RU2106814C1 - Method for surgical treatment of bladder extrophia - Google Patents

Abstract

FIELD: medicine, juvenile urology. SUBSTANCE: ureters are separated from a bladder followed by their implantation into sigmoid flexure by directing them via a tunnel developed in submucosal layer of sigmoid flexure. For implantation a semi-isolated intestinal segment is used which was developed by creating anastomosis between proximal end of sigmoid flexure and lateral surface of its distal department. Narrowed entrance is developed into semi-isolated segment by gathering sutures. Bladder mucosal membrane is separated and dissected, the rest muscular membrane is gathered into longitudinal folds by P-shaped sutures. Defect of anterior abdominal wall is substituted by two cutaneous fragments cut in pubic area. During the process of fragments' isolation penis cavernous bodies are isolated from pubic bones. EFFECT: higher efficiency to prevent ascending infection, pyelonephritis and avoid suppuration of postoperative wound. 9 dwg

Description

 The invention relates to medicine, namely to pediatric urology.

 Bladder exstrophy is considered the most severe congenital malformation of the urinary system. Due to the impossibility at this time of creating a radical method of treating this category of sick children, which allows them to be fully rehabilitated, all known methods of surgical treatment of bladder exstrophy are aimed at the social adaptation of patients.

 There is a method of surgical treatment of bladder exstrophy by forming a container for collecting urine from local tissues (Lopatkin N.A. Genitourinary system anomalies. Kiev .: Health, 1987, p. 238).

 However, the method does not allow to rehabilitate the patient even at the level of social adaptation. There is urinary incontinence due to the absence of a sphincter apparatus, which is exacerbated by the occurrence of postoperative complications, including urinary fistula.

 There is a method of surgical treatment of bladder exstrophy, including transplantation of the ureters into the sigmoid colon, excision of the bladder and plastic surgery of the defect of the anterior abdominal wall by mobilizing local tissues (Lopatkin N.A. Genitourinary system anomaly. Kiev .: Health, 1987, p. 239) .

 However, the method is not effective. Significant tissue tension in the area of the operation often leads to divergence of the postoperative wound, the occurrence of fistulas. The contact of the ureters with the fecal contents of the intestine contributes to the recurrent course of pyelonephritis due to an emerging infection.

 As a prototype, a method has been adopted for the surgical treatment of bladder exstrophy in children according to Berenheim (Lopatkin N.A., Lyulko A.V. Genitourinary system anomaly. Kiev.: Health, 1987, pp. 240-241). The method includes transplantation of the ureters, excision of the remains of the bladder and plastic surgery of the anterior abdominal wall and is carried out as follows.

 Oval flaps are cut around the ureters, each ureter is excreted along with the surrounding fiber, preserving the vessels and nerves. A tube with mandrin is inserted into the rectum. Having felt the end of the tube with his hand, the surgeon casts a fold of the peritoneum from the rectum. Two provisional silk sutures are placed on the sides of the proposed incision, the ureter is brought down and the intestinal lumen is opened over the tube. The free ends of the ureters are inserted into the hole. The left ureter is transplanted into the intestine above the right. Bladder remnants are removed. A rubber tube is inserted into the rectum. Plastic surgery of the anterior abdominal wall is performed by local tissues mobilizing their edges.

 However, the known method has significant disadvantages, one of which is the transplantation of the ureters without antireflux protection into the intestine that is not isolated from the intestinal contents. Gas reflux and the release of intestinal contents into the kidneys leads to a recurrent course of pyelonephritis and the development of reflux nephropathy.

The technique of plastic surgery of the anterior abdominal wall is also fraught with complications such as the occurrence of fistulas, divergence of the edges of the wound
The objective of the invention is to provide a highly effective method of surgical treatment of bladder exstrophy in children, which allows to reduce the number of postoperative complications.

