In situ extracorporeal shock wave lithotripsy for acute colic due to obstructing ureteral stones.. Heidenreich A., Desgrandschamps F., Terrier F.[r]
(1)PHAN 5
TIET NIEU
1 CON DAU QUAN THAN■ ■
Cdn dau quan than la trieu chiing cam nhan dtfdc ap ltfc dtfdng tiet nieu tren tang len gay cang gian dot ngot dai be than nieu quan tac d ben hay ngoai nieu quan Nguyen nhan gay tac thtfdng gap nhat la soi nieu quan dang di chuyen gay co that va viem phu ne nieu quan Can chan doan sdm va chi'nh xac Dieu tri nham giai quyet cdn dau va hau qua cua hoi chtfng tac dtfdng tiet nieu tren
1 T R I E U C H t r N G L A M S A N G
1.1 Tien suf
Ban than hoac ngtfdi gia dinh co tien stf dieu tri benh soi tiet nieu va cdn dau thtfdng xuat hien sau mot chuyen di xa, sau tap the due hoac lao dong nang
1.2. Trieu ch iin g cd n a n g
- Benh nhan dau ttfng cdn dtf doi vung that ltfng vdi ctfdng tang len vai phut den hang gid Benh nhan thtfdng lan Ion, luon thay doi ttf the, nhien moi ttf the giam dau deu khong co hieu qua neu khong dieu tri giam dau thi kho cat dtfdc cdn dau Cdn dau thtfdng co htfdng lan ro ret:
- Soi 1/3 tren dau lan xuong tinh hoan cung ben - Soi 1/3 gitfa thtfdng dau lan xuong ho chau - Soi 1/3 dtfdi thtfdng lan xuong biu
- Dau am i cang ttfc vung that ltfng co tf dong d nieu quan - be than - Cdn dau kem theo buon non va non
- Dai mau toan bai: l't va thoang qua
- Dai kho, di tieu nhieu lan va buot soi nieu quan nam sat hoac bang quang gay kich thich
- Mot so trtfdng hdp gap dai it hoac vo nieu
(2)1.3 Trieu chtfng thiic the
- Tham kham nhe nhang vung that ltfng, co sd thay than to Bung hdi trtfdng va cdn dau co the thay co ctfng cd vung that ltfng va ntfa bung ben ton thtfdng
- Cac vung bung khac binh thtfdng, khong kham thay thoat vi ben dui - Tham trtfc trang binh thtfdng, trtf soi n&m sat bang quang
1.4 Trieu chufng toan than
- Trong cdn dau benh nhan luon keu la, kich thich, vat va - Mach, huyet ap co the tang len
- Nhiet binh thtfdng hoac co sot nhe
- Sot cao soi gay t i c dtfdng bai xuat va co nhiem khuan tiet nieu - Soi nieu quan hai ben hoac soi than mot ben, soi nieu quan mot ben se gay anh htfdng toan than nhanh chong: Id md, hon me suy than, ure mau cao
2 X E T N G H IE M SIN H H O A
2.1 X e t n g h ie m niidc tieu
- Nhieu hong cau va bach cau thoai hoa
2.2 X e t n gh ie m m au
- Ure va creatinin mau: binh thtfdng hoac tang len
- C o n g thtfc b a c h cau: thtfdng k h o n g tang
3 C H A N D O A N H i N H A N H
3.1 Chup X q u a n g he tiet nieu k h o n g ch u an bi
- C h u p t h a n g h a y n g h i e n g
- Phat hien hinh anh can quang n l m tren dtfdng di cua nieu quan co hinh thoi hai dau htfdng len tren va xuong dtfdi Soi co the gap d mot ben hoac hai ben meu quan hoac di kem vdi soi than Can ltfu y nhtfng trtfdng hdp soi khong can quang Trong cdn dau thtfdng gap tinh trang ruot non gian liet ruot cd nang gay kho khan cho viec phat hien soi
- Phan biet soi nieu quan vdi cac hinh anh can quang doc dtfdng di nieu quan cua hach canh cot song voi hoa (vet can quang khong dong deu, bd khong ro ret thudng nhieu rai rac mot ben hoac hai ben cot song) va soi tinh mach vung tieu khung (phlebolith — vet can quang nho, tron nam sat tieu k h u n g >
3.2 Sieu am b u n g
(3)ltfdng soi Hinh anh can am cua soi doi khong ro bi nhieu bdi hinh hdi va phan d ruot
- Nhu mo than day hay mong, dai be than va nieu quan co gian hay khong - Hinh anh bat thtfdng: ung thtf te bao chuyen tiep d be than va nieu quan (l't gap) - Phan biet vdi cac benh cap ctfu bung khac: viem ruot thtfa, viem tui mat soi v.v
Vdi hai phtfdng phap tren co the chan doan dtfdc cdn dau quan than thong thtfdng
3.3 Chup nieu tin h m ach (UIV)
- Chi lam ngoai cdn dau de thu thap thong tin ve nguyen nhan tac (soi, u) - Danh gia chtfc nang than: gian dai be than nieu quan, than cham bai tiet, bai xuat
