RU2163093C1 - Method for performing enterocystoplastic repair - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves using T-shaped loop from the ileum. Holes in mesenterium are created between the sutured segments of the ileum. The ureters are brought through the holes. The ileum is cut on the T-shaped loop segment. Intestinal reservoir is formed. The distal end of the intestine is brought down to the perineum. The distal segment is placed in the canal between the rectal sphincter and separated anal canal mucosa. EFFECT: enhanced effectiveness in repairing reservoir function of the urinary bladder. 8 dwg

Description

 The invention relates to medicine, namely to the technique of forming the bladder from the small intestine in the surgical treatment of cancer.

 Current requirements for the surgical treatment of bladder cancer in many cases suggest its complete removal. In this case, immediately or after a certain period of time, the question arises of restoring the function of the bladder. A solution to this problem involves the restoration of the reservoir function of the bladder while restoring the mechanism of diversion and retention of urine. In practice, in most cases, to restore the capacity of the bladder, various sections of the intestine are used - small and large. To restore urine retention, natural sphincters of the gastrointestinal tract are used - the Bauginium damper, the rectal sphincter. Many surgeons restore the natural urinary tract by forming an anastomosis between a section of the intestine and the urethra. It is far from always possible to achieve satisfactory results of intestinal plasty. Until now, unresolved issues related to the prevention of reflux of intestinal contents into the ureters, the reliability of the ureter-intestinal and urethral-intestinal anastomoses, and the creation of a reliable mechanism for the retention of urine. In some cases, when a tumor is localized in the area of the mouth of the urethra during surgery, part of the urethra has to be resected. In these cases, it is technically impossible to restore the natural path of urination at all.

 There is a method of small intestinal plasty of the bladder according to Bricker (Shepilov V. I. Bladder cancer. - M .: Medicine, 1983. - 192 p. On page 115), in which "produce a lower middle laparotomy. The ileum is found and 30 -40 cm from the place where it enters the cecum, a 25-30 cm long segment with a well-defined vascular pattern is cut in. Distal parts of the ureters are mobilized, the left being passed through the mesosigmoidum, the polyethylene tubes are inserted into them and implanted into the lumen of the segment using one of the methods described above . Place an astomoses are carefully peritonized with the peritoneum. The segment is laid transversely at the level of the promontorium to the posterior peritoneum and fixed with several sutures so that the intestine cannot be pinched between them. The end of the segment through the incision in the right or left iliac region is brought out 2-3 cm above the skin surface and fix it to the aponeurosis and skin. The intestinal-skin anastomosis should be located in such a way that it is convenient to wear a fixing belt for the urinal. A defect in the mesentery is sutured and the integrity of the small intestine is restored by anastomosis side to side. "

 The disadvantages of this method are the small capacity of the newly formed bladder, reflux of intestinal contents in the upper urinary tract and the resulting infection (chronic pyelonephritis, sepsis) leading to the development of renal failure, complications from the stoma (stenosis of the intestinal-skin stoma, paralostomy hernia). However, the main disadvantage of this method is the presence of a stoma on the anterior abdominal wall, bringing the patient severe physical and mental suffering.

 A known method of small bowel plastic surgery of the bladder according to Shilling A. et al. (Schilling A., Friesen A., Grinvald V.A. New method for surgical treatment of bladder cancer and its immediate results // Herald of Surgery. - 1994. - N 1-2. - p. 82-90.), In which to create an artificial bladder, use a segment of the ileum with a length of 45-50 cm. Depending on the anatomical structure of the mesenteric vessels, an M- or W-shaped bladder is formed from the mobilized segment of the ileum. Intestinal plasty is performed according to the method described by Kock using a continuous suture. For implantation of the ureters, the Camey and Le Duc methods are used in the form of the so-called bifurcated sleeve. After the formation of the intestinal dome of the new bladder, an anastomosis is placed between it and the funnel-shaped prostatic part of the urethra. In this case, two semicircular continuous seams of 1 CT1 Dexon filament are applied at the level of 6 hours and carried out in different directions, forming a knot at the level of 12 hours. A continuous suture sutures the dome of a new bladder. The lumen of the anastomosis is drained with a silicone catheter N 22. The ureters are drained with two ureteral catheters that lead to the anterior abdominal wall through the bladder stoma. Another urethral catheter N 20 is carried out in a newly formed bladder for constant irrigation and excretion of the secret of its mucous membrane. After 12 days, the ureteric catheters are removed and after 21 days the cystic catheter is removed.

