Evaluating the results of laparoscopic surgery in the treatment of total appendicitis peritonitis at 115 people’s hospital – Nguyen Quang Huy

Journal of military pharmaco-medicine n o 8-2018 188 EVALUATING THE RESULTS OF LAPAROSCOPIC SURGERY IN THE TREATMENT OF TOTAL APPENDICITIS PERITONITIS AT 115 PEOPLE’S HOSPITAL Nguyen Quang Huy1; Vu Huy Nung2; Van Tan1 SUMMARY Objectives: To evaluate safety, feasibility and result of laparoscopic surgery in management of total appendicitis peritonitis. Subjects and methods: A prospective observational study on 82 patients with appendicitis peritonitis who were performed by laparoscopic surgery at 115 People’s Hospital from 1th January 2011 to 31th December 2016. Results: The rate of farting time over 72 hours was 52.2%. The mean hospital stay was 5.9 ± 3.5 days. The rate of postoperative complication was 9.7%, including five cases of paralytic intestine, two cases of wound infection and one case of post-operative intra-abdominal abscess. The general result of surgery was excellent (92.8%), good (5.8%), fair (1.4%) and poor (0%). Conclusion: Laparoscopic surgery for total appendicitis peritonitis was safe, efficacious and feasible and could be widely applied. * Keywords: Appendicitis peritonitis; Laparoscopic surgery. INTRODUCTION In Vietnam, the proportion of acute appendicitis occupied from 40 to 45% in emergent operations [1]. Acute appendicitis complicated exclusively with peritonitis (ACP) accounts for 10 to 20%. Laparoscopic surgery is a good choice for management of this disease. We studied this topic aiming: To evaluate the results of laparoscopic surgery for the treatment of appendicitis peritonitis in terms of the safety, efficacy and feasibility of the procedure. SUBJECTS AND METHODS 1. Subjects. 82 patients (male: 49 cases, female: 33 cases) with the ages from 16 to 95 years old. Mean age was 45.7 ± 21.4. All patients were diagnosed ACP and treated by laparoscopic surgery at 115 People’s Hospital from 1th January 2011 to 31th December 2016. 2. Methods. Prospective observative and descriptive clinical study. * Selective criteria: Patients with appendicitis peritonitis were diagnosed by clinical, paraclinical, abdominal endoscopy and biopsy, were applied by laparoscopic surgery for the treatment. Adequate information for the study. * Exclusive criteria: Peritonitis with the other causes, lack of information for the study. * The technical progress: + Indications: Appendicitis peritonitis in patient over 16 years old. The patient agreed with the laparoscopic surgery. 1. 115 People’s Hospital 2. Vietnam Military Medical University Corresponding author: Nguyen Quang Huy (huyphat.vn115@gmail.com) Date received: 10/08/2018 Date accepted: 03/10/2018 Journal of military pharmaco-medicine n o 8-2018 189 + Contraindication: The patient cannot be applied laparoscopic surgery (serious disease of cardiovascular or lung). - Preparation: The patient lied on the supine position, general anesthesia. The surgeon stood on the left of the patient, the assistant stood beside of the surgeon on the left. * Technical steps: + Trocar insertion, gaz pump: 3 trocars (umbilicus, left iliac forsa, hypogastric area). Abdominal pump CO2 with 12 - 14 mmHg. + Check injuries: Check all abdominal cavity, find appendix. + Appendectomy: Using monopolair electric surgery for appendix mesentery, ligation of appendage with haemolock. + Abdominal suction-irrigation: Natricloride 0.9% solution. Abdominal drainage insertion. + Check again all abdominal cavity, removing appendix, incision suture. * Process of data: SPSS 22.0, Chi- squared test. - Studying target: Hospital time, farting time, the time of drainage, complication rate and general results of the procedure. RESULTS 1. Characteristics of patients. 82 patients with ACP was operated by laparoscopic approach, males were more than females (59.9% compared with 40.2%), male/female ratio = 1.5. The mean age was 45.7 ± 21.4 years old (from 16 to 95). The proportion of patients with drainage over 72 hours was the most (72.5%); this rate under 25 hours was 1.4% and from 25 to 48 hours was 4.3%. Post-operative flatulence from 49 to 72 hours accounted for 23.2%, over 72 hours was 52.2%; below 25 hours was 2.9%. The average length of hospital stay was 5.9 ± 3.5 days; the shortest time was 1 day and the longest was 30 days. * Post-operative complications (n = 82): Post-operative complications were paralytic intestine 5 patients (6.1%); wound infection 2 patients (2.4%); intra- abdominal abscess 1 patient (1.2%). The rate of total post-operative complications was 9.7% (8/82 cases). The