 The essence of the invention lies in the fact that in the method of surgical treatment of the bladder, including cutting off the ureters from the bladder, implanting them into the sigmoid colon and plastic of the anterior abdominal wall, the ureters are implanted by passing through a tunnel created in the submucosal layer of the wall of the section of the sigmoid colon, made previously in the form of a semi-isolated segment by creating an anastomosis between the proximal end of the sigmoid colon and the lateral surface of its distal section and the formation of a narrowed in yes to the segment with the help of suturing sutures, after which the mucous membrane of the bladder is peeled off and excised, the remaining muscle wall is collected into longitudinal folds by U-shaped suturing sutures, and the defect on the anterior abdominal wall is replaced by two skin flaps cut out in the form of squares with rounded edges in the area of the womb, which after mobilization is turned into the zone of the defect and stitched together, while in the process of isolating the flaps, the cavernous bodies of the penis are separated from the pubic bones.

 Using the invention allows to obtain the following technical result.

 Unlike all known methods, the proposed method allows you to isolate the ureters and urine from direct contact with intestinal contents, which prevents or minimizes the possibility of ascending infection, the development of recurrent pyelonephritis and reflux nephropathy.

 The method allows you to reliably strengthen the maximum abdominal wall with a strong elastic frame made of muscle tissue of the bladder and close the defect with wide full-layer skin flaps, without tensioning the tissues, which allows you to create a coarse cosmetic scar in the inguinal region, to avoid suppuration and divergence of the edges of the postoperative wound and reduce treatment time.

 As a result of surgical treatment, a deformed penis assumes a physiological position.

 The method is less traumatic compared to the known one, since it does not require dissection and deforming movement of a large mass of muscle tissue, it is not accompanied by large blood loss, since it does not involve excision of the bladder.

 In the postoperative period, serious complications such as intestinal events, adhesive obstruction, and urinary fistulas do not develop.

 The proposed method is more effective than the known. It provides a higher level of social adaptation of children and a more pronounced improvement in quality of life.

 The technical result is achieved by forming a semi-isolated segment of the sigmoid colon by suturing the proximal intestine into the side of the distal section 15 cm below the site of implantation of the ureters. At the same time, the entrance to the segment is narrowed with stripping seams. Intestinal contents descend into the rectum through the anastomosis, bypassing the semi-disconnected segment. As a result, fecal contents do not contact directly with urine and ureters, and the created antireflux mechanism prevents infection with gas and intestinal contents, which prevents or minimizes the development of pyelonephritis and nephropathy reflux.

 Refusal to excise the bladder allows not only to avoid severe blood loss, the formation of a defect requiring replacement, but also to strengthen the front abdominal wall with a strong elastic frame from the muscle folds of the bladder, while simultaneously reducing the size of the defect.

 The skin flaps cut in the pubic region are wide and full-layer and easily turn into the defect zone. The wound is sutured without tissue tension, which avoids suppuration and discrepancy of the edges in the postoperative period and reduce treatment time.

 Due to the separation of the cavernous bodies of the penis from adhesions with the bosom, it assumes a physiological position.

 The method is as follows (Fig. 1-9).

 In the position of the patient on the back under a general anesthetic anesthesia, median laparotomy is performed.

 The sigmoid colon is crossed in the middle section (15 cm from the rectum) in the transverse direction, taking into account the vascular arcades (Fig. 1). The proximal end of the sigmoid colon is anastomosed with the lateral surface of its distal section at a distance of 3-5 cm from the rectum using a two-row suture: an internal continuous screwing catgut and an external serous-muscular nodal vicryl. Then, by preparation, the visceral peritoneum in the region of the rectum and posterior wall of the bladder is bluntly peeled off. Through a small hole in the visceral peritoneum, the distal end of the sigmoid colon (above the anastomosis) is moved into the retroperitoneal space. The wall of the distal sigma is longitudinally dissected for 3 cm (Fig. 2). Tubes are inserted into the lumen of the ureters, after which they are cut off from the wall of the bladder. Peel off the mucous membrane of the sigmoid colon from the muscle wall by hydropreparation (injection under pressure of physiological saline using a syringe). Using the dissector, a tunnel is created in the submucosal layer within 5 cm from the edge of the intestine, where the ureters are brought in and implanted, suturing the ureter wall to the intestinal wall with interrupted vicryl sutures (Fig. 3). Outside, the site of implantation of the ureters into the sigmoid colon is strengthened with separate interrupted sutures. The distal segment of the sigmoid colon with transplanted ureters is sutured at the site of its dissection tightly with two rows of nodal screwing sutures with vicryl. For temporary urine diversion, drainage tubes are introduced into the ureters to the pelvis, which are fixed with catgut to the mucous membrane of the sigmoid colon and out through the rectum. To reduce the lumen of the semi-disconnected segment at the junction with the proximal sigmoid colon, 2-3 stripping nodal sutures are applied. To decompensate the intestine, a double-lumen tube is inserted through the rectum into the sigmoid one 10 cm deep beyond the anastomotic zone. The decompression tube and ureteral catheters, highlighted outward, are fixed to the perianal skin with nodular sutures of nylon (Fig. 4).

