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5
II. ХИРУРГИЯ
THE USE OF THE METHOD OF RETROGRADE PYELOLITHOTRIPSY WITH KIDNEY STONES
УДК 616.613-0.89
Mami D.E.12, Malikh M.A.2, Sengirbaev D.I.1, Asoev R.R.2
1NJSC "National Medical University named after S.D. Asfendiyarov"
JSC "Scientific Center of Urology named after B.U. Dzharbusynov", Almaty, Kazakhstan
Abstract
The article provides a brief review of the literature on the effectiveness of the method of intrarenal surgery - retrograde pyelolithotripsy (RPT) in urolithiasis. The method has been actively introduced since 2005 with the development of flexible ureteroscopes. In our center, the method has been introduced since 2015. There is a sufficient number of studies on the use of retrograde pyelolithotripsy with kidney stones more than 2 cm, the effectiveness, minimally invasiveness and safety of this method have been proved so far. There are few studies to study the possibilities of using RPT for staghorn calculi and multiple stones, which confirms the relevance of research in this direction. The purpose of this work is to analyze literature data on the topic of intrarenal surgery for staghorn and multiple stones. Methods: We conducted a systematic search of literature data and selected sources from the Cochrane database, MEDLINE, PubMed, EMBASE, Google Scholar, as well as research works and online educational publications in Russian. Twenty works were included that met inclusion criteria. Results: The review article describes the method of surgical treatment of patients with kidney stones, indications and contraindications. Evaluation of the effectiveness of the method is assessed by the complete release of the cavity system from concernments (stone-free rate). Conclusion: Thereby, the problem of the study of RPT and its effectiveness in the treatment of nephrolithiasis is undoubtedly relevant and requires further study. RPT is a good method of choice, with anatomical difficult accesses, with obesity and prolonged use of anticoagulants. But this is a relatively effective method in the treatment of patients with staghorn stones, and is the method of choice for a certain contingent of patients in whom the formation of percutaneous access to the stone is impossible or is associated with a high risk of complications.
Ретроградтьщ пиололитотрипсия эдюн бYЙрек тастарына колдану
ABOUT THE ÄUTHORS
Mami Darkhan Erlanuly - a resident mentor at the Department of Urology of the NJSC "National Medical University named after S.D. Asfendiyarov", doctor in Department of urolithiasis and Endourology, JSC "Scientific Center of Urology named after B.U. Dzharbusynov". Darhan.md@gmail. com, +77017107374
Malikh Mohammad Aref - Head of the Department of ICD and Endourology of the JSC "Scientific Center of Urology named after B.U. Dzharbusynov", MD, professor.
Sengirbaev Daurenbek Isakovich - Professor of the Department of Urology of the NJSC "National Medical University named after S.D. Asfendiyarov", Ph.D.
Asoev Rasuldzhon Rakhimovich - doctor in Department of urolithiasis and Endourol-ogy, JSC "Scientific Center of Urology named after B.U. Dzharbusynov".