- Than “khong ngam thuoc” , khong bai tiet bieu hien ngtfng hoat dong tam thdi phan xa hoac giam chtfc nang Khi can dung cac bien phap chup cham he tiet nieu sau 60 — 120 phut, hoac kich thich chtfc nang bai tiet bang tiem lasix mdi danh gia dung dtfdc chtfc nang than
- Chup UIV cho thay cac di dang cua than va nieu quan
3.4 Chup nieu q u a n - be th an ngtfdc d on g (U PR )
- Phat hien dtfdc soi nieu quan khong can quang, nhtfng soi nieu quan to day nieu quan nam trung trtfdc cot song
- Chan doan phan biet vdi cac trtfdng hdp tac dtfdng bai xuat khong soi
3.5 Chup cat ldp vi tin h (CLVT)
- Chi dinh thtfc hien chtfa xac dinh dtfdc chan doan
- Phat hien dtfdc soi nieu quan co can quang it, khong phat hien dtfdc tren phim chup Xquang thong thtfdng
- Danh gia dtfdc chtfc nang than va phat hien cac di dang bam sinh dtfdng tiet nieu
4 c A c TH E lAm sAnG
4.1 The k h o n g co b ien chtfng
- Hay gap soi nieu quan kich thtfdc - 5mm, khong gay nhiem khuan va khong gav tac hoan toan
- Dien bien lam sang thtfdng thuan ldi, soi hay di chuyen xuong thap va co the dtfdc dao thai ngoai sau dieu tri noi khoa
4.2 The co b ien chtfng
- Soi nieu quan gay bien chtfng tai cho: viem, xd hoa va chit hep nieu quan cho co soi Doi gap thung nieu quan soi hoac vd be than — nieu quan gian
(4)tron soi gay tu dich ntfdc tieu sau phuc mac hoac gav viem phuc mac ntfdc tieu (hiem gap)
- Soi nieu quan gay bien chtfng tren than: than tf ntfdc, nhiem khuan tf mu va co the gay nhiem khuan huyet, soc nhiem trung can chi dinh dieu tri ngoai khoa cap ctfu
- Soi nieu quan gay bien chtfng toan than: vo nieu soi nieu quan hai ben, soi tren than duv nhat hoac than ben doi dien mat chtfc nang Dieu tri ngoai khoa la rat can thiet de ctfu chtfc nang than va ctfu ti'nh mang benh nhan
- Cdn dau dtf doi va keo dai, khong giam vdi thudc giam dau, cd the phai chi dinh can thiep ngoai khoa
- Soi tiet nieu tren benh nhan cd thai kem theo nhiem khuan rat nang
5 CAC T H E L A M S A N G T H E O N G U Y E N N H A N G A Y T A C N G H E N
5.1 N guyen n han gay tac ttf ben tron g dtfdng tiet nieu tren
- Hay gap nhat la soi can quang (oxalat calci, phosphat calci) va khdng can quang (acid uric)
- Ung thtf te bao chuyen tiep cua dtfdng bai tiet (Transitional Cell Carcinoma) - Hep nieu quan be than lao, giang mai
5.2 N gu y en n h a n gay tac ttf ben ngoai dtidng tiet n ieu tren
- Hach
- U ac ti'nh, lanh ti'nh (u xd ttf cung) - Xd dinh, co keo sau md
- Benh xd hoa sau phuc mac
6 C H AN D O A N P H A N B IE T
Cdn dau quan than can dtfdc chan doan phan biet vdi:
6.1 Cac benh cap ctfu co sot
- Viem dtfdng mat, viem tui mat cap - Viem ruot thua cap
- Thung o loet da day ta trang - Thung tui thtfa dai trang - U manh trang ap xe hoa - Viem phan phu
(5)6.2 Cac benh cap ctfu khac
- Cdn dau da day - Viem dai trang - Viem cap - Giun chui ong mat - Thoat vi ben, dui
- TSc ruot u dai trang, ba thtfc an, sau mo - U nang buong trtfng xoan, chay mau
- Chtfa ngoai ttf cung
Chu y: Khong de sot phong dong mach chu bung
7 DIEU TRI
7.1 Doi vdi cac the k h o n g bien chtfng
- Dung cac loai thuoc chong viem khong steroid tiem bap hoac tinh mach
- Dung thuoc gian cd trdn: visceralgin, papaverin, nospa, spasfon v.v Neu dau nhieu khong thuyen giam co phai chi dinh dung morphin theo chi dan cua thay thuoc
- Soi bang quang dat ong thong nieu quan day soi len tren than va ltfu ong thong - Dieu tri nguyen nhan soi: tan soi ngoai cd the, tan soi noi soi nieu quan ngtfdc dong, mo lay soi qua noi soi o bung sau phtfc mac hoac qua mo md
7.2. Doi vdi cac the cd bien chtfng (nhiem khuan, vo nieu)
- Khang sinh: nhom cephalosporin the he thtf hoac - Soi bang quang dat ong thong nieu quan
- Dan ltfu than qua da hoac bang mo md
- Khi benh nhan on dinh, dieu tri nguyen nhan soi: tan soi ngoai cd the, tan soi noi soi nieu quan, mo lay soi qua noi soi o bung sau phuc mac hoac qua mo md
