{"id":801,"date":"2026-05-16T15:28:24","date_gmt":"2026-05-16T08:28:24","guid":{"rendered":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/?p=801"},"modified":"2026-05-16T15:28:25","modified_gmt":"2026-05-16T08:28:25","slug":"chuong-131-tiep-can-than-qua-da","status":"publish","type":"post","link":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/chuong-131-tiep-can-than-qua-da\/","title":{"rendered":"Ch\u01b0\u01a1ng 131: Ti\u1ebfp c\u1eadn Th\u1eadn qua da"},"content":{"rendered":"\n

T\u00e1c gi\u1ea3: NICOLE MILLER V\u00c0 JAMES E. LINGEMAN<\/strong><\/p>\n\n\n\n

D\u1ecbch thu\u1eadt: B\u00e1c s\u0129 Ph\u00fa Ti\u1ebft Ni\u1ec7u <\/strong><\/p>\n\n\n\n

Ti\u1ebfp c\u1eadn th\u1eadn qua da l\u1ea7n \u0111\u1ea7u ti\u00ean \u0111\u01b0\u1ee3c Goodwin v\u00e0 c\u00e1c c\u1ed9ng s\u1ef1 m\u00f4 t\u1ea3 v\u00e0o n\u0103m 1955 nh\u1eb1m m\u1ee5c \u0111\u00edch gi\u1ea3i \u00e1p cho th\u1eadn b\u1ecb \u1ee9 n\u01b0\u1edbc. S\u1ef1 ph\u00e1t tri\u1ec3n nhanh ch\u00f3ng c\u1ee7a c\u00e1c k\u1ef9 thu\u1eadt ti\u1ebfp c\u1eadn th\u1eadn qua da \u0111\u00e3 d\u1eabn \u0111\u1ebfn nh\u1eefng \u1ee9ng d\u1ee5ng v\u01b0\u1ee3t xa vi\u1ec7c d\u1eabn l\u01b0u \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u \u0111\u01a1n thu\u1ea7n. Ph\u1eabu thu\u1eadt th\u1eadn qua da hi\u1ec7n \u0111\u00f3ng vai tr\u00f2 n\u1ed5i b\u1eadt trong \u0111i\u1ec1u tr\u1ecb nhi\u1ec1u t\u00ecnh tr\u1ea1ng b\u1ec7nh l\u00fd ti\u1ebft ni\u1ec7u kh\u00e1c nhau. Vi\u1ec7c th\u1ef1c hi\u1ec7n ti\u1ebfp c\u1eadn qua da an to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3 l\u00e0 kh\u00eda c\u1ea1nh then ch\u1ed1t nh\u1ea5t \u0111\u1ec3 ph\u1eabu thu\u1eadt th\u1eadn qua da th\u00e0nh c\u00f4ng.<\/p>\n\n\n\n

CH\u1ec8 \u0110\u1ecaNH<\/strong><\/p>\n\n\n\n

Ti\u1ebfp c\u1eadn th\u1eadn qua da \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n cho c\u1ea3 c\u00e1c can thi\u1ec7p ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb. C\u00e1c x\u00e9t nghi\u1ec7m ch\u1ea9n \u0111o\u00e1n s\u1eed d\u1ee5ng ti\u1ebfp c\u1eadn qua da bao g\u1ed3m ch\u1ee5p b\u1ec3 th\u1eadn xu\u00f4i d\u00f2ng v\u00e0 nghi\u00ean c\u1ee9u \u00e1p l\u1ef1c\/t\u01b0\u1edbi m\u00e1u (nghi\u1ec7m ph\u00e1p Whitaker). C\u00e1c ch\u1ec9 \u0111\u1ecbnh \u0111i\u1ec1u tr\u1ecb ph\u1ed5 bi\u1ebfn bao g\u1ed3m d\u1eabn l\u01b0u th\u1eadn b\u1ecb t\u1eafc ngh\u1ebdn, \u0111i\u1ec1u tr\u1ecb s\u1ecfi th\u1eadn ph\u1ee9c t\u1ea1p, x\u1ebb b\u1ec3 th\u1eadn n\u1ed9i soi xu\u00f4i d\u00f2ng (antegrade endopyelotomy) cho t\u1eafc ngh\u1ebdn kh\u00fac n\u1ed1i b\u1ec3 th\u1eadn – ni\u1ec7u qu\u1ea3n (UPJ), c\u1eaft b\u1ecf n\u1ed9i soi ung th\u01b0 bi\u1ec3u m\u00f4 t\u1ebf b\u00e0o chuy\u1ec3n ti\u1ebfp \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u tr\u00ean, \u0111i\u1ec1u tr\u1ecb h\u1eb9p ni\u1ec7u qu\u1ea3n, l\u1ea5y d\u1ecb v\u1eadt (v\u00ed d\u1ee5: stent b\u1ecb b\u1ecf qu\u00ean) v\u00e0 b\u01a1m c\u00e1c t\u00e1c nh\u00e2n t\u1ea1i ch\u1ed7 v\u00e0o trong th\u1eadn (thu\u1ed1c tan s\u1ecfi, h\u00f3a tr\u1ecb\/li\u1ec7u ph\u00e1p mi\u1ec5n d\u1ecbch).<\/p>\n\n\n\n

L\u1ea5y s\u1ecfi th\u1eadn qua da (PNL) cho \u0111\u1ebfn nay l\u00e0 ph\u1eabu thu\u1eadt ph\u1ed5 bi\u1ebfn nh\u1ea5t s\u1eed d\u1ee5ng \u0111\u01b0\u1eddng v\u00e0o th\u1eadn qua da. PNL \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh cho \u0111i\u1ec1u tr\u1ecb s\u1ecfi san h\u00f4 (staghorn calculi), s\u1ecfi c\u00f3 k\u00edch th\u01b0\u1edbc l\u1edbn (> 2 cm), s\u1ecfi th\u00e0nh ph\u1ea7n cystine, brushite, struvite ho\u1eb7c canxi oxalat monohydrat, s\u1ecfi ni\u1ec7u qu\u1ea3n \u0111o\u1ea1n g\u1ea7n k\u00edch th\u01b0\u1edbc l\u1edbn ho\u1eb7c b\u1ecb k\u1eb9t, s\u1ecfi t\u00fai th\u1eeba \u0111\u00e0i th\u1eadn, s\u1ecfi th\u1eadn l\u1ea1c ch\u1ed7 (th\u1eadn m\u00f3ng ng\u1ef1a, th\u1eadn ch\u1eadu ho\u1eb7c th\u1eadn gh\u00e9p), t\u1eafc ngh\u1ebdn UPJ k\u00e8m s\u1ecfi th\u1eadn, s\u1ecfi c\u1ef1c d\u01b0\u1edbi th\u1eadn l\u1edbn h\u01a1n 1 cm v\u00e0 c\u00e1c s\u1ecfi \u0111\u00e3 th\u1ea5t b\u1ea1i sau n\u1ed9i soi ni\u1ec7u qu\u1ea3n ho\u1eb7c t\u00e1n s\u1ecfi ngo\u00e0i c\u01a1 th\u1ec3.<\/p>\n\n\n\n

\u0110\u00c1NH GI\u00c1 TR\u01af\u1edaC M\u1ed4<\/strong><\/p>\n\n\n\n

C\u1ea7n khai th\u00e1c b\u1ec7nh s\u1eed v\u00e0 th\u0103m kh\u00e1m l\u00e2m s\u00e0ng \u0111\u1ea7y \u0111\u1ee7 cho t\u1ea5t c\u1ea3 b\u1ec7nh nh\u00e2n tr\u01b0\u1edbc khi ti\u1ebfp c\u1eadn qua da. \u0110\u1eb7c bi\u1ec7t l\u01b0u \u00fd x\u00e1c \u0111\u1ecbnh c\u00e1c t\u00ecnh tr\u1ea1ng ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh ti\u1ebfp c\u1eadn qua da nh\u01b0 r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u v\u00e0 nhi\u1ec5m khu\u1ea9n \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u (UTI) ho\u1ea1t \u0111\u1ed9ng, tr\u1eeb khi v\u00ec m\u1ee5c \u0111\u00edch gi\u1ea3i \u00e1p t\u1eafc ngh\u1ebdn ho\u1eb7c nhi\u1ec5m tr\u00f9ng huy\u1ebft. N\u1ebfu \u0111i\u1ec1u ki\u1ec7n y khoa cho ph\u00e9p, n\u00ean ng\u01b0ng aspirin v\u00e0 c\u00e1c thu\u1ed1c ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u kh\u00e1c 7 ng\u00e0y tr\u01b0\u1edbc ph\u1eabu thu\u1eadt. X\u00e9t nghi\u1ec7m tr\u01b0\u1edbc m\u1ed5 bao g\u1ed3m c\u00f4ng th\u1ee9c m\u00e1u to\u00e0n b\u1ed9, \u0111i\u1ec7n gi\u1ea3i \u0111\u1ed3 huy\u1ebft thanh v\u00e0 \u0111\u00e1nh gi\u00e1 ch\u1ee9c n\u0103ng th\u1eadn. T\u1ea5t c\u1ea3 b\u1ec7nh nh\u00e2n ph\u1ea3i \u0111\u01b0\u1ee3c c\u1ea5y n\u01b0\u1edbc ti\u1ec3u tr\u01b0\u1edbc m\u1ed5 \u0111\u1ec3 lo\u1ea1i tr\u1eeb UTI. \u0110i\u1ec1u n\u00e0y \u0111\u1eb7c bi\u1ec7t quan tr\u1ecdng \u1edf b\u1ec7nh nh\u00e2n c\u00f3 b\u00e0ng quang th\u1ea7n kinh v\u00e0 d\u1eabn l\u01b0u n\u01b0\u1edbc ti\u1ec3u v\u1ed1n th\u01b0\u1eddng c\u00f3 vi khu\u1ea9n \u0111\u1ecbnh c\u01b0 v\u00e0\/ho\u1eb7c nhi\u1ec5m c\u00e1c ch\u1ee7ng kh\u00e1ng thu\u1ed1c.<\/p>\n\n\n\n

\u1ede b\u1ec7nh nh\u00e2n th\u1ef1c hi\u1ec7n PNL, khuy\u1ebfn c\u00e1o d\u00f9ng kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng trong 2 tu\u1ea7n ngay c\u1ea3 khi c\u1ea5y n\u01b0\u1edbc ti\u1ec3u \u00e2m t\u00ednh v\u00ec s\u1ecfi c\u00f3 th\u1ec3 ch\u1ee9a vi khu\u1ea9n. Cephalosporin l\u00e0 kh\u00e1ng sinh ph\u00f9 h\u1ee3p nh\u1ea5t \u0111\u1ec3 d\u1ef1 ph\u00f2ng ngay tr\u01b0\u1edbc m\u1ed5 \u1edf b\u1ec7nh nh\u00e2n s\u1ecfi kh\u00f4ng nhi\u1ec5m tr\u00f9ng, v\u00ec t\u00e1c nh\u00e2n g\u00e2y nhi\u1ec5m tr\u00f9ng th\u1ee9 ph\u00e1t ph\u1ed5 bi\u1ebfn nh\u1ea5t l\u00e0 Staphylococcus epidermidis<\/em>. B\u1ec7nh nh\u00e2n b\u00e9o ph\u00ec \u0111\u1ed9 III (morbidly obese) c\u1ea7n l\u01b0u \u00fd \u0111\u1eb7c bi\u1ec7t v\u00ec h\u1ecd th\u01b0\u1eddng c\u00f3 b\u1ec7nh l\u00fd tim m\u1ea1ch v\u00e0\/ho\u1eb7c ph\u1ed5i, g\u00e2y th\u00e1ch th\u1ee9c cho g\u00e2y m\u00ea, \u0111\u1eb7c bi\u1ec7t khi n\u1eb1m s\u1ea5p.<\/p>\n\n\n\n