management of post-operative complications: Conservative management were 8/8 cases (100%). Successful result rate was 100%. * The early post-operative complications (n = 82): The early post-operative complications were wound infection (2.4%) and intra- abdominal abscess (2.4%). The rate of the early post-operative complications was 4.8% (4/82 cases). The management of the early post-operative complications: Conservative management were 4/4 cases (100%). Successful result rate was 100%. * Post-operative mortality: The rate of post-operative mortality was 0%. * The grade of result of laparoscopic appendectomy: This grade was based on the criteria of 115 People’s Hospital. Journal of military pharmaco-medicine n o 8-2018 190 Chart 1: The grade of result of laparoscopic appendectomy (n = 82). Excellent results explained 92.8%, good 5.8%, fair 1.4% and bad 0%. Table 1: The relationship between successful laparoscopic appendectomy and duration of peritonitis (n = 82). Laparoscopy Success Conversion to open laparotomy Total Medical history Number Percentage (%) Number Percentage (%) Number Percentage (%) p (χ2) Peritonitis ≤ 12 hours 56 87.5 8 12.5 64 100 Peritonitis > 12 hours 13 72.2 5 27.8 18 100 015 The proportion of successful laparoscopic appendectomy between the groups with peritonitis ≤ 12 hours or > 12 hours; there was no statistically significant difference (χ2, p > 0.05). Table 2: The relationship between successful laparoscopic appendectomy and the condition of intra-abdomen (n = 82). Laparoscopy Success Conversion to laparotomy Total p (χ2) Condition of intra-abdomen n % n % n %) Mild and moderate distended intestine 64 91.4 6 8.6 70 100 Severe distended intestine 5 41.7 7 58.3 12 100 0.00 Little and average pyogenic membrane 49 92.5 4 7.5 53 100 Much pyogenic membrane 20 69.0 9 31.0 29 100 0.01 - The proportion of successful laparoscopy in group with mild and moderate distended intestine was 91.4%, compared to that of group with severe distended intestine (41.7%): the higher rate was statistically significantly different (χ2, p < 0.05). Journal of military pharmaco-medicine n o 8-2018 191 - The proportion of successful laparoscopy in group with little and average pyogenic membrane was 92.5%, compared to that of group of much pyogenic membrane (69%): the higher rate was statistically significantly different (χ2, p < 0.05). Table 3: The relationship between successful laparoscopic appendectomy and the general clinical condition of appendix (n = 82). Laparoscopy Success Conversion to laparotomy Total General clinical condition of appendix n % n % n % p (χ2) Normal position 43 84.3 8 15.7 51 100 Abnormal position 26 83.9 5 16.1 31 100 1.00 Gangrenous base 17 77.3 5 22.7 22 100 No gangrenous base 52 86.7 8 13.3 60 100 0.32 - The proportion of successful laparoscopy in group with normal position of appendix was 84.3%, compared to that of group with abnormal position of appendix (83.9%): there was no statistically significant difference (χ2, p > 0.05). - The proportion of successful laparoscopy in group with gangrenous base of appendix was 77.3%, which was 86.7% in the group with no gangrenous base; there was no statistically significant difference (χ2, p > 0.05). DISCUSSION The mean time of abdominal drainage was 3.9 ± 1.7 days in all of the laparoscopy and was 3.7 ± 1.1 days in open laparotomy. We took out the abdominal drainage tube fairly early when patients’ condition was acceptable (with fluid of abdominal drainage was clear and no pus, which is standard of getting out drainage). Launay-Savary’s advice: Abdominal drainage should be applied on appendicitis with diffuse peritonitis. Petrowsky’s retrospective research indicated that abdominal drainage after appendectomy with perforated or ruptured cause more infections in group with drainage (43 - 85%) than group without (29 - 54%); about infection of peritoneum cavity, there were two researches with results of increasing infectious rate in patients without abdominal drainage, one research admitted that this rate increased in the group with drainage and one research reported that there were the same rates in both of groups. Typically, cecum leak was found in patients with abdominal drainage with proportion of 2 - 7% [2]. The mean time of flatus passage was 1.6 ± 0.9 days. When patients had flatus passage, we advised them to eat. This indicated that duration of paralytic intestine in diffuse peritonitis was relatively longer because of severe infectious conditions. Journal of military pharmaco-medicine n o 8-2018 192 The shortest time of hospital stay was 3 days, the longest was 31 days and