of percutaneous nephrolithotomy should also emphasize the following points: 1 cross-healing; 2 fasting and water-free after midnight 1 day; 3 antibiotics and sedatives according to intra-urine bacteria; 4 diuretic, Mainly to increase the visibility of endoscopy; 5 if the renal stoma tube placement exceeds 10d, it is necessary to repeatedly check hemoglobin, potassium and urinary bacteria culture; 6 immediately after anesthesia through the urethra indwelling balloon catheter. 9. Ureteral intubation Although retrograde ureteral intubation will add discomfort to the patient, it has been proved to have many advantages: 1 ureteral catheter can be slowly filled with contrast agent, so that the collection system can be developed, avoiding preoperative high-dose venous angiography And reduce renal pelvic puncture. 2 helps to prevent small stones from entering or remaining in the ureter after small stones or gravel; continuous perfusion of the renal pelvis can prevent the formation of blood clots in the renal pelvis. 3 Injecting isotonic saline through the catheter to maintain the dilated state of the renal pelvis, which is convenient for puncture and stoma; when using a bendable choledochoscopy, it can better show the superiority of transcatheter perfusion, such as reducing perforation of the renal pelvis when dilating with a dilator Opportunity; if severe perforation of the renal pelvis occurs, the guide wire can be inserted through the ureteral catheter, and the guidewire can be smoothly and accurately placed into the renal stoma or ureteral stent tube. 4 angiography or balloon type ureteral catheter can push the ureteral stones back into the renal pelvis. 5 When the nephrostomy tube fails to be placed or renal pelvic perforation occurs secondary to urinary extravasation, the ureteral catheter can provide adequate drainage. 10. Indwelling the catheter in the bladder before surgery to avoid overfilling the bladder due to diuresis. Surgical procedure 1. Ultrasound nephroscope insertion In order to insert an ultrasonic lithotripsy, the renal stoma access must be expanded to 26-28F for easy access to 24F Wolf or 26F Storz nephroscopes. After the renal stoma has been expanded, the nephroscope can be introduced in one of three ways: 1 Under the screen monitoring, the renal sheath and the hollow obturator are introduced along the working guide wire (the guide wire is inserted into the channel of the obturator). When passing through the mirror sheath, the working guide wire must be straightened to prevent being caught. Bend or tortuous, if the guide wire is tortuous, it must be replaced. Otherwise, a curved or tortuous guidewire is passed through the sheath, causing a false passage and bleeding. The mirror sheath and obturator are under the monitor of the fluorescent screen. When the spiral guide is rotated along the visible guide wire, the tip of the obturator must be placed well in the kidney or next to the stone, once inserted into the renal pelvis or lower renal pelvis. Inside, remove the obturator and insert the nephroscope. If the position of the instrument is not proper, re-insert the obturator and enter the sheath into the desired position. Never push the sheath separately without the obturator. Otherwise, the blunt end can be Tearing the passage or other tissue in front of it; 2 With a fascial dilator as a obturator, the 24F Wolf nephroscope needs a 22F fascia dilator in the working sheath. If a 26F Storz nephroscope is used, a 24F fascial dilator is preferred. Ensure that the dilator and the nephroscope are guided along the guidewire under the screen monitoring; 3 The easiest way to insert the lens is to introduce a 32F teflon amplatz sheath along the 28F fascia dilator. The 24F and 26F nephroscopes are the most suitable and easiest to pass through the 28F lumen of the 32F sheath. There are several advantages to using the Aplatz sheath: it can prevent the generation of pseudo-channels when UL is used. The channel is always filled by the mirror sheath during the whole operation, which can reduce the bleeding of the channel tissue, which is beneficial to the direct removal of large stone fragments; it is easy to place at the end of the operation. Renal stoma tube. The disadvantage of using the amplatz sheath is to reduce the flexibility of the nephroscope in the kidney and easily cause perforation of the renal pelvis. 2. Intrarenal ultrasound lithotripsy After the ultrasonic lithotripsy device is assembled, the ultrasound probe is inserted through the nephroscope, and the position of the renal sheath sheath and the relationship between the stones are checked again under the monitor of the fluorescent screen. If the operator looks at the right eye, the left hand must hold the renal sheath in the whole process, and the right hand manipulates the acoustic oscillator (the ultrasonic transducer plus the hollow metal ultrasonic head) in the nephroscope instrument tube. The right arm is placed on the patient to reduce the operator's fatigue on the one hand, and to ensure that the sheath is not displaced during the entire operation. If the lens sheath is displaced, with the operation, the nephroscope may enter too deep in the renal pelvis, causing perforation. If the operator is accustomed to using the left eye, hold the acoustic oscillator with his left hand and hold the sheath with his right hand. This position allows for a maximum distance between the transducer and the doctor's ear, and ears near the sensor side should be protected by earplugs. First, the stones were peeked under the nephroscope, and the renal mirror was contacted with the stones by a fluorescent screen. After seeing the stone, don't let it leave the field of vision. Then, the assistant puts the ultrasonic head into the operator, and the operator continues to put it into direct contact with the stone to start the gravel. When the acoustic oscillator starts to work, keep the flushing fluid flowing and let it cool. In order to ensure proper contact between the ultrasound head and the stone, the stone must be placed against the renal wall, but it must be light. When crushing stone, if there is no flushing liquid sucked out through the ultrasonic machine, you can not continue to step on the gravel to prevent overheating. The end of the transducer must be held during operation, and the metal rod cannot be grasped to avoid burns. The fragments of the ultrasonic lithotripsy can be sucked out through the hollow tube of the ultrasonic lithotripter. The smallest stone can be crushed in 5 to 15 minutes, and the larger one needs to be 60 to 90 minutes. Softer stones break faster, and calcium oxalate dihydrate, calcium phosphate and cystine stones take longer. Uric acid or some calcium oxalate monohydrate ultrasonic lithotripsy is more difficult. When crushing stones, concentrate a little. Larger ones can be divided into several points on one line. It is easier to shatter the large pieces into small pieces, so that the diameter of the stones gradually becomes smaller. If the rubble falls into the ureter, it can be taken out by sight glass or taken out with a set of stone baskets under the supervision of a fluorescent screen. To prevent it from falling into the ureter, an angiographic catheter, a flute-shaped ureteral catheter, or a 7F angioplasty balloon catheter with 6F or 7F open end can be retrogradely inserted or antegrade prior to the lithotripsy. Immediately after the end of the ultrasonic lithotripsy (before placing the nephrostomy tube), a urinary X-ray plain film was taken on the operating table to find out whether there was any residual stone fragments for timely treatment. complication 1. Hemorrhage is the most important and serious complication of percutaneous nephrolithotomy, with an incidence of about 0.7%. 2. Infection is the most common complication. 3. Renal perforation is most common in surgical operation accidental injury, such as the use of fascia dilator or metal dilator to expand the channel when inserted too deep; puncture needle pierced too deep; ultrasonic or liquid electric lithotripsy accidental injury.

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