Dr. Gaspar Ibarluzea González, urologist at Top Doctors, will talk about extra and intracorporeal lithotripsy.
Introduction
The revolution that began in the 80’s of the last century, to treat urinary tract stones, has continued, especially in recent years, with an unstoppable evolution of the hand of technological development. The miniaturization of devices, the incredible advances in imaging that we all know from our telephones, video cameras and photographs in continuous evolution, new materials, 3D vision, robotics, etc., etc. All this applied to medicine, in our case to urology, and especially with regard to the treatment of lithiasis, has allowed us to minimize the aggression to the patient in a way that was unthinkable a few years ago when, on occasions, the only option was extremely cruel and aggressive surgery. As a clarification for non-urologists I will tell you that we use the terms lithiasis, stones or calculi as synonyms.
Extracorporeal Lithotripsy by shock waves
Extracorporeal Lithotripsy was invented in the 1980s. The first device was developed by Dornier, a German company, when they realized that shock waves produced in experiments they performed with missiles and airplanes could be focused and produced tensile forces that were capable of breaking stones or kidney stones. The first device consisted of a container of water in which the patient had to be placed, the medium through which the wave propagated was water, and that is why the method was popularized as the bathtub. This is the seventh generation of Dornier devices, the Dornier Geminis. It is the most sophisticated device on the market, with highly advanced, fully robotized patient location and positioning systems. The main disadvantage of this method is that once the stone is broken into more or less large fragments, they must be eliminated by their natural route, so that from a certain volume of lithiasis, of stones, we find ourselves with the serious problem of obstruction in the urinary tract.
Intracorporeal lithotripsy
Endoscopic techniques to treat bladder stones began at the beginning of the last century. We have great admiration for the skill of those urologists who solved problems with rudimentary means in our eyes but which in their day constituted a great advance. This is a mechanical lithotictor from my private museum that I show to a patient I want to scare. It was introduced through the urethra into the bladder and with very poor vision the calculus was removed with these forceps.
It was not until the 1980s that we were able to enter the upper urinary tract, that is to say, the ureter and the renal cavities, under direct vision. The set of endoscopic techniques for exploring and acting on the upper urinary tract are known as endourology. In the ureter and renal cavities we can enter by two main ways, through the main orifice, that is, through the urethra and through the bladder to access one or the other ureter, this requires the use of very thin and fragile instruments and this is one of the fields of greatest evolution in the last decade.
Retrograde intra-renal surgery
The flexible urethenoscopy with instruments of 3 millimeters in diameter with a high definition television camera at the tip and totally manageable allow us to navigate through the urethra and bladder penetrating the ureter and ascending through it reaching the innermost part of the urinary tract in an exciting underwater journey.
Obviously all this requires a miniaturized instrumentation to the maximum and an essential tool such as the Holmium laser that with a fiber of 200 microns, almost like a hair, allows us to cut coagulate and break stones.
Percutaneous intra-kidney surgery.
The technique of choice to treat large kidney stones is accessing the renal cavities through a path established from the skin of the lumbar area to the kidney. By puncture with a needle directed by ultrasound and X-rays, a metallic guide is introduced. After removing the needle, the guide is dilated until a hollow tube the thickness of a pen is placed, which will communicate the interior of the kidney with the exterior through which we will introduce the endoscopes, which in this case are called nephroscopes and can be either rigid or flexible.
The latest addition to our therapeutic arsenal is the microperc, which consists in performing the surgery by percutaneous puncture but without the need to enlarge the trajectory since the same needle can be used to insert a miniaturized optical system to the maximum and a laser fiber to break the stone.
Conclusion of the subject
I completely ignore where the future will lead us because when I started my specialty, more than 30 years ago, all this was unthinkable and not even a science fiction author would have imagined it. What I am sure of is that as long as human beings have to pee and the opposite is not on the horizon, they will need good urologists to fix the clogs in our pipes.