the mean time was 6.6 ± 3.6 days. The reason for long hospital stay was due to postoperative pain, especially postoperative abdominal abscess and infectious wound must be treated for a long time with antibiotics. According to Ball’s research: The mean time of hospital stay was 2.2 days and the patients could return to work normally after 9.3 days, the complication rate was 6%. The advantages of laparoscopy in complicated appendicitis was shorter hospital stay and patients could return to normal activity quickly [3]. J Cueto indicated that the mean time of hospital stay was 3.5 days [4]. We had a case (1.4%) of fluid accumulation after surgery for residual abscess after surgery. In this case, the abscess was small, patient was treated with antibiotics, no need to puncture the pus, did not have to resuscitate. This cause may be in the unclean peritoneum cavity also left muchpyogenic membrane as well as do not clean up the fluid washing, and that the drainage tube, the remaining residue will be out. We had 1 case of infectious wound in trocar site for laparoscopy (1.2%) and 1 case of wound infection with conversion to laparotomy (1.2%). These two cases had been treated with patch replacement, in combination with antibiotics. In this study, 5 patients had early bowel paralysis on day 5 after surgery with such symptoms: Vomiting, unable to pass stool or gas, abdominal pain. Medical internal treatment: Continuous gastric emptying, antibiotics, electrolyte solution, then patients were released from the hospital on 10th day. Theoretically, trochanteric infections are more related to the traction of appendix through trocar holes and appendix lesions. In our opinion, this rate is acceptable. Katkhouda found that 4 cases of postoperative laparoscopic appendectomy needed reoperation: Of which, there were 3 cases of injuring hypogastric artery due to the site where the right iliac trocar inserted and bleeding from appendix artery, one case of burning ileum due to that monopolar cauterizing to stop bleeding caused intestinal leak [5]. Fukami’s research found that the rate of postoperative abscess in peritonitis was 5.9% [6]. According to Katkhouda’s research, the proportion of postoperative complication was 17% such as infectious wound of trocar inserted site (6.2%), abdominal abscess (5.3%), these patients were managed by antibiotics and drainage following by CT-scanner. Fukami’s statistic indicated that the proportion of postoperative complications were infectious wound (8.9%), postoperative abdominal abscess (5.9%) and hernia in trocar site (2%) [6]. Our research found that there was no mortality. However, in European and American researches with a great number of samples, they recorded some rate of mortality in appendicitis in general and in diffuse peritonitis appendicitis in particular, the causes were patients’ other diseases. Journal of military pharmaco-medicine n o 8-2018 193 According to G.Mancini’s research, the rate of mortality was 2.7 in general while that rate of postoperative elder patient was 0.4% because of complication of myocardial ischemia [7]. CONCLUSION The studying results of this topic showed that: The farting time over 72 hours after laparoscopic surgery for the treatment of appendicitis peritonitis was 52.2%; the mean hospital stay was 5.9 ± 3.5 days; the rate of complication was 9.7%, including paralytic intestine, wound infection and peritoneal abscess. The general results: excellent (92.8%), good (5.8%), fair (1.4%) and poor (0%). The laparoscopic surgery for the treatment of appendicitis peritonitis was safe, affective and feasible. REFERENCES 1. Dương Mạnh Hùng. Nghiên cứu ứng dụng trong phẫu thuật nội soi viêm phúc mạc ruột thừa. Luận án Tiến sỹ Y học. 2009. 2. Launay-Savary M.V, Slim K. Analyse factuelle du drainage abdominal prophylactique, evidence-based analysis of prophylactic abdominal drainage. Annales de Chirurgie. 2006, 131, pp.302-305. 3. Ball C.G, Kortbeek J.B, Kirkpatrick A.W et al. Laparoscopic appendectomy for complicated appendicitis: An evaluation of postoperative factors. Surg Endosc. 2004, 18, pp.969-973. 4. Cueto J, D’Allemange B, Vazquez-Frias J.A et al. Morbidity of laparoscopic surgety for complicated appendicitis: An international study. Surg Endosc. 2006, 20, pp.717-720. 5. Katkhouda N, Mason J, Twofigh S. Laparoscopic versus open appendectomy. A prospective randomized double-blind study. Annal of Surgery. 2005, 242 (3), pp.439-450. 6. Fukami Y, Hasegawa H, Sakamoto E et al. Value of laparoscopic appendectomy in perforated appendicitis. World J Surg. 2007, DOI:10 1007/s00268-006-0065-x. 7. Mancini G.J, Mancini M.L, Nelson H.S. Efficacy of laparoscopic appendectomy in appendicitis with peritonitis. The American Surgeon. 