Electrohydraulic Impulse Lithotripsy of Bladder Stones with URAT-I M. F. Trapeznikova, G. G. Borodulin MONIKI, Urological Department, Moscow, USSR

Summary

The electrohydraulic method of crushing bladder

stones due to many aforesaid advantages can fully replace mechanical lithotripsy as being both

more effective and having little danger of trau-

mas. In rare cases when the stone cannot be crushed with Urat-I its removal should be performed by way of cystotomy.

Key-Words: Electrohydraulic lithotrypsy, bladder stones.

Die elektrohydraulische Impulslithotripsie der Blasensteine mit dem Urat-I-Gerät Zunächst wird die geschichtliche Entwicklung und

mentarium und die Technik der elektrohydraulischen Lithotripsie abgehandelt. Die Erfahrung wurde an 201 Patienten gesammelt, wobei in ca. 90°/o der Fälle der Eingriff in einer Sitzung und in 10°/o der Fälle in zwei Sitzungen durchgeführt wurde. Gröf3e, Anzahl und chemische Zusammen-

setzung der Steine sowie andere Erkrankungen der Patienten werden angeführt. Die Dauer des Krankenhausaufenthaltes nach dem Eingriff betrug im Durchschnitt etwa 6 Tage. Ernste, mit der Operation zusammenhängende Komplikationen wurden nicht beobachtet. Hervorzuheben sind akute Prostatitis (1,9°/o) und Epididymitis (1,49°/o). Zusammenfassend wird festgestellt, dal3

die elektrohydraulische Lithotripsie die mechanische an Effektivität iibertrifft und letztere vollstandig ersetzen kann. In seltenen Fallen, wenn der Stein nicht zertriimmert werden kann, muf3

Allein in der UdSSR wurden 1000 Operationen die rasche Verbreitung der Methode beschrieben. erfolgreich durchgeführt. Es werden das Instru- eine Beseitigung durch Zystotomie erfolgen.

Downloaded by: University of British Columbia. Copyrighted material.

Endoscopy 9 (1977) 6-12 C) Georg Thieme Verlag, Stuttgart

Electrohydraulic Impulse Lithotripsy of Bladder Stones with URAT-I

At present the electrohydraulic impulse method of crushing bladder stones is widely used in urological practice. The story of the discovery is as follows.

L. V. Rose, an engineer of the Technical Research department of the VEF plant was operated on for ureteral stone by V. Goldberg in the Urological Department of the Ist Clinical Hospital in Riga in 1959. Ever since both have been looking for a way of bloodless removal of ureteral stones. The persist-

The success of stone crushing and the following evacuation of the debris largely depend on the type of the cystoscope. We have used the universal cystoscope with a

back curve tube, made at the Leningrad plant, "Krasnogvardeets". Besides a good visual control during the lithotripsy this cystoscope allows to evacuate the debris without removing the tube by way of an aspirator attached to the cystoscope. The cysto-

scope was removed only after the control examination of the bladder.

ent search was crowned with success. For the

crushing of ureteral stones they the used electrohydraulic effect, discovered by a Leningrad engineer, L. A. Yutkin, in 1950. The term, "electrohydraulic effect", was given by the author to the phenomena occurring at the specially created impulse high

voltage discharge in liquid medium. The result of this is the intensive mechanical crushing of solid objects in the immediate vicinity of the discharge. Instruments A special apparatus, designed and constructed at the VEF plant, generated a high voltage dis-

charge directed at the stone and crushing it without any damage to the surrounding tissues and to the whole organism.

The crushing of bladder stones with electrohydraulic method was first performed on May 7, 1959 by Dr. V. V. Goldberg (5, 6, 7, 8) who reported this at the meeting of the Latvian Urological Society on May 13, 1959. Later the appa-

ratus for electrohydraulic lithotripsy was modernized for serial production under the name Urat-I by a group of Kiev engineers headed by O. E. Balayev. At present Urat-I has become widely popular and is used in many countries (Reuter, 10, 11, 12), Rouvalis (13). Electrohydraulic cystolithotripsy has been successfully used in different clinics of the Soviet Union in more than 1000 cases (Y. G. Ediny, 4, G. G. Borodulin, 2, 3, A. N. Tsoy, 16, E. E. Snithens, 14).

Technique

The introduction of the stone probe and the crushing of stones should be carried out only under visual control. The lithotriptor is placed vertically to the stone. The crush-

ing is done by a short series of electrohydraulic shocks of no longer than 1 to 3 seconds duration at the impulse frequency of

50 to 70 cycles per second. The interval between the series is not less than 5 to 6 seconds. The success of the process depends on making a hole in the surface of the stone. In case the hole cannot be made during a few

series of shocks, the frequency should be increased to 100 cycles per second. After the stone has been broken, its pieces are crushed at the minimum voltage.