- Vdi nguyen nhan u dtfdng bai tiet: cat doan nieu quan hoac cat toan bo than nieu quan ben co u
- V6i nguyen nhan hep nieu quan lao: nong nieu quan qua noi soi ngtfdc dong, cat doan hep tao hinh nieu quan
- Vdi nguyen nhan chen ep ttf ben ngoai nieu quan: phau thuat cat u xd ttf cung Gd dinh giai phong nieu quan khoi to chtfc xd sau phuc mac va dtfa vao o phuc mac
Cdn dau quan than la mot cap ctfu ngoai khoa thtfdng gap soi nieu quan gay nen Chan doan chu yeu dua vao sieu am va chup nieu tinh mach da dd
17* CC NGQW KHOA-TC
(6)cdn dau Dieu tri can lam giam cdn dau va tao dieu kien cho soi di chuyen xuong dtfdi Khi co vo nieu hoac nhiem khuan can dieu tri khang sinh kjp thdi va co bien phap dan ltfu ntfdc tieu thich hdp Dieu tri theo nguyen nhan gay tac duoe thtfc hien benh nhan da on dinh
tAi l i e u t h a m k h a o
1 Doublet JD., Tchala K., Tligui M et al In situ extracorporeal shock wave lithotripsy for acute colic due to obstructing ureteral stones Scand J Urol N ephrol 1997, 31: 137
2 Heidenreich A., Desgrandschamps F., Terrier F Modern approach of diagnosis and management of acute flank pain: review o f all imaging modalities E ur Urol 2002, 41: 351
3 Joshi HB, Obadeyi 0 , Rao PN A comparative analysis o f nephrostomy JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones B JU Int 1999, 84: 264
4 Kravchick S., Bunkin I., Stepnov E et al Emergency extracorporeal shockwave lithotripsy for acute renal colic caused by upper urinary tract stone J Endourol 2005, 19:1
(7)2 VO NIEU DO TAC NGHEN
Vo nieu tSc la hoi chiing than ngtfng bai xuat lam cho bang quang khong co hoac co it ntfdc tieu (<200ml/24 gid) Khac vdi bi dai, vo nieu tac la tinh trang suy than sau than can trd d hay ngoai dtfdng tiet nieu tren Nguyen nhan hay gap nhat la soi nieu quan
Vo nieu tSc la mot cap ctfu noi - ngoai khoa can chan doan sdm va xtf tri kjp thdi de tranh suy than nang va cac bien chtfng toan than nguy hiem den ti'nh mang benh nhan
1 SINH LY B E N H
Khi bi tac nghen, ap ltfc he thong dtfdng tiet nieu tren tang len dot ngot Neu ap ltfc ong than tang len tren 40cm H20 thi chtfc nang loc cua cau than ngtfng han, se xuat hien cac roi loan cua suy than cap:
- U ntfdc va dien giai gay phu ne Tang kali mau - Ure va creatinin mau tang Toan chuyen hoa - Co the kem theo hoi chtfng nhiem trung
2 N G U YE N N H A N G A Y T A C N G H E N
2.1 Vo nieu soi h ay gap nhat
- 80% la soi nieu quan tren than nhat hoat dong
- 20% soi nieu quan hai ben, thtfdng gap d ddan 1/3 dtfdi nieu quan
2.2 Nieu quan bi tac n gh en tac n han ben tro n g
- Do mam ung thtf than, ung thtf be than - nieu quan, polyp nieu quan - Manh hoai ttf nhu than (hiem gap)
- Hep nieu quan lao tiet nieu
2.3 Nieu q u a n bi ch en ep ttf ben ngoai
- Tai 16 nieu quan u bang quang, ung thtf tuyen tien liet xam lan
9,
- doan sat bang quang ung thu co ttf cung, ung thtf buong trtfng u xd ttf cung, ung thtf trtfc trang va benh xd hoa sau phuc mac
- Tai bien sau mo san phu khoa va tieu khung: cat, buoc that phai nieu quan
(8)3 C H A N D O A N X A C D I N H
3.1 T i e n stf
Dieu tri soi tiet nieu, phau thuat cat than, ung thu vung tieu khung, dj dang bam sinh dudng tiet nieu, than lac cho, sau mo san phu khoa hoac phau thuat tieu khung
3.2 T r i e u c h t f n g l a m s a n g
Chan doan lam sang dUa tren dau hieu cua Anvert: benh nhan khong co cam giac buon di tieu, kham khong thay cau bang quang va dat ong thong nieu dao khong co nUdc tieu (dudi 200ml/24h)
3.2.1 T rieu c h iin g tie t n ie u
- Vo nieu (bang quang khong co hoac co it nUdc tieu < 200ml/24 gid) - Thieu nieu (ludng nUdc tieu < 500ml/24 gid)
- Co bieu hien cua cdn dau quan than
- Tham trUc trang, am dao: ung thu trUc trang hoac ung thu co tu cung - Sau phau thuat san phia khoa hoac phau thuat vung tieu khung
3.2.2 T rieu c h iin g to a n th a n : theo mUc suy than: - Phu, non, kho thd
- Nhip tim nhanh, tang huvet ap - Roi loan tri giac