 The disadvantages of this method are the technical complexity of the operation, reflux of intestinal contents in the upper urinary tract and the resulting infection (chronic pyelonephritis, sepsis). However, the main disadvantage of this method is the impossibility of its use for primary bladder repair in patients with localization of the tumor in the area of the mouth of the urethra, which makes it necessary to remove part of it for oncological reasons. In this situation, anastomosis between the intestine and the resected part of the urethra is extremely difficult. The use of this method is also impossible for secondary plasty of the bladder after a previously performed cystectomy due to developing scar-sclerotic processes in the urethral stump.

 A known method of small bowel plastic surgery of the bladder according to Chukhrienko D.P. (Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M .: Medicine, 1972.- 376 p.), In which "after removal of the bladder open the abdominal cavity and, retreating 20-30 cm from the ileocecal angle, a loop of the small intestine up to 25 cm long is resected. Bowel patency is restored with anastomosis side to side or end to end. The loop of the resected intestine is pulled into the pelvis. The peritoneal edge is sewn around the mesentery of the loop. The abdominal cavity is closed tightly. The ends of the isolated loop are sutured. Both ureters at a distance of 6-7 cm from d "they are transplanted into a newly formed reservoir. Then, along the outer edge between the ureters, the loop is cut and a drainage tube is inserted into the incision, which is discharged through the urethra. The edges of the bladder with interrupted sutures are fixed to the urethra and surrounding tissues."

 The disadvantages of this method are the insufficient capacity of the newly formed bladder, a high risk of developing a urethrointestinal anastomosis, the inability to use it for primary bladder repair in patients with localization of the tumor in the area of the mouth of the urethra, which makes it necessary to remove part of it for oncological reasons. The use of this method is also impossible for secondary plasty of the bladder after a previously performed cystectomy due to developing scar-sclerotic processes in the urethral stump.

 There is a method of small bowel plastic surgery according to Camey-Le Due (Managadze L.G., Chigogidze T.G., Rodionov I.A., Gotsadze D.T. Methods of over-bladder diversion of urine and cystoplasty // Urology and Nephrology. - 1994. - N 3. - c. 45-49.), Selected as a prototype, in which 30-40 cm of the small intestine are isolated at a distance of 15 cm from the cecum, trying to isolate the segment so that its middle freely reaches the urethra without tension. The left ureter antireflux anastomose with the left "horn" of the intestinal segment. The next step is an intestinal-urethral anastomosis, and then the right ureter is transplanted according to the antireflux technique to the top of the right "horn" of the intestinal segment.

 The disadvantages of this method are often developing nighttime urinary incontinence, the causes of which are "in significant peristaltic contractions of the tubular intestinal transplant and in the weakening of the muscles of the pelvic floor" (Managadze L. G., Chigogidze T. G., Rodionov I. A., Gotsadze D. T. Methods of over-bladder diversion of urine and cystoplasty // Urology and Nephrology. - 1994. - N 3. - p. 45-49.), As well as in the above analogues, the impossibility of its use for primary bladder repair in patients with tumor localization in the mouth area Retro and impossibility to use plastic materials for secondary bladder after cystectomy previously formed due to the developing scar-sclerotic processes of the urethral stump.

 The basis of the invention is the task of reliably restoring the reservoir function of the formed bladder and the mechanism of holding urine while removing the bladder, for example for cancer, and with localization mainly in the area of the mouth of the urethra.

 The problem is solved in that when forming an artificial bladder, a T-shaped loop is used, made from the ileum of the small intestine by stitching its mesenteric edge with interrupted gray-serous sutures, then holes are made between the stitched portions of the ileum of the small intestine in the avascular zone of the mesentery, in these holes, the ureters along with the catheters placed in them, fixing each of them, after which the small intestine is dissected throughout the T-shaped loop, the ureters are placed in colon light and form enteric reservoir ureters placed therein, then the crotch degrade the distal end of the small intestine, the latter being placed at a downgrade in the channel between the sphincter and the rectum mucosa otseparovannoy anal canal.

 New in the claimed solution is that in the formation of an artificial bladder, a T-shaped loop of the intestine is used, the ureters are held between the stitched walls of the small intestine, the small intestine is lowered to the perineum, and the latter is placed in the canal between the sphincter and the separated mucous membrane of the anal canal when reduced. Using a T-shaped loop allows you to get a sufficient capacity of the bladder with a minimum number of stitches. Carrying out the ureters between the stitched portions of the small intestine allows you to get a sufficiently large area of the fused surfaces and to avoid the need to use complex techniques to form the ureter-intestinal anastomosis. Lowering the small intestine to the perineum in the tunnel between the separated mucosa of the anal canal and the sphincter allows, on the one hand, to retain the retention function, and on the other hand, to delimit the intestinal contents of the rectum from the urine.