Cu\u1ed1i c\u00f9ng, ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh tr\u01b0\u1edbc m\u1ed5 l\u00e0 thi\u1ebft y\u1ebfu \u0111\u1ec3 l\u1eadp k\u1ebf ho\u1ea1ch ti\u1ebfp c\u1eadn qua da. Ch\u1ee5p b\u1ec3 th\u1eadn t\u0129nh m\u1ea1ch (IVP) \u0111\u00e3 \u0111\u01b0\u1ee3c thay th\u1ebf ph\u1ea7n l\u1edbn b\u1edfi ch\u1ee5p c\u1eaft l\u1edbp vi t\u00ednh (CT). CT \u0111\u1eb7c bi\u1ec7t h\u1eefu \u00edch trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p d\u1ecb t\u1eadt th\u1eadn b\u1ea9m sinh, th\u1eadn gh\u00e9p, b\u00e9o ph\u00ec \u0111\u1ed9 III v\u00e0 bi\u1ebfn d\u1ea1ng c\u1ed9t s\u1ed1ng \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 c\u00e1c c\u1ea5u tr\u00fac t\u1ea1ng l\u00e2n c\u1eadn. M\u1eb7c d\u00f9 hi\u1ebfm g\u1eb7p (< 1%), CT c\u0169ng c\u00f3 th\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ea1i tr\u00e0ng sau th\u1eadn (retrorenal colon), t\u1ec9 l\u1ec7 n\u00e0y c\u00f3 th\u1ec3 cao h\u01a1n \u1edf b\u1ec7nh nh\u00e2n c\u00f3 ph\u1eabu thu\u1eadt n\u1ed1i t\u1eaft h\u1ed7ng h\u1ed3i tr\u00e0ng (jejunoileal bypass) ho\u1eb7c ch\u1ea5n th\u01b0\u01a1ng t\u1ee7y s\u1ed1ng. IVP v\u00e0\/ho\u1eb7c ch\u1ee5p b\u1ec3 th\u1eadn ng\u01b0\u1ee3c d\u00f2ng v\u1eabn h\u1eefu \u00edch \u1edf b\u1ec7nh nh\u00e2n c\u00f3 t\u00fai th\u1eeba \u0111\u00e0i th\u1eadn \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh m\u1ed1i li\u00ean quan gi\u1eefa khoang t\u00fai th\u1eeba v\u00e0 h\u1ec7 th\u1ed1ng g\u00f3p. Phim CT 3D t\u00e1i t\u1ea1o ho\u1eb7c CT h\u1ec7 ti\u1ebft ni\u1ec7u (CT urogram) c\u00f3 th\u1ec3 h\u1eefu \u00edch trong vi\u1ec7c l\u1eadp k\u1ebf ho\u1ea1ch ti\u1ebfp c\u1eadn \u0111i\u1ec1u tr\u1ecb u bi\u1ec3u m\u00f4 \u0111\u01b0\u1eddng ni\u1ec7u, t\u1eafc ngh\u1ebdn UPJ ho\u1eb7c s\u1ecfi \u1edf th\u1eadn l\u1ea1c ch\u1ed7.<\/p>\n\n\n\n

C\u00c1C C\u00c2N NH\u1eaeC GI\u1ea2I PH\u1eaaU<\/strong><\/p>\n\n\n\n

Vi\u1ec7c n\u1eafm v\u1eefng gi\u1ea3i ph\u1eabu th\u1eadn c\u01a1 b\u1ea3n l\u00e0 thi\u1ebft y\u1ebfu \u0111\u1ec3 ti\u1ebfp c\u1eadn th\u1eadn qua da an to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3. Th\u1eadn n\u1eb1m nghi\u00eang trong khoang sau ph\u00fac m\u1ea1c, ph\u00eda tr\u01b0\u1edbc c\u01a1 th\u1eaft l\u01b0ng (psoas) v\u00e0 c\u01a1 vu\u00f4ng th\u1eaft l\u01b0ng (quadratus lumborum). C\u00e1c l\u1edbp c\u01a1 n\u00e0y m\u1ecfng h\u01a1n \u1edf ph\u00eda tr\u00ean; do \u0111\u00f3, c\u1ef1c tr\u00ean c\u1ee7a th\u1eadn n\u1eb1m s\u00e2u (ph\u00eda sau) h\u01a1n c\u1ef1c d\u01b0\u1edbi. Th\u1eadn ph\u1ea3i n\u1eb1m c\u1ea1nh x\u01b0\u01a1ng s\u01b0\u1eddn 12, gan, t\u00e1 tr\u00e0ng v\u00e0 g\u00f3c gan c\u1ee7a \u0111\u1ea1i tr\u00e0ng, v\u00e0 n\u1eb1m th\u1ea5p h\u01a1n th\u1eadn tr\u00e1i 2 – 3 cm do v\u1ecb tr\u00ed c\u1ee7a gan. C\u00e1c c\u1ea5u tr\u00fac gi\u00e1p th\u1eadn tr\u00e1i g\u1ed3m x\u01b0\u01a1ng s\u01b0\u1eddn 11 v\u00e0 12, t\u1ee5y, l\u00e1ch v\u00e0 g\u00f3c l\u00e1ch c\u1ee7a \u0111\u1ea1i tr\u00e0ng. M\u00e0ng ph\u1ed5i th\u01b0\u1eddng b\u00e1m ngang m\u1ee9c x\u01b0\u01a1ng s\u01b0\u1eddn 11, c\u1ea7n l\u01b0u \u00fd \u0111i\u1ec1u n\u00e0y, \u0111\u1eb7c bi\u1ec7t khi l\u1eadp k\u1ebf ho\u1ea1ch ti\u1ebfp c\u1eadn tr\u00ean s\u01b0\u1eddn (supracostal access).<\/p>\n\n\n\n

Ki\u1ebfn th\u1ee9c v\u1ec1 c\u00e1c c\u1ea5u tr\u00fac m\u1ea1ch m\u00e1u ch\u00ednh c\u1ee7a th\u1eadn v\u00e0 m\u1ed1i li\u00ean quan c\u1ee7a ch\u00fang v\u1edbi h\u1ec7 th\u1ed1ng g\u00f3p c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m nguy c\u01a1 tai bi\u1ebfn xu\u1ea5t huy\u1ebft. \u0110\u1ed9ng m\u1ea1ch th\u1eadn ch\u00ednh th\u01b0\u1eddng chia th\u00e0nh nh\u00e1nh tr\u01b0\u1edbc v\u00e0 nh\u00e1nh sau. V\u00f9ng v\u00f4 m\u1ea1ch gi\u1eefa hai nh\u00e1nh n\u00e0y \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 \u0111\u01b0\u1eddng v\u00f4 m\u1ea1ch Br\u00f6del<\/strong>, l\u00e0 \u0111i\u1ec3m l\u00fd t\u01b0\u1edfng \u0111\u1ec3 v\u00e0o th\u1eadn. Do h\u01b0\u1edbng c\u1ee7a th\u1eadn trong khoang sau ph\u00fac m\u1ea1c, \u0111\u01b0\u1eddng v\u00e0o qua \u0111\u00e0i sau<\/strong> th\u01b0\u1eddng \u0111i qua \u0111\u01b0\u1eddng n\u00e0y. V\u00ec l\u00fd do n\u00e0y, \u0111\u00e0i sau l\u00e0 v\u1ecb tr\u00ed \u01b0u ti\u00ean \u0111\u1ec3 ti\u1ebfp c\u1eadn qua da v\u00ec n\u00f3 li\u00ean quan \u0111\u1ebfn nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u th\u1ea5p h\u01a1n v\u00e0 th\u01b0\u1eddng cho ph\u00e9p \u0111\u01b0a d\u00e2y d\u1eabn ra kh\u1ecfi \u0111\u00e0i th\u1eadn v\u00e0 xu\u1ed1ng ni\u1ec7u qu\u1ea3n (H\u00ecnh 131-1).<\/p>\n\n\n\n

\"\"
H\u00ccNH 131-1. \u0110\u00e0i th\u1eadn sau l\u00e0 v\u1ecb tr\u00ed \u01b0u ti\u00ean \u0111\u1ec3 ti\u1ebfp c\u1eadn th\u1eadn qua da v\u00ec n\u00f3 th\u01b0\u1eddng \u0111i ngang qua \u0111\u01b0\u1eddng Brodel.<\/figcaption><\/figure>\n\n\n\n

\u0110\u1eb7t b\u1ec7nh nh\u00e2n n\u1eb1m s\u1ea5p s\u1ebd \u0111\u01b0a c\u00e1c \u0111\u00e0i sau v\u1ec1 v\u1ecb tr\u00ed th\u1eb3ng \u0111\u1ee9ng (end-on), thu\u1eadn l\u1ee3i cho vi\u1ec7c ch\u1ecdc d\u00f2 v\u00e0o \u0111\u00e0i sau. V\u00f4 t\u00ecnh ch\u1ecdc qu\u00e1 m\u1eb7t tr\u01b0\u1edbc c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p c\u00f3 nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng c\u00e1c m\u1ea1ch m\u00e1u ph\u00e2n th\u00f9y tr\u01b0\u1edbc l\u1edbn; \u0111\u00e2y l\u00e0 bi\u1ebfn ch\u1ee9ng ph\u1ee9c t\u1ea1p v\u00ec c\u00e1c m\u1ea1ch n\u00e0y kh\u00f3 c\u00f3 th\u1ec3 ch\u00e8n \u00e9p b\u1eb1ng \u1ed1ng d\u1eabn l\u01b0u th\u1eadn ho\u1eb7c b\u00f3ng ch\u00e8n.<\/p>\n\n\n\n

V\u1ecb tr\u00ed ch\u1ecdc \u01b0u ti\u00ean v\u00e0o \u0111\u00e0i sau l\u00e0 qua nh\u00fa th\u1eadn (papilla)<\/strong> ho\u1eb7c v\u00f2m \u0111\u00e0i th\u1eadn (fornix)<\/strong>. N\u00ean tr\u00e1nh ch\u1ecdc v\u00e0o c\u1ed5 \u0111\u00e0i (infundibular puncture) ho\u1eb7c ch\u1ecdc tr\u1ef1c ti\u1ebfp v\u00e0o b\u1ec3 th\u1eadn do nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u l\u1edbn \u0111\u00e1ng k\u1ec3. H\u01a1n n\u1eefa, ti\u1ebfp c\u1eadn tr\u1ef1c ti\u1ebfp v\u00e0o b\u1ec3 th\u1eadn c\u00f3 r\u1ee7i ro g\u00e2y r\u00f2 r\u1ec9 n\u01b0\u1edbc ti\u1ec3u k\u00e9o d\u00e0i ho\u1eb7c d\u1ec5 tu\u1ed9t \u1ed1ng d\u1eabn l\u01b0u. Khi \u0111\u01b0\u1eddng v\u00e0o qua nh\u00fa th\u1eadn ho\u1eb7c v\u00f2m \u0111\u00e0i th\u1eadn v\u00e0 th\u1eb3ng h\u00e0ng v\u1edbi c\u1ed5 \u0111\u00e0i, \u1ed1ng soi th\u1eadn c\u1ee9ng c\u00f3 th\u1ec3 thao t\u00e1c hi\u1ec7u qu\u1ea3 m\u00e0 kh\u00f4ng c\u1ea7n l\u1ef1c xo\u1eafn (torque) qu\u00e1 m\u1ee9c g\u00e2y ch\u1ea5n th\u01b0\u01a1ng th\u1eadn v\u00e0 ch\u1ea3y m\u00e1u. \u0110\u1ec3 gi\u1ea3m nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng \u0111\u1ea1i tr\u00e0ng, v\u1ecb tr\u00ed ch\u1ecdc n\u00ean n\u1eb1m \u1edf ph\u00eda trong so v\u1edbi \u0111\u01b0\u1eddng n\u00e1ch sau v\u00ec \u0111\u1ea1i tr\u00e0ng th\u01b0\u1eddng n\u1eb1m \u1edf ph\u00eda tr\u01b0\u1edbc ho\u1eb7c tr\u01b0\u1edbc b\u00ean so v\u1edbi ph\u1ea7n ngo\u00e0i c\u00f9ng c\u1ee7a th\u1eadn. C\u0169ng n\u00ean tr\u00e1nh ch\u1ecdc qu\u00e1 s\u00e1t \u0111\u01b0\u1eddng gi\u1eefa v\u00ec s\u1ebd \u0111i xuy\u00ean qua kh\u1ed1i c\u01a1 c\u1ea1nh s\u1ed1ng l\u00e0m t\u0103ng \u0111au sau m\u1ed5. Cu\u1ed1i c\u00f9ng, khi ti\u1ebfp c\u1eadn tr\u00ean s\u01b0\u1eddn, kh\u00f4ng n\u00ean ch\u1ecdc qu\u00e1 s\u00e1t x\u01b0\u01a1ng s\u01b0\u1eddn v\u00ec c\u00f3 th\u1ec3 t\u1ed5n th\u01b0\u01a1ng th\u1ea7n kinh v\u00e0\/ho\u1eb7c m\u1ea1ch m\u00e1u li\u00ean s\u01b0\u1eddn.<\/p>\n\n\n\n