The crushing of stones under the impact of electrohydraulic shocks varies depending

on the relief of their surface and on their chemical structure. Rough concrements are easy to crush; smooth polished ones are hard to crush. This can be explained by the fact that as a result of an electric discharge the hydraulic wave is easily deflected from the smooth sufface which lowers the effectiveness of the shock.

Phosphate stones are easily destroyed at

Urat-I is an electric impulse generator

the 30 Hz impulse frequency. The whole pro-

equipped with an electrohydraulic litho-

cess in these cases takes 15 to 20 minutes.

triptor, i.e., a sound which in its thickest part (the butt end) does not exceed 3 mm.

Oxalate stones and coarse-grained stones are crushed regardless of their size at the impulse

Downloaded by: University of British Columbia. Copyrighted material.

Introduction

7

0

11

12

13

10

)

11

12

13

Fig. 1 A concrement consisting of uric acid salts, in size of 5.0 x 4.0. Splinters caused by electrohydraulic discharges can be observed on the periphery of the stone.

Fig. 2 A concrement consisting of oxalate salts in size of 3.0 x 2.0 cm. The damage of surface layer caused by electrohydraulic discharges can

frequency of 70 to 90 Hz (Fig. 1); uric acid stones with occasional smooth and polished

to avoid complications which may arise if they penetrate the urethra. If lithotripsy is performed in stages and there is no possibility to aspirate all the small splinters, a permanent catheter should be applied for 2

surface are crushed with difficulty at the impulse frequency of 90 to 100 Hz (Fig. 2). In two cases stones could not be crushed. In one case it was a 5.0 x 4.0 cm urate with smooth surface. In the second case there were oxalates of 3.0 x 3.0 cm and 3.0 x 2.0 cm with polished surface.

be observed in the centre of the stone.

to 3 days. However, in most cases the application of the permanent catheter after lithotripsy is not required. In 182 (90.50/0) cases

lithotripsy was performed in one stage; in

Numerous small urates of rounded shape and smooth surface of 0.5 x 0.7 cm in dia-

19 (9.505) cases

meter are also hard to crush due to their

Results

small mass, as during the discharge they fly off from the probe. In such cases the stones

in two stages.

The crushing of bladder stones with Urat-I

crushed.

was performed in the Urological Clinic of MONIKI in 201 cases: 176 men (87.6°/o),

The crushing of splinters should be performed down to the diameter of the lithotriptor electrode. Splinters of this size can easily pass through the cystoscope tube. In

74.10/o of the patients developed bladder stones in an elderly and old age. The stones were from 0.5 to 7.0 cm in diameter.

are pressed against the bladder wall and

our opinion the complete aspiration of splin-

ters from the bladder is necessary in order

25 women (13.4°/o).

The number of stones varied from one to several dozen, which could not be counted.

Downloaded by: University of British Columbia. Copyrighted material.

M. F. T rapeznikova, G. G. Borodulin

8

Electrohydraulic Impulse Lithotripsy of Bladder Stones with URAT-I

9

Table 1 Age distribution of cases. Age

1-5

6-10

11-15

16-20 21-30

3

2

2

3

31-40

41-50

51-60

61-70

71-80 81±> 201

12

17

45

65

35

Number of cases

3

4

Total

uric acid salts (37%), and oxalates (12.5%).

The majority of patients who underwent the concrement crushing with Urat-I had the

following local and general concomitant diseases:

Local and general concomitant diseases were diagnosed in 182 (90.5%) cases. They were: adenoma of the prostate (Stage I) in 84 cases; adenoma of the prostate (Stage II) in 3 cases; condition following adenomectomy 27; traumatic stricture of the urethra

amenable to probing 7; carcinoma of the prostate 6; bladder diverticulum 6; neurogenic bladder 4; vesicovaginal fistula 5;

ligatura of the vesical wall 12; nephrolithiasis 25. In 146 (72.60/0) cases concomitant diseases

caused disturbance in the urinary flow. No concomitant diseases either of upper or of lower urinary tract were found in 19 (9.50/o) cases.

General concomitant diseases were diag-

nosed in 85 (42.30/0) cases. There were: hypertensive disease of I and II Stage 72; hypertensive disease of III Stage 6; angina pectoris 70; myocardial infarction dated as far back as 6 to 12 months and more 30; bronchial asthma 4; paraplegia 3; diabetes mellitus 5.