2005, 71, pp.1-5. Journal of military pharmaco-medicine n o 8-2018 194 FLEXIBLE CALICO-PYELOSCOPY USING HOLMIUM LASER LITHOTRIPSY DURING PYELOLITHOTOMY IN TREATMENT OF KIDNEY STONES: INITIAL EXPERIENCE Nguyen Duy Thinh1; Dao Quang Minh1; Nguyen Phu Viet2 SUMMARY Objectives: To report our initial experience with flexible calico-pyeloscopy using holmium laser lithotripsy during pyelolithotomy in the treatment of renal stones. Subjects and methods: 55 patients/56 kidney stones undergoing open pyelolithotomy combined with endoscopic control of stone clearance, using laser homium energy to break stones at Thanhnhan Hospital from March 2012 to October 2017. Patients with many stones in the kidney were only opened renal pelvis for remove the stones. Then use the flexible tube station 14Fr to control the entire renal pelvis test sticks left. The small stones were dragged out of the basket Dormia, the larger stones will be approved by holmium laser. The sonde JJ was placed and withdrawn after 3 weeks. Preoperative characteristics of renal stones and the results of pyelolithotomy associated flexible calicopyeloscopy were assessed. Operative time and complications were reviewed. Results: Endoscopic technique was performed in 47 cases (83.9%). 9 cases (16.1%) failed. The adsolute cleanlines ratio of gravel in 40/47 cases accounted for 82.2%, in which 7 cases suffered from remaining stones, which caused bleeding during the gravel. Among 9 cases of failure, 4 cases of small kidney stones when the grafts bleed multiple tubes do not control the neck of the kidney due to drainage out, 3 cases when the soft tube into the neck on the test small neck corner, 2 narrowing the neck of the kidneys. There were no cases where kidney tissue was removed to remove stones. No blood transfusion in surgery was taken. Average surgery time was 120 ± 30 minutes, no serious complication after surgery was observed. Conclusion: The flexible calico-pyeloscopy during pyelolithotomy was feasible and effective to control calculi clearance in the treatment of complex renal stones with minimal damage of renal parenchyma. * Keywords: Kidney stones; Flexible endoscopy; Laser holmium. INTRODUCTION Although significant progress has been made in the treatment of multiple kidney stones, the open pyelolithotomy surgery is still largely applied in the treatment of kidney stones. In treatment of multiple kidney stones, the rate of stone remains relatively high. In a recent research by Nguyen Hong Truong (2007), coral surgery at Vietduc Hospital showed good result at only 19.8%, average 51.5%, bad 15.8%, of which the rate of leftover stones in the surgery was 34.6%. Research by Tran Van Hinh, Hoang Manh An et al in coral surgery, the leftover stone rate accounted 1. Thanhnhan Hospital 2. 103 Military Hospital Corresponding author: Nguyen Duy Thinh (nguyenthuha21@gmail.com) Date received: 20/08/2018 Date accepted: 02/10/2018 Journal of military pharmaco-medicine n o 8-2018 195 for 47% [1]. Huynh Van Nghia (2010) applied three techniques: Turner-Warwich, advanced Gil-Vernet, renal kidney tissue enlargement along Brodel in surgery for 100 patients, its results were as followed: good 69%, remaining stones 17% [3]. On the other hand, there is a high risk of renal parenchyma, even multiple locations for the removal of stones, renal function damage. How to overcome these two weaknesses is of great concern today. There are many applications of anti-stone in surgery such as ultrasound, X-ray or endoscopy in surgery. However, the results are still limited. The rate of leftover stones after surgery has decreased but still met with high rate [1]. Open surgeries for kidney coronary stones combined with endoscopic hysterectomy using homium laser are less invasive methods bringing high efficacy [2]. In Vietnam, this method is relatively new and has only been applied in some large hospitals in Vietnam recently [4]. From March 2012 to July 2017, we conducted the study at Institute of Relaxation Technology for the application of soft tube endoscopy and laser energy to detect and deal with stones in calyx, in the open multiple kidney stones surgery for 56 cases. The initial experience of this application will be shared in this article. SUBJECTS AND METHODS 1. Subjects. 55 patients/56 kidneys were diagnosed with multiple kidney stones using renal endoscopy to detect and treat the remaining stones with homium laser in surgery from 3 - 2012 to 7 - 2017. * Requirements: - Multiple kidney stones. - Endoscopy combined with using homium laser. 