TI\u1ebeP C\u1eacN QUA DA C\u1ef0C D\u01af\u1edaI TI\u00caU CHU\u1ea8N<\/strong><\/p>\n\n\n\n

D\u1ee5ng c\u1ee5<\/strong><\/p>\n\n\n\n

    \n
  • M\u00e0n t\u0103ng s\u00e1ng (C-arm fluoroscopy)<\/li>\n\n\n\n
  • \u1ed0ng soi b\u00e0ng quang c\u1ee9ng 22-French<\/li>\n\n\n\n
  • Catheter ni\u1ec7u qu\u1ea3n \u0111\u1ea7u h\u1edf 5-French ho\u1eb7c catheter b\u00f3ng ch\u00e8n (occlusion balloon)<\/li>\n\n\n\n
  • Sonde Foley 16-French<\/li>\n\n\n\n
  • Kim ch\u1ecdc d\u00f2 \u0111\u1ea7u kim c\u01b0\u01a1ng (diamond-tip) 18-gauge<\/li>\n\n\n\n
  • D\u00e2y d\u1eabn (Wires):<\/strong> Glidewire \u0111\u1ea7u th\u1eb3ng 0.035-inch, d\u00e2y l\u00f5i th\u00e1o r\u1eddi (removable core wire) th\u1eb3ng 0.035-inch, d\u00e2y Amplatz superstiff 0.035-inch, d\u00e2y J-wire l\u00f5i th\u00e1o r\u1eddi 0.035-inch.<\/li>\n\n\n\n
  • Catheter ch\u1ee5p m\u1ea1ch 5-French<\/li>\n\n\n\n
  • B\u1ed9 nong c\u00e2n (fascial dilator) 8-French; b\u1ed9 nong \u0111\u1ed3ng tr\u1ee5c (coaxial dilator) 8\/10-French<\/li>\n\n\n\n
  • B\u00f3ng nong Nephromax; b\u01a1m LeVeen<\/li>\n\n\n\n
  • V\u1ecf Amplatz (Amplatz sheath) 30-French<\/li>\n<\/ul>\n\n\n\n

    Soi b\u00e0ng quang, \u0111\u1eb7t catheter ni\u1ec7u qu\u1ea3n<\/strong><\/p>\n\n\n\n

    B\u01b0\u1edbc \u0111\u1ea7u ti\u00ean l\u00e0 soi b\u00e0ng quang \u0111\u1eb7t catheter ni\u1ec7u qu\u1ea3n \u0111\u1ec3 b\u01a1m thu\u1ed1c c\u1ea3n quang ng\u01b0\u1ee3c d\u00f2ng l\u00e0m hi\u1ec7n h\u00ecnh h\u1ec7 th\u1ed1ng g\u00f3p. Th\u1ee7 thu\u1eadt n\u00e0y \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u1edf t\u01b0 th\u1ebf ph\u1ee5 khoa \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o \u0111\u1eb7t catheter nhanh ch\u00f3ng v\u00e0 x\u1eed tr\u00ed d\u1ec5 d\u00e0ng c\u00e1c t\u00ecnh tr\u1ea1ng b\u1ec7nh l\u00fd nh\u01b0 h\u1eb9p ni\u1ec7u \u0111\u1ea1o ho\u1eb7c ni\u1ec7u qu\u1ea3n. Th\u01b0\u1eddng d\u00f9ng catheter ni\u1ec7u qu\u1ea3n \u0111\u1ea7u h\u1edf 5 ho\u1eb7c 6-French; tuy nhi\u00ean, n\u00ean c\u00e2n nh\u1eafc d\u00f9ng catheter b\u00f3ng ch\u00e8n 7-French khi s\u1ecfi l\u1edbn ho\u1eb7c ni\u1ec7u qu\u1ea3n \u0111o\u1ea1n g\u1ea7n gi\u00e3n. Sonde Foley \u0111\u1ea3m b\u1ea3o d\u1eabn l\u01b0u b\u00e0ng quang trong su\u1ed1t qu\u00e1 tr\u00ecnh can thi\u1ec7p qua da.<\/p>\n\n\n\n

    M\u1ed9t s\u1ed1 ph\u1eabu thu\u1eadt vi\u00ean \u01b0u ti\u00ean t\u01b0 th\u1ebf n\u1eb1m s\u1ea5p t\u00e1ch ch\u00e2n (prone split-leg). T\u01b0 th\u1ebf n\u00e0y th\u01b0\u1eddng d\u00f9ng khi th\u1ef1c hi\u1ec7n ti\u1ebfp c\u1eadn k\u1ebft h\u1ee3p xu\u00f4i d\u00f2ng v\u00e0 ng\u01b0\u1ee3c d\u00f2ng. C\u1ea7n c\u00f3 b\u00e0n m\u1ed5 cho ph\u00e9p t\u00e1ch ch\u00e2n. Sau \u0111\u00f3 soi b\u00e0ng quang \u1ed1ng m\u1ec1m \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u0111\u1ec3 thi\u1ebft l\u1eadp \u0111\u01b0\u1eddng v\u00e0o ng\u01b0\u1ee3c d\u00f2ng, th\u01b0\u1eddng th\u00f4ng qua v\u1ecf ti\u1ebfp c\u1eadn ni\u1ec7u qu\u1ea3n (access sheath).<\/p>\n\n\n\n

    T\u01b0 th\u1ebf b\u1ec7nh nh\u00e2n<\/strong><\/p>\n\n\n\n

    B\u1ec7nh nh\u00e2n n\u1eb1m s\u1ea5p, b\u00ean c\u1ea7n \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c n\u00e2ng cao 30 \u0111\u1ed9 b\u1eb1ng \u0111\u1ec7m x\u1ed1p (H\u00ecnh 131-2). T\u01b0 th\u1ebf n\u00e0y h\u1ed7 tr\u1ee3 th\u00f4ng kh\u00ed v\u00e0 \u0111\u01b0a c\u00e1c \u0111\u00e0i sau v\u1ec1 v\u1ecb tr\u00ed th\u1eb3ng \u0111\u1ee9ng. C\u00e1c \u0111i\u1ec3m t\u00ec \u0111\u00e8 \u0111\u01b0\u1ee3c \u0111\u1ec7m l\u00f3t. C\u00e1nh tay b\u00ean ph\u1eabu thu\u1eadt \u0111\u01b0\u1ee3c g\u1ea5p \u1edf khu\u1ef7u v\u00e0 \u0111\u1eb7t tr\u00ean gi\u00e1 \u0111\u1ee1, tay \u0111\u1ed1i di\u1ec7n \u0111\u1eb7t d\u1ecdc th\u00e2n m\u00ecnh. Trong PNL hai b\u00ean, b\u1ec7nh nh\u00e2n n\u1eb1m s\u1ea5p th\u1eb3ng, x\u1eed tr\u00ed b\u00ean c\u00f3 tri\u1ec7u ch\u1ee9ng ho\u1eb7c s\u1ecfi l\u1edbn h\u01a1n tr\u01b0\u1edbc. \u1ed0ng n\u1ed1i d\u00e0i t\u0129nh m\u1ea1ch \u0111\u01b0\u1ee3c k\u1ebft n\u1ed1i v\u1edbi catheter ni\u1ec7u qu\u1ea3n ho\u1eb7c c\u1ed5ng b\u00f3ng ch\u00e8n \u0111\u1ec3 b\u01a1m\/x\u1ea3 b\u00f3ng ho\u1eb7c b\u01a1m thu\u1ed1c c\u1ea3n quang.<\/p>\n\n\n\n

    \"\"
    H\u00ccNH 131-2. T\u01b0 th\u1ebf b\u1ec7nh nh\u00e2n. Cu\u1ed9n ng\u1ef1c\/\u0111\u1ec7m n\u00e2ng 30 \u0111\u1ed9 gi\u00fap \u0111\u01b0a c\u00e1c \u0111\u00e0i th\u1eadn ph\u00eda sau v\u00e0o v\u1ecb tr\u00ed th\u1eb3ng \u0111\u1ee9ng.<\/figcaption><\/figure>\n\n\n\n

    Thi\u1ebft l\u1eadp h\u00ecnh \u1ea3nh – M\u00e0n t\u0103ng s\u00e1ng<\/strong><\/p>\n\n\n\n

    M\u1eb7c d\u00f9 si\u00eau \u00e2m v\u00e0 CT d\u1eabn \u0111\u01b0\u1eddng \u0111\u00e3 \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3, m\u00e0n t\u0103ng s\u00e1ng C-arm hai m\u1eb7t ph\u1eb3ng (biplanar fluoroscopy) v\u1eabn l\u00e0 ph\u01b0\u01a1ng ph\u00e1p ph\u1ed5 bi\u1ebfn nh\u1ea5t. X\u00e1c \u0111\u1ecbnh h\u01b0\u1edbng \u0111\u00e0i th\u1eadn v\u00e0 l\u1ef1a ch\u1ecdn \u0111\u00e0i th\u1eadn m\u1ee5c ti\u00eau t\u1ed1t nh\u1ea5t b\u1eb1ng C-arm hai m\u1eb7t ph\u1eb3ng. H\u1ec7 th\u1ed1ng C-arm \u01b0u vi\u1ec7t h\u01a1n b\u00e0n ti\u1ebft ni\u1ec7u c\u00f3 b\u00f3ng X-quang c\u1ed1 \u0111\u1ecbnh v\u00ec cho ph\u00e9p di chuy\u1ec3n linh ho\u1ea1t gi\u1eefa c\u00e1c g\u00f3c nh\u00ecn th\u1eb3ng (AP) v\u00e0 nghi\u00eang (oblique), \u0111\u1ed3ng th\u1eddi gi\u1ea3m ph\u01a1i nhi\u1ec5m b\u1ee9c x\u1ea1 t\u00e1n x\u1ea1 cho ph\u1eabu thu\u1eadt vi\u00ean do ngu\u1ed3n ph\u00e1t d\u01b0\u1edbi b\u00e0n. Toan b\u1ecdc C-arm \u0111\u01b0\u1ee3c d\u00f9ng \u0111\u1ec3 duy tr\u00ec v\u00f4 khu\u1ea9n.<\/p>\n\n\n\n

    L\u1ef1a ch\u1ecdn v\u1ecb tr\u00ed ch\u1ecdc v\u00e0 Ti\u1ebfp c\u1eadn b\u1eb1ng kim<\/strong><\/p>\n\n\n\n

