RESUMO
BACKGROUND: Endoscopic removal of packed, large, or impacted stones, in which a basket cannot be deployed or is unable to grasp the stone(s), is challenging and inevitably leads to repeated procedures such as stent insertion and extra- or intracorporal lithotripsy. In this study, we describe the results of an alternative stone disintegration technique in a considerable series of patients using an esophageal/pyloric balloon for stone fragmentation or making working space in the bile duct to allow the deployment of the basket, a technique we call endoscopic biliary large balloon lithotripsy. METHODS: We retrieved data from 1,429 endoscopic retrograde cholangiopancreatographies (ERCPs) from 2 prospective trials performed between 2014 and 2019. Patients with difficult bile duct stones, in which a balloon dilator up to 15 mm was used to crush or increase the working space parallel to the stones in the common or hepatic duct, were included in the study. RESULTS: From the 1,429 ERCPs, 299 had difficult stones (>1 cm, impacted or multiple stones). Large balloon lithotripsy was employed in 46 cases after endoscopic papillotomy and endoscopic biliary large balloon dilation with failed attempted balloon or basket stone(s) extraction. Failure to clear the bile duct at first ERCP occurred in 4 cases (91.3% of success). Complications were observed in 5 patients (10.8%; 1 perforation, 1 pancreatitis, and 3 bleedings), who were treated conservatively. CONCLUSIONS: Large balloon lithotripsy, in order to crush the stones or make working room for baskets or balloons in the bile duct, is an effective, safe, and low cost technique for impacted, packed, or giant bile duct stones.
Assuntos
Cateterismo/métodos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Dilatação/métodos , Cálculos Biliares/cirurgia , Litotripsia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Ductos Biliares/cirurgia , Cateterismo/efeitos adversos , Cateterismo/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Dilatação/efeitos adversos , Dilatação/instrumentação , Feminino , Cálculos Biliares/patologia , Humanos , Litotripsia/efeitos adversos , Litotripsia/instrumentação , Masculino , Pessoa de Meia-Idade , Complicações Cognitivas Pós-Operatórias/etiologia , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
ABSTRACT In complicated urinary tract infection with ureteral calculi, urinary diversion is inevitable. So, stenting or percutaneous drainage can be an option. In hemodynamically unstable patients, percutaneous drainage is superior to ureteral stenting (1). Once acute infection is controlled, definite treatment of the stone is necessary. According to a guideline, semirigid ureteroscopy is recommended for lower and mid - ureter stone and flexible ureteroscopy for upper ureter stone (2). Semi - rigid ureteroscopy can migrate stone to kidney, especially in upper ureter stone, lowering stone free rate (3). Not only flexible ureteroscopy creates additional costs but also is barely available in developing countries (4, 5). So, the authors would like to introduce anterograde irrigation - assisted ureteroscopic lithotripsy in patients with percutaneous nephrostomy. Retrograde irrigation was connected and flowed minimally enough to secure visual field. Once stone is noted, another saline irrigation, which is placed above 40 cm over the patient is connected to nephrostomy. Retrograde irrigation is disconnected from ureteroscope and the previous connected channel on ureteroscope is opened. Actual pressure detected by barometer from the opened channel of ureteroscope is usually about 30 cmH2 O while anterograde irrigation is administered in maximal flow, which means fully opened anterograde irrigation is not hazardous to kidney. There was no complication in 17 patients submitted to this method. Video shows advantages of our practice: clear visual field; reduced risk of stone migration into kidney; induced spontaneous passage of fragments without using instrumentation; and decreased operation time. In short, most of surgeons, even unexperienced, can perform an excellent procedure with less time consuming using our method.
Assuntos
Humanos , Nefrostomia Percutânea/métodos , Litotripsia/métodos , Cálculos Ureterais/cirurgia , Ureteroscopia/métodos , Irrigação Terapêutica/métodos , Litotripsia/instrumentaçãoRESUMO
The purpose of this work was to develop a metamodel (Kriging model) to identify the most important input parameters of shock wave pressure profiles as used in biomedical applications without solving a large number of differential equations. Shock wave-induced cavitation is involved in several biological effects. During bubble collapse, secondary shock waves and microjets are formed. For some applications, it is desirable to enhance this phenomenon by applying a second shock wave before bubble collapse; however, the delay between the leading shock wave and the second pressure pulse has yet to be optimized. This optimization can be done using numerical analysis. A metamodel that predicts the most convenient ranges for the input variables and provides information on the joint effects between the input variables was tested. Because the metamodel is an analytical expression, running it fifty thousand times and analyzing variables, such as the pressure amplitude, delay between pulses, and pressure rise time, was fast and easy. Furthermore, this method can be a helpful tool to study the joint effect between the input variables and reduce the computation time. The metamodel can also be adapted to analyze simulations based on equations different from the Gilmore-Akulichev formulation, which was used in this study.