 The method is as follows.

 After removal of the bladder and catheterization of the ureters, the small intestine is intersected with the mesentery using the UO-40 apparatus, preserving the feeding small intestinal vessels, 30 cm and 80 cm from the Bauginium damper. Intestinal continuity is restored by the small intestine anastomosis end to end. Restore the integrity of the mesentery of the small intestine. A portion of the small intestine on the mesenteric leg is rotated in such a way that the proximal end descends into the small pelvis. Moreover, if the length of the mesentery is not enough for free placement of the graft in the pelvis, the dissection of the avascular sections of the mesentery is performed. The distal end of the intestine, sutured with a hardware suture, is immersed in a purse string suture. A T-shaped loop is formed by the ileum of the small intestine by stitching its mesenteric edge with nodular gray-serous nylon sutures. At the base of the T-shaped loop, between the stitched portions of the small intestine, the clip makes holes in the avascular zone of the mesentery. The ureters are passed through these openings together with urethral catheters and each of them is fixed with 3 interrupted sutures placed between the serous membrane of the intestine and the adventitious membrane of the ureter. The small intestine is dissected throughout the entire T-shaped loop. The ureters along with catheters are placed in the lumen of the intestine. A continuous catgut suture is applied to the posterior lip of the inter-intestinal anastomosis and to the anterior using Connell's suture. Nodal nylon gray-serous sutures are imposed, thus completing the formation of a small intestinal reservoir with ureters placed in it. A tunnel is formed in front of the rectum to the muscles of the pelvic floor and the proximal end of the small intestine is placed in it. From the perineum, the anal mucosa is dissected at the border with the perianal skin along the anterior semicircle by 1/3 of its length. Peel the mucous membrane of the anal canal to the level of the internal sphincter. Above the level of the internal sphincter, the muscle and adventitious membranes of the intestine cross, thus penetrating into the pelvic cavity. The proximal end of the small intestine is captured and reduced to the perineum in the canal between the sphincter of the rectum and the separated mucosa of the anal canal. Sutures are made between the reduced small intestine and perianal skin along its anterior semicircle and the separated mucosa of the anal canal along its posterior semicircle. From the side of the abdominal cavity, it is drained and the wound of the abdominal wall is sutured.

The essence of the method is illustrated by drawings, where in FIG. 1-8 shown:
FIG. 1.

1 - Bauginiya damper;
2 - small intestine;
3 - the direction of dissection of the small intestine and its mesentery;
4 - mesentery of the small intestine;
5 - vessels of the mesentery of the small intestine;
6 - direction of rotation of the small intestine.

 FIG. 2.

7 - hardware seam;
8 - mesenteric edge of the small intestine;
9 - gray-serous sutures;
10 - purse string suture.

 FIG. 3.

 11 - holes between the stitched sections of the small intestine.

 Fig 4.

12 - ureters;
13 - urethral catheters;
14 - sutures that fix the ureters to the intestine.

 FIG. 5.

 15 - direction of dissection of the wall of the small intestine.

 FIG. 6.

12 - ureters;
13 - urethral catheters;
16 - the direction of movement of the ureters into the lumen of the small intestine;
17 - the lumen of the small intestine.

 FIG. 7.

 18 - continuous catgut seam.

 FIG. 8.

12 - ureters;
19 - gray-serous sutures;
20 - formed small intestinal reservoir.

