RU2499573C1 - Method of treating kidney carbuncles - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to nephrology. Kidney carbuncle is cut is cross-like way through retroperitoneoscopic intermuscular access after decapsulation. Cryoinfluence on carbuncle zone is performed at temperature minus 160-180°C with 10-second exposure.

EFFECT: method improves results of kidney carbuncle treatment, wound healing, reduces trauma of operation at lower cost.

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Description

The invention relates to urology and can be used to treat patients with kidney carbuncles.

The kidney carbuncle is a purulent necrotic lesion that is formed as a result of destruction of the parenchyma cells of the cortical and medullary layers of the kidney. This is a serious disease, may be accompanied by the onset of a septic condition, which is an indication for nephrectomy. But even it does not always prevent death.

A known method of treating a kidney carbuncle in the postoperative period by laser therapy is to use a helium-neon laser with a wavelength of 0.63 μm, a power of 40 mW / cm ² and 2 mW at the end of the fiber. The laser fiber is installed directly in the carbuncle zone and fixed to the nephrostomy drainage during the operation, which, together with the fiber, is attached to the muscle and skin of the patient. Laser irradiation is carried out daily for 5 minutes for 10 days. The method provides fixation of the fiber to the nephrostomy drainage, which protects it from damage throughout the entire treatment period and ensures its removal from the kidney along with the drainage at the end of treatment, as well as the exact installation of the fiber in the carbuncle focus. The method is aimed at quick resolution of the process in the kidney and normalization of the patient's condition (description of the invention to patent RU 2286111 C2, p. 4, 2006.01).

The known method is as follows. Under intubation anesthesia in the corresponding lumbar region, a cut parallel to the costal arch cuts the skin, subcutaneous tissue, muscles, and excrete the kidney. The kidney is revised and, after detecting the carbuncle, they are crosswise dissected to healthy kidney tissue. The renal pelvis is opened, nephrostomy drainage is established. A light guide is inserted through its lumen into the renal pelvis, the end of which, under the control of the eye, is installed in the carbuncle zone and fixed to the nephrostomy drainage. Remove the renal capsule. The renal pelvis incision is sutured, layered sutures are applied to the wound. Nephrostomy drainage along with the light guide is fixed to the muscles and skin of the patient. The next day, intrarenal therapy sessions with a helium-neon laser with a wavelength of 0.63 μm, a power of 40 mW / cm ² and a power at the end of the fiber in mW, lasting 5 minutes, which are carried out for 10 days, are started (description of the invention to patent RU 2286111 C2, pp. 1-2, 2006.01).

The known method is quite traumatic due to the use of large access parallel to the costal arch in the corresponding lumbar region, opening the pelvis and applying a nephrostomy in all cases, regardless of the presence of occlusion of the ureters. Decapsulation after opening the carbuncle can contribute to the spread of infection by contact, in addition, without decapsulation, small carbuncles cannot be immediately detected, which makes it difficult to decide on the degree of damage, the type and extent of the intervention. The main thing is that the carbuncle is not irradiated with a laser directly, but through the sutured renal pelvis. The end of the laser is rigidly installed, so it is difficult to conduct uniform, dosed irradiation of the entire affected area. Particular difficulties arise with multiple carbuncles, in the projection of different segments (for example, upper and lower). A nephrostomy is installed only in one of them. The known method requires long-term treatment in the postoperative period, 10 days. For the implementation of the method in the clinic requires the presence of complex, expensive equipment.

An object of the present invention is to provide a more effective, less traumatic, simple and low-cost method for treating kidney carbuncles.

To perform the claimed method, a less traumatic retroperineoscopic intermuscular access is used in the lumbar region from the affected side with a length of 3.0 cm. The kidney is revised and decapsulated, the degree of damage and the volume of intervention are determined. The carbuncles are crosswise dissected and, if possible, supplemented by removal. necrotic masses. Nephrostoma with opening of the pelvis is performed only in the presence of occlusion of the ureters. During the operation, contact cryotherapy is performed on the entire area of the dissected carbuncle using specially made nozzles with a diameter of 5 to 10 mm. With a large area of damage - nozzles move. Cryotherapy parameters: temperature - minus 160-180 ° С, exposure - 10 seconds. This stops the bleeding. The operation is completed by drainage of the perinephric fiber with control drainage to the lower pole of the kidney. Layered stitches are placed on the wound.

The proposed method is less traumatic than the method using a helium-neon laser. The method uses a less traumatic minimally invasive retroperitoneoscopic approach, nephrostomy is used only in the presence of ureteral occlusion, and not always. Decapsulation carried out before exposure to carbuncles, contributes less to the contact spread of infection, allows you to determine the degree of damage, the type and amount of intervention before dissection. carbuncles.

The proposed method allows the uniform dosed cryotherapy for all lesions. At the same time, bleeding stops in the area of the dissected carbuncle, exudation decreases, proliferation processes predominate, which, in comparison with postoperative helium-neon laser irradiation, contributes to the cessation of discharge and accelerates healing.