3.3 X e t n g h i e m s i n h h o a Bat dau nguy hiem neu:
- Creatinin huyet tudng > 150mmol/l, ure mau > 17mmol/l, kali mau > 6mmol/l, du tru kiem > 15mmol/1, pH mau < 7,25, bach cau mau tang
•y •» x
3.4 C h a n d o a n h i n h a nh (rat quan trong)
3.4.1 C h u p p h im h e tie t n ie u k h o n g c h u a n bi
- Bong than to, soi can quang he tiet nieu: vi tri, so ludng, kich thudc
3.4.2 S ieu dm r a t c o g id tri
- Danh gia bong than to, xac dinh day nhu mo than - MUc gian cua dai be than va nieu quan
- Phat hien soi it hoac khong can quang tren phim Xquang thong thudng - Khdi u bang quang u tieu khung
3.4.3 C h u p n ie u d o tin h m a c h (UIV neu khong co chong chi dinh): - Chup phim thi sdm va muon (sau 12 gid)
- Phat hien nguyen nhan va vi tri tdc
(9)3.4.4 Soi bdng quang vd chup nieu quan ngitOc dong (UPR)
- Phat hien soi ft hoac khong can quang khong thay ro tren phim chup he tiet nieu - Xac dinh ton thtfdng chit hep va ro nieu quan sau phau thuat san phu khoa
3.4.5 Chup cdt lap vi tinh
- Chup phim co tiem thuoc can quang hoac khong theo mtfc suy than - Chu y tranh chup phim Xquang benh nhan co thai thang dau - Phat hien nhtfng vi tri soi nieu quan it hoac khong can quang khong thay dtfdc tren phim chup Xquang thong thtfdng
- Xac dinh chi'nh xac nguyen nhan gay nen va vi tri tac nghen, danh gia chtfc nang than va phat hien dtfdc cac di tat bam sinh cua than va dtfdng tiet nieu di kem
4 CHAN D O A N P H A N B IE T
4.1 Vo nieu suy th a n trtfdc than (suy than chtfc nang)
- Soc mat mau, nhiem khuan - Mat ntfdc ngoai te bao
- TSc dong mach than
4.2 Vo nieu suy th a n tai than• ** • • •
- Viem ong than ke (hau san)
- Ngo doc (sot ret ac tinh, mat ca tr^m)
4.3 Vo nieu tac n gh en sau than
- Soi tiet nieu
- Ung thtf tuyen tien liet, co tii cung, buong trtfng
- Ton thtfdng nieu quan sau phau thuat san phu khoa va vung tieu Khung
5 TIEN LLfdN G P H U T H U O C V A O CAC Y E U TO
5.1 N guyen n h a n gay tac
- Tien ltfdng xau neu nguyen nhan tac la ung thtf
- Thuan loi neu nguyen nhan soi nieu quan chtfa gay bien chtfng Co soi nieu quan mot ben cung gay vo nieu hoan toan Day la mot cap ctfu khong tri hoan
5.2 Thdi gian d en d ieu tri
- Neu den cham sau vo nieu 48 gid, benh nhan se gap cac roi loan dien giai kali mau tang, phu phoi cap, nguy cd nhiem trung tang
- Can phat hien sdm vo nieu giai doan thieu nieu (ntfdc tieu dtfdi 500ml/24h) Ty le song phu thuoc vao thdi gian phat hien
(10)5.3 Chtfc nang than va tinh tran g toan than
- Suy than soi nieu quan co miic do: - Suy than co kha nang hoi phuc
- Suy than khong kha nang hoi phuc (vo nieu qua ngay)
- Cao huvet ap soi nieu quan co the la bieu hien cua suv than man hoac soi gay tSc dan den thieu mau nhu mo than
5.4 C hien th u at xtf tri va kha nang dieu tri cua c d sd (hoi siic cap ciiu, than nhan tao)
6 D IEU TRI
6.1 Giai p h o n g tac la Uu tien hang dau Hien co nhieu bien phap: - D in ltfu than qua da dtfdi htfdng dan cua sieu am hay bang phau thuat - Dtfa ong thong nieu quan vtfdt qua vien soi va dat ong thong JJ
- Lay soi nieu quan bang phau thuat hay tan soi qua noi soi nieu quan - Dtfa nieu quan da
- Neu ton thtfdng nieu quan phau thuat: noi phuc hoi ltfu thong nieu quan va dan ltfu than qua da hay dat ong thong JJ
6.2 Dieu tri cac bien chtfng cua suy than cap va n h ie m k h u an
- Hoi stfc tich ctfc va neu can chi dinh chay than nhan tao xuat hien cac veu to nguy cd: creatinin mau > 800mmol/l ure mau > 45mmol/l, kali mau > 6mmol/l pH mau < 7,15
- Dieu tri khang sinh tot nhat theo ket qua khang sinh neu benh nhan sot cao, ret run, bach cau tang cao den muon hoac co nhiem khuan ttf trtfdc
- Sau giai quyet nguyen nhan tac hoac dan ltfu than can theo doi va dieu tri de phong cac bien chtfng sau can thiep: da nieu, roi loan dien giai dac biet la mat kali
6.3 D ieu tri n gu y e n nhan sau da giai q u y et x o n g vo nieu
