• Nenhum resultado encontrado

Int. braz j urol. vol.34 número2

N/A
N/A
Protected

Academic year: 2018

Share "Int. braz j urol. vol.34 número2"

Copied!
8
0
0

Texto

(1)

Outcomes of Flexible Ureteroscopic Lithotripsy with Holmium

Laser for Upper Urinary Tract Calculi

Marcello Cocuzza, Jose R. Colombo Jr, Antonio L. Cocuzza, Frederico Mascarenhas, Fabio Vicentini, Eduardo Mazzucchi, Miguel Srougi

Division of Urology, University of Sao Paulo, USP and Department of Urology, Syrian-Lebanese Hospital, Sao Paulo, Brazil

ABSTRACT

Objective:7RDVVHVVWKHSHULRSHUDWLYHDQG¿QDQFLDORXWFRPHVRIÀH[LEOHXUHWHURVFRSLFOLWKRWULSV\ZLWKKROPLXPODVHUIRU

XSSHUWUDFWFDOFXOLLQSDWLHQWV

Materials and Methods:

%HWZHHQ)HEUXDU\DQG6HSWHPEHUSDWLHQWVWUHDWHGIRUXSSHUWUDFWVWRQHZLWKÀH[-LEOHXUHWHURVFRSLFOLWKRWULSV\ZHUHHYDOXDWHG5HQDOVWRQHVZHUHDVVRFLDWHGZLWKFROOHFWLQJV\VWHPREVWUXFWLRQLQ SDWLHQWVIDLOHGH[WUDFRUSRUHDOVKRFNZDYHOLWKRWULSV\6:/RFFXUUHGLQSDWLHQWVXQLODWHUDOPXOWLSOHVWRQHVLQ SDWLHQWVDQGPXOWLSOHELODWHUDOVWRQHVLQ,QSDWLHQWVWKHVWRQHZDVORFDWHGLQWKHLQIHULRUFDO\[ 3HULRSHUDWLYHDQG¿QDQFLDORXWFRPHVZHUHDOVRHYDOXDWHG

Results:SURFHGXUHVZHUHSHUIRUPHGLQSDWLHQWV7KHPHDQVWRQHEXUGHQRQSUHRSHUDWLYH&7VFDQZDVr

PP7KHPHDQRSHUDWLYHWLPHZDVrPLQ7KHVWRQHIUHHUDWHZDVDIWHURQHSURFHGXUHDQGDIWHUD VHFRQGSURFHGXUHZLWKRYHUDOOFRPSOLFDWLRQUDWHRI7KHUDSHXWLFVXFFHVVRFFXUUHGLQDQGRISDWLHQWVZLWK ORZHUSROHVWRQHVDQG6:/IDLOXUHUHVSHFWLYHO\7UHDWPHQWIDLOXUHRIDVLQJOHVHVVLRQZDVDVVRFLDWHGZLWKSUHVHQFHRID VWRQHVL]HODUJHUWKDQPP(S EXWQRWDVVRFLDWHGZLWKLQIHULRUFDO\[ORFDWLRQS 6XUJLFDOGLVSRVDEOHV ZHUHUHVSRQVLEOHIRURIRYHUDOOFRVWV

Conclusion:)OH[LEOHXUHWHURVFRS\XVLQJKROPLXPODVHULVDVDIHDQGHIIHFWLYHRSWLRQIRUWKHWUHDWPHQWRIXSSHUXULQDU\

WUDFWFDOFXOL,QDGGLWLRQLWFDQEHFRQVLGHUHGDQDWWUDFWLYHRSWLRQDVVDOYDJHWKHUDS\DIWHU6:/IDLOXUHRUNLGQH\FDOFXOL DVVRFLDWHGZLWKXUHWHUDOVWRQHV6WRQHVL]HODUJHUWKDQPPLVDVVRFLDWHGZLWKVLQJOHVHVVLRQWUHDWPHQWIDLOXUH

Key words: ureter; calculi; Lithotripsy; Holmium laser

Int Braz J Urol. 2008; 34: 143-50

INTRODUCTION

8UHWHURVFRS\ KDV HYROYHG DV WKH PRVW PLQLPDOO\LQYDVLYHDSSURDFKWRWKHXUHWHUDQGNLGQH\

VLQFHLWZDV¿UVWXVHGLQE\+DPSWRQZKRDF

-FLGHQWDOO\HQWHUHGDPDVVLYHGLODWHGXUHWHUZLWKD) F\VWRVFRSH7KHPDQDJHPHQWRIXSSHUWUDFWVWRQH GLVHDVHKDVVKLIWHGIURPWKHLQYDVLYHQHSKUROLWKRWRP\

WRPHWKRGVZLWKPRUHHIIHFWLYHWKHUDSHXWLFRSWLRQV DQGORZHUPRUELGLW\6:/KDVUHYROXWLRQL]HGWKH WUHDWPHQWRIXSSHUWUDFWVWRQHVDQGKDVEHFRPHWKH PRVWHPSOR\HGRSWLRQIRUWKHVHW\SHVRIVWRQHVDV

ZHOO+RZHYHULWVVXFFHVVUDWHVDUHIDUIURPVDW

(2)

LWSRVVLEOHWRDFKLHYHDVWRQHIUHHUDWHRIPRUHWKDQ ZLWKLQKHUHQWULVNVRIWKHSHUFXWDQHRXVDFFHVV 5HFRJQLWLRQRIWKHOLPLWDWLRQVRI6:/DQG3&1/ KDVDOORZHGWKHLQFUHDVHGSRSXODULW\RIXUHWHURVFRSLF WUHDWPHQWRIUHQDOVWRQHV

)OH[LEOH XUHWHURVFRS\ EHFDPH FOLQLFDOO\

DYDLODEOHDIWHUWKHGHYHORSPHQWRIWKHVPDOOGLDP

-HWHUXUHWHURVFRSHZLWKSDVVLYHDQGDFWLYHGHÀHFWLRQ DOORZLQJDFFHVVWRWKHHQWLUHFROOHFWLQJV\VWHPLQXS WRRIWKHSURFHGXUHV,WVDELOLW\WRDFFHVVWKH XSSHUWUDFWFROOHFWLQJV\VWHPDVVRFLDWHGZLWKWKHGH

-YHORSPHQWRIDVDIHUHOLDEOHDQGÀH[LEOHHQGRVFRSLF OLWKRWULSV\VRXUFHFRPELQHGZLWKPRUHHI¿FLHQWH[

-WUDFWLRQLQVWUXPHQWVPDGHWKHÀH[LEOHXUHWHURVFRSLF ODVHUOLWKRWULSV\PRUHDWWUDFWLYHWRHIIHFWLYHO\WUHDW UHQDOVWRQHVZLWKKLJKVXFFHVVUDWHVDQGORZPRUELG