    Vi\u1ec7c x\u00e1c \u0111\u1ecbnh h\u01b0\u1edbng \u0111\u00e0i th\u1eadn v\u00e0 l\u1ef1a ch\u1ecdn \u0111\u00e0i th\u1eadn m\u1ee5c ti\u00eau t\u1ed1t nh\u1ea5t \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n trong m\u1ed5 b\u1eb1ng h\u00ecnh \u1ea3nh th\u1eddi gian th\u1ef1c. Nh\u01b0 \u0111\u00e3 \u0111\u1ec1 c\u1eadp, \u0111\u00e0i sau l\u00e0 v\u1ecb tr\u00ed \u01b0u ti\u00ean \u0111\u1ec3 v\u00e0o c\u1ef1c d\u01b0\u1edbi th\u1eadn. H\u01b0\u1edbng d\u1eabn X-quang th\u01b0\u1eddng s\u1eed d\u1ee5ng m\u1ed9t trong hai k\u1ef9 thu\u1eadt: “m\u1eaft kim” (eye of the needle) v\u00e0 “tam gi\u00e1c \u0111\u1ea1c” (triangulation). C\u1ea3 hai k\u1ef9 thu\u1eadt \u0111\u1ec1u b\u1eaft \u0111\u1ea7u b\u1eb1ng vi\u1ec7c b\u01a1m thu\u1ed1c c\u1ea3n quang l\u00e0m hi\u1ec7n h\u00ecnh ng\u01b0\u1ee3c d\u00f2ng h\u1ec7 th\u1ed1ng g\u00f3p.<\/p>\n\n\n\n

      \n
    • M\u1eaft kim:<\/strong> Kim ch\u1ecdc 18-gauge \u0111\u1ea7u kim c\u01b0\u01a1ng \u0111\u01b0\u1ee3c \u0111\u1ecbnh v\u1ecb sao cho \u0111\u00e0i th\u1eadn m\u1ee5c ti\u00eau, \u0111\u1ea7u kim v\u00e0 \u0111\u1ed1c kim c\u00f9ng n\u1eb1m tr\u00ean m\u1ed9t \u0111\u01b0\u1eddng th\u1eb3ng v\u1edbi b\u1ed9 t\u0103ng s\u00e1ng h\u00ecnh \u1ea3nh, t\u1ea1o hi\u1ec7u \u1ee9ng bia b\u1eafn (bulls-eye) tr\u00ean m\u00e0n h\u00ecnh (H\u00ecnh 131-3A). Ph\u1eabu thu\u1eadt vi\u00ean nh\u00ecn d\u1ecdc theo th\u00e2n kim v\u00e0o \u0111\u00e0i th\u1eadn m\u1ee5c ti\u00eau. Kim \u0111\u01b0\u1ee3c ti\u1ebfn theo h\u01b0\u1edbng n\u00e0y d\u01b0\u1edbi s\u1ef1 gi\u00e1m s\u00e1t li\u00ean t\u1ee5c. \u0110\u1ed9 s\u00e2u \u0111\u01b0\u1ee3c ki\u1ec3m tra b\u1eb1ng c\u00e1ch xoay C-arm sang g\u00f3c th\u1eb3ng \u0111\u1ee9ng (H\u00ecnh 131-3B). N\u1ebfu kim th\u1eb3ng h\u00e0ng v\u1edbi \u0111\u00e0i th\u1eadn \u1edf g\u00f3c nh\u00ecn n\u00e0y, ph\u1eabu thu\u1eadt vi\u00ean c\u00f3 th\u1ec3 h\u00fat ra n\u01b0\u1edbc ti\u1ec3u, x\u00e1c nh\u1eadn v\u1ecb tr\u00ed \u0111\u00fang.<\/li>\n<\/ul>\n\n\n\n
      \"\"
      H\u00ccNH 131-3. C\u00e1c ph\u01b0\u01a1ng th\u1ee9c h\u00ecnh \u1ea3nh: \u201cm\u1eaft kim\u201d. A, M\u1eb7t ph\u1eb3ng AP. Quan s\u00e1t tr\u1ef1c ti\u1ebfp ph\u00eda tr\u00ean kim v\u00e0 \u0111\u00e0i th\u1eadn n\u01a1i b\u1ecb \u0111\u00e2m th\u1ee7ng. S\u1ebd th\u1ea5y h\u00ecnh d\u1ea1ng \u201cm\u1eaft b\u00f2\u201d khi quan s\u00e1t d\u1ecdc theo th\u00e2n kim. B, M\u1eb7t ph\u1eb3ng xi\u00ean. Cho ph\u00e9p \u0111\u00e1nh gi\u00e1 \u0111\u1ed9 s\u00e2u xuy\u00ean th\u1ea5u c\u1ee7a kim.<\/figcaption><\/figure>\n\n\n\n
        \n
      • K\u1ef9 thu\u1eadt tam gi\u00e1c \u0111\u1ea1c:<\/strong> V\u1ecb tr\u00ed ch\u1ecdc da th\u01b0\u1eddng c\u00e1ch kho\u1ea3ng 1 cm d\u01b0\u1edbi v\u00e0 1 cm trong so v\u1edbi \u0111\u1ea7u x\u01b0\u01a1ng s\u01b0\u1eddn 12 (H\u00ecnh 131-4). <\/li>\n<\/ul>\n\n\n\n
        \"\"
        H\u00ccNH 131-4. C\u00e1c m\u1ed1c gi\u1ea3i ph\u1eabu \u0111\u1ec3 ti\u1ebfp c\u1eadn th\u1eadn qua da \u1edf c\u1ef1c tr\u00ean v\u00e0 c\u1ef1c d\u01b0\u1edbi.<\/figcaption><\/figure>\n\n\n\n

        Khi C-arm \u0111\u1ecbnh h\u01b0\u1edbng song song v\u1edbi \u0111\u01b0\u1eddng ch\u1ecdc, th\u1ef1c hi\u1ec7n \u0111i\u1ec1u ch\u1ec9nh theo h\u01b0\u1edbng trong-ngo\u00e0i (tr\u00e1i\/ph\u1ea3i) (H\u00ecnh 131-5A). Xoay C-arm sang g\u00f3c nghi\u00eang \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh h\u01b0\u1edbng \u0111\u1ea7u-\u0111u\u00f4i (l\u00ean\/xu\u1ed1ng) v\u00e0 \u0111\u00e1nh gi\u00e1 \u0111\u1ed9 s\u00e2u (H\u00ecnh 131-5B).
        <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-5. C\u00e1c ph\u01b0\u01a1ng th\u1ee9c ch\u1ee5p \u1ea3nh: k\u1ef9 thu\u1eadt tam gi\u00e1c h\u00f3a. A, M\u1eb7t ph\u1eb3ng AP (\u0111i\u1ec1u ch\u1ec9nh tr\u00e1i-ph\u1ea3i). B, M\u1eb7t ph\u1eb3ng xi\u00ean (\u0111i\u1ec1u ch\u1ec9nh l\u00ean xu\u1ed1ng).<\/figcaption><\/figure>\n\n\n\n

        \u0110\u1ec3 gi\u1ea3m ph\u01a1i nhi\u1ec5m b\u1ee9c x\u1ea1, C-arm \u0111\u01b0\u1ee3c ch\u1ebfch xa kh\u1ecfi \u0111\u01b0\u1eddng ch\u1ecdc. Khi \u0111\u00e3 \u0111\u1ea1t h\u01b0\u1edbng \u0111\u00fang, b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ng\u01b0ng th\u1edf \u1edf th\u00ec th\u1edf ra h\u1ebft. Kim ch\u1ecdc 18-gauge \u0111\u01b0\u1ee3c ti\u1ebfn v\u1ec1 ph\u00eda \u0111\u00e0i th\u1eadn mong mu\u1ed1n \u1edf g\u00f3c nghi\u00eang \u0111\u1ec3 \u0111o \u0111\u1ed9 s\u00e2u. Vi\u1ec7c duy tr\u00ec h\u01b0\u1edbng kim \u1edf m\u1ed9t m\u1eb7t ph\u1eb3ng khi \u0111i\u1ec1u ch\u1ec9nh \u1edf m\u1eb7t ph\u1eb3ng kia l\u00e0 r\u1ea5t quan tr\u1ecdng. Thao t\u00e1c n\u00e0y d\u1ec5 d\u00e0ng h\u01a1n b\u1eb1ng c\u00e1ch t\u1ef1a c\u1eb3ng tay ph\u1eabu thu\u1eadt vi\u00ean l\u00ean c\u01a1 th\u1ec3 b\u1ec7nh nh\u00e2n. Tr\u01b0\u1edbc khi v\u00e0o bao th\u1eadn, th\u1ef1c hi\u1ec7n c\u00e1c \u0111i\u1ec1u ch\u1ec9nh cu\u1ed1i c\u00f9ng. Tr\u00e1nh di chuy\u1ec3n kim sau khi \u0111\u00e3 v\u00e0o nhu m\u00f4 th\u1eadn v\u00ec c\u00f3 th\u1ec3 l\u00e0m di l\u1ec7ch th\u1eadn v\u00e0 \u1ea3nh h\u01b0\u1edfng v\u1ecb tr\u00ed \u0111\u00e0i th\u1eadn m\u1ee5c ti\u00eau. Vi\u1ec7c h\u00fat ra n\u01b0\u1edbc ti\u1ec3u khi kim v\u00e0o h\u1ec7 th\u1ed1ng g\u00f3p s\u1ebd x\u00e1c nh\u1eadn ch\u1ecdc \u0111\u00e0i th\u1eadn \u0111\u00fang.<\/p>\n\n\n\n

        <\/p>\n\n\n\n

        \u0110\u1eb7t d\u00e2y d\u1eabn ti\u1ebfp c\u1eadn<\/strong><\/p>\n\n\n\n

        D\u00e2y d\u1eabn Glidewire l\u00f5i nitinol \u01b0a n\u01b0\u1edbc \u0111\u01b0\u1ee3c lu\u1ed3n qua kim v\u00e0o h\u1ec7 th\u1ed1ng g\u00f3p. Lo\u1ea1i d\u00e2y n\u00e0y \u0111\u01b0\u1ee3c \u01b0u ti\u00ean cho l\u1ea7n ti\u1ebfp c\u1eadn \u0111\u1ea7u ti\u00ean v\u00ec t\u00ednh linh ho\u1ea1t v\u00e0 ch\u1ed1ng g\u1eadp. D\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn m\u00e0n t\u0103ng s\u00e1ng, c\u1ed1 g\u1eafng \u0111\u1ea9y d\u00e2y d\u1eabn xu\u1ed1ng ni\u1ec7u qu\u1ea3n (H\u00ecnh 131-6). <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-6. Ch\u1ecdc kim ban \u0111\u1ea7u v\u00e0 \u0111\u1eb7t cu\u1ed9n d\u00e2y v\u00e0o b\u1ec3 th\u1eadn ho\u1eb7c, n\u1ebfu c\u00f3 th\u1ec3, xu\u1ed1ng ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n

        N\u1ebfu kh\u00f4ng xu\u1ed1ng \u0111\u01b0\u1ee3c, c\u00f3 th\u1ec3 cu\u1ed9n d\u00e2y trong b\u1ec3 th\u1eadn. \u0110\u01b0a m\u1ed9t \u1ed1ng nong c\u00e2n 8-French v\u00e0o \u0111\u00e0i th\u1eadn, theo sau l\u00e0 m\u1ed9t catheter ch\u1ee5p m\u1ea1ch \u0111\u1ea7u Cobra 5-French. Catheter ch\u1ee5p m\u1ea1ch gi\u00fap d\u1eabn h\u01b0\u1edbng d\u00e2y d\u1eabn v\u1ec1 ph\u00eda kh\u00fac n\u1ed1i b\u1ec3 th\u1eadn – ni\u1ec7u qu\u1ea3n, thu\u1eadn l\u1ee3i cho vi\u1ec7c lu\u1ed3n d\u00e2y xu\u1ed1ng ni\u1ec7u qu\u1ea3n (H\u00ecnh 131-7). <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-7. S\u1eed d\u1ee5ng \u1ed1ng th\u00f4ng ch\u1ee5p m\u1ea1ch \u0111\u1ec3 \u0111\u01b0a d\u00e2y d\u1eabn xu\u1ed1ng ni\u1ec7u qu\u1ea3n v\u00e0 thay th\u1ebf b\u1eb1ng d\u00e2y d\u1eabn si\u00eau c\u1ee9ng Amplatz.<\/figcaption><\/figure>\n\n\n\n