- Dieu tri soi bkng cac phu'dng phap noi khoa (soi acid uric) va ngoai khoa (tan soi ngoai cd the, tan soi qua noi soi nieu quan, tan soi va lay soi qua da>
- Ung thu' bang quang: cat bang quang toan bo tao hinh bang quang
- Ung thu tuyen tien liet giai doan di can: dua hai nieu quan ngoai da cat tinh hoan va dieu tri hormon Uc che androgen
(11)- Xd hoa sau phuc mac: giai phong nieu quan doan hep va dua vao phuc mac, dieu tri tiep bang thuoc chong viem nhom steroid: cortisol
Vo nieu tac thtfdng gap soi nieu quan va la mot cap ctfu noi ngoai khoa can dtfdc chan doan va xtf tri kip thdi Giai quyet tinh trang tac dtfdng tiet nieu song song vdi hoi stfc noi khoa tich ctfc trtfdc, va sau dieu tri ngoai khoa Sau giai doan dieu tri cap ctfu, can chu y giai quyet cac nguyen nhan gay tac
TAI LIEU T H A M K H A O
1 Chistale SV., Scott—Barrett S., Ho ET et al The management of ureteric obstruction secondary to malignant pelvic disease Clin Radiol 2002, 57: 1118 Chung SY., Stein RJ., Landsitte ID et al 15—year experience with the
management of extrinsic ureteral obstruction with indwelling ureteral stents
J Urol 2004, 172: 592
3 Donat SM., Russo P Ureteral decompression in advanced nonurologic malignancies A nn Surg Oncol 1996, 3: 393
4 Park DS., Park JH., Lee YT Percutaneous nephrostomy versus indwelling ureteral stents in patients with bilateral nongenitourinary malignant extrinsic obstruction J E ndourol 2002, 16: 153
5 Shokeir AA., Shoma AM., Mosbah A et al Noncontrast computed tomography in obstructive anuria: a prospective study Urology 2002, 59: 861
(12)3 OAI MAU
Dai mau dai the la tinh trang ntfdc tieu co mau vdi so ltfdng hong cau nhieu hdn 5000/ml Phan biet vdi dai mau vi the, ntfdc tieu khong co mau nhin bang m;it thtfdng nhtfng co so ltfdng hong cau cao hdn binh thtfdng tren hong cau/1 trtfdng dem
CAn phan biet dai mau vdi:
- Chay mau nieu dao hoac ntfdc tieu lan mau hanh kinh d ntf
- Ntf6c tieu khong co hong cau ma chi co sac to' mat, hemoglobin, myoglobin - Ntfdc tieu co mau s&c dung thuoc nhtf phenothiazin, rifampicin hay cua thtfc an nhtf cu cai
1 TR IE U CHLTNG L A M S A N G
1.1 Tien siY
- Hut thuoc la, dieu tri thuoc chong dong mau
- Benh nhan mac benh than: soi than, than da nang, lao than
- Benh nhan da dtfdc chan doan u bang quang, phi dai hoac ung thtf tuyen tien liet
- Chan thtfdng vung bung, that ltfng hoac tang sinh mon, vd xtfdng chau tai nan giao thong, lao dong
1.2 Thdi d iem x u a t h ien dai m au
- Dai mau bat dau di tieu thtfdng ton thtfdng d co bang quang va nieu dao - Dai mau cuoi di tieu la ton thtfdng tai bang quang: u hoac soi bang quang - Dai mau toan bai nguyen nhan tren than: u than, u dtfdng bai tiet, lao than hoac u bang quang gay chay mau nang Thtfdng bieu hien dai mau dai the co mau cuc
Dai mau thtfdng di kem dai kho, dai dat, dai buo't Doi co cdn dau quan than mau cuc gay tac dtfdng bai tiet
1.3 K h am thvfc the
- Trong trtfdng hdp dai mau nang chan thtfdng than IV - V u than vd, chay mau sau mo benh than, tuyen tien liet, benh nhan co tinh trang soc mat mau: nhdt nhat, va mo hoi, mach nhanh, huyet ap tut, kham thav khoi tu mau ldn sau phiic mac hoac co cau bang quang cang to dtfdi ron Can thiet phai xtf tri cap ctfu
(13)kiem tra vung dtfdi ron co the thay cau bang quang hoac sd thay khoi u Kham biu phat hien gian tinh mach tinh u than co huyet khoi tinh mach than hoac tinh mach chu dtfdi Nghe o bung de phat hien tieng thoi cac bat thtfdng mach mau cua than Cuoi cung, tham trtfc trang danh gia tinh trang tuyen tien liet va vung co bang quang
2 X E T N G H IE M SIN H H O A
Xet nghiem: hong cau, huyet sac to, hematocrit danh gia mtfc mat mau Xet nghiem: ure mau, creatinin mau, cong thtfc bach cau, dong mau toan bo Xet nghiem te bao, vi khuan ntfdc tieu, tinh the, tru nieu, protein nieu Tim te bao ung thtf than, ung thtf bang quang, nam ntfdc tieu