-LW\

7KLVVWXG\HYDOXDWHVWKHRXWFRPHVRIKROPL

-XPODVHUOLWKRWULSV\IRUXSSHUWUDFWFDOFXOLSHUIRUPHG YLDÀH[LEOHXUHWHURVFRS\

MATERIAL AND METHODS

%HWZHHQ)HEUXDU\DQG6HSWHPEHU

FRQVHFXWLYHSDWLHQWVZKRXQGHUZHQWÀH[LEOHXUH

-WHURVFRS\ZLWKKROPLXPODVHUOLWKRWULSV\IRUXSSHU WUDFWVWRQHGLVHDVHZHUHHYDOXDWHG5HOHYDQWGHPR

-JUDSKLFGDWDDQGRSHUDWLYHRXWFRPHVZHUHUHWULHYHG IURPPHGLFDOUHFRUGVZLWKLQVWLWXWLRQDOUHYLHZERDUG DSSURYDO

3DWLHQWV7KHSDWLHQWFRKRUWSUHVHQWHGDPHDQ

DJHRIr\HDUVZLWKWKHPDOHJHQGHULQ

SDWLHQWV7KHLQGLFDWLRQIRUVXUJLFDOWUHDWPHQW ZDVUHQDOVWRQHVDVVRFLDWHGZLWKFROOHFWLQJV\VWHP REVWUXFWLRQLQIDLOXUHRI6:/LQ SDWLHQWVXQLODWHUDOPXOWLSOHVWRQHVLQDQG

PXOWLSOHELODWHUDOVWRQHVLQ7DEOH$OOSD

-WLHQWVXQGHUZHQWDSUHRSHUDWLYHQRQFRQWUDVW&7VFDQ ZLWKLPDJHVDFTXLUHGDW- PPFROOLPDWLRQWKLFNQHVV

DWPPLQWHUYDOZLGWK&ROOHFWLQJV\VWHPREVWUXF

-WLRQZDVGH¿QHGLQSDWLHQWVSUHVHQWLQJZLWKÀDQNSDLQ DQGK\GURQHSKURVLVDVVRFLDWHGZLWKXUHWHUDOVWRQHV GHPRQVWUDWHGE\&7VFDQ

7KHPHDQVWRQHVL]HWUHDWHGZDV

PPORFDWHGRQO\LQWKHULJKWNLGQH\LQ FDVHVOHIWNLGQH\LQDQGELODWHUDOO\LQ

1LQHSDWLHQWVSUHVHQWHGZLWKDWOHDVWRQHVWRQH !PPLQGLDPHWHU7ZHQW\QLQHRQO\KDGLQWUDUHQDO VWRQHVDQGKDGFRPELQHGXUHWHUDODQGUHQDOVWRQHV 7ZHQW\QLQHSDWLHQWVKDGDWOHDVWRQHVWRQH ORFDWHGLQWKHORZHUSROHKDGWKHVWRQHLQWKH UHQDOSHOYLVDQGLQPRUHWKDQRQHORFDWLRQ 7DEOH

6XUJLFDO SURFHGXUH $OO SDWLHQWV UHFHLYHG

SURSK\ODFWLFSDUHQWHUDOWKLUGJHQHUDWLRQFHSKDORVSRULQ DQWLELRWLFVSULRUWRWKHSURFHGXUH,QHDFKFDVHLQWHU

-YHQWLRQZDVSHUIRUPHGXQGHUJHQHUDODQHVWKHVLDDQG HQGRWUDFKHDOLQWXEDWLRQRUODU\QJHDOPDVNDVVRFLDWHG ZLWKQHXURPXVFXODUEORFNDJHDOORZLQJUHVSLUDWRU\ PRWLRQWREHLQWHUUXSWHGIRUVKRUWSHULRGV

%ULHÀ\DIWHUWKHUHWURJUDGHS\HORJUDSK\D

VDIHW\ JXLGH ZLUH ZDV VPRRWKO\ SRVLWLRQHG LQ WKH NLGQH\WRDYRLGEOHHGLQJLQWRWKHSHOYLVGXHWRXUR

-WKHOLDO OHVLRQ WKDW FRXOG DOWHU YLVLELOLW\ GXULQJ WKH SURFHGXUH8UHWHUGLODWDWLRQZDVSHUIRUPHGZLWKWKH LQQHUSDUWRIWKHDFFHVVVKHDWKIRUPLQXWHVZLWK FRPSOHWHLQVHUWLRQRIWKHVKHDWKRYHUWKHZLUHXQGHU ÀXRURVFRSLFJXLGDQFH)LJXUH7KHSUHVHQFHRID SUHH[LVWLQJVWHQWRUXUHWHUDOGLODWDWLRQGXHWRXUHWHUDO VWRQHREVWUXFWLRQREYLDWHGWKHQHHGIRUGLODWDWLRQ :KHQXUHWHUDOVWRQHVZHUHQRWDVVRFLDWHGWKHDXWKRUV HPSOR\HGD)FP$SSOLHG0HGLFDODFFHVV

VKHDWKIRUIHPDOHSDWLHQWVDQGD)FP$S

-SOLHG0HGLFDODFFHVVVKHDWKIRUPDOHV\LHOGLQJGLUHFW DFFHVVWRWKHUHQDOSHOYLV$VXSSHUXUHWHUDOVWRQHV ZHUHDVVRFLDWHG)FP$SSOLHG0HGLFDO Table 1 –'HPRJUDSKLFVRISDWLHQWVWUHDWHGZLWKÀH[LEOH

ureteroscopy lithotripsy with holmium laser for upper tract calculi.