All these patients underwent the corresponding medicamentous therapy before lithotripsy. The process of stone crushing is painless, so local anaesthesia can be successfully used along with general anaesthesia.

Fig. 3

Pat. L., Scanning roentgenogram: Con-

crement in the urinary bladder.

In half of our cases the stone was crushed without general anaesthesia following the previous premedication, with 2.5°/o pipolfen solution 2.0, with 2°/0 promedoli 1.0, and with 0.1°/o atropine 0.5.

The patients were given antibiotics 3 to 5 days following the stone crushing process according to the antibiogram of the urine. If the surgeon is absolutely sure that the stone is crushed and the splinters are evacuated, control cystoscopy is not obligatory. Hospitalization period after lithotripsy averaged up to 6 days. Complications directly connected with the method itself are practically nonexistant.

Downloaded by: University of British Columbia. Copyrighted material.

Single stones occurred in 130 (64.70/0) cases, numerous in 71 (35.30/e) cases. According to composition all the stones were of compound nature and consisted of phosphates (50.5%),

M. F. Trapeznikova, G. G. Borodulin

Fig. 4

Pat. S., Urethrogram: Stricture of back urethra.

Fig. 5

Pat. S., Pneumourethrogram: Concrement of the back urethra of 1.0 cm in diameter and a concrement in the urinary bladder of 3.0 x 2.0 cm.

During the crushing focal hyperemia of various degrees and haemorrhage could be observed in most cases under the mucous membrane at the sites hit by splinters. They considerably decrease on the third day and completely disappear 5 to 6 days after the stone crushing process.

Vaguely expressed dysuria following the stone crushing process was observed almost in all cases; momentary increase in temperature in 38 cases (18.90/o); mild haematuria 20

acute prostatitis 4 (1.990/o); acute orchiepididymitis 3 (1.490/o); splinters lodged in the urethra 2 (0.99°A); incontinence of urine for 24 hours 1 (0.490/0); acute retention (9.90/o);

of urine 1 (0.49°/o).

Literature describes complications connected with splinters lodged in the urethra, as a result of which a suprapubic fistula was applied in one case; the second patient died from ascending acute purulent pyelonephritis. In the third case the bladder wall was

Downloaded by: University of British Columbia. Copyrighted material.

10

11

Fig. 6

Pat. B., Scanning roentgenogram: Numerous stones in the urinary bladder and the diverticulum.

perforated by the tip of the cystoscope as a

result of neglect in safety arrangements while working with Urat-I (the apparatus was not grounded). A. Rabia, K. N. Koracv and A.N.Tsoy (1971).

Late results after stone crushing with Urat-I are known in 148 cases (73.60/o). The

period of observation varies from 1 to 7 years. Recurrence of stones was observed in 32 (21.6%) cases. It is necessary to point out that the recurrence percentage depends not upon the kind of lithotripsy, but mainly on the cause of stone formation. So, in the case of a combination of bladder stones with the adenoma of the prostate, the treatment

should be directed at the cure of the basic disease.

formed at the minimum volume of the bladder. Case Report Pat. L., aged 54 years with the diagnosis: recurrence of bladder stone, vesicovaginal fistula; condition following operation for cancer of cervix uteri; a big postoperative ventral hernia. The stone occupies all the bladder cavity; exceeds 6 cm in diameter, phosphate. Before crushing the vagina was tightly plugged with an oily tampon. The washing liquid was fed through a permanent

rubber catheter to the urinary bladder. Lithotriptor sound was introduced and contacted the stone. The crushing was performed to the touch.

After a part of the stone was crushed and evacuated, the process was finished under optical control in one stage (Fig. 3).

Discussion

The new electrohydraulic method

the stone (with rare exceptions) do not inhibit the process; stone crushing can be per-

In 32 (15.90/o) cases lithotripsy was perof

formed at 100 ml bladder volume; in 18 cases

crushing bladder stones has many advantages

(8.9°/o) at less than 50 ml; and in 2 cases

over mechanical lithotripsy, which fact is pointed out by a number of authors: Y. G.

(0.99%) with no volume at all.

Ediny (1965), G. G. Borodulin (1967), A. N. Tsoy (1969, 1970), Buttger (1969), Rouvalis

stone crushing method lies in the fact that it can be used in patients with traumatic stricture of the urethra amenable to probing and

(1970).

One of the advantages of the new method

is the fact that the size and consistency of

Another advantage of electrohydraulic

in some cases in the urethra and bladder diverticulum.

Downloaded by: University of British Columbia. Copyrighted material.