Assuntos
Litotripsia/instrumentação , Microbolhas , Modelos Teóricos , Ultrassom , Microfluídica , Estresse MecânicoRESUMO
In complicated urinary tract infection with ureteral calculi, urinary diversion is inevitable. So, stenting or percutaneous drainage can be an option. In hemodynamically unstable patients, percutaneous drainage is superior to ureteral stenting (1). Once acute infection is controlled, definite treatment of the stone is necessary. According to a guideline, semirigid ureteroscopy is recommended for lower and mid - ureter stone and flexible ureteroscopy for upper ureter stone (2). Semi - rigid ureteroscopy can migrate stone to kidney, especially in upper ureter stone, lowering stone free rate (3). Not only flexible ureteroscopy creates additional costs but also is barely available in developing countries (4, 5). So, the authors would like to introduce anterograde irrigation - assisted ureteroscopic lithotripsy in patients with percutaneous nephrostomy. Retrograde irrigation was connected and flowed minimally enough to secure visual field. Once stone is noted, another saline irrigation, which is placed above 40 cm over the patient is connected to nephrostomy. Retrograde irrigation is disconnected from ureteroscope and the previous connected channel on ureteroscope is opened. Actual pressure detected by barometer from the opened channel of ureteroscope is usually about 30 cmH2O while anterograde irrigation is administered in maximal flow, which means fully opened anterograde irrigation is not hazardous to kidney. There was no complication in 17 patients submitted to this method. Video shows advantages of our practice: clear visual field; reduced risk of stone migration into kidney; induced spontaneous passage of fragments without using instrumentation; and decreased operation time. In short, most of surgeons, even unexperienced, can perform an excellent procedure with less time consuming using our method.
Assuntos
Litotripsia/métodos , Nefrostomia Percutânea/métodos , Irrigação Terapêutica/métodos , Cálculos Ureterais/cirurgia , Ureteroscopia/métodos , Humanos , Litotripsia/instrumentaçãoRESUMO
ABSTRACT Background: We analyzed the outcome and complications of rigid (R-URS) and flexible (F-URS) ureteroscopic lithotripsy for treatment of proximal ureteric stone (PUS). Subjects and methods: Retrospective data of 135 patients (93 males and 42 females) submitted to R-URS and F-URS for treatment of PUS in the period between July 2013 and January 2015 were investigated. (R-URS, group 1) was performed in 72 patients while 63 patients underwent (F-URS, group 2).We compared the 2 groups for success, stone characteristics, operative time, intraoperative and postoperative complications. Results: The overall stone free rate (SFRs) was 49/72 (68%) in group 1 and 57/63 (91%) patients in group 2, (P=0.005). The operative time was shorter in group 1 in comparison to group 2 with statistically significant difference (P=0.005). There was not any statistically significant difference between 2 groups in complication rate (P=0.2). Conclusıon: Both R-URS and F-URS could be a feasible option for treatment of PUS. R-URS is less successful for treatment of PUS and should be used cautiously and with availability of F-URS.
Assuntos
Humanos , Masculino , Feminino , Adulto , Litotripsia/métodos , Cálculos Ureterais/terapia , Ureteroscopia/métodos , Complicações Pós-Operatórias , Litotripsia/efeitos adversos , Litotripsia/instrumentação , Estudos Retrospectivos , Resultado do Tratamento , Ureteroscopia/efeitos adversos , Ureteroscopia/instrumentação , Intervalo Livre de Doença , Duração da Cirurgia , Complicações Intraoperatórias , Tempo de Internação , Pessoa de Meia-IdadeRESUMO
BACKGROUND: We analyzed the outcome and complications of rigid (R-URS) and flexible (F-URS) ureteroscopic lithotripsy for treatment of proximal ureteric stone (PUS). SUBJECTS AND METHODS: Retrospective data of 135 patients (93 males and 42 females) submitted to R-URS and F-URS for treatment of PUS in the period between July 2013 and January 2015 were investigated. (R-URS, group 1) was performed in 72 patients while 63 patients underwent (F-URS, group 2).We compared the 2 groups for success, stone characteristics, operative time, intraoperative and postoperative complications. RESULTS: The overall stone free rate (SFRs) was 49/72 (68%) in group 1 and 57/63 (91%) patients in group 2, (P=0.005). The operative time was shorter in group 1 in comparison to group 2 with statistically significant difference (P=0.005). There was not any statistically significant difference between 2 groups in complication rate (P=0.2). Conclusion: Both R-URS and F-URS could be a feasible option for treatment of PUS. R-URS is less successful for treatment of PUS and should be used cautiously and with availability of F-URS.