2. Methods. Research to perform process, description. * Tools and methods: - Soft 10F urography can turn heads in any directions. - Light source, screen, camera, wires light. - Homium laser. - Other tools: Dormia goblet, stone plier... - Continuous watering system (Nacl 0.9%). RESULTS 1. Characteristics of multiple kidney stone in the study (n = 56). Renal pelvis + upper calyx: 0; renal pelvis + middle calyx: 3 kidney stones (5.4%); renal pelvis + lower calyx: 2 kidney stones (3.6%); renal pelvis + middle, lower calyx: 24 kidney stones (42.9%); renal pelvis + upper, middle calyx: 15 kidney stones (26.8%); renal pelvis + upper, lower calyx: 3 kidney stones (5.4%); renal pelvis + upper, middle, lower: 9 kidney stones (16.1%). * Level of renal insufficient: No water stagnant: 45 kidney stones (80.4%); water stagnant lv I: 4 kidney stones (7.1%); water stagnant lv II: 6 kidney stones (10.7%); water stagnant lv III: 1 kidney stones (1.8%) * Characteristics of the kidney: Outside of sinuses: 32 cases (57.1%); reservoir in the sinus: 15 cases (26.8%); intermediate: tanks: 9 cases (16.1%). Journal of military pharmaco-medicine n o 8-2018 196 Table 1: Number of stones per patient. Number of stones/kidney Number of kidney Number of stone Percentage (%) 3 stones 1 3 1.8% 4 stones 20 80 35.7% 5 stones 23 115 41.1% ≥ 6 stones 12 74 21.5% Total 56 272 100% 2. Results of Calyx - renal pelvis endoscopy with soft tube. The success of the technique: - Successful endoscopic treatment for 47 cases of stones. - Soft tube endoscopy failure: 09 cases (4 cases of torning renal pelvis, 3 cases of small angle of renal pelvis - lower calyx of small minor calyx angle, 2 cases of narrow neck of calyx). - The rate of stone clearance immediately after surgery was achieved in 47 cases, accounting for 82.2% of total cases performed successful laparoscopy. Table 2: Treatment of stone in the group of patients with stone clearance. Method of removing stones Number of kidney Number of stone Percentage (%) Dormia muxle 34 47 32.9% Crush with Holmium laser 53 96 67.1% Total 143 100% Stones were found in 16 patients, accounting for 28.6%; its cause was due to tornadoes of the neck damage, small angle of the kidneys, corner, neck, neck damage. * Surgery time: Average operation time was 140 ± 30 minutes, the fastest was 100 minutes, the longest was 200 minutes. 3. Postoperative complications. Urine monitoring in 24 hours after surgery: 14 patients with dark red urine, 42 patients with pink urine. These cases were received medical treatment and hemostatic drugs. After treatment for 3 - 5 days, the patient did not need any interventions. No serious complications were found. DISCUSSION Extralotomy and multiple kidney stones were the first choice in treating multiple kidney stones. However, after long-term use, many authors have indicated that certain limitations such as kidney parenchymal injury are difficult to apply to many tablets scattered in the kidney. Fabrizio (1998) used a soft endoscopy through endoscopic urethral retrograde renal catheterization in general, achieving a success rate of 89%. Grasso et al (1999) achieved a 91% success rate. In 1964, Victor F. Marshall used soft endoscopy for ureteral stones and pyelonephritis. Terris M.K then tested for corneal grafting using a soft-cannula, a stethoscope, or even a cystoscope to check, locate and remove some small stones in the kidney [5]. In 1980, Zingg E.J et al used rigid endoscopy for corneal renal excretion and multiple pelvic examinations, which resulted in more than 60% of multiple kidney stones, remainly located in the kidney [6]. In 2004, Unsal A used a "pulsed" stone scoop that passed through the pelvic opening to graft the stone and Journal of military pharmaco-medicine n o 8-2018 197 pebbles in the stools after grafting stones in the pelvis [7]. Traxel. O (2005) used soft lasers and laser energy to find and dissolve small stones in the kidney [8]. This rate in Pham Ngoc Hung et al’s study (2012) was 63.6% [4]. Compared with other methods of limiting stones in coronary renal excretion and multiple pelvic exams such as X-rays or ultrasound in surgery, endoscopic surgery is more effective than just detecting and treating the remaining stones, multiple kidney stones. With a soft 6.5Fr tube, it can be inserted into all the neck to find stones. However, this method also has certain disadvantages. This is a difficult technique, depending on many factors. If the technique of opening the kidneys is not good, picking up multiple kidney stones causes bleeding in the