3 CHAN D O A N H iN H A N H
Dong vai tro quan de biet r6 nguyen nhan va mtfc ton thtfdng
- Sieu am dtfdc stf dung dau tien de phat hien cac ton thtfOng tren than: chan thtfdng, soi, nang than va cac ton thtfdng d bang quang va co bang quang: u bang quang, soi bang quang, u tuyen tien liet
- Chup nieu tinh mach phat hien soi than, lao than, u bang quang va danh gia dtfdc chtfc nang than ttfng ben
- Soi bang quang phat hien cac ton thtfdng cua bang quang gay chay mau va chup nieu quan be than ngtfdc dong phat hien ton thtfdng cua dtfdng bai tiet: u dtfdng bai xuat, soi than nieu quan
- Chup cat ldp vi tinh can thiet de xac dinh ro nguyen nhan va mtfc ton thtfdng - Chup dong mach than phat hien cac bat thtfdng mach mau nhu mo than: thong dong - tinh mach than, gia phinh dong mach than, u cd md mach than
4 CHAN D O A N N G U Y E N N H A N
* *>
4.1 N guyen n h a n de ch a n doan
- Sau chan thtfdng: chan thtfdng than, vd bang quang trong, ngoai phuc mac, chan thtfdng nieu dao trtfdc nga dap tang sinh mon va chan thtfdng nieu dao sau (di kem vd xtf dng chau)
- Sau phau thuat benh ly d than, u bang quang, phi dai tuyen tien liet, dac biet co nhiem khuan, nhiem nam
4.2 N gu y en n h a n th eo tuoi benh nhan
- Tre em: Ung thtf nguyen bao than (u Wilms), u cd trdn bang quang Soi than tren di dang bam sinh he tiet nieu
Soi bang quang
(14)- Thanh thieu men: chan thtfdng than, bang quang, nieu dao, soi than
- Ngtfdi ldn: soi than, ung thtf than, ung thtf bang quang, chan thtfdng tiet nieu - Ngtfdi gia: phi dai tuyen tien liet, ung thtf tuyen tien liet, ung thtf than, ung thtf bang quang
4.3 N guyen nhan it gap
- Cac benh co roi loan dong mau: benh tfa chay mau, benh bach cau, suy - Bat thtfdng ve mach mau than: thong dong - tinh mach than, gia phinh dong mach than
- Dai dtfdng chap benh giun chi di kem vdi dai mau
- Lac noi mac ttf cung bang quang va nieu dao d ntf Dai mau trung vdi ky hanh kinh
- Nhiem trung tiet nieu, viem bang quang hay gap d ntf - Benh san bang quang (Bilharziose) hay gap d chau Phi
5 TH A I D O X t f TR I
Nguyen tac:
- Hoi stfc cap ctfu, boi phu mau
- Bdm riia bang quang lay mau cuc co cau bang quang - Cam mau va giai quyet nguyen nhan gay chay mau - Chu y bao ton chtfc nang than
5.1 C han thtfdng th a n n an g IV - V
Chi dinh can thiep cap ctfu chan thtfdng nang dtft cuong than, huyet dong khong on dinh hoac kem theo cac ton thtfdng khac o bung co chi dinh mo Can thiep s6m lam tang kha nang bao ton than: khau cam mau nhu mo than, cat ban phan than, khau phuc hoi mach mau va dtfdng bai tiet Hien nay, tinh trang huyet dong on dinh, co the thtfc hien chup mach va nut chon loc mach ton thtfdng gay chay mau Can thiep dem lai ket qua tot dac biet chay mau vet thtfdng than hoac sau phau thuat than
5.2 C hay m au n a n g u b a n g q u a n g
(15)5.3 C hay m au di d a n g don g - tinh m ach than
Thtfdng chain doan dtfa tren chup dong mach than ket hdp dieu tri bang nut mach than chon loc nhanh dong mach cap mau cho khoi di dang
5.4 Dai m au k em th eo dtfdng chap giun chi
Hien nay, benh ly hiem gap Co the bdm dung dich co chtfa 0,1% - 0,5% Nitrat bac vao ben be than co thoat dtfdng chap va mau
Dai mau rat hay gap cap ctfu noi va ngoai khoa Chan doan thtfdng khong kho trtf mot so trtfdng hdp dac biet Dieu tri dai mau nang can hoi stfc cap ctfu va co bien phap xtf tri thich hdp ve ngoai khoa va Xquang can thiep
t A i l i e u t h a m k h a o
1 Ganatra AM., Loughlin KR The management of malignant ureteral obstruction treated with ureteral stents J Urol 2005, 174: 2125
2 Kristjansson A., Pedersen J (1993), Management of blunt renal trauma, The Bristish Journal o f U rology, 72, pp 692 — 696
3 Mansi M.K., Alkhudair W.K (1997), Conservative management with percutaneous intervention of major blunt renal injuries, The American Journal o f Emergency Medicine, Vol 15, No 7, pp 633 — 637