Keywords
urolithiasis, staghorn calculus, RPT
Мэми Д.Е.12, Малих М.А.2, Сенгирбаев Д.И.1, Асоев Р.Р.2
1НАО «Национальный медицинский университет, им. С.Д. Асфендиярова» 2АО «Научный центр урологии им. Б.У. Джарбусынова», Алматы, Казахстан
Ацдатпа
Макалада несеп-тас ауруы (НТА) кез\нде кыскаша интрареналды хирургия - ретроградтьщ пиололитотрипсия эд\с\н\н ти\мд\л\г\ туралы эдеби шолу усынылган. Бул эд\с икемдi уретероскоптарды жа-саумен 2005жылдан бастап белсендi енг\з\луде. Б\зд\н орталыкта эдю 2015 жылдан бастап енг\з\лген. Бупнп куш 2 см-ден асатын буйрек тастарына ретроградтык пиололитотрипсия эдюi колдану бойын-ша зерттеулер жетк\л\кт\, бул эдютщ ти\мд\л\г\, кш инвазивт\л\г\ жэне кау\пс\зд\г\ дэлелдендi. Осы эд\ст\ маржан тэрiздi тастарга жэне буйректе бэрнеше тастар кешде колдану бойынша зерттеулер аз, сондыктан осы багыттагы зерттеулердн езект\л\г\н растайды. Бул жумыстын максаты маржан тэрiздi тастарга жэне буйректеп бiрнеше тастарга арналган интрареналды хирургия тацырыбындагы эдебиеттерге талдау жасау. 9д!с: Б1з Кокрейн, MEDLINE, TubMed, EMBASE, Google Scholar, эдеби деректердщ жуйел\ \здеу етк\з\п жэне дереккeздердi тандап, сонымен б\рге орыс т\л\ндег\ зерттеу жумыстарды жэне оку онлайн-басылымдары косылган. К,осу критерийлер\не жауап берет жиырма кужат енпзтд\. Нэтижелер\: Шолу макалада буйректерще тастары бар наукастарды ота емдеудщ заманауи эд\с\, керсет.к\ш\ мен карсы кврсетiлiмдерi. ЭдЫц ти\мд\л\г\н багалау куыс жуйеан тастар-дан толык босатумен багаланады (stone-free rate). %орытынды: Осылайша, РПТ зерттеу мэселес\ жэне оныц нефролитиазды емдеудег\ ти\мд\л\г\ сезс\з езект\ жэне одан эр\ зерттеуд\ кажет етед\. РПТ - анатомиялык киын кол жет\мд\л\кс\з кезде, сем\зд\кпен жэне антикоагулянттарды узак колданыланда тацдаудыц жаксы эд\с\. Б\рак маржан тэр\зд\ тастар кез\нде салыстырмалы турде ти\мд\ эд\с жэне белг\л\ наукастарда перкутандык кол жет\мд\л\г\н калыптастыру мумюн емес немесе аскыну кауп\ жогаруына байланысты тандау эд\с\ болып табылады.
АВТОРЛАР ТУРАЛЫ
Мэми Дархан Ерланупы -
наставник резидентов на кафедре урологии НАО «Национального медицинского университета, им. С.Д. Асфендиярова», врач отделения МКБ и эндоурологии АО «Научного центра урологии им. Б.У. Джарбусынова». Darhan.md@gmail.com, +77017107374
Малих Мохаммад Ареф -
заведующий отделением МКБ и эндоурологии АО «Научного центра урологии им. Б.У. Джарбусынова», д.м.н., профессср.
Сенгирбаев Дауренбек Исакович -
профессор кафедры урологии НАО «Национального медицинского университета, им. С.Д. Асфендиярова», к. мм.
Асоев Расулджон Рахимович - врач отделения МКБ и эндоурологии АО «Научного центра урологии им. Б.У. Джарбусынов¡а»
ТуЙ1И сездер
НТА, маржан тэр\зд\ тас, РПТ
Применение метода ретроградной пиелолитотрипсии при конкрементах почек
ОБ АВТОРАХ
Мэми Дархан Ерланулы -
наставник резидентов на кафедре урологии НАО«Национального медицинского университета, им. С.Д. Асфендиярова», врач отделения МКБ и эндоурологии АО «Научного центра урологии им. Б.У. Джарбусынова». Darhan.md@gmail.com, +77017107374
Малих Мохаммад Ареф -
заведующий отделением МКБ и эндоурологии АО «Научного центра урологии им. Б.У. Джарбусынова», д.м.н., профессор.
Сенгирбаев Дауренбек Исакович -
профессор кафедры урологии НАО «Национального медицинского университета, им. С.Д. Асфендиярова», к.м.н.
Асоев Расулджон Рахимович - врач отделения МКБ и эндоурологии АО «Научного центра урологии им. Б.У.