N 44

$JH\HDUV r

0DOH

6\PSWRPDWLF

$VVRFLDWHGXUHWHUDOVWRQH

6:/)DLOXUH

0HDQVWRQHVL]HPP r

%LODWHUDOVWRQHV

0XOWLSOHVWRQHV

(3)

DQG FP 1DYLJDWRU %RVWRQ 6FLHQWL¿F VKHDWKV ZHUHHPSOR\HGIRUIHPDOHVDQGPDOHVUHVSHFWLYHO\ DOORZLQJODUJHUIUDJPHQWUHPRYDODQGEHWWHULUULJD

-WLRQÀRZ:HDWWHPSWHGWRXVHWKHDFFHVVVKHDWKLQ DOOFDVHV:KHQUHVLVWDQFHDWWKHLOLDFYHVVHOOHYHOZDV HQFRXQWHUHGWKHÀH[LEOHXUHWHURVFRSHZDVLQWURGXFHG ZLWKRXWDQDFFHVVVKHDWKYLDLWVSODFHPHQWRYHUDJXLGH ZLUHXQGHUÀXRURVFRSLFJXLGDQFHWRDYRLGIXUWKHU GLODWLRQRIWKHPLGXUHWHU,IDQDFFHVVVKHDWKZDVQRW XVHGDVPDOOFDOLEHU)ROH\FDWKHWHUZDVLQVHUWHGLQWR WKHEODGGHUWRDVVLVWLQXSSHUWUDFWGUDLQDJH

7KHÀH[LEOHXUHWHURVFRSH).DUO6WRU]

)OH[;RU)$&0,'85ZDVLQWURGXFHGRYHU WKHJXLGHZLUHWRWKHUHQDOSHOYLV7KHZLUHZDVWKHQ ZLWKGUDZQWRRSWLPL]HLUULJDQWÀRZDQGDFRPSOHWHLQ

-VSHFWLRQRIWKHFROOHFWLQJV\VWHPZDVSHUIRUPHG+RO

-PLXP<$*ODVHUOLWKRWULSV\ZDVSHUIRUPHGWKURXJK DȝPFRUHVL]HG¿EHU'RUQLHU/LJKWJXLGH6XSHU IRUIUDJPHQWDWLRQXQWLORQO\YHU\VPDOOVWRQH IUDJPHQWVPPZHUHREVHUYHGDYRLGLQJWKHQHHG IRUEDVNHWVWRQHUHWULHYDO2XUFXUUHQWVHWWLQJVIRU WKHODVHU0HGLODV+:DYH/LJKW/DVHU7HFKQRORJ\ *HUPDQ\ZHUH-RXOHDW+HUW]ZLWKDWRWDOSRZHU RI:DWWV,IWKHORZHUSROHFDO\[VWRQHVFRXOGQRWEH IUDJPHQWHGLQVSLWHRIDIXOO\GHÀHFWHGXUHWHURVFRSH

LWZDVPRYHGWRDOHVVGHSHQGHQWFDO\[SRVLWLRQE\ XVLQJ D ]HURWLS QLWLQRO EDVNHW RU ZDWHU ÀXVK WKXVIDFLOLWDWLQJVWRQHIUDJPHQWDWLRQ$OOFROOHFWLQJ V\VWHPVZHUHLQVSHFWHGDWWKHHQGRIIUDJPHQWDWLRQ$ GRXEOH-VWHQWZDVSODFHGLQDOOSDWLHQWVDWWKHFRQFOX

-VLRQRIVXUJHU\DQGZDVUHPRYHGDIWHUDSSUR[LPDWHO\ ZHHNV6WHQWVDWWDFKHGZLWKSXOOVWULQJVZHUHXVHG LQDIHZFDVHVZKHUHVPDOOVWRQHVZHUHFRPSOHWHO\ IUDJPHQWHGDQGWKHDFFHVVVKHDWKZDVQRWXVHG,Q WKHVHFDVHVVWHQWUHPRYDOZDVSHUIRUPHGZHHN ODWHURQDQRXWSDWLHQWEDVLV

2SHUDWLYHRXWFRPHV6WRQHIUHHVWDWXVZDV

GHWHUPLQHGDIWHUVWHQWUHPRYDOE\&7VFDQDWDS

-SUR[LPDWHO\PRQWKVSRVWRSHUDWLYHO\LQDOOSDWLHQWV 5HVXOWVZHUHFODVVL¿HGE\WKHODUJHVWVLQJOHIUDJPHQW DVVWRQHIUHHQRUHVLGXDOIUDJPHQWVREVHUYHGRUUH

-VLGXDOIUDJPHQWVVPDOOHUWKDQPPUHVLGXDOVWRQHV JUHDWHUWKDQPPUHTXLULQJDVHFRQGSURFHGXUHDQG IDLOXUHZKHQLWZDVQRWSRVVLEOHUHDFKVWRQHIUHHGXH WRLQWUDRSHUDWLYHFRPSOLFDWLRQVRUWHFKQLFDOSUREOHPV &RPSOLFDWLRQVZHUHFDWHJRUL]HGLQWRLQWUDRSHUDWLYH FRPSOLFDWLRQVOLPLWHGWRXUHWHUDOSHUIRUDWLRQRUSRVW

-RSHUDWLYHFRPSOLFDWLRQVFKDUDFWHUL]HGE\FRQVLVWHQW KRVSLWDOL]DWLRQIRUSDLQWKDWUHTXLUHGDSDWLHQWKRVSLWDO VWD\IRUPRUHWKDQQLJKW

)LQDQFLDODQDO\VLV'HWDLOHGVXUJLFDOFRVW

GDWDIURPRQHSULYDWHLQVWLWXWLRQ6/+ZDVDYDLODEOH IRUVHOHFWHGSDWLHQWVZLWKQRSHULRSHUDWLYHFRPSOL

-FDWLRQ7KHGDWDZDVFROOHFWHGIURPSDWLHQWV¶ELOOLQJ VWDWHPHQWVDQGFDWHJRUL]HGLQPDWHULDODQGRSHUDWLQJ URRPFRVWV7KH¿UVWRQHLQFOXGHGWKHUHJXODUO\XVHG GLVSRVDEOHVXUHWHUDOVKHDWKEDVNHWJXLGHZLUHDQG XUHWHUDOVWHQWDQGWKHVHFRQGLQFOXGHGRSHUDWLQJ URRPODVHUDQGYLGHRXQLWVDQGÀXRURVFRS\[UD\ XVLQJWLPHIRUHDFKSURFHGXUH7KHFRVWVRIDQHV

-WKHVLDVXSSOLHVODERUDWRU\PHGLFDWLRQDQGQXUVLQJ ZHUHQRWDQDO\]HGDQGQRDGMXVWPHQWIRULQÀDWLRQ ZDVPDGH:KHQDSDWLHQWVWD\HGRYHUQLJKWGXHWR DODWHVXUJLFDOVFKHGXOHDQGWKH\ZHUHGLVFKDUJHG HDUO\LQWKHQH[WPRUQLQJDQGWKHRYHUQLJKWVWD\ZDV QRWFKDUJHG&RVWVIRU6:/ZHUHQRWDYDLODEOHLQRXU ,QVWLWXWLRQV