Assuntos
Litotripsia/métodos , Cálculos Ureterais/terapia , Ureteroscopia/métodos , Adulto , Intervalo Livre de Doença , Feminino , Humanos , Complicações Intraoperatórias , Tempo de Internação , Litotripsia/efeitos adversos , Litotripsia/instrumentação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento , Ureteroscopia/efeitos adversos , Ureteroscopia/instrumentaçãoRESUMO
BACKGROUND: Training devices for percutaneous renal access are expensive, have hazardous biological materials, or radiation. Two devices were designed that eliminate some or all of these characteristics (ManiPERC and iPERC). OBJECTIVE: To compare the improvement in access time to the posterior lower calix with 2 inanimate models in a group of Urology residents. MATERIAL AND METHODS: Quasi-experimental clinical trial with 16 Urology residents to compare the improvement over time of percutaneous renal access by training in 2 inanimate models (iPERC: simulated fluoroscopy and ManiPERC: real fluoroscopy). RESULTS: Subjects were assigned to one of 2 groups (iPERC and ManiPERC) and a video analysis of all of them was performed before and after 20 training sessions. Both groups improved their access time; with iPERC from 133.88±41.40 to 76±12.62s (p=0.006) and from 176.5±85.81 to 68.75 to 18.40s (p=0.007) with ManiPERC. Comparing iPERC versus ManiPERC there was no difference between them in improving access time (ANCOVA: Model F (1.13)=1.598, p=0.228). CONCLUSIONS: Both models are equivalent in improving skills; however, even though none of them generated bio-waste, the absence of radioactive emissions makes iPERC the more advantageous model.
Assuntos
Fluoroscopia/instrumentação , Rim/cirurgia , Litotripsia/instrumentação , Modelos Anatômicos , Imagens de Fantasmas , Cirurgia Assistida por Computador/instrumentação , Adulto , Competência Clínica , Desenho de Equipamento , Feminino , Fluoroscopia/efeitos adversos , Fluoroscopia/métodos , Humanos , Internato e Residência , Período Intraoperatório , Curva de Aprendizado , Litotripsia/métodos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Punções , Exposição à Radiação/prevenção & controle , Cirurgia Assistida por Computador/métodos , Urologia/educação , Gravação em VídeoRESUMO
OBJECTIVE: To identify whether stabilization of larger bladder stones would improve the efficacy of combination (ultrasonic/pneumatic) lithotripsy in a phantom bladder stone model for percutaneous cystolithopaxy. MATERIALS AND METHODS: Using 1cm phantom Bego stones, a spherical model bladder was used to simulate percutaneous bladder access. A UroNet (US Endoscopy, USA) was placed alongside a Swiss Lithoclast probe through the working channel of a Storz 26Fr rigid nephroscope. Using a 30Fr working sheath, the stone was captured, and fragmented for 60 seconds. Resulting fragments and irrigation were filtered through a 1mm strainer, and recorded. Five trials were performed with and without the UN. Durability was then assessed by measuring net defects, and residual grasp strength of each instrument. Descriptive statistics (mean, standard deviations) were used to summarize the data, and Student's t-tests (alpha < 0.05) were used to compare trials. RESULTS: The mean time to stone capture was 12s (8-45s). After fragmentation with UN stabilization, there were significant improvements in the amount of residual stone (22% dry weight reduction vs 8.1% without UN, p < 0.001), number of fragments (17.5 vs 5.0 frag/stone, p=0.0029), and fragment size (3.6mm vs. 7.05 mm, p=0.035). Mesh defects were noted in all nets, ranging from 2-14 mm, though all but one net retained their original grip strength (36.8N). CONCLUSIONS: Bladder stone stabilization improved fragmentation when used in conjunction with ultrasonic/pneumatic lithotripsy. However, due to limitations in maneuverability and durability of the UN, other tools need to identified for this indication.
Assuntos
Litotripsia/instrumentação , Litotripsia/métodos , Cálculos da Bexiga Urinária/terapia , Desenho de Equipamento , Ilustração Médica , Reprodutibilidade dos Testes , Fatores de TempoRESUMO
Objective To identify whether stabilization of larger bladder stones would improve the efficacy of combination (ultrasonic/pneumatic) lithotripsy in a phantom bladder stone model for percutaneous cystolithopaxy. Materials and Methods Using 1cm phantom Bego stones, a spherical model bladder was used to simulate percutaneous bladder access. A UroNet (US Endoscopy, USA) was placed alongside a Swiss Lithoclast probe through the working channel of a Storz 26Fr rigid nephroscope. Using a 30Fr working sheath, the stone was captured, and fragmented for 60seconds. Resulting fragments and irrigation were filtered through a 1mm strainer, and recorded. Five trials were performed with and without the UN. Durability was then assessed by measuring net defects, and residual grasp strength of each instrument. Descriptive statistics (mean, standard deviations) were used to summarize the data, and Student’s t-tests (alpha<0.05) were used to compare trials. Results The mean time to stone capture was 12s (8-45s). After fragmentation with UN stabilization, there were significant improvements in the amount of residual stone (22% dry weight reduction vs 8.1% without UN, p<0.001), number of fragments (17.5 vs 5.0 frag/stone, p=0.0029), and fragment size (3.6mm vs. 7.05 mm, p=0.035). Mesh defects were noted in all nets, ranging from 2-14 mm, though all but one net retained their original grip strength (36.8N). Conclusions Bladder stone stabilization improved fragmentation when used in conjunction with ultrasonic/pneumatic lithotripsy. However, due to limitations in maneuverability and durability of the UN, other tools need to identified for this indication. .