        Khi d\u00e2y d\u1eabn \u0111\u00e3 \u1edf ni\u1ec7u qu\u1ea3n, n\u00f3 \u0111\u01b0\u1ee3c thay th\u1ebf b\u1eb1ng m\u1ed9t d\u00e2y l\u00e0m vi\u1ec7c (working wire) c\u1ee9ng h\u01a1n c\u00f3 ph\u1ee7 Teflon nh\u01b0 d\u00e2y Amplatz super-stiff. Kh\u00f4ng d\u00f9ng Glidewire l\u00e0m d\u00e2y l\u00e0m vi\u1ec7c v\u00ec t\u00ednh tr\u01a1n tr\u01b0\u1ee3t d\u1ec5 g\u00e2y di l\u1ec7ch. \u0110\u00f4i khi kh\u00f4ng th\u1ec3 \u0111\u1ea9y d\u00e2y xu\u1ed1ng ni\u1ec7u qu\u1ea3n (s\u1ecfi k\u1eb9t ho\u1eb7c h\u1eb9p UPJ); khi \u0111\u00f3 d\u00e2y d\u1eabn \u0111\u01b0\u1ee3c \u0111\u1eb7t \u1edf m\u1ed9t \u0111\u00e0i th\u1eadn c\u00e1ch xa \u0111\u01b0\u1eddng h\u1ea7m m\u1edf th\u1eadn ban \u0111\u1ea7u ho\u1eb7c cu\u1ed9n trong b\u1ec3 th\u1eadn. Sau \u0111\u00f3 d\u00f9ng b\u1ed9 nong \u0111\u1ed3ng tr\u1ee5c 8\/10-French \u0111\u1ec3 \u0111\u1eb7t d\u00e2y d\u1eabn an to\u00e0n (safety wire) th\u1ee9 hai, th\u01b0\u1eddng l\u00e0 d\u00e2y l\u00f5i th\u00e1o r\u1eddi th\u1eb3ng 0.035-inch (H\u00ecnh 131-8).
        <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-8. B, \u0110\u01b0\u1eddng v\u00e0o hai d\u00e2y, s\u1eed d\u1ee5ng \u1ed1ng nong \u0111\u1ed3ng tr\u1ee5c 10 French ho\u1eb7c 8\/10 French.<\/figcaption><\/figure>\n\n\n\n

        Ph\u1ea7n nong 8-French \u0111\u01b0\u1ee3c ti\u1ebfn v\u00e0o tr\u01b0\u1edbc, sau \u0111\u00f3 l\u00e0 ph\u1ea7n 10-French b\u00ean ngo\u00e0i. R\u00fat \u1ed1ng nong trong 8-French cho ph\u00e9p lu\u1ed3n d\u00e2y an to\u00e0n. D\u00e2y an to\u00e0n ph\u1ea3i \u0111\u01b0\u1ee3c k\u1eb9p c\u1ed1 \u0111\u1ecbnh v\u00e0o toan m\u1ed5. Vi\u1ec7c \u0111\u1eb7t d\u00e2y an to\u00e0n l\u00e0 b\u1eaft bu\u1ed9c tr\u01b0\u1edbc khi nong \u0111\u01b0\u1eddng h\u1ea7m \u0111\u1ec3 duy tr\u00ec \u0111\u01b0\u1eddng v\u00e0o n\u1ebfu d\u00e2y l\u00e0m vi\u1ec7c b\u1ecb tu\u1ed9t.<\/p>\n\n\n\n

        Nong \u0111\u01b0\u1eddng h\u1ea7m<\/strong><\/p>\n\n\n\n

        C\u00f3 m\u1ed9t s\u1ed1 ph\u01b0\u01a1ng ph\u00e1p nong, bao g\u1ed3m c\u00e1c b\u1ed9 nong kim lo\u1ea1i l\u1ed3ng v\u00e0o nhau (telescoping), b\u1ed9 nong Amplatz b\u00e1n c\u1ee9ng v\u00e0 b\u00f3ng nong. Nong \u0111\u01b0\u1eddng h\u1ea7m ph\u1ea3i th\u1ef1c hi\u1ec7n tr\u00ean m\u1ed9t d\u00e2y d\u1eabn c\u1ee9ng d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn m\u00e0n t\u0103ng s\u00e1ng. B\u00f3ng nong \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00e0 g\u00e2y ch\u1ea3y m\u00e1u \u00edt h\u01a1n \u0111\u00e1ng k\u1ec3 so v\u1edbi c\u00e1c b\u1ed9 nong tu\u1ea7n ti\u1ebfn v\u00ec l\u1ef1c n\u1edf xuy\u00ean t\u00e2m \u00edt g\u00e2y ch\u1ea5n th\u01b0\u01a1ng nhu m\u00f4 h\u01a1n l\u1ef1c c\u1eaft ho\u1eb7c x\u00e9. T\u00e1c gi\u1ea3 \u01b0u ti\u00ean d\u00f9ng b\u00f3ng nong 30-French d\u00e0i 12 cm v\u1edbi v\u1ecf Amplatz 30-French \u0111\u1eb7t s\u1eb5n ph\u00eda sau b\u00f3ng. V\u1ea1ch c\u1ea3n quang \u1edf \u0111\u1ea7u b\u00f3ng \u0111\u01b0\u1ee3c \u0111\u1eb7t d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn m\u00e0n t\u0103ng s\u00e1ng ngay b\u00ean trong \u0111\u00e0i th\u1eadn ch\u1ecdc d\u00f2, sau \u0111\u00f3 b\u01a1m c\u0103ng b\u1eb1ng b\u01a1m LeVeen (H\u00ecnh 131-9A) \u0111\u1ebfn t\u1ed1i \u0111a 18 atmosphere. <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-9. A, Nong b\u00f3ng \u0111\u01b0\u1eddng d\u1eabn l\u01b0u th\u1eadn. B, \u0110\u1eb7t \u1ed1ng th\u00f4ng Amplatz. C, \u0110\u01b0\u1eddng ti\u1ebfp c\u1eadn cu\u1ed1i c\u00f9ng v\u1edbi \u1ed1ng th\u00f4ng Amplatz \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1eb7t \u0111\u00fang v\u1ecb tr\u00ed.<\/figcaption><\/figure>\n\n\n\n


        N\u1ebfu c\u00f3 s\u1eb9o quanh th\u1eadn (t\u1ea1o h\u00ecnh th\u1eaft eo – “waist”), c\u00f3 th\u1ec3 d\u00f9ng kim r\u1ea1ch c\u00e2n 4.5-mm (Cook Urological) lu\u1ed3n qua d\u00e2y l\u00e0m vi\u1ec7c \u0111\u1ec3 r\u1ea1ch s\u1eb9o h\u1ed7 tr\u1ee3 nong b\u00f3ng. Ngo\u00e0i ra, c\u00e1c b\u1ed9 nong tu\u1ea7n ti\u1ebfn c\u0169ng h\u1eefu \u00edch; tuy nhi\u00ean, kh\u00f3 ki\u1ec3m so\u00e1t \u00e1p l\u1ef1c khi nong, c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn th\u1ee7ng b\u1ec3 th\u1eadn ho\u1eb7c xu\u1ea5t huy\u1ebft. Sau khi nong, v\u1ecf Amplatz 30-French \u0111\u01b0\u1ee3c \u0111\u1ea9y xoay qua b\u00f3ng ho\u1eb7c \u1ed1ng nong cho \u0111\u1ebfn khi v\u00e0o \u0111\u00fang v\u1ecb tr\u00ed trong \u0111\u00e0i th\u1eadn (H\u00ecnh 131-9B). Nong \u0111\u01b0\u1eddng h\u1ea7m lu\u00f4n ph\u1ea3i th\u1ef1c hi\u1ec7n d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn m\u00e0n t\u0103ng s\u00e1ng, tr\u00e1nh \u0111\u1ea9y v\u1ecf qu\u00e1 s\u00e2u g\u00e2y ch\u1ea3y m\u00e1u, ch\u1ea5n th\u01b0\u01a1ng nhu m\u00f4 ho\u1eb7c th\u1ee7ng h\u1ec7 th\u1ed1ng g\u00f3p.<\/p>\n\n\n\n

        \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n b\u00e9o ph\u00ec \u0111\u1ed9 III, c\u1ea7n l\u01b0u \u00fd s\u1eed d\u1ee5ng v\u1ecf Amplatz d\u00e0i (20 cm) v\u00e0 \u1ed1ng soi th\u1eadn c\u1ee9ng d\u00e0i do kho\u1ea3ng c\u00e1ch t\u1eeb da \u0111\u1ebfn h\u1ec7 th\u1ed1ng g\u00f3p l\u1edbn.<\/p>\n\n\n\n

        C\u00c1C T\u00ccNH HU\u1ed0NG TI\u1ebeP C\u1eacN \u0110\u1eb6C BI\u1ec6T<\/strong><\/p>\n\n\n\n

        Ti\u1ebfp c\u1eadn tr\u00ean s\u01b0\u1eddn\/c\u1ef1c tr\u00ean<\/strong><\/p>\n\n\n\n

        Ti\u1ebfp c\u1eadn tr\u00ean s\u01b0\u1eddn ho\u1eb7c c\u1ef1c tr\u00ean c\u00f3 l\u1ee3i th\u1ebf v\u00ec \u0111\u01b0\u1eddng ch\u1ecdc n\u1eb1m th\u1eb3ng h\u00e0ng v\u1edbi b\u1ec3 th\u1eadn v\u00e0 UPJ (H\u00ecnh 131-10), cho ph\u00e9p quan s\u00e1t t\u1ed1t UPJ v\u00e0 ni\u1ec7u qu\u1ea3n g\u1ea7n. <\/p>\n\n\n\n

        \"\"

        H\u00ccNH 131-10. \u0110\u01b0\u1eddng ti\u1ebfp c\u1eadn c\u1ef1c tr\u00ean th\u1eb3ng h\u00e0ng v\u1edbi UPJ, nh\u01b0ng c\u00f3 th\u1ec3 l\u00e0m t\u1ed5n th\u01b0\u01a1ng m\u00e0ng ph\u1ed5i.<\/figcaption><\/figure>\n\n\n\n

        N\u00f3 \u0111\u01b0\u1ee3c \u1ee7ng h\u1ed9 \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb s\u1ecfi ni\u1ec7u qu\u1ea3n \u0111o\u1ea1n g\u1ea7n k\u00edch th\u01b0\u1edbc l\u1edbn b\u1ecb k\u1eb9t ho\u1eb7c t\u1eafc ngh\u1ebdn UPJ khi c\u00f3 k\u1ebf ho\u1ea1ch x\u1ebb b\u1ec3 th\u1eadn n\u1ed9i soi xu\u00f4i d\u00f2ng. N\u00f3 c\u0169ng h\u1eefu \u00edch khi s\u1ecfi l\u1edbn \u1edf \u0111\u00e0i tr\u00ean (s\u1ecfi san h\u00f4 ho\u00e0n to\u00e0n), t\u00fai th\u1eeba \u0111\u00e0i tr\u00ean, ho\u1eb7c nhi\u1ec1u \u0111\u00e0i d\u01b0\u1edbi ch\u1ee9a s\u1ecfi. Ti\u1ebfp c\u1eadn th\u1eadn m\u00f3ng ng\u1ef1a c\u0169ng th\u01b0\u1eddng th\u1ef1c hi\u1ec7n qua \u0111\u00e0i tr\u00ean, nh\u01b0ng h\u1ea7u h\u1ebft l\u00e0 qua \u0111\u01b0\u1eddng d\u01b0\u1edbi s\u01b0\u1eddn do th\u1eadn \u0111i l\u00ean kh\u00f4ng ho\u00e0n to\u00e0n.<\/p>\n\n\n\n