6WDWLVWLFDODQDO\VLV8QLYDULDEOHDQDO\VLVWR

LGHQWLI\DOOSRWHQWLDOSUHGLFWRUVRIWUHDWPHQWIDLOXUH ZDVSHUIRUPHG,WZDVFRQGXFWHGXVLQJWKH3HDUVRQF VWDWLVWLFRU)LVKHU¶VH[DFWWHVWIRUFDWHJRULFDOGDWDWKH 6WXGHQW¶VW-WHVWIRUFRQWLQXRXVQRUPDOO\GLVWULEXWHG Figure 1 – Access sheath placed over a guide wire in the right

(4)

GDWDDQGWKH:LOFR[RQUDQNVXPWHVWIRUFRQWLQXRXV QRQQRUPDOO\GLVWULEXWHGGDWD$OOVWDWLVWLFDOWHVWVZHUH

WZRWDLOHGDQGSZDVFRQVLGHUHGVWDWLVWLFDOO\

VLJQL¿FDQW

RESULTS

)LIW\SURFHGXUHVZHUHSHUIRUPHGLQSD

-WLHQWVZLWK D PHDQRSHUDWLYHWLPH RI r

PLQ7KH XUHWHUDO VKHDWK ZDV XVHG LQ RI WKH SURFHGXUHV7KHVWRQHIUHHUDWHZDVDIWHURQH SURFHGXUHDQGDIWHUDVHFRQGSURFHGXUH7KUHH SDWLHQWVUHTXLUHGWZRSURFHGXUHVLQRUGHUWREHFRPH VWRQH IUHH7UHDWPHQW VXFFHVV RFFXUUHG LQ RI SDWLHQWVZLWKORZHUSROHVWRQHV,QWKHSDWLHQWVZLWK VDOYDJHWKHUDS\DIWHU6:/IDLOXUHDQGPXOWLSOHVWRQHV WKHVWRQHIUHHUDWHZHUHDFKLHYHGLQDQG UHVSHFWLYHO\+RZHYHUWKHUDSHXWLFVXFFHVVRFFXUUHG LQDQGRISDWLHQWVZLWKVWRQHVL]H!PP DQG!PPUHVSHFWLYHO\2SHUDWLYHGDWDDUHVKRZQ LQ7DEOH

1LQHW\WZRSHUFHQWRIWKHSDWLHQWVZHUHGLV

-FKDUJHGGD\DIWHUWKHSURFHGXUH7KHRYHUDOOFRP

-SOLFDWLRQUDWHZDV,QWUDRSHUDWLYHFRPSOLFDWLRQV FRQVLVWHGRIWZRSUR[LPDOXUHWHUDOSHUIRUDWLRQVFDXVHG E\WKHJXLGHZLUHDQGFRQ¿UPHGE\WKHUHFRJQLWLRQ RIFRQWUDVWOHDNDJHXQGHUÀXRURVFRSLFHYDOXDWLRQ

,QRQHFDVHWKHLQQHUSDUWRIWKHXUHWHUDOVKHDWKZDV SDVVHGRYHUWKHZLUHDQGPLVWDNHQO\GLODWHGWKURXJK WKHSHUIRUDWLRQKHQFHWKHSURFHGXUHZDVVXVSHQGHG %RWKFDVHVZHUHWUHDWHGZLWKXUHWHUDOVWHQWLQJIRU GD\VDQGQRIXUWKHUFRPSOLFDWLRQVRFFXUUHGWKHUHDI

-WHUXQWLORQH\HDURIPHDQIROORZXS3RVWRSHUDWLYH FRPSOLFDWLRQVFRQVLVWHGRIWZRSDWLHQWVZKRUHTXLUHG SRVWRSHUDWLYHKRVSLWDOL]DWLRQIRUSDLQFRQWUROGXULQJ GD\V1RSDWLHQWSUHVHQWHGV\PSWRPVRIXULQDU\ WUDFWLQIHFWLRQQRUZDVUHDGPLWWHGWRWKHKRVSLWDOXQWLO IROORZXSZLWK&7VFDQDWDSSUR[LPDWHO\PRQWKV DIWHUWKHSURFHGXUH

7UHDWPHQWIDLOXUHRIRQHVLQJOHVHVVLRQZDV

DVVRFLDWHGZLWKWKHSUHVHQFHRIVWRQHJUHDWHUWKDQ PPS EXWQRWDVVRFLDWHGZLWKWKHLQIHULRU FDO\[VWRQHORFDWLRQS QRUWKHSUHVHQFHRI PXOWLSOHVWRQHVS :KHQFRQVLGHULQJVWRQH ORFDWLRQQRVLJQL¿FDQWGLIIHUHQFHVZHUHIRXQGEH

-WZHHQLQWUDRSHUDWLYHSDUDPHWHUVDQGPXOWLSOHYHUVXV VROLWDU\VWRQHV

7KHPHDQRYHUDOOFRVWr6'IRUSURFHGXUH

ZDV86r6XUJLFDOGLVSRVDEOHVZHUHUH

-VSRQVLEOHIRURIWKHWRWDO86rDQG

WKHUHPDLQLQJ86rZHUHGXHWR

RSHUDWLQJURRPH[SHQVHV

COMMENTS

7HFKQRORJLFDODGYDQFHVRYHUWKHSDVWGH

-FDGHVZHUHUHVSRQVLEOHIRUWKHÀH[LEOHXUHWHURVFRS\ HYROXWLRQIURPDVLPSOHGLDJQRVWLFSURFHGXUHWRD EDVLFWKHUDSHXWLFWRRO7KHVHFKDQJHVLQFOXGHGGRZQ

-VL]LQJWKHXUHWHURVFRSHXSVL]LQJZRUNLQJFKDQQHOV PRGHUQVWRQHH[WUDFWLRQWRROVDQGKROPLXPODVHUDV DQHQHUJ\VRXUFH:LWKWKHDFWLYHO\GHÀHFWDEOHXUH

-WHURVFRSHVDOOFDO\FHVFDQEHDFFHVVHGLQXSWR RINLGQH\VLQFOXGLQJORZHUSROH

)OH[LEOHXUHWHURVFRS\IRUXSSHUXULQDU\WUDFW

VWRQHVLVDGHOLFDWHSURFHGXUHFRPSULVHGRILQWULFDWH GHWDLOV7KHVHGHWDLOVPXVWEHUHVSHFWHGVLQFHWKH\ PD\EHWKHGLIIHUHQFHEHWZHHQVXFFHVVRUIDLOXUH7KH SURFHGXUHLVEHVWSHUIRUPHGXQGHUJHQHUDODQHVWKHVLD VLQFHLWDOORZVWHPSRUDU\UHVSLUDWRU\PRWLRQLQWHUUXS

-WLRQHQKDQFLQJWKHSUHFLVLRQRIWKHODVHUSUREHDVZHOO DVUHGXFLQJWKHUDWHRIXURWKHOLDOOHVLRQVDQGRSHUDWLRQ WLPH

Table 2 –2SHUDWLYHGDWDRIÀH[LEOHXUHWHURVFRS\OLWKRWULSV\

with holmium laser for upper tract calculi.