A new technical result achieved by the invention is to improve the results of treatment of kidney carbuncles, reduce the time of wound healing, early rehabilitation of patients, reduce the invasiveness of the intervention, ease of implementation at a lower cost of equipment.

Clinical example

Patient M.K, 28 years old, case history No. 34566 was urgently admitted to the urology department of the Central Clinical Hospital-1 in Yekaterinburg with complaints of intense pain in the right lumbar region, chills up to 2-3 times a day, fever up to 39.0.

In the anamnesis: about a week ago, cramps, pains during urination began to disturb. I took nolicin on my own (at a dosage of 400 mg 2 times a day), without a significant effect. Over the past 3 days, the onset and increase of pain in the right lumbar region, chills up to 2-3 times a day, later an increase in body temperature to 39.0 ° C, continued to take nolicin without effect. Due to a sharp deterioration in the general condition (severe pain, weakness), she called the ambulance team and was delivered to the urology department.

Objective: Consciousness is clear, active position. The skin and visible mucous membranes are pale, dry. Pulse 120 per minute, Art. Pressure 100/60, body temperature 39.0 ° C.

The abdomen is regular in shape, not swollen. On palpation of the abdomen, pain on the right flank is determined. An enlarged painful right kidney is palpated. Pasternatsky’s symptom is sharply positive on the right, negative on the left. Diuresis is reduced.

Laboratory data: OAK: White blood cells 11.0 × 10_9, p-10, s-30, l-40, m 10 Red blood cells 3.0 × 10_12, Нb 120 g / l; OAM: Leukocyturia, erythrocyturia, density 1020, protein 0.066 g / l, sugar - 6 mmol / l.

Ultrasound of the kidneys: The kidney is enlarged in size 142 × 56 mm, pronounced edema of the parenchyma up to 28 mm, with multiple hypoechoic areas from 0.5 to 1.0 cm. Peloectasia is not determined. On the opposite side, the kidney is intact. Excretory urography: The excretory function of the affected kidney is reduced.

In an emergency, the operation was performed on the first day of hospitalization: Retroperitoneoscopic intermuscular access of 3.0 cm in the X intercostal space on the right along the front axillary line. Revision, decapsulation of the kidney. During the audit, the kidney is enlarged, purple-cyanotic in color. In the middle segment along the anterior surface of the carbuncle 3.0 × 4.0 cm. A cross-sectional dissection of the carbuncle was performed, with the removal of necrotic tissue. Sowing from a wound; material for histology. Cryogenic effect of the zone of location of the dissected carbuncle with an electrode with a diameter of 1.0 cm, a temperature of minus 160 ° С, an exposure of 10 seconds was performed. Hemostasis is satisfactory. Control drainage to the lower pole of the kidney.

In the postoperative period: detoxification therapy, the introduction of antibacterial and vascular drugs.

The results of observations in the postoperative period.

On the first day after surgery: Pain in the lumbar region decreased. Hemodynamics stabilized, pulse 90 per minute, Art. Pressure 110/60. Diuresis is normal. Wound discharge by control drainage - 50 ml.

On the second day: Marks minor pain in the area of the postoperative wound. There are no chills and sweating. The body temperature returned to normal. According to the control drainage there is no discharge, the latter is removed.

On the third day: no complaints. Normalization of indicators of the general analysis of blood, leukocyte formula. Ultrasound of the kidneys: a decrease in edema of the parenchyma of the right kidney, hypoechoic foci are not visualized.

On the fourth day: in the general analysis of urine, leukocyturia, erythrocyturia decreased.

On the seventh day in the general analysis of urine leukocyturia, proteinuria was not observed.

The patient was discharged on the 8th day from the hospital with recovery.

According to this method, 12 patients with kidney carbuncles from 0.5 to 4.0 cm in size were operated on. When observed in the postoperative period, patients showed a rapid improvement in general condition, normalization of clinical and laboratory parameters, and a decrease in serous-hemorrhagic discharge through drainage. So, on the 1st day, the pain syndrome is significantly reduced, hemodynamics are stabilized, and kidney function is restored. On the 2-3rd day, the temperature reaction normalizes, indicators of a general blood test, leukocyte formula come to normal. The wound discharge ceases, the control drainage is removed. Ultrasound of the kidneys: a decrease in edema of the kidney parenchyma, hypoechoic foci are not visualized. On the 4-5th day, leukocyturia, erythrocyturia decreases. By the 7-8th day, changes in urine are not detected. Clinical recovery occurred on the 8-10th day. Moreover, the claimed method of treatment of kidney carbuncles is less traumatic, simple and low cost.

Claims (1)

A method for treating kidney carbuncles, including access, revision and renal capsulation, cross-section of carbuncle and intrarenal exposure, characterized in that the carbuncle is exposed during surgery, for which retroperitoneoscopic intermuscular access is used in the lumbar region from the affected side with a length of 3.0 cm, the carbuncle is dissected after decapsulation of the kidney and contact cryotherapy is performed on the entire area of the dissected carbuncle at a temperature of minus 160-180 ° С with an exposure of 10 s.