Джарбусынова»
Ключевые слова
МКБ, коралловидный конкремент, РПТ
Мэми Д.Е.1,2, Малих М.А.2, Сенгирбаев Д.И.1, Асоев Р.Р.2
1НАО «Национальный медицинский университет, им. С.Д. Асфендиярова» 2АО «Научный центр урологии им. Б.У. Джарбусынова», Алматы, Казахстан
Аннотация
Врожденный синдром удлиненного интервала QT (СУИQT) характеризуется аномально продолжительной реполяризацией желудочков из-за наследственных дефектов в натриевых и калиевых каналах сердца, которые предрасполагают пациентов к синкопальным состояниям, желудочковым аритмиям и внезапной сердечной смерти. Ранняя диагностика и профилактическое лечение играют важную роль в предотвращении внезапной сердечной смерти у пациентов с врожденным СУИQT. Диагностические критерии врожденного СУИQT основаны на определенных электрокардиографических данных, клинических данных и результатах теста на адреналин. Недавно также был описан специфический для генотипа электрокардиографический паттерн врожденной СУИQT. Недавние исследования предполагают выполнимость генотип-специфического лечения СУИQT, и в ближайшем будущем специфичное для мутаций лечение, вероятно, станет новым подходом к этому потенциально смертельному синдрому. Мы представляем клинический случай, который подтверждается электрокардиографическими и клиническими диагностическими критериями, свидетельствующий о синдроме удлиненного QT. В данном случае, пациентке был имплантирован кардиовертер-дефибриллятор для вторичной профилактики внезапной сердечной смерти. У пациентки возникают приступы внезапного сердцебиения с обмороками, и имплантированный дефибриллятор проводит спасительную терапию от жизенугрожающей желудочковой тахикардии.
Relevance
Urolithiasis is the most common urological disease that affects people of both sexes at any age, diagnosed an average of not less than 1-3% of the population, and most often in people of working age 20-50 years. Currently, in different countries of the world, out of 10 million people, 400 thousand observe urolithiasis. Annually 85 thousand diseases of the urolithiasis are recorded. The guidelines and clinical recommendations of the European Association of Urology for the treatment of urolithiasis are reviewed annually, however, over the past decade, percutaneous nephrolithotripsy (PCNL) and remote shock wave lithotripsy (ESWL) are the most recommended methods for minimally invasive surgery of kidney stones. ESWL is the "gold" standard for the treatment of calculi less than 2 cm and according to some authors, its percentage of effectiveness reaches 90% [1]. However, the effectiveness of ESWL depends on many factors: the size, density and localization of calculus. Due to the fact that residual calculi are diagnosed in 54% of cases after ESWL, this method is not applicable for stones sizes greater than 2 cm. Egilmez T. et al. in their study found that the effectiveness of ESWL with stones over 1.5 cm is from 45-60% [2]. Albala D. et al. indicate that the efficiency of ESWL with the localization of calculus in the lower calyxes is about 37-50% [3]. PCNL has
the highest efficiency in the treatment of calculi over 2 cm, including staghorn calculus. According to Singla M. et al. (2008), the effectiveness of PCNL with staghorn stones is from 74 to 83% [4]. Preminger G. (2005) and Michel M. (2007) indicate that the effectiveness of this treatment is from 78 - 95%. However, it has been reliably proven that PCNL is associated with the risk of complications such as bleeding, urosepsis, embolization [5, 6]. An alternative approach to the treatment of urolithiasis, which reduces the risk of complications, is transurethral access to the pyelocaliceal system, i.e. retrograde pyelolithotripsy. This method is characterized by less trauma and a lower frequency of complications. In recent years, in connection with the development of technical capabilities to ensure effective disintegration of calculi, constant access to the kidney through the ureter, good endoscopic imaging and miniaturization of instruments, this method has been widely used, and the attention of endourologists has focused on studying the effectiveness and improving the technique of retrograde intrarenal surgery in the treatment of single large and staghorn stones. According to the authors, indications for retrograde pyelolithotripsy with staghorn stones are the presence of a patient's blood coagulation system disease, aggravated somatic history, overweight, lack of dilatation of the pyelocaliceal system, renal and upper urinary
tract abnormalities that do not allow or significantly impede PCNL [7].