Procedures 50

2SHUDWLYHWLPHPLQ r

8UHWHUDOVKHDWK

6WRQHIUHHSURFHGXUH

6WRQHIUHHSURFHGXUHV

6WRQHIUHH6WRQHVL]H!PP

6WRQHIUHH6WRQHVL]H!PP

6WRQHIUHH/RZHUFDO\[

6WRQHIUHH0XOWLSOHVWRQHV

6WRQHIUHH6:/)DLOXUH

,QWUDRSHUDWLYHFRPSOLFDWLRQV

(5)

7KH SURSRVHG DGYDQWDJHV RI WKH XUHWHUDO VKHDWKDOORZIDVWVDIHDQGPXOWLSOHDFFHVVHVWRWKH XSSHUXULQDU\WUDFW7KHVKHDWKDOVRLQFUHDVHVXUH

-WHURVFRSH OLIH VSDQ GHFUHDVHV LQWUDUHQDO SUHVVXUH DQGSURYLGHVLPSURYHGYLVLELOLW\DVDUHVXOWRIPRUH HIIHFWLYHLUULJDQWÀRZ

7KHRWKHUPDMRUIDFWRUWKDWPDGHLWSRVVLEOH

WR H[SDQG WKH ÀH[LEOH XUHWHURVFRS\ XVH IRU XSSHU WUDFWVWRQHVZDVWKHLQWURGXFWLRQRIKROPLXP<$* ODVHUHQHUJ\7KLVHQHUJ\LVUDSLGO\DEVRUEHGE\ZDWHU

DQGKDVPLQLPDOWLVVXHHIIHFWWKURXJKDPPFRUH

VL]HG¿EHUZKLOHDOORZLQJIRUJUHDWHUXUHWHURVFRSH GHÀHFWLRQZLWKRXWFRPSURPLVLQJLUULJDQWÀRZDQG FRQVHTXHQWO\YLVLELOLW\,QIHZFDVHVZKHUHWKH

PPFRUHVL]HG¿EHUFDXVHGDGHÀHFWLRQDQJOH

ORVVWKHIUDJPHQWDWLRQRIORZHUSROHVWRQHVFRXOG EHIDFLOLWDWHGDIWHUUHSRVLWLRQLQJWKHVWRQHWRDPRUH FHSKDOLFFDO\[$XJHHWDOUHSRUWHGUHGXFHGVWUDLQRQ HQGRVFRSHVDQGLPSURYHGVWRQHIUHHUDWHVZKHQXVLQJ WKHUHSRVLWLRQLQJWHFKQLTXH

0LQLPDOO\ LQYDVLYH WHFKQLTXHV VKRXOG EH

FRQVLGHUHG DQ DWWUDFWLYH RSWLRQ IRU DV\PSWRPDWLF UHQDOVWRQHVZKHQDVVRFLDWHGXUHWHUDOVWRQHREVWUXF

-WLRQLVSUHVHQWUHTXLULQJLQWHUYHQWLRQ7UHDWPHQWIRU DV\PSWRPDWLFFDO\FHDOFDOFXOLLVUHFRPPHQGHGEDVHG RQWKHSUHPLVHWKDWRIWKHVHVWRQHVLQFUHDVHDQG ZLOOFDXVHV\PSWRPVUHTXLULQJWUHDWPHQWGXULQJD \HDUSHULRG

6WRQHIUHH VWDWXV DIWHU D VLQJOH SURFHGXUH

DSSHDUVGLUHFWO\UHODWHGWRVWRQHEXUGHQ6:/VKRXOG EHFRQVLGHUHGWKH¿UVWOLQHRIWKHUDS\IRUVWRQHVd PPZLWKVWRQHIUHHUDWHUHSRUWVDVKLJKDVDIWHU RQHSURFHGXUH$OWKRXJKVXFFHVVUDWHVRIÀH[LEOH XUHWHURVFRS\PD\EHVLPLODUWKHPRUHLQYDVLYHQDWXUH RI HQGRVFRSLF VXUJHU\ FRXQWHUDFWV WKLV DGYDQWDJH 7KHSUHVHQFHRIUHVLGXDOIUDJPHQWVIROORZLQJ6:/ QHFHVVLWDWLQJPXOWLSOHSURFHGXUHVLVRIWHQDVVRFLDWHG ZLWKVWRQHVJUHDWHUWKDQPPDQGORZHUFDO\FHDO ORFDWLRQ)OH[LEOHUHWURJUDGHXUHWHURVFRS\FDQ EHFRQVLGHUHGIRUVDOYDJHWKHUDS\DIWHU6:/IDLOXUH EDVHGRQWKHXQLYHUVDOHIIHFWRIWKHKROPLXPODVHULQ IUDJPHQWLQJXQUHVSRQVLYHVWRQHV

6WRQHVJUHDWHUWKDQPPPD\EHFRQVLG

-HUHUDOLPLWDWLRQIRU6:/DQGIOH[LEOHXUHWHURVFRS\ ZLWKDSSUR[LPDWHO\DQGVWRQHIUHHUDWHV UHVSHFWLYHO\ ZLWK 3&1/ EHLQJ FRQVLGHUHG WKH ILUVWOLQHWKHUDS\LQWKLVVLWXDWLRQ+RZHYHU

*UDVVR HW DO VKRZHG VXFFHVVIXO WUHDWPHQW IRU VWRQHVJUHDWHUWKDQPPZLWKUHWURJUDGHIOH[LEOH XUHWHURVFRS\ZLWKDQDYHUDJHRISURFHGXUHV SHUSDWLHQW

$OWKRXJK WHFKQLFDO HIIRUWV ZHUH PDGH WR

LQFUHDVH XUHWHURVFRSH GXUDELOLW\$IDQH HW DO UH

-SRUWHGDQDYHUDJHRIWRSURFHGXUHVLQWKH¿UVW JHQHUDWLRQ RI VPDOOFDOLEHU XUHWHURVFRSHV EHIRUH UHTXLULQJVRPHVRUWRIUHSDLU7KHORVVRIGHÀHFWLRQ GXULQJWUHDWPHQWRIORZHUSROHVWRQHZDVWKHPRVW IUHTXHQWGHIHFW7KHVHUHSDLUVDUHH[SHQVLYH DQGWKHGXUDELOLW\RIWKHVHLQVWUXPHQWVUHSUHVHQWV

