如何使逆行性腎臟內手術能成為一個輕鬆的手術
陳鴻毅、吳俊德、林政鋒、陳文祥、林承家
基隆長庚醫院 外科部 泌尿科
How we make the retrograde intrarenal surgery an easier operation
Hung-Yi Chen, Chun-Te Wu, Cheng-Feng Lin, Wen-Hsiang Chen, Cheng-chia Lin
Divisions of Urology, Department of Surgery, Chang Gung Memorial Hospital, Keelung
Purpose:
Retrograde intrarenal surgery (RIRS) has become a trend in urological stone management because of its high stone-free rate and low morbidity. However, it was thought a challenge operation as its expensive learning curve from ureteroscope damage and both radiation and orthopedic injury to the surgeon. We create an ergonomic, sitting manipulation to handle this operation
Materials and Methods
Traditionally, the surgeon and the assistant all stand wearing lead protective clothing, right foot shift between laser pad and fluoroscopic pad, the body weight bear by the spine and left leg. We change the standing to sitting posture with the laser and fluoroscopic peddles placed both sides of the surgeon's feet where he or she could operate easily. The assistant conventionally stands beside or behind the surgeon that makes the space crowded. We shift his position between the C arm and the patient's right leg, sitting as well. The surgeon holds the handpiece with his left hand and leaves the distal ureteroscope and ureteral access sheath to the assistant. By the same time, the surgeons right hand is free to operate the laser probe, stone basket as his wish. Besides, we change the conventional handpiece holding upside down. Otherwise, we shift to index finger control the deflection system instead of the thumb, which improves the comfort level for the surgeon. We developed this ergonomic way to manipulate this operation since Aug 2015 and got very good results including time-saving, surgeons comfort, improving the stone-free rate (SFR) and prolong the durability of the ureteroscope.
Result
We retrospectively reviewed 328 consecutive patients who underwent RIRS for between Jan 2018 and Jan 2019 at our institute. Patient group according to stone size : <10mm (N=79); 10-20mm (N=136); 20-30mm (N=81); >30mm (N=32), the mean operation time and primary SFR at 1-mo follow up are: 25.4mins, 38.2mins, 58.2mins, 85.2 mins and 97.5%, 93.3%, 76.5%, 43.7% respectively. Overall complications were observed in 77 patients (23.4%), with Clavien grade 1 in 40 patients (12.2%), grade 2 in 26 patients (7.9%), grade 3 in 9 patients (2.7%), grade 4 in 2 patient (0.6%), and none of grade 5. We had once flexible ureteroscopy (fURS) repair during the study period with 201cases durability. Visual analog scale for fatigue assessment of our method for 10 doctor and nurses are lower compare to conventional standing manipulation..
Conclusion
Performing RIRS with our technique is effective, ergonomic, which also improves surgeon comfortable and prologs fURS durability.