 Then carry out the plate of the front wall. To do this, a skin incision bordering the bladder is performed, by hydropreparation, the mucous membrane of the bladder is peeled from the muscle tissue and excised throughout it (Fig. 5). After that, on the entire surface of the muscular wall of the bladder impose U-shaped suturing sutures in the transverse direction (Fig. 6). Injections are made every 5 mm. The suturing sutures tighten, forming longitudinal folds, which, being duplicates of the muscular wall of the bladder, reliably strengthen the anterior abdominal wall.

 To replace the defect, two skin flaps are cut out in the bosom in the form of squares with rounded edges, the width and length of which are equal to the size of the surface feeding them. Separation of the flaps is carried out bluntly with the preservation of the nourishing vascular pedicle (Fig. 7). After mobilization, the flaps are turned into the defect zone and sutured with interconnected nylon sutures (Fig. 8).

 The cavernous bodies of the penis are freed from fusion with the fold, bluntly and sharply separating them from the pubic bones. As a result, the penis assumes a physiological position.

 The entire wound is sutured with interrupted kapron sutures to the rubber graduates, which are left for drainage of the sacred discharge in the corners (Fig. 9). The operation is completed by applying a pressure dressing.

 In the postoperative period, much attention is paid to washing the double-lumen decompression tube, the child is on parenteral nutrition for the first 5 days, then they begin to feed with kefir, gradually expanding the diet. The decompression tube is removed on the 7-8th day ureteral catheters on the 10th. Wounds, dressings are carried out daily, rubber graduates are pulled 2 cm daily until they are completely removed. Physiotherapy is actively carried out with a decongestant and anti-inflammatory goal.

 The method has passed clinical trials at the Department of Pediatric Surgery RMAPO, in the urology department of the hospital of St. Vladimir. The proposed method operated on 6 patients. The results of treatment were tracked in the period from 6 months to 1.5 years after surgery. All patients achieved a satisfactory effect and the absence of postoperative complications. Renal function is satisfactory, there is no dilatation of the CHS and ureters, signs of exacerbation of pyelonephritis were observed in only one patient, once a year. Children urinate separately from the act of defecation, urine and feces are retained. In the early postoperative period, only one child observed partial divergence of sutures in the bosom. The cause of the complication is ischemia of the displaced flap as a result of errors in the allocation of its nourishing vascular pedicle. To confirm the advantages of the proposed method in comparison with the known one, we present comparative data of the previous treatment of patients in the same clinic according to the known method of treatment of the proposed method (see table).

 An analysis of the results showed that the proposed operation compares favorably with that used previously. Exacerbations of pyelonephritis, reflux nephropathy were observed much less frequently, such serious complications as urinary fistula, intestinal event were not noted, the number of differences in the edges of the postoperative wound was sharply reduced.

 Example. Patient A., 1.5 years old. He entered the urological clinic 06/14/93. with a diagnosis of bladder exstrophy. 03/20/93. the operation of the proposed method.