DPDMRU¿QDQFLDOFRQFHUQ'XULQJSUR

-FHGXUHV D GLVUXSWLRQ LQ WKH ODVHU ¿EHU GXULQJ D ORZHUSROHVWRQHIUDJPHQWDWLRQZLWKIXOOGHÀHFWLRQ GDPDJHGWKHZRUNLQJFKDQQHORIRQHXUHWHURVFRSH /RZHUSROHXUHWHURQHSKURVFRS\UHTXLUHVWUDQVPLV

-VLRQRIKROPLXP<$*HQHUJ\DORQJDGHÀHFWHG¿EHU 7KHUHLVDOVRDULVNRI¿EHUIUDFWXUHIURPWKHUPDO EUHDNGRZQDQGODVHUHQHUJ\WUDQVPLVVLRQWRWKHHQ

-GRVFRSH7KHSHUIRUPDQFHDQGVDIHW\RIODVHU¿EHUV GLIIHUVERWKEHWZHHQPDQXIDFWXUHUVDQGDVUHJDUGV PDQXIDFWXUHU¶VOLQHRI¿EHUV

7KHQHZJHQHUDWLRQRIXUHWHURVFRSHVDVWKH

'85(OLWH$&0,6RXWKERURXJK0$KDVVHF

-RQGDU\DFWLYHGHÀHFWLRQLPSURYLQJDFFHVVWRORZHU SROHFDO\[DQGDOVRH[KLELWLQJLPSURYHGGXUDELOLW\ &DUH\HWDOUHSRUWHGWKDWQHZHUPRGHOÀH[LEOH XUHWHURVFRSHVOHVVWKDQ)SURYLGHGPRUHWKDQXVHV EHIRUHDQLQLWLDOUHSDLUZDVQHHGHG

7ZRXUHWHUDOSHUIRUDWLRQVRFFXUUHGGXULQJWKH

XVHRIDVWDQGDUGZLUHQRQK\GURSKLOLFSULRUWRWKH LQVHUWLRQRIDQDFFHVVVKHDWK%RWKRIWKHPRFFXUUHG LQDGLODWHGXUHWHUVHWWLQJGXHWRGLVWDOVWRQHV:H FXUUHQWO\UHFRPPHQGWKHXVHRIK\GURSKLOLFJXLGH ZLUHVEHIRUHLQVHUWLQJWKHDFFHVVVKHDWK7KHRYHUDOO FRPSOLFDWLRQ UDWH RI REVHUYHG LQ WKLV VWXG\ LV FRPSDUDEOHWRWKDWUHSRUWHGLQWKHOLWHUDWXUH8UH

-WHUDOVWULFWXUHUDWHRIKDVEHHQUHSRUWHGKRZHYHU WKHSRVWRSHUDWLYHIROORZXSLVQRWORQJHQRXJKWR GHWHUPLQHLWVLQFLGHQFHLQWKLVVHULHV$OWKRXJKWKH VWDQGDUGFDUHIRUXUHWHURVFRS\LVWRGLVFKDUJHSDWLHQWV WKHVDPHGD\RXUSDWLHQWVUHPDLQHGLQKRVSLWDORYHU

-QLJKWDVWKHSURFHGXUHZDVSHUIRUPHGXQGHUJHQHUDO DQHVWKHVLDODWHLQHYHQLQJ

7KHFXUUHQWVWXG\SUHVHQWHGVWRQHIUHHUDWHV

(6)

OLWHUDWXUH7KLVUHVXOWPD\EHGXHWRWKHVPDOOHU PHDQVWRQHVL]HDQGORQJHURSHUDWLYHWLPHLQRXUVH

-ULHVZKLFKFRXOGLQGLFDWHVORQJHUODVHU¿ULQJWLPHWR DFKLHYHVPDOOUHVLGXDOIUDJPHQWV7KHXVHRIXUHWHUDO VKHDWKLQWKHPDMRULW\RIFDVHVFRXOGSRVVLEO\KDYHD UROHLQWKHRYHUDOOUHVXOWVDQGVKRXOGEHLQYHVWLJDWH IXUWKHULQDUDQGRPL]HGVWXG\FRQWH[W$OVRVWRQH IUHHUDWHVZHUHVWURQJO\LQÀXHQFHGE\GH¿QLWLRQRI VXFFHVVUHVLGXDOIUDJPHQWVVPDOOHUWKDQPPDQG RQO\RXWRISDWLHQWVZHUHIRXQGWREH FRPSOHWHO\VWRQHIUHH3RUWLVHWDOUHSRUWHG VWRQHIUHHUDWHZKHQVXFFHVVZDVGH¿QHGDVDFKLHYLQJ IUDJPHQWVVPDOOHUWKDQPP,QDGGLWLRQRXU SURWRFROXVHGPPVHFWLRQVIRUQRQFRQWUDVW&7 VFDQKRZHYHUVPDOOFDOFXOLPPPD\EHPLVVHG RQPPWKLFNVHFWLRQV

+ROPLXPODVHUÀH[LEOHXUHWHURVFRS\LVDQ

HFRQRPLFDOO\ YLDEOH WUHDWPHQW PRGDOLW\ DQG GHP

-RQVWUDWHV DQ DFFHSWDEOH ¿QDQFLDO DQDO\VLV SUR¿OH 0DWHULDOFRVWVH[FOXGLQJRSHUDWLQJURRPH[SHQGLWXUH KDVDFFRXQWHGIRUWKHPDMRULW\RIWUHDWPHQWUHODWHG H[SHQVHVLQWKLVVWXG\7KHUHLVVRPHUHOXFWDQFHWR DFFHSWWKLVSURFHGXUHGXHWRKLJKHTXLSPHQWFRVWV DQGE\WKHLQKHUHQWOHDUQLQJFXUYHUHODWHGWRDQHZ VXUJLFDOWHFKQLTXH6RPHVHULHVKDYHGHPRQVWUDWHG WKDWÀH[LEOHXUHWHURVFRS\LVDVHIIHFWLYHDV6:/LQWKH WUHDWPHQWRIUHQDOVWRQHVZLWKORZFRPSOLFDWLRQVUDWHV EXWLQDQHUDRIFRVWFRQWDLQPHQWLWLVDOVRQHFHVVDU\ WRHYDOXDWHWKH¿QDQFLDOGLIIHUHQFHVRIWKHWUHDWPHQWV $OWKRXJKLQWKH8QLWHG6WDWHVXUHWHURVFRSLF ODVHUVWRQHWUHDWPHQWLVFRQVLGHUHGPRUHFRVWHIIHF