        M\u1eb7c d\u00f9 k\u1ef9 thu\u1eadt t\u01b0\u01a1ng t\u1ef1 c\u1ef1c d\u01b0\u1edbi, m\u1ed9t s\u1ed1 kh\u00eda c\u1ea1nh c\u1ea7n nh\u1ea5n m\u1ea1nh: R\u1ee7i ro ch\u00ednh l\u00e0 t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i v\u00e0 m\u00e0ng ph\u1ed5i v\u00ec c\u1ef1c tr\u00ean n\u1eb1m ngay ph\u00eda tr\u01b0\u1edbc ph\u1ea7n sau x\u01b0\u01a1ng s\u01b0\u1eddn 11 v\u00e0 12, th\u1eadm ch\u00ed cao t\u1edbi x\u01b0\u01a1ng s\u01b0\u1eddn 10. Nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u00e0ng ph\u1ed5i cao nh\u1ea5t \u1edf th\u00ec h\u00edt v\u00e0o; do \u0111\u00f3 g\u00e2y m\u00ea n\u1ed9i kh\u00ed qu\u1ea3n l\u00e0 thi\u1ebft y\u1ebfu \u0111\u1ec3 ki\u1ec3m so\u00e1t nh\u1ecbp th\u1edf. V\u1ecb tr\u00ed ch\u1ecdc n\u00ean n\u1eb1m \u1edf ph\u1ea7n tr\u00ean c\u1ee7a khoang li\u00ean s\u01b0\u1eddn, ngay ph\u00eda ngo\u00e0i kh\u1ed1i c\u01a1 c\u1ea1nh s\u1ed1ng v\u00e0 tr\u00e1nh ch\u1ecdc tr\u00ean x\u01b0\u01a1ng s\u01b0\u1eddn 11 n\u1ebfu c\u00f3 th\u1ec3 (H\u00ecnh 131-11).
        <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-11. \u0110\u01b0\u1eddng ti\u1ebfp c\u1eadn c\u1ef1c tr\u00ean c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n th\u00f4ng qua \u0111\u01b0\u1eddng tr\u00ean s\u01b0\u1eddn, gi\u1eefa s\u01b0\u1eddn ho\u1eb7c d\u01b0\u1edbi s\u01b0\u1eddn. (H\u00ecnh v\u1ebd c\u1ee7a Sharon Teal. B\u1ea3n quy\u1ec1n thu\u1ed9c v\u1ec1 H\u1ed9i \u0111\u1ed3ng qu\u1ea3n tr\u1ecb \u0110\u1ea1i h\u1ecdc Indiana, \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng v\u1edbi s\u1ef1 cho ph\u00e9p.)<\/figcaption><\/figure>\n\n\n\n

        \u0110\u00f4i khi c\u1ef1c tr\u00ean c\u00f3 th\u1ec3 ti\u1ebfp c\u1eadn qua \u0111\u01b0\u1eddng ph\u00eda b\u00ean gi\u1eefa \u0111\u1ea7u x\u01b0\u01a1ng s\u01b0\u1eddn 11-12 ho\u1eb7c th\u1eadm ch\u00ed d\u01b0\u1edbi s\u01b0\u1eddn. C\u00e1ch n\u00e0y gi\u1ea3m nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u00e0ng ph\u1ed5i nh\u01b0ng c\u00f3 th\u1ec3 h\u1ea1n ch\u1ebf quan s\u00e1t b\u1ec3 th\u1eadn, c\u1ef1c d\u01b0\u1edbi v\u00e0 UPJ.<\/p>\n\n\n\n

        B\u1eaft bu\u1ed9c d\u00f9ng v\u1ecf Amplatz \u0111\u1ec3 gi\u1ea3m nguy c\u01a1 tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i. Bi\u1ebfn ch\u1ee9ng ph\u1ed5i b\u00e1o c\u00e1o kho\u1ea3ng 16% tr\u01b0\u1eddng h\u1ee3p (3-4% c\u1ea7n can thi\u1ec7p). Sau m\u1ed5, n\u00ean d\u00f9ng m\u00e0n t\u0103ng s\u00e1ng ki\u1ec3m tra tr\u00e0n kh\u00ed\/tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i \u0111\u00e1ng k\u1ec3 l\u00e2m s\u00e0ng. C\u00f3 th\u1ec3 ch\u1ecdc h\u00fat d\u1ecbch m\u00e0ng ph\u1ed5i khi b\u1ec7nh nh\u00e2n c\u00f2n g\u00e2y m\u00ea. N\u1ebfu X-quang ng\u1ef1c b\u00ecnh th\u01b0\u1eddng t\u1ea1i ph\u00f2ng m\u1ed5, ch\u1ec9 c\u1ea7n ch\u1ee5p X-quang ch\u00ednh th\u1ee9c t\u1ea1i ph\u00f2ng h\u1ed3i t\u1ec9nh n\u1ebfu b\u1ec7nh nh\u00e2n c\u00f3 tri\u1ec7u ch\u1ee9ng. Tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i nh\u1eb9 c\u00f3 th\u1ec3 theo d\u00f5i, d\u1ecbch nhi\u1ec1u ho\u1eb7c tr\u00e0n kh\u00ed \u0111\u00e1ng k\u1ec3 c\u1ea7n \u0111\u1eb7t d\u1eabn l\u01b0u ng\u1ef1c. V\u00ec t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i hi\u1ebfm g\u1eb7p, c\u00e1c \u1ed1ng d\u1eabn l\u01b0u nh\u1ecf (pigtail) th\u01b0\u1eddng l\u00e0 \u0111\u1ee7 v\u00e0 d\u1ec5 ch\u1ecbu h\u01a1n \u1ed1ng d\u1eabn l\u01b0u l\u1edbn.<\/p>\n\n\n\n

        CT tr\u01b0\u1edbc m\u1ed5 r\u1ea5t quan tr\u1ecdng \u0111\u1ec3 lo\u1ea1i tr\u1eeb gan\/l\u00e1ch to. T\u1ed5n th\u01b0\u01a1ng c\u00e1c t\u1ea1ng n\u00e0y c\u1ef1c k\u1ef3 hi\u1ebfm khi ti\u1ebfp c\u1eadn d\u01b0\u1edbi x\u01b0\u01a1ng s\u01b0\u1eddn 12 n\u1ebfu t\u1ea1ng kh\u00f4ng to. Tuy nhi\u00ean, ti\u1ebfp c\u1eadn tr\u00ean s\u01b0\u1eddn t\u0103ng nguy c\u01a1 n\u00e0y, \u0111\u1eb7c bi\u1ec7t khi ch\u1ecdc \u1edf th\u00ec h\u00edt v\u00e0o ho\u1eb7c tr\u00ean x\u01b0\u01a1ng s\u01b0\u1eddn 11. N\u00ean ch\u1ecdc c\u00e0ng s\u00e1t kh\u1ed1i c\u01a1 c\u1ea1nh s\u1ed1ng c\u00e0ng t\u1ed1t \u0111\u1ec3 gi\u1ea3m r\u1ee7i ro.<\/p>\n\n\n\n

        T\u00fai th\u1eeba \u0111\u00e0i th\u1eadn\/\u0110\u00e0i th\u1eadn b\u1ecb t\u1eafc<\/strong><\/p>\n\n\n\n

        C\u1ea7n k\u1ef9 thu\u1eadt \u0111\u1eb7c bi\u1ec7t khi \u0111i\u1ec1u tr\u1ecb s\u1ecfi t\u00fai th\u1eeba \u0111\u00e0i th\u1eadn ho\u1eb7c \u0111\u00e0i th\u1eadn c\u00f3 c\u1ed5 \u0111\u00e0i b\u1ecb t\u1eafc ch\u1ee9a s\u1ecfi. Ch\u1ecdc tr\u1ef1c ti\u1ebfp v\u00e0o t\u00fai th\u1eeba c\u00f3 th\u1ec3 kh\u00f3 n\u1ebfu t\u00fai th\u1eeba nh\u1ecf v\u00e0\/ho\u1eb7c \u1edf c\u1ef1c tr\u00ean. Ngay c\u1ea3 khi ch\u1ecdc th\u00e0nh c\u00f4ng, vi\u1ec7c lu\u1ed3n d\u00e2y d\u1eabn qua l\u1ed7 th\u00f4ng v\u1edbi h\u1ec7 th\u1ed1ng g\u00f3p th\u01b0\u1eddng l\u00e0 kh\u00f4ng th\u1ec3.<\/p>\n\n\n\n

        T\u00e1c gi\u1ea3 \u01b0u ti\u00ean k\u1ef9 thu\u1eadt ti\u1ebfp c\u1eadn m\u1ed9t th\u00ec, kh\u00f4ng c\u1ea7n \u0111\u1eb7t catheter ni\u1ec7u qu\u1ea3n. D\u00f9ng m\u00e0n t\u0103ng s\u00e1ng \u0111\u1ecbnh v\u1ecb s\u1ecfi t\u00fai th\u1eeba, ch\u1ecdc tr\u1ef1c ti\u1ebfp (\u01b0u ti\u00ean d\u01b0\u1edbi s\u01b0\u1eddn). Khi \u0111\u00e3 v\u00e0o, lu\u1ed3n d\u00e2y J-wire l\u00f5i th\u00e1o r\u1eddi cu\u1ed9n trong khoang t\u00fai th\u1eeba (H\u00ecnh 131-12A). \u01afu \u0111i\u1ec3m l\u00e0 \u0111\u1ea7u J linh ho\u1ea1t th\u00edch \u1ee9ng v\u1edbi k\u00edch th\u01b0\u1edbc t\u00fai th\u1eeba, trong khi ph\u1ea7n c\u00f2n l\u1ea1i \u0111\u1ee7 c\u1ee9ng \u0111\u1ec3 l\u00e0m d\u00e2y l\u00e0m vi\u1ec7c. Sau \u0111\u00f3 d\u00f9ng b\u1ed9 nong \u0111\u1ed3ng tr\u1ee5c 8\/10-French \u0111\u1eb7t d\u00e2y d\u1eabn an to\u00e0n th\u1ee9 hai (H\u00ecnh 131-12B).
        <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-12. K\u1ef9 thu\u1eadt ti\u1ebfp c\u1eadn t\u00fai th\u1eeba \u0111\u00e0i th\u1eadn.<\/figcaption><\/figure>\n\n\n\n

        Tr\u00e1nh \u0111\u1ea9y b\u00f3ng nong v\u00e0 v\u1ecf qu\u00e1 s\u00e2u g\u00e2y th\u1ee7ng th\u00e0nh \u0111\u1ed1i di\u1ec7n c\u1ee7a t\u00fai th\u1eeba. \u0110\u1ea7u thon c\u1ee7a b\u00f3ng nong \u0111\u00f4i khi ng\u0103n v\u1ecf v\u00e0o tr\u1ef1c ti\u1ebfp khoang t\u00fai th\u1eeba; khi \u0111\u00f3 c\u00f3 th\u1ec3 d\u00f9ng k\u1eb9p alligator 11-French qua \u1ed1ng soi th\u1eadn c\u1ee9ng l\u1ec7ch t\u00e2m (offset) \u0111\u1ec3 nong th\u1ee7 c\u00f4ng \u0111o\u1ea1n h\u1ea7m ngay s\u00e1t t\u00fai th\u1eeba (H\u00ecnh 131-12C).<\/p>\n\n\n\n