Huffman first described this technique in 1983, after using a rigid ureteroscope and ultrasonic lithotripter, he crushed a large calculus in the pelvis. Since 2002, retrograde pyelolithotripsy has become widely used in the treatment of small kidney stones and the upper third of the ureter. The results of studies in Europe and the United States showed that the effectiveness of the method reaches 90-93%. Since 2008, research has begun on the possibilities of using retrograde pyelolithotripsy in the treatment of large and staghorn stones. [8].
To date, in the literature there are studies on the effectiveness of RPT, including in a comparative aspect with other minimally invasive methods of treating urolithiasis. The development of new technologies has led to the miniaturization of the endoscopic instrument and improved visualization, which allowed to expand indications for retrograde intrarenal surgery (RIRS). [9] In 1990 Fuchs A. with co-authors published the first try of observation of 208 patients, who had the removal of kidney stones by using retrograde ureteropyeloscopy [10].
In 1998 Grasso M. with co-authors [11], showed effectiveness and safety of RIRS methods by using flexible ureteroscope with a diameter 9 Ch and laser lithotripter for the treatment of patients with a stones in their kidneys and the over 2 sm upper part of ureter, who had concomitant diseases that do not allow PCNL. At the same time, the authors managed to achieve complete removal of the stone in 93% and 100% of cases with localization of the stone in the kidney and upper third of the ureter, respectively. According to some authors, a flexible ureteroscope, due to certain technical features, along the upper urinary tract is not always possible without increasing the risk of damage to both the instrument itself and the ureter wall [12, 13].
The results of using RPT by foreign researchers are still contradictory. So Perlmutter et al. when studying the effectiveness of RPT of kidney stones up to 2 m in size of different localization, it indicates 100% efficiency of the method for calculi of the upper groups of calyx, 95.8% of effectiveness for localization of stones in the middle groups of calyx and 90.9% of efficiency for calculi of the lower calyx of kidneys. Also, the authors concluded that the localization of calculus does not affect the effectiveness of RPT and the percentage of liberation from calculi [14]. In contrast, a study by Pearle et al. argue that the effectiveness of RPT is 50% and does not have statistically significant advantages over ESWL in crushing stones of the lower groups of kidney cups up to 1 cm in size [15]. Breda et al. in their study demonstrated the effectiveness of RPT in multiple unilateral kidney stones: after 1
session, the percentage of kidney cleansing from stones was 64.7%, after 2 sessions - 92.2% [16]. In 2010, Korean scientists published the results of an analysis of the effectiveness of RPT and the factors affecting it. The study included 66 patients. The average size of stones was 16.8 mm. In 25 patients, more than 2 kidney stones were diagnosed. In 18 patients, the stones were localized in the upper or middle group of calyx, in 48 in the lower groups. 32 patients underwent RPT due to the inefficiency of ESWL, 4 patients previously underwent PCNL. The effectiveness of RPT in this study was 69.7%, and after 1 month it increased to 72.7%. In 13 patients, RPT was ineffective. Scientists conducted a one-factor analysis of factors that influenced the effectiveness of RPT. It was found that important factors were the size of the calculus (common with multiple stones), localization, as well as the primacy of the operation. So, it was reliably proved that the effectiveness of RPT with stones with a total area of less than 15 mm was 83.7%, while with large sizes - 29.4%. With localization of calculi in the upper groups of calyx, the effectiveness of RPT was 94.4%, with localization of only the lower calyx 73.3%, and with the location of multiple calculi in different groups of calyx, the effectiveness of RPT decreased to 38.9%. The effectiveness of RPT was also evaluated depending on the primary operation. So, in patients who underwent RPT as the first therapy, the effectiveness of the method was 83.3%, in patients who underwent RPT after unsuccessful ESWL and PCNL sessions, 58.3% [17]. In 2012, a group of Chinese scientists investigated the effectiveness of using RPT for staghorn stones in patients with a single kidney. Staghorn calculus in patients with a single kidney are the most dangerous clinical cases in the practice of urologists. The potential risk of complications increases by 2-3 times with any surgical or minimally invasive intervention. The study involved 20 patients. The average size of the calculus was 10 mm. All patients had concomitant diseases, in addition, all were overweight. 