-WLYHWKDQ6:/LQ%UD]LOWKHFRVWVUHODWHGWR6:/DUH PXFKORZHUKHQFHDSURVSHFWLYHVWXG\LVVWLOOQHHGHG WRGHWHUPLQHWKHFRVWHIIHFWLYHQHVVRIHDFKWHFKQLTXH LQRXUFRXQWU\

7KHOLPLWHGQXPEHURISDWLHQWVLVDGUDZ

-EDFNLQWKLVVHULHV+RZHYHUWKHGDWDZHUHFROOHFWHG SURVSHFWLYHO\DQGDOOSDWLHQWVUHFHLYHGDFORVHDQG SUHHVWDEOLVKHGIROORZXSZKLFKFRXOGEHFRQVLGHUHG VWUHQJWKVRIWKLVVWXG\

7KHDXWKRUVEHOLHYHWKHGDWDSUHVHQWHGKHUHLQ

VXSSRUWWKHPLQLPDOO\LQYDVLYHWUHDWPHQWZLWKÀH[

-LEOHXUHWHURVFRS\DQGKROPLXPODVHURIXSSHUWUDFW VWRQHV3UHFLVHLQGLFDWLRQNQRZOHGJHRIFDSDELOLW\ DQGOLPLWDWLRQVRIÀH[LEOHHQGRVFRSHVDUHFUXFLDOIRU DKLJKVXFFHVVUDWHZKLOHSUHVHUYLQJWKHHTXLSPHQW IRUDORQJOLIHVSDQ

CONCLUSION

)OH[LEOHXUHWHURVFRS\ZLWK+ROPLXP<$*

ODVHULVDVDIHDQGHIIHFWLYHRSWLRQIRUWKHWUHDWPHQWRI XSSHUXULQDU\WUDFWFDOFXOL7KHSURFHGXUHVKRXOGEH FRQVLGHUHGDQDWWUDFWLYHWUHDWPHQWRSWLRQIRUDVVRFL

-DWHGNLGQH\FDOFXOLZLWKREVWUXFWLQJXUHWHUDOVWRQHVDV ZHOODVVDOYDJLQJWKHUDS\DIWHU6:/IDLOXUHDVZHOO 6WRQHVL]HODUJHUWKDQPPLVDVVRFLDWHGZLWKVLQJOH VHVVLRQWUHDWPHQWIDLOXUH

CONFLICT OF INTEREST

1RQHGHFODUHG

REFERENCES

-RKQVWRQ:.UG/RZ5.'DV67KHHYROXWLRQDQG SURJUHVVRIXUHWHURVFRS\8URO&OLQ1RUWK$P

*UDII - 'LHGHULFKV: 6FKXO]H + /RQJWHUP IRO-ORZXSLQH[WUDFRUSRUHDOVKRFNZDYHOLWKRWULSV\ SDWLHQWV-8URO

9DOODQFLHQ*'HIRXUPHVWUDX[1/HR-3&RKHQ/ 3XLVVDQ-9HLOORQ%HWDO2XWSDWLHQWH[WUDFRUSRUHDO OLWKRWULSV\ RI NLGQH\ VWRQHV WUHDWPHQWV (XU 8URO

%XVE\-(/RZ5.8UHWHURVFRSLFWUHDWPHQWRIUHQDO FDOFXOL8URO&OLQ1RUWK$P

*UDVVR0%DJOH\'6PDOOGLDPHWHUDFWLYHO\GHÀHFW-DEOHÀH[LEOHXUHWHURS\HORVFRS\-8URO GLVFXVVLRQ

%DJOH\'+,QWUDUHQDODFFHVVZLWKWKHÀH[LEOHXUHWHUR-S\HORVFRSHHIIHFWVRIDFWLYHDQGSDVVLYHWLSGHÀHFWLRQ -(QGRXURO

/¶HVSHUDQFH-2(NHUXR:26FDOHV&'-U0DUJXHW &*6SULQJKDUW:30DORQH\0(HWDO(IIHFWRI XUHWHUDODFFHVVVKHDWKRQVWRQHIUHHUDWHVLQSDWLHQWV XQGHUJRLQJXUHWHURVFRSLFPDQDJHPHQWRIUHQDOFDOFXOL 8URORJ\

$XJH %. 'DKP 3:X 1= 3UHPLQJHU *0 8UH-WHURVFRSLFPDQDJHPHQWRIORZHUSROHUHQDOFDOFXOL WHFKQLTXHRIFDOFXOXVGLVSODFHPHQW-(QGRXURO

(7)

1HWWR15-U&ODUR-)/HPRV*&&RUWDGR3/5HQDO FDOFXOLLQORZHUSROHFDOLFHVZKDWLVWKHEHVWPHWKRG RIWUHDWPHQW"-8URO

/LQJHPDQ-(6LHJHO<,6WHHOH%1\KXLV$::RRGV -50DQDJHPHQWRIORZHUSROHQHSKUROLWKLDVLVDFULWL-FDODQDO\VLV-8URO

6WDY.&RRSHU$=LVPDQ$/HLERYLFL'/LQGQHU$ 6LHJHO<,5HWURJUDGHLQWUDUHQDOOLWKRWULSV\RXWFRPH DIWHUIDLOXUHRIVKRFNZDYHOLWKRWULSV\-8URO

*UDVVR0&RQOLQ0%DJOH\'5HWURJUDGHXUHWHURS\-HORVFRSLFWUHDWPHQWRIFPRUJUHDWHUXSSHUXULQDU\ WUDFWDQGPLQRU6WDJKRUQFDOFXOL-8URO

$IDQH-62OZHQ\(2%HUFRZVN\(6XQGDUDP&3 'XQQ0'6KDOKDY$/HWDO)OH[LEOHXUHWHURVFRSHV DVLQJOHFHQWHUHYDOXDWLRQRIWKHGXUDELOLW\DQGIXQFWLRQ RIWKHQHZHQGRVFRSHVVPDOOHUWKDQ)U-8URO