        Nhi\u1ec1u \u0111\u01b0\u1eddng v\u00e0o<\/strong><\/p>\n\n\n\n

        Th\u01b0\u1eddng d\u00f9ng khi PNL cho s\u1ecfi ph\u1ee9c t\u1ea1p. C\u00e2n nh\u1eafc khi m\u1ed9t \u0111\u00e0i th\u1eadn ch\u1ee9a s\u1ecfi > 2 cm kh\u00f4ng th\u1ec3 ti\u1ebfp c\u1eadn b\u1eb1ng d\u1ee5ng c\u1ee5 c\u1ee9ng t\u1eeb \u0111\u01b0\u1eddng h\u1ea7m ch\u00ednh, ho\u1eb7c s\u1ecfi k\u00edch th\u01b0\u1edbc b\u1ea5t k\u1ef3 kh\u00f4ng th\u1ec3 ti\u1ebfp c\u1eadn b\u1eb1ng d\u1ee5ng c\u1ee5 m\u1ec1m. C\u00f3 th\u1ec3 th\u1ef1c hi\u1ec7n k\u1ef9 thu\u1eadt ch\u1ecdc ch\u1eef Y (Y-puncture): sau khi s\u1ea1ch s\u1ecfi \u1edf \u0111\u00e0i ban \u0111\u1ea7u, r\u00fat v\u1ecf l\u00e0m vi\u1ec7c ra ngo\u00e0i bao th\u1eadn, h\u01b0\u1edbng v\u1ec1 ph\u00eda \u0111\u00e0i th\u1ee9 hai v\u00e0 ch\u1ecdc kim qua ch\u00ednh v\u1ecf l\u00e0m vi\u1ec7c \u0111\u00f3 (H\u00ecnh 131-13). C\u00e1ch n\u00e0y \u0111\u1ea3m b\u1ea3o th\u1ea9m m\u1ef9 v\u00ec d\u00f9ng chung m\u1ed9t v\u1ebft r\u1ea1ch da.<\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-13. Ch\u1ecdc kim h\u00ecnh ch\u1eef Y.<\/figcaption><\/figure>\n\n\n\n

        Ch\u1ecdc d\u00f2 kh\u00f4ng nong (Nondilated Puncture)<\/strong><\/p>\n\n\n\n

        D\u00f9ng cho d\u1eabn l\u01b0u th\u1eadn, nghi\u1ec7m ph\u00e1p Whitaker, b\u01a1m thu\u1ed1c tan s\u1ecfi\/h\u00f3a ch\u1ea5t, ho\u1eb7c h\u1ed7 tr\u1ee3 \u0111\u1ecbnh v\u1ecb m\u1ed9t \u0111\u00e0i th\u1eadn kh\u00f3 t\u00ecm trong PNL ti\u00eau chu\u1ea9n. Ch\u1ecdc kim v\u00e0o \u0111\u00e0i mong mu\u1ed1n nh\u01b0ng kh\u00f4ng nong \u0111\u01b0\u1eddng h\u1ea7m. Khi d\u1eabn l\u01b0u ho\u1eb7c b\u01a1m thu\u1ed1c, lu\u1ed3n m\u1ed9t d\u00e2y d\u1eabn v\u00e0o b\u1ec3 th\u1eadn \u0111\u1ec3 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn. Trong PNL, n\u1ebfu m\u1ed9t \u0111\u00e0i ch\u1ee9a s\u1ecfi kh\u00f4ng th\u1ec3 t\u00ecm th\u1ea5y, ch\u1ecdc kim tr\u1ef1c ti\u1ebfp l\u00ean s\u1ecfi. C\u1ed1 g\u1eafng lu\u1ed3n d\u00e2y d\u1eabn ra kh\u1ecfi \u0111\u00e0i \u0111\u00f3 v\u00e0o b\u1ec3 th\u1eadn \u0111\u1ec3 l\u00e0m “b\u1ea3n \u0111\u1ed3” d\u1eabn \u0111\u01b0\u1eddng. Ho\u1eb7c b\u01a1m xanh methylen\/kh\u00ed CO2 qua kim \u0111\u1ec3 d\u1eabn \u1ed1ng soi m\u1ec1m v\u00e0o (H\u00ecnh 131-14).
        <\/p>\n\n\n\n

        \"\"
        H\u00ccNH 131-14. A, D\u00e2y d\u1eabn kim ch\u1ecdc th\u1ee7ng kh\u00f4ng gi\u00e3n n\u1edf v\u1edbi \u0111\u01b0\u1eddng v\u00e0o xuy\u00ean su\u1ed1t. B, \u0110\u01b0a \u1ed1ng n\u1ed9i soi th\u1eadn\/ni\u1ec7u qu\u1ea3n ng\u01b0\u1ee3c tr\u1edf l\u1ea1i qua d\u00e2y d\u1eabn v\u00e0o \u0111\u00e0i th\u1eadn mong mu\u1ed1n \u1edf v\u1ecb tr\u00ed kh\u00f3 ti\u1ebfp c\u1eadn.<\/figcaption><\/figure>\n\n\n\n

        \u0110\u00f4i khi c\u1ea7n k\u1ef9 thu\u1eadt \u0111\u1ea9y-k\u00e9o (push-pull) \u0111\u1ec3 \u0111\u01b0a \u1ed1ng soi th\u1eadn\/ni\u1ec7u qu\u1ea3n m\u1ec1m v\u00e0o \u0111\u00e0i mong mu\u1ed1n qua d\u00e2y d\u1eabn. \u01afu \u0111i\u1ec3m l\u00e0 kh\u00f4ng c\u1ea7n \u0111\u1eb7t th\u00eam \u1ed1ng d\u1eabn l\u01b0u th\u1eadn qua \u0111\u01b0\u1eddng h\u1ea7m kh\u00f4ng nong n\u00e0y.<\/p>\n\n\n\n

        BI\u1ebeN CH\u1ee8NG<\/strong><\/p>\n\n\n\n

        Xu\u1ea5t huy\u1ebft.<\/strong> Bi\u1ebfn ch\u1ee9ng quan tr\u1ecdng nh\u1ea5t c\u1ee7a ti\u1ebfp c\u1eadn th\u1eadn qua da l\u00e0 ch\u1ea3y m\u00e1u. Xu\u1ea5t huy\u1ebft c\u1ea7n truy\u1ec1n m\u00e1u \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o chi\u1ebfm t\u1ec9 l\u1ec7 t\u1eeb 1% \u0111\u1ebfn 15%. Khi g\u1eb7p t\u00ecnh tr\u1ea1ng ch\u1ea3y m\u00e1u l\u00e0m c\u1ea3n tr\u1edf kh\u1ea3 n\u0103ng quan s\u00e1t, tr\u01b0\u1edbc ti\u00ean n\u00ean ki\u1ec3m tra v\u1ecb tr\u00ed c\u1ee7a v\u1ecf ti\u1ebfp c\u1eadn (access sheath) v\u00ec vi\u1ec7c \u0111\u1eb7t v\u1ecf ch\u01b0a t\u1edbi \u0111\u00e0i th\u1eadn ch\u1ecdc d\u00f2 c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn ch\u1ea3y m\u00e1u nhu m\u00f4 th\u1eadn. N\u1ebfu v\u1ecf ti\u1ebfp c\u1eadn \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1eb7t \u0111\u00fang v\u1ecb tr\u00ed m\u00e0 v\u1eabn c\u00f2n ch\u1ea3y m\u00e1u \u0111\u00e1ng k\u1ec3, n\u00ean ng\u1eebng th\u1ee7 thu\u1eadt v\u00e0 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn ra da. Ch\u1ea3y m\u00e1u th\u01b0\u1eddng c\u00f3 b\u1ea3n ch\u1ea5t l\u00e0 t\u0129nh m\u1ea1ch v\u00e0 th\u01b0\u1eddng \u0111\u01b0\u1ee3c ki\u1ec3m so\u00e1t b\u1eb1ng c\u00e1ch \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn v\u00e0\/ho\u1eb7c k\u1eb9p \u1ed1ng d\u1eabn l\u01b0u th\u1eadn \u0111\u1ec3 ch\u00e8n \u00e9p c\u1ea7m m\u00e1u (tamponade). N\u1ebfu c\u00e1c bi\u1ec7n ph\u00e1p n\u00e0y kh\u00f4ng ki\u1ec3m so\u00e1t \u0111\u01b0\u1ee3c xu\u1ea5t huy\u1ebft ho\u1eb7c m\u00e1u ch\u1ea3y ki\u1ec3u m\u1ea1ch \u0111\u1eadp, n\u00ean nghi ng\u1edd ch\u1ea3y m\u00e1u \u0111\u1ed9ng m\u1ea1ch. \u0110\u1eb7t m\u1ed9t catheter b\u00f3ng ch\u00e8n d\u1eabn l\u01b0u th\u1eadn Kaye (Kaye nephrostomy tamponade balloon catheter) (Cook Urological, Spencer, IN) bao g\u1ed3m m\u1ed9t b\u00f3ng 12-mm \u00e1p l\u1ef1c th\u1ea5p trong \u0111\u01b0\u1eddng h\u1ea7m th\u1eadn th\u01b0\u1eddng s\u1ebd ki\u1ec3m so\u00e1t \u0111\u01b0\u1ee3c ch\u1ea3y m\u00e1u; tuy nhi\u00ean, xu\u1ea5t huy\u1ebft b\u1ea5t k\u1ec3 c\u00e1c thao t\u00e1c n\u00e0y \u0111\u00f2i h\u1ecfi ph\u1ea3i \u0111\u00e1nh gi\u00e1 b\u1eb1ng ch\u1ee5p m\u1ea1ch kh\u1ea9n c\u1ea5p v\u00e0 n\u00fat m\u1ea1ch si\u00eau ch\u1ecdn l\u1ecdc ngu\u1ed3n ch\u1ea3y m\u00e1u. Xu\u1ea5t huy\u1ebft mu\u1ed9n hi\u1ebfm khi x\u1ea3y ra (< 0,5%); tuy nhi\u00ean, trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y n\u00ean nghi ng\u1edd th\u00f4ng \u0111\u1ed9ng-t\u0129nh m\u1ea1ch ho\u1eb7c gi\u1ea3 ph\u00ecnh m\u1ea1ch v\u00e0 th\u1ef1c hi\u1ec7n ch\u1ee5p m\u1ea1ch.<\/p>\n\n\n\n

        Nhi\u1ec5m tr\u00f9ng.<\/strong> M\u1eb7c d\u00f9 s\u1ed1t sau m\u1ed5 \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y \u1edf g\u1ea7n m\u1ed9t ph\u1ea7n t\u01b0 s\u1ed1 b\u1ec7nh nh\u00e2n, nhi\u1ec5m khu\u1ea9n huy\u1ebft ch\u1ec9 x\u1ea3y ra \u1edf 0,3% \u0111\u1ebfn 2,5%. Nguy c\u01a1 nhi\u1ec5m khu\u1ea9n huy\u1ebft c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c gi\u1ea3m thi\u1ec3u b\u1eb1ng li\u1ec7u ph\u00e1p kh\u00e1ng sinh ph\u00f9 h\u1ee3p d\u1ef1a tr\u00ean k\u1ebft qu\u1ea3 c\u1ea5y n\u01b0\u1edbc ti\u1ec3u tr\u01b0\u1edbc m\u1ed5. N\u1ebfu g\u1eb7p n\u01b0\u1edbc ti\u1ec3u m\u1ee7 trong qu\u00e1 tr\u00ecnh ti\u1ebfp c\u1eadn qua da, kh\u00f4ng n\u00ean nong \u0111\u01b0\u1eddng h\u1ea7m. C\u00e1ch t\u1ed1t nh\u1ea5t \u0111\u1ec3 ti\u1ebfn h\u00e0nh l\u00e0 g\u1eedi n\u01b0\u1edbc ti\u1ec3u \u0111\u1ec3 c\u1ea5y, \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn v\u00e0 d\u00f9ng kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng cho \u0111\u1ebfn khi x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c vi sinh v\u1eadt c\u1ee5 th\u1ec3. Kh\u00e1ng sinh d\u1ef1 ph\u00f2ng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o ngay c\u1ea3 khi c\u1ea5y n\u01b0\u1edbc ti\u1ec3u tr\u01b0\u1edbc m\u1ed5 \u00e2m t\u00ednh \u0111\u1ec3 gi\u1ea3m nguy c\u01a1 bi\u1ebfn ch\u1ee9ng nhi\u1ec5m tr\u00f9ng. C\u1ea5y s\u1ecfi trong m\u1ed5 c\u0169ng c\u00f3 l\u1ee3i trong vi\u1ec7c l\u1ef1a ch\u1ecdn li\u1ec7u ph\u00e1p kh\u00e1ng sinh khi x\u1ea3y ra s\u1ed1t ho\u1eb7c nhi\u1ec5m khu\u1ea9n huy\u1ebft sau m\u1ed5.<\/p>\n\n\n\n