4 Margenthaler J.A., Weber T.R., Keller M.S (2002), Blunt Renal Trauma in Children: Experience with Conservative Management at a Pediatric Trauma Center, The J ou rn a l o f Traum a Injury, Infection and C ritical Care. 52, pp -
5 Shekarriz B., Shekarriz H., Upadhyay J et al Outcome of palliative urinary diversion in the treatment o f advanced malignancies Cancer 1999, 85: 998
(16)4 BI OAI CAP
Bi dai cap la tinh trang benh nhan rat buon di tieu nhung khong the chu dong cho ntfdc tieu thoat khoi bang quang, gay dau ddn Khac vdi vo nieu, bi dai bieu hien cd cau bang quang cang to
C&n phan biet bi dai cap vdi:
- Bi dai man tinh, thtfdng gap d ngtfdi gia cd phi dai lanh ti'nh tuyen tien liet Khi bang quang qua day thi ntfdc tieu ttf tran va khong gay dau
- Bi dai khong hoan toan benh nhan van di tieu binh thtfdng nhtfng ltfdng ntfdc tieu ton dtf cdn tren 100ml
1 CH AN D O A N X A C D IN H
1.1 Tien stf
- Phat hien va dieu tri sdi tiet nieu
- Cd rdi loan tieu tien: dai khd, dai nhieu lan
- Chan thtfdng vung khung chau va bo phan sinh due - Mo’ benh ly tiet nieu, san phu khoa, dai trtfc trang
1.2 Trieu chtfng lam san g
- Toan than: benh nhan kich thich, keu la Kiem tra mach, huyet ap, nhiet - Kham thay cau bang quang cang to dtfdi ron, go due va dau
- Kham nieu dao: phat hien hep mieng sao, sdi ket nieu dao
- Tham trtfc trang: phat hien phi dai tuyen tien liet hoac u tuyen tien liet
ty
- 0 phu ntf, kham am dao de xac dinh sa ttf cung, u xd ttf cung, u nieu dao - Kham than kinh: danh gia phan xa cd that hau mon va phan xa hanh hang d nam
1.3 X e t n g h ie m sin h h oa
- Ure mau va creatinin mau binh thtfdng hoac tang - Cong thtfc bach cau
- Dinh ltfdng PSA mau binh thtfdng hoac tang tren 4ng/ml
1.4 C han d oan h in h anh
(17)- Sieu am: bang quang cang day niidc tieu, thay hinh anh phi dai tuyen tien liet u bang quang va danh gia mtfc gian cua dtfdng tiet nieu tren
1.5 T ham nieu dao b an g on g th o n g m em
- Danh gia hep nieu dao trtfdc hay nieu dao sau - Phat hien xd ctfng co bang quang
2 CHAN D O AN N G U Y E N N H A N
2.1 Cac benh tuyen tien liet
- Ngtfdi cao tuoi:
+ Phi dai lanh tinh tuyen tien liet: roi loan tieu tien, th&m trtfc trang
+ Ung thtf tuyen tien liet: roi loan tieu tien, xet nghiem PSA tang, tham trtfc trang - Ngtfdi tre: viem tuyen tien liet, ap xe tuyen tien liet
2.2 Cac benh of b a n g q u a n g
- Xd ctfng co bang quang nguyen phat hay mac phai sau mo - U vung co bang quang gay tac
2.3 Cac benh of nieu dao
- Soi ket nieu dao
- Hep mieng sao, hep nieu dao trtfdc, hep nieu dao sau - U nieu dao d ntf va nam
- Van nieu dao sau d tre nam
3 CHAN D O A N P H A N B IE T
- Bi dai man tinh
- Bi dai khong hoan toan - Bi dai phan xa sau mo
- Bi dai nguyen nhan than kinh
4 DIEU TR I
4.1 D at on g th o n g n ieu dao th eo n gu yen tac
- Vo trung, nhe nhang, dung ky thuat vdi ong thong mem 18Fr hay ong thong Tieman theo benh ly
- Chu y cho ntfdc tieu chay ttf ttf, tranh gay chay mau d niem mac bang quang ntfdc tieu thoat qua nhanh
- Chong chi dinh: viem tuyen tien liet, dtft nieu dao, viem mu bang quang
(18)4.2 Choc dan ltfu b a n g q u a n g qua da h oac dSn ltfu b a n g q u a n g tren xtfdng m u
- Chi dinh thtfc hien khong dat dtfdc ong thong nieu dao hoac co chong chi dinh dat o’ng thong nieu dao
- Chong chi dinh choc dan ltfu bang quang qua da neu u bang quang vi se gay chay mau va lan rong ung thtf
4.3 Trtfdng hdp dac biet
- Soi ket nieu dao: bom day soi vao bang quang va tan soi noi soi Xeu khong day dtfdc vao bang quang, phai rach nieu dao d phfa tren, lay soi va khau vtfi nhieu ldp de tranh ro nieu dao
- Ap xe tuyen tien liet: dan ltfu bang quang va choc hut mu qua tang sinh mon Trong moi trtfdng hdp, sau dan ltfu ntfdc tieu can chuan bi tot benh nhan de giai quyet nguyen nhan gay bf dai
tAi l i e u t h a m k h a o
1 Choong S, Emberton M (2000), Acute urinary retention BJU Int, 85:186 Fitzpatrick JM, Kirby RS (2006), Management of acute urinary retention