 Under general anesthesia in the position of the patient lying on his back, a laparotomy was performed. Crossed the sigmoid colon 15 cm from the rectum and formed an anastomosis between the proximal end of the sigmoid colon and the lateral surface of its distal section at a distance of 3-5 cm from the rectum, using a double-row suture. Then, by preparation, the visceral peritoneum in the rectal region and the posterior wall of the bladder was bluntly exfoliated. Through a small hole in the visceral peritoneum, the distal end of the sigmoid colon was moved into the retroperitoneal space. The wall of the distal longitudinal sigmoid colon was dissected for 3 cm. Tubes were inserted into the lumen of the ureters and cut off from the bladder. The mucous membrane of the sigmoid colon was peeled off from the muscle wall by hydropreparation and a tunnel was created over 5 cm from the edge of the intestine, where the ureters were brought in and implanted, suturing the ureter wall to the wall of the intestine, thus forming an antireflux mechanism. Outside, the ureteral implantation site was strengthened with separate interrupted sutures. The distal segment of the intestine with transplanted ureters was sutured at the site of its dissection with two rows of nodal screwing sutures. For temporary urine diversion, drainage tubes were inserted into the ureters, which were fixed with a catgut to the mucous membrane of the sigmoid colon and brought out through the rectum. To reduce the lumen of the semi-disconnected segment at the junction with the proximal sigmoid colon, 3 suturing sutures were applied. To decompensate the intestine, a double-lumen tube was installed through the rectum into the sigmoid 10 cm beyond the anastomotic zone. The decompression tube and ureteral catheters brought out were fixed to the perianal skin with interrupted sutures. Then, plastic surgery of the anterior abdominal wall was performed. To do this, we performed a skin incision bordering the bladder, by hydro-steaming, the mucous membrane of the bladder was exfoliated from muscle tissue and excised throughout. After that, U-shaped suturing sutures were placed on the entire surface of the muscular wall of the bladder and tightened them, forming longitudinal folds. To replace the defect, two skin flaps were cut out in the bosom in the form of squares with rounded edges, the width and length of which are equal to the size of the supply from the surface. Separation of the flaps was carried out while maintaining the feeding vascular pedicle. After mobilization, the flaps were turned into the defect zone and sewn together with interrupted sutures. The cavernous bodies of the penis were bluntly and sharply separated from the pubic bones, as a result of which the penis assumed a physiological position. The entire wound was sutured with interrupted kapron sutures to the rubber graduates who were left to drain the sacred discharge in the corners of the wound. The operation was completed by applying a pressure bandage.

 The postoperative period was uneventful, without complications. Graduates are removed on the 3rd day. Sutures were removed on day 12. There were no urinary fistulas. The wound healed by primary intention. There were no signs of bowel event. During the control intravenous urography of kidney function on both sides for 6 min, a moderate deformation of the pyelocaliceal system and a somewhat delayed emptying of the contrast were revealed. Urination and defecation in the form of divided acts. Control examination was carried out after 6 months. The anterior abdominal wall does not swell. There are no signs of ventral hernia. Postoperative scars are soft. There are no urinary fistulas. The result of the operation is rated as good. Yr

Claims (1)

 A method for surgical treatment of bladder exstrophy, including cutting off the ureters from the bladder, implanting them into the sigmoid colon and plastic of the anterior abdominal wall, characterized in that the ureters are implanted by passing through a tunnel created in the submucosal layer of the wall of the section of the sigmoid colon, previously made in the form of a semi-insulated segment by creating an anastomosis between the proximal end of the sigmoid colon and the lateral surface of its distal section and the formation of a narrowed entrance in the segment nt using suturing sutures, after which the mucous membrane of the bladder is peeled off and excised, the remaining muscle wall is collected into longitudinal folds with U-shaped suturing sutures, and the defect on the anterior abdominal wall is replaced by two skin flaps cut out in the form of squares with rounded edges in the area of the pubis which, after mobilization, are turned into the zone of the defect and stitched together, while in the process of isolation of the flaps, the cavernous bodies of the penis are separated from the pubic bones.

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