        Th\u1ee7ng.<\/strong> Th\u1ee7ng b\u1ec3 th\u1eadn c\u00f3 th\u1ec3 x\u1ea3y ra do h\u1ec7 qu\u1ea3 c\u1ee7a ti\u1ebfp c\u1eadn th\u1eadn qua da. Do \u0111\u00f3, c\u00e1c dung d\u1ecbch sinh l\u00fd nh\u01b0 n\u01b0\u1edbc mu\u1ed1i b\u00ecnh th\u01b0\u1eddng l\u00e0 b\u1eaft bu\u1ed9c \u0111\u1ec3 ng\u0103n ng\u1eeba c\u00e1c b\u1ea5t th\u01b0\u1eddng v\u1ec1 \u0111i\u1ec7n gi\u1ea3i. Trong tr\u01b0\u1eddng h\u1ee3p th\u1ee7ng nh\u1ecf, th\u01b0\u1eddng kh\u00f4ng c\u1ea7n thi\u1ebft ph\u1ea3i ch\u1ea5m d\u1ee9t th\u1ee7 thu\u1eadt v\u00ec h\u1ec7 th\u1ed1ng \u00e1p l\u1ef1c th\u1ea5p \u0111\u01b0\u1ee3c t\u1ea1o ra b\u1edfi v\u1ecf l\u00e0m vi\u1ec7c Amplatz h\u1ea1n ch\u1ebf s\u1ef1 tho\u00e1t d\u1ecbch ra ngo\u00e0i ph\u00fac m\u1ea1c. C\u00e1c v\u1ebft th\u1ee7ng r\u1ed9ng h\u01a1n ho\u1eb7c nh\u1eefng v\u1ebft th\u1ee7ng v\u00e0o trong ph\u00fac m\u1ea1c t\u1ed1t nh\u1ea5t n\u00ean \u0111\u01b0\u1ee3c x\u1eed tr\u00ed b\u1eb1ng c\u00e1ch ch\u1ea5m d\u1ee9t th\u1ee7 thu\u1eadt v\u00e0 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn ra da.<\/p>\n\n\n\n

        L\u1ed3ng ng\u1ef1c.<\/strong> Ch\u1ecdc d\u00f2 tr\u00ean s\u01b0\u1eddn c\u00f3 li\u00ean quan \u0111\u1ebfn nguy c\u01a1 tr\u00e0n kh\u00ed m\u00e0ng ph\u1ed5i ho\u1eb7c tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i t\u1eeb 4% \u0111\u1ebfn 16%. Nguy c\u01a1 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c gi\u1ea3m thi\u1ec3u b\u1eb1ng c\u00e1ch cho b\u1ec7nh nh\u00e2n ng\u01b0ng th\u1edf \u1edf th\u00ec th\u1edf ra h\u1ebft trong khi ch\u1ecdc kim. M\u00e0n t\u0103ng s\u00e1ng trong m\u1ed5 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh v\u00e0 \u0111i\u1ec1u tr\u1ecb tr\u00e0n kh\u00ed m\u00e0ng ph\u1ed5i ho\u1eb7c tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i b\u1eb1ng c\u00e1ch h\u00fat ngay l\u1eadp t\u1ee9c kh\u00ed v\u00e0\/ho\u1eb7c d\u1ecbch. N\u1ebfu ph\u1eabu thu\u1eadt vi\u00ean nghi ng\u1edd cao ho\u1eb7c c\u00e1c ph\u00e1t hi\u1ec7n l\u00e2m s\u00e0ng sau m\u1ed5 g\u1ee3i \u00fd bi\u1ebfn ch\u1ee9ng l\u1ed3ng ng\u1ef1c, n\u00ean ch\u1ee5p X-quang ng\u1ef1c v\u00e0 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u m\u00e0ng ph\u1ed5i.<\/p>\n\n\n\n

        C\u01a1 quan n\u1ed9i t\u1ea1ng.<\/strong> May m\u1eafn thay, t\u1ed5n th\u01b0\u01a1ng c\u01a1 quan n\u1ed9i t\u1ea1ng l\u00e0 m\u1ed9t bi\u1ebfn ch\u1ee9ng hi\u1ebfm g\u1eb7p c\u1ee7a ti\u1ebfp c\u1eadn qua da. T\u1ed5n th\u01b0\u01a1ng \u0111\u1ea1i tr\u00e0ng l\u00e0 ph\u1ed5 bi\u1ebfn nh\u1ea5t, x\u1ea3y ra trong \u00edt h\u01a1n 1% c\u00e1c tr\u01b0\u1eddng h\u1ee3p. C\u00e1c d\u1ea5u hi\u1ec7u c\u1ee7a th\u1ee7ng \u0111\u1ea1i tr\u00e0ng bao g\u1ed3m tho\u00e1t kh\u00ed ho\u1eb7c ph\u00e2n qua \u0111\u01b0\u1eddng h\u1ea7m th\u1eadn, ti\u00eau ch\u1ea3y trong m\u1ed5, ti\u00eau m\u00e1u \u0111\u1ea1i th\u1ec3, vi\u00eam ph\u00fac m\u1ea1c ho\u1eb7c m\u1ed9t bi\u1ebfn c\u1ed1 nhi\u1ec5m tr\u00f9ng kh\u00f4ng d\u1ef1 b\u00e1o tr\u01b0\u1edbc. V\u00ec t\u1ed5n th\u01b0\u01a1ng th\u01b0\u1eddng n\u1eb1m sau ph\u00fac m\u1ea1c, c\u00e1c d\u1ea5u hi\u1ec7u v\u00e0 tri\u1ec7u ch\u1ee9ng c\u1ee7a vi\u00eam ph\u00fac m\u1ea1c c\u00f3 th\u1ec3 kh\u00f4ng xu\u1ea5t hi\u1ec7n, v\u00e0 vi\u1ec7c ch\u1ea9n \u0111o\u00e1n th\u01b0\u1eddng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n d\u1ef1a tr\u00ean CT sau m\u1ed5 ho\u1eb7c ch\u1ee5p b\u1ec3 th\u1eadn qua \u1ed1ng d\u1eabn l\u01b0u th\u1eadn. Th\u1ee7ng ngo\u00e0i ph\u00fac m\u1ea1c c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd theo d\u00f5i v\u1edbi vi\u1ec7c \u0111\u1eb7t catheter ni\u1ec7u qu\u1ea3n ho\u1eb7c stent ch\u1eef J k\u00e9p (double-J) \u0111\u1ec3 gi\u1ea3i \u00e1p h\u1ec7 th\u1ed1ng g\u00f3p v\u00e0 r\u00fat \u1ed1ng d\u1eabn l\u01b0u th\u1eadn t\u1eeb v\u1ecb tr\u00ed trong th\u1eadn ra v\u1ecb tr\u00ed trong \u0111\u1ea1i tr\u00e0ng \u0111\u1ec3 \u0111\u00f3ng vai tr\u00f2 nh\u01b0 m\u1ed9t \u1ed1ng m\u1edf \u0111\u1ea1i tr\u00e0ng ra da. \u1ed0ng m\u1edf \u0111\u1ea1i tr\u00e0ng n\u00e0y \u0111\u01b0\u1ee3c \u0111\u1ec3 t\u1ea1i ch\u1ed7 t\u1ed1i thi\u1ec3u 7 ng\u00e0y v\u00e0 \u0111\u01b0\u1ee3c r\u00fat sau khi nghi\u00ean c\u1ee9u c\u00f3 thu\u1ed1c c\u1ea3n quang ph\u00f9 h\u1ee3p cho th\u1ea5y kh\u00f4ng c\u00f2n s\u1ef1 th\u00f4ng th\u01b0\u01a1ng gi\u1eefa \u0111\u1ea1i tr\u00e0ng v\u00e0 th\u1eadn. Trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p t\u1ed5n th\u01b0\u01a1ng trong ph\u00fac m\u1ea1c ho\u1eb7c nhi\u1ec5m tr\u00f9ng huy\u1ebft, c\u1ea7n ph\u1ea3i th\u0103m d\u00f2 \u1ed5 b\u1ee5ng v\u00e0 m\u1edf \u0111\u1ea1i tr\u00e0ng ra da. M\u1eb7c d\u00f9 \u00edt ph\u1ed5 bi\u1ebfn h\u01a1n t\u1ed5n th\u01b0\u01a1ng \u0111\u1ea1i tr\u00e0ng, t\u1ed5n th\u01b0\u01a1ng t\u00e1 tr\u00e0ng \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o sau khi ti\u1ebfp c\u1eadn th\u1eadn ph\u1ea3i qua da. Th\u1ee7ng t\u00e1 tr\u00e0ng th\u01b0\u1eddng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1ea3o t\u1ed3n b\u1eb1ng c\u00e1ch \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn, ng\u01b0ng \u0103n u\u1ed1ng qua \u0111\u01b0\u1eddng mi\u1ec7ng, \u0111\u1eb7t \u1ed1ng th\u00f4ng d\u1ea1 d\u00e0y h\u00fat d\u1ecbch v\u1ecb v\u00e0 nu\u00f4i d\u01b0\u1ee1ng ngo\u00e0i \u0111\u01b0\u1eddng ti\u00eau h\u00f3a. T\u1ed5n th\u01b0\u01a1ng gan v\u00e0 l\u00e1ch may m\u1eafn l\u00e0 hi\u1ebfm g\u1eb7p n\u1ebfu kh\u00f4ng c\u00f3 t\u00ecnh tr\u1ea1ng t\u1ea1ng to. Ti\u1ebfp c\u1eadn th\u1eadn qua da d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn c\u1ee7a CT \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p gan to ho\u1eb7c l\u00e1ch to. R\u00e1ch l\u00e1ch th\u01b0\u1eddng d\u1eabn \u0111\u1ebfn ch\u1ea3y m\u00e1u \u0111\u00e1ng k\u1ec3, v\u00e0 trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p nghi\u00eam tr\u1ecdng c\u00f3 th\u1ec3 y\u00eau c\u1ea7u th\u0103m d\u00f2 ph\u1eabu thu\u1eadt. T\u1ed5n th\u01b0\u01a1ng gan th\u01b0\u1eddng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd b\u1ea3o t\u1ed3n b\u1eb1ng c\u00e1ch \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn v\u00e0 hi\u1ebfm khi c\u1ea7n can thi\u1ec7p ph\u1eabu thu\u1eadt.<\/p>\n\n\n\n

        T\u00e0i li\u1ec7u tham kh\u1ea3o g\u1ee3i \u00fd<\/strong><\/p>\n\n\n\n

          \n
        • Kim SC, Kuo RL, Tinmouth WW, Watkins S, Lingeman JE. (2005). Percutaneous nephrolithotomy for caliceal diverticular calculi: a novel single stage approach. J Urol 173(4):1194-1198.<\/li>\n\n\n\n
        • Lingeman JE, Matlaga BR, Evan AP. (2007). Surgical management of upper urinary tract calculi. Trong: Wein AJ, Kavoussi L, Novick AC, Partin AW, Peters CA, ch\u1ee7 bi\u00ean. Campbell-Walsh urology, t\u00e1i b\u1ea3n l\u1ea7n th\u1ee9 9. Philadelphia: Saunders (Elsevier Science), tr 1431-1507.<\/li>\n\n\n\n
        • Miller NL, Evan AP, Lingeman JE. (2007). Pathogenesis of renal calculi. Urol Clin North Am 34(2):295-313.<\/li>\n<\/ul>\n\n\n\n

          <\/p>\n","protected":false},"excerpt":{"rendered":"

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