Electrohydraulic Impulse Lithotripsy of Bladder Stones with URAT-I

M. F. Trapeznikova, G. G. Borodulin: Electrohydraulic Impulse Lithotripsy

Case Report

Ref erences

Pat. S., aged 45 years, with the diagnosis: traumatic stricture of urethra, recurrence of stone in

the back urethra and urinary bladder; stones of the right ureter, incontinence of the urine, nonfunctioning right kidney. The anamnesis shows a bullet wound in the bladder and urethra with the injury to the pelvic bones, vesicoperineal fistula. One stone of up to 1.0 cm in diameter and

another in size of 3.0 x 2.0 cm in the bladder. Unter the permanent flow of liquid the stone was

crushed in the urethra and afterwards the bougienage up to 22 Benike was made with great difficulty, and the bladder stone was also crushed (Fig. 4, 5).

Abranzian, A. Y.: The Apparatus Urat - I. International Urologie an Nephrologie 2 (3) (1970) 313

2 Borodulin, G. G.: The crushing of bladder stones with the electrohydraulic impulse method. "Progress of clinical and experimental surgery". Moscow (1967) 467 (Russ.)

3 Borodulin, G. G.: Advantages of the electrohydraulic impulse method of crushing of bladder stones with Urath-I. Aktualnye Voprosy Urologii Moscow (1967) 119 (Russ.)

4 Ediny, Y. G.: Method of bladder stones treatment using electrohydraulic

lithotriptor.

Instruction.

Kiev,

1965

(Russ)

5 Goldberg, V. V.: Electrohydraulic lithotripsy as a new method of crushing of bladder stones. Proc. of Latvian Urological Society May 13, 1959. Urologia 3 (1960) (Russ)

6 Goldberg, V. V.: A new method of crushing of bladder stones - electrohydraulic lithotripsy. Presentation at the Convention of the Moscow Urological Society on April 13, 1960

Pat. B., aged 73 years with the diagnosis: recurrence of bladder stones; stones in the bladder diverticulum (Fig. 6). The stone crushing in the bladder and the diverticulum was performed in

7 Goldberg, V. V.: A new method of crushing bladder stones. Republican Conference of the Ukranian SSR, 27-29

two stages.

9 Rabia, A., K. M. Koraev, A. N. Tsoy: Complications at electrohydraulic cystolithotripsy. Urologia i nephrologia.

It should be pointed out that girls aged 3 and more years can also undergo electrohydraulic treatment. We have made 6 such observations.

june. Kiev (1960) 31 (Russ.)

8 Goldberg, V. V.: On the history of the discovery of the electrohydraulic lithotripsy method. (Letter to the editor) Urologia and Nephrologia 1(1974) 90 (Russ.) (1970) 68 (Russ.)

10 Reuter, H. J.: Elektrische Lithotripsie mit Urat-I. Med. Markt 16 (1968) 414

11 Reuter, H. J.: Electronic Lithotripsy, a new method for transurethral treatment of bladder stones. Endoscopy (1969) 63

Electrohydraulic impulse lithotripsy is contraindicated in cases of acute inflammation of the urinary system, urethral strictures

not amenable to probing; adenoma of the prostate in Stage III; adenoma of the pros-

tate in Stage II with enlargement of the middle lobe (for the most part); residual urine volume of more than 70 to 100 ml.

12 Reuter, H. J.: Electronic Lithotripsy: transurethral treatment of bladder stones of 50 cases. J. lfrol. 104 (1970) 834

13 Rouvalis, P.: Electronic Lithotripsy for vesical calculus with Urath-I. Brit. J. Urol. 42 (1970) 486 14 Smiltens, E. E.: Electrohydraulic Lithotripsy in Urology "Nephrologia and other questions of practical medicine" Riga (1967) 95

15 Doy, A. N.: On the Method of Bladder Stones Treatment with Urat-I. Nauchnye Trudy aspirantov i ordinatorov. Moscow 3 (1967) 57 (Ruso.)

16 Tsoy, A. N.:

Electrohydraulic impulse treatment of

Bladder Stones Sovremennye Voprosy Urologii. Moscow (1969) 58 (Russ.)

Dr. M. E. Trapeznikova, MONIKI, Urologi cal Department, Moscow, USSR

Downloaded by: University of British Columbia. Copyrighted material.

12

Electrohydraulic impulse lithotripsy of bladder stones with URAT-I.

Electrohydraulic Impulse Lithotripsy of Bladder Stones with URAT-I M. F. Trapeznikova, G. G. Borodulin MONIKI, Urological Department, Moscow, USSR Su...
605KB Sizes 0 Downloads 0 Views