5 patients previously underwent surgery, in 10 patients a nephrectomy was performed for the same reason (staghorn calculus). The average age of the patients was 52.7 years. The operation consisted of two stages, however, they were carried out simultaneously by two medical teams. The first team conducted PCNL, the second - RPT. The average surgery time was 154 minutes. Postoperative complications were observed in 5 patients. Complete release of the kidney from calculi was observed in 95%. In 1 patient, a residual calculus was found in the lower calyx (less than 6 mm), after 1 month in another patient, a recurrent calculus of up to 4 mm was detected. In conclusion, the authors point to the
need for a combined minimally invasive surgical approach and the important role of RPT in the most difficult clinical situations [18]. In 2013, a group of Turkish scientists published the results of a comparative analysis of the effectiveness of surgical methods such as laparoscopic ureterotomy, ESWL and retrograde intrarenal surgery. The average size of stones was 13.5 mm. The stones were localized in the pelvis-ureteric segment and the proximal ureter. 51 patients underwent laparoscopic calculus extraction, 52 ESWL, 48 RPT. Full extraction of calculus (stone-free rate) was achieved in 92%, 81% and 79%, respectively [19]. The lowest percentage of complications was observed in the group of patients who underwent retrograde pyelolithotripsy using a flexible ureteroscope. Despite the fact that ESWL is the most optimal and recommended method for the treatment of kidney stones, the authors indicate that this method has significant drawbacks - the formation of stone paths, inflammatory processes, the migration of small fragments into the lower cups, residual calculi, which require repeated sessions. Yuruk E. et al. proved that morphological changes in the kidney parenchyma after the shock wave are also present in the distant period, and with multiple sessions can cause fibrosis. Therefore, the ESWL method cannot be considered non-invasive [20]. Despite a sufficient number of studies, a number of issues related to RPT are still open. First of all, this
References
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2. Egilmez T, Tekin M.I, Gonen M, Kilinc F, Goren R, Ozkardes H. Efficacy and safety of a new generation shockwave lithotripsy machine in the treatment of single renal or ureteral stones: experience with 2670 patients. // J Endourol. 2007. - № 21. - pp. 23-27.
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is due to the small number of patients, as well as the lack of studying the long-term consequences. Clear indications and contraindications to this method have not been determined, however, many authors have described RPT as a safe and effective method of surgical minimally invasive treatment of kidney stones. The results of studies on the use of RPT for staghorn and multiple calculus of the upper urinary tract are quite contradictory.
Results
The review article describes the method of surgical treatment of patients with kidney stones, indications and contraindications. Evaluation of the effectiveness of the method was assessed by the complete release of the cavity system from stones (free-stone rate).
Conclusion
Thereby, the problem of the study of RPT and its effectiveness in the treatment of nephrolithiasis is undoubtedly relevant and requires further study. RPT is a good method of choice, with anatomical difficult accesses, with obesity and prolonged use of anticoagulants. But this is a relatively effective method in the treatment of patients with staghorn stones, and is the method of choice for a certain contingent of patients in whom the formation of percutaneous access to the stone is impossible or is associated with a high risk of complications.
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15. Pearle M.S, Lingeman J.E, Leveillee R, Kuo R, Preminger G.M, Nadler R.B, et al. Prospective, randomized trial comparing shockwave lithotripsy and ure-teroscopy for lower pole caliceal calculi 1 cm or less // J Urol. - 2005. - № 173. - pp. 2005-2009.
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