kidneys, performing endoscopy in the surgery is so difficult, even impossible. Indications for multiple-dose granulomatous colposcopic catheterization with homium laser are well suited. For kidney openings alone, multiple kidney stones and some tablets in the station can be picked up. The remaining stones will be removed or broken through the endoscopy. Particularly for coral stones and multiple pellets, the indication of the method of opening the kidneys alone to remove stones combined with soft endoscopy should be strictly specified. Not every coral is taken through the opening of the kidneys, but also to extend the opening into the kidney parenchyma. Therefore, the opening of the kidney is very wide, causing bleeding again so the ability to use the tube is very difficult. Some authors recommend coral reefs through open kidney lines alone. We have no experience with this technique. In 9 cases failed to perform pyeloscopy, there were 4 cases of pyelonephritis in the sinus cavity, because of small size, we can not bring the soft tube through the kidney into the kidney, especially the lower station, 3 cases of angle. The lower craniofaciens can not enter the coronary tube, 2 cases of neck obstruction. Placement of a soft tube through the kidneys into the middle neck, upper and lower is a decisive step to the success of the procedure. For the small neck, we had calcicectomy. In the process of calcicectomy, bleeding occurred and we must stop surgery. Combination in the procedure, we used the supportive tools such as pumping in the surgery to collect the stone as well as use Dormia or pens to see through the endoscope to extend the soft tube. A total of 157 stones needed to be treated with a soft tube. We collected 47 capsules/34 kidneys (26.5%) and the remaining 110 tablets were used laser. The use of lithotripsy laser energy in renaloscopy has many advantages. We have not seen any cases where the stone is not cracked when using holmium laser pebble. Grafts are usually quite smooth and do not cause damage to the kidney mucosa. This is a superior advantage of the laser compared to the electric pulses. Due to the use of endoscopic surgery, surgical time is considerably longer. Journal of military pharmaco-medicine n o 8-2018 198 Our average operative time was 120 ± 30 minutes. The longest was 165 minutes. Maybe this is the first case, so our experience and techniques are not good. However, there was no evidence of complications of using rinse water during surgery. No changes in kidney or electrolyte disturbances occurred during or after surgery. Excellent results for successful endoscopic procedures were 71.3%, good results were 15.3%, no discomfort was 13.4%. This was a promising result. We think this is a very "delicate" technique, which requires the surgeon to be gentle and skillful. The advantage of this method lies in the opening of the kidney parenchyma to grafts of the stones. Therefore, in addition to limiting stone, postoperative care is usually mild. CONCLUSION Through research we have some comments as follows: - The use of a flexible catheter combined with laser energy holmium stone is a feasible method that can be used in combination therapy of multiple kidney stones by simply opening the kidney with a success rate of 83.9%. The rate of stone clearance was 82.2%, no complications and severe complications were found. - One case of technical failure is the one of multiple kidney stones in the sinus, multiple kidney stones difficult or narrow neck, large angles. REFERENCES 1. Tran Van Hinh. Research on some risk factors and application of high technology in treating urolithiasis. State Independent Subject. 2001. 2. Pham Ngoc Hung et al. Soft endoscopic treatment of renal stones through endoscopic retrograde infiltration. University of Medicine. 2012, Vol 16, pp.265-268. 3. Huynh Van Nghia. Study on the results of surgical removal of coral stones at the 108 Central Military Hospital. Doctoral Dissertation. 2010. 4. Breda A, Ogunyemi O, Lepert J.T, Schulam P.G. Flexible ureteroscopy and laser lithotripsy for multiple unilateral intratenal stones. Eur Urol. 2008, Jun, 13. 5. Terris M.K, Cherukuri S.V, Jadick R.H. Pyelolithomy, Specialties, Urology, Stone, Medicine. 2006. 6. Zingg E.J, Futterlieb A. Nephroscopy in stone surger. Br J Urol. 1980, 52, p.333. 7. Unsal A, Cimentepe E, Saglam R, Balbay M.D. Pneumatic lithotripsy through pyelotomy incision during open surgery for staghorn calculi. Urol Int. 2004, 72, pp.140-144. 8. Traxel O et al. Flexible ureterorenoscopy with holmium laser in horseshoe kidneys. Urology Dec. 2010, 76 (6), pp.1334-1337.