&DUH\5,*RPH]&60DXULFL*/\QQH&0/HYHLOOHH 5-%LUG9*)UHTXHQF\RIXUHWHURVFRSHGDPDJHVHHQ DWDWHUWLDU\FDUHFHQWHU-8URO GLVFXVVLRQ

.QXGVHQ%(*OLFNPDQ5'6WDOOPDQ.-0DVZDGL6 &KHZ%+%HLNR'7HWDO3HUIRUPDQFHDQGVDIHW\RI

KROPLXP<$*ODVHURSWLFDO¿EHUV-(QGRXURO

0RQJD0%HVW69HQNDWHVK5$PHV&/HH&.XV-NRZVNL0HWDO'XUDELOLW\RIÀH[LEOHXUHWHURVFRSHV DUDQGRPL]HGSURVSHFWLYHVWXG\-8URO

6RIHU0:DWWHUVRQ-':ROOLQ7$1RWW/5D]YL+ 'HQVWHGW-'+ROPLXP<$*ODVHUOLWKRWULSV\IRUXSSHU XULQDU\WUDFWFDOFXOLLQSDWLHQWV-8URO

3RUWLV$-5\JZDOO5+ROW]&3VKRQ1/DOLEHUWH0 8UHWHURVFRSLFODVHUOLWKRWULSV\IRUXSSHUXULQDU\WUDFW FDOFXOLZLWKDFWLYHIUDJPHQWH[WUDFWLRQDQGFRPSXWHU-L]HGWRPRJUDSK\IROORZXS-8URO GLVFXVVLRQ

0HPDUVDGHJKL0+HLQ]3HHU*+HOELFK7+6FKDH- IHU3URNRS&.UDPHU*6FKDULW]HU0HWDO8QHQ-KDQFHGPXOWLGHWHFWRUURZ&7LQSDWLHQWVVXVSHFWHGRI KDYLQJXULQDU\VWRQHGLVHDVHHIIHFWRIVHFWLRQZLGWK RQGLDJQRVLV5DGLRORJ\

3DUNHU%')UHGHULFN5:5HLOO\73/RZU\36%LUG (7(I¿FLHQF\DQGFRVWRIWUHDWLQJSUR[LPDOXUHWHUDO VWRQHVVKRFNZDYHOLWKRWULSV\YHUVXVXUHWHURVFRS\ SOXVKROPLXP\WWULXPDOXPLQXPJDUQHWODVHU8URO-RJ\GLVFXVVLRQ

Accepted after revision: July 4, 2007

Correspondence address:

'U0DUFHOOR&RFX]]D 'LYLVLRQRI8URORJ\

8QLYHUVLW\RI6mR3DXOR863 5XD$GPD-DIHW 6DR3DXOR63%UD]LO )D[

(PDLOPFRFX]]D#XROFRPEU

EDITORIAL COMMENT

:KLOH VKRFNZDYH OLWKRWULSV\ KDV EHHQ WKH

¿UVWOLQHWUHDWPHQWIRUXSSHUXUHWHUDOFDOFXOL

FPRYHUWKHODVWWZHQW\\HDUVWKHUHDSSHDUVWREHDQ

(8)

XULQDU\WUDFWFDOFXOLLQSDWLHQWV-8URO

3RUWLV$-5\JZDOO5+ROW]&3VKRQ1/DOLEHUWH0 8UHWHURVFRSLFODVHUOLWKRWULSV\IRUXSSHUXULQDU\WUDFW FDOFXOLZLWKDFWLYHIUDJPHQWH[WUDFWLRQDQGFRPSXWHU-L]HGWRPRJUDSK\IROORZXS-8URO GLVFXVVLRQ

.UDPEHFN$(*HWWPDQ075RKOLQJHU$//RKVH &03DWWHUVRQ'(6HJXUD-:'LDEHWHVPHOOLWXVDQG K\SHUWHQVLRQDVVRFLDWHGZLWKVKRFNZDYHOLWKRWULSV\ RIUHQDODQGSUR[LPDOXUHWHUDOVWRQHVDW\HDUVRI IROORZXS-8URO

Dr. Bodo Knudsen Department of Urology The Ohio State University Medical Center Director, Ohio State University Comprehensive Kidney Stone Program Columbus, Ohio, USA E-mail: bodo.knudsen@osumc.edu

XUHWHURVFRSHWKHGHYHORSPHQWRIWKHKROPLXP<$* ODVHUXUHWHUDODFFHVVVKHDWKVDQGVPDOOFDOLEHUWLSOHVV QLWLQROVWRQHEDVNHWVKDYHOHGWRVDIHUPRUHHI¿FD

-FLRXVSURFHGXUHV)XUWKHUPRUHDUHFHQWUHSRUW VXJJHVWLQJDOLQNEHWZHHQVKRFNZDYHOLWKRWULSV\DQG GLDEHWHVPHOOLWXVKDVUDLVHGFRQFHUQV+RZHYHU IXUWKHUUH¿QHPHQWRIÀH[LEOHXUHWHURVFRS\LVUHTXLUHG WRERWKLPSURYHSDWLHQWRXWFRPHDQGUHGXFHFRVWV

7KHGHYHORSPHQWRIGXUDEOH)UVL]HGGLJLWDO

XUHWHURVFRSHVLPSURYHPHQWVLQKROPLXP<$*ODVHU ¿EHUWHFKQRORJ\WRUHGXFH¿EHUIDLOXUHGXULQJORZHU SROHSURFHGXUHVDQGXSGDWHGVWHQWGHVLJQVWKDWPLQL

-PL]HV\PSWRPVDUHDOOQHHGHGWRIXUWKHUDGYDQFHWKLV ¿HOG

REFERENCES

Imagem

Figure 1 – Access sheath placed over a guide wire in the right  ureter.

Referências

Documentos relacionados

Atividade específica utilizada para realizar desmatamento, aceiro, roçada, cortar bambu, árvores especiais e/ou derrubar vegetação diversificada em linhas de distribuição de

Aduz que a Lei nº 13.467/2017 - Reforma Trabalhista, visou desmontar o sistema de custeio sindical, tendo em vista que as alterações dos artigos 545, 578, 579, 582, 583, 587 e 602 -

Until now no information on the chromosomes of these two species is available, although wide karyotypic diversity has been already reported for other Ciconiiformes, including

O ângulo de rotor resultante e a saída de potência reativa em MVA se a corrente de campo for reduzida a 842 A enquanto a potência fornecida no eixo pela máquina motriz primária

O objetivo principal deste trabalho é analisar a relação entre a reeleição para os titulares do poder executivo – prefeitos nortistas – com a situação dos gastos

Os resultados dos modelos contribuem para enriquecer o debate teórico sobre políticas públicas e comportamento eleitoral, na medida em que as estimativas corroboram para

Existem critérios para aceitação de presentes, brindes, convites, viagens ou quaisquer outras formas de cortesia oferecidas para os colaboradores do Grupo, bem

O artigo 22º do Codigo da Familia 50 angolano faz menção da promessa de casamento, seguindo a mesma linha da lei portuguesa, atribuindo ineficácia juridica da promessa