BJU Int, 97: 16
3 Gulmi FA., Felsen D., Vaughan ED Jr Pathophysiology of lower tract obstruction In.Walsh PC et al (eds) Campbell’s urology, 8th edn Saunders, Philadelphia 2002, pp 411
(19)5 SOI KET NIEU DAO■ ■ ■
Soi ket nieu dao phan ldn tu: bang quang va dtfdng tiet nieu tren di chuyen xudng va dtfng d nieu dao gay dau ddn, dai khd va bi dai Sdi ket nieu dao thtfdng gap d nam gidi, 1/3 nam d nieu dao sau va 2/3 nam d nieu dao trtfdc vdi nhtfng vi tri xoang tuyen tien liet, nieu dao hanh goc dtfdng vat va ho' thuyen nieu dao Thanh phan hoa hoc hay gap nhat la sdi oxalate calci xu xi, cd nhieu gai va kha ran
Trong mot so trtfdng hdp, sdi dtfdc hinh tai chd tren mot doan hep cua nieu dao hoac tui thtfa nieu dao d goc dtfdng vat cd ttf trtfdc Sdi loai thtfdng la sdi phosphate calci va amoni magie phosphate (struvit) cd mau trang nga, de vd
1 CH AN D O A N
1.1 Tien stf
- Dieu tri sdi than hoac da dai sdi mot vai lan
- Dieu tri hep nieu dao hoac cd bieu hien dai khd ttf trtfdc
1.2 Trieu chtfng la m san g thtfdng de ch an doan
- Hay gap cac trieu chtfng bao trtfdc: khd dai, dai buot, dai tac va dai mau dau bai
- Benh nhan thay dau vung nieu dao tang sinh mon, dai khd va tac dai mot cach dot ngot, cd bi dai hoan toan Benh nhan co ran dai chi vai giot ntfdc tieu mau dd
- Kem theo la cdn dau quan vung bung dtfdi ron bi dai hoan toan
- Neu sdi nam tui thtfa nieu dao thi thtfdng gap trieu chtfng viem nhiem: dai due, viem nieu dao
- Tham kham cd the thay chd sdi nam phong len d gan lo sao, d nieu dao goc dtfdng vat hay vung biu tang sinh mon
- Neu sdi nam d nieu dao sau tham dd bang que nong kim loai se thay dau hieu cham sdi
1.3 Trieu chtfng can la m sang
- Chup Xquang he tiet nieu lay qua khdp mu de chan doan nhtfng trtfdng hdp khd phat hien nhtf soi hep nieu dao, soi tui thtfa meu dao co lo thong nhd
- Chup Xquang toan bo he tiet nieu de phat hien soi tiet nieu ket hdp d tren than, nieu quan va bang quang
(20)2 D IEU TRI
2.1 T uyet doi tranh dun g kim phau thuat gap soi ngoai qua nieu dao
vi thudng khong co ket qua va chac chan se lam ton thtfdng niem mac nieu dao gay hep nieu dao
2.2 Phau th u at cap ctfu soi ket nieu dao gay bi dai
- Neu soi d ho thuyen hay gan lo thi nen rach rong lo ve phia gid, lay soi trtfc tiep va khau phuc hoi lai lo
- Neu soi ket d nieu dao goc dtfdng vat hay vtfng biu thi nen dung ap ltfc nude day soi vao bang quang, sau dung may tan soi qua noi soi ngudc dong hoac mo md bang quang lav soi
- Doi vdi soi hinh nguyen nhan tai cho (hep, ro, di vat ttfi thtfa), soi thtfdng bi ket lau hoac co chit hep nieu dao d phia trtfdc thi co the rach nieu dao lay soi De tranh ro nieu dao, nen rach nieu dao d phia tren (12 gid) sau boc tach nieu dao khoi vat hang, lay soi va xoay nieu dao 90 do, sau khau lai nieu dao va dat vao vi tri cu (phtfdng phap Monseur)
2.3 Sau lay soi ket nieu dao can giai q u y et n g u y e n nhan
- Soi tren than va nieu quan: tan soi ngoai cd the hay tan soi noi soi nieu quan - Soi bang quang: giai quyet hep co bang quang, dieu tri u phi dai tuyen tien liet - Dieu tri hep nieu dao: cat nieu dao, tao hinh nieu dao
Chan doan soi ket nieu dao khong kho nhtfng can tim bien phap lay soi ket nieu dao dam bao an toan nhat va khong lam ton thtfdng nieu dao Sau lay soi nieu dao, can dieu tri nguyen nhan d than, nieu quan, bang quang hay d nieu dao
TAI L IE U T H A M K H A O
1 Emberton M, Anson K (1999), Acute urinary retention in men: an age old problem BMJ, 318: 921
2 Morey AF, Hernandez J, M cAm nch JW (1999), Reconstructive surgery for trauma of the lower urinary tract Urol Clm North Am, 26: 49
3 Segura JW., Preminger GM., Assimos DG et al Ureteral stones clinical guidelines panel summary report on the management o f ureteral calculi The American Urological Association J Urol 1997, 158: 1915