 The method is as follows. Produce an upper median laparotomy. After performing a cystectomy, a catheterization of the ureters is performed according to the usual method. Then make the intersection (Fig. 1, p. 3) of the small intestine (Fig. 1, p. 2) with the mesentery (Fig. 1, p. 4) using the UO-40 apparatus, preserving the feeding small intestinal vessels (Fig. 1, p. 5), 30 cm and 40 cm from the Bauginiya damper (Fig. 1, p. 1). Intestinal continuity is restored by the small intestine anastomosis end to end. Restore the integrity of the mesentery of the small intestine. A section of the small intestine on the mesenteric leg is rotated (Fig. 1, p. 6) so that the proximal end descends into the small pelvis. Moreover, if the length of the mesentery is not enough for free placement of the graft in the pelvis, the dissection of the avascular sections of the mesentery is performed. The distal end of the intestine, sutured with a hardware suture (Fig. 2, p. 7), is immersed in a purse string suture (Fig. 2, p. 10). A T-shaped loop is formed from part of the ileum by stitching its mesenteric edge (Fig. 2, p. 8) with nodular gray-serous nylon sutures (Fig. 2, p. 9). At the base of the T-shaped loop, between the stitched portions of the small intestine, the clamps make holes (Fig. 3., p. 11) in the avascular zone of the mesentery. The ureters (Fig. 4, p. 12) are passed through these holes together with the urethral catheters (Fig. 4, p. 13) and each of them is fixed with 3-4 interrupted sutures (Fig. 4, p. 14) placed between the serous the lining of the intestine and the adventitia lining of the ureter. Dissect (Fig. 5, p. 15) the small intestine throughout the entire T-shaped loop. The ureters (Fig. 6, p. 12) together with the catheters (Fig. 6, p. 13) are placed (Fig. 6, p. 16) into the lumen of the intestine (Fig. 6, p. 17). A continuous catgut suture (Fig. 7, p. 18) is applied to the posterior lip of the inter-intestinal anastomosis and to the anterior using Connell's suture. Continuous or nodular kapron gray-serous sutures are applied (Fig. 8, p. 19), thus completing the formation of a small intestinal reservoir (Fig. 8, p. 20) with ureters placed in it (Fig. 8, p. 12) . A tunnel is formed in front of the rectum to the muscles of the pelvic floor and the distal end of the small intestine is placed in it. From the perineum, the anal mucosa is dissected at the border with the perianal skin along the anterior semicircle by 1/3 of its length. Peel the mucous membrane of the anal canal to a level above the internal sphincter. Above the level of the internal sphincter, the muscle and adventitious membranes of the intestine cross, thus penetrating into the pelvic cavity. The distal end of the small intestine is seized and lowered to the perineum in the canal between the sphincter of the rectum and the separated mucosa of the anal canal. Sutures are made between the reduced small intestine and perianal skin along its anterior semicircle and the separated mucosa of the anal canal along its posterior semicircle. From the side of the abdominal cavity, it is drained and the wound of the abdominal wall is sutured.

 An example of a specific implementation of the method.

Patient S., 65 years old, medical history N 7584, was admitted to the urology department of the Donetsk regional antitumor center 03/15/99 with a diagnosis of bladder cancer T ₃ N ₀ M ₀ . After further examination and preoperative preparation, it was decided to perform a cystectomy with primary plastic surgery of the small intestine according to the developed technique, which was done. They performed an upper median laparotomy. After an intraoperative assessment of the prevalence of the tumor process, it was decided to perform the intended operation. Cystectomy was performed according to the usual method. Catheterized the ureters. The small intestine was flashed with a UO-40 stapler and crossed twice at a distance of 40 and 80 cm from the Bauginia flap. We crossed the mesentery of the small intestine while preserving the supply vessels. Intestinal continuity was restored with a small bowel anastomosis end to end. Restored the integrity of the mesentery of the small intestine. A portion of the small intestine on the mesenteric leg was rotated in such a way that the proximal end descended into the small pelvis. The distal end of the intestine, sutured with a hardware suture, was immersed in a purse string suture. A T-shaped loop was formed from the part of the ileum by stitching its mesenteric edge with nodular gray-serous nylon sutures. At the base of the T-shaped loop, between the stitched portions of the intestine, the clip made holes in the avascular zone of the mesentery. The ureters along with the urethral catheters were passed through these holes and each of them was fixed with 3-4 interrupted sutures placed between the serous membrane of the intestine and the adventitious membrane of the ureter. Dissected the intestine throughout the T-shaped loop. The ureters, along with catheters, were placed in the lumen of the intestine. A continuous catgut suture was placed on the posterior lip of the inter-intestinal anastomosis and on the anterior using Connell's suture. Superimposed nodular nylon gray-serous sutures, thus completing the formation of a small intestinal reservoir with ureters placed in it. A tunnel was formed in front of the rectum to the muscles of the pelvic floor and the distal end of the small intestine was placed in it. From the perineum, the mucous membrane of the anal canal was cut at the border with the perianal skin along the anterior semicircle by 1/3 of its length. The mucous membrane of the anal canal was exfoliated to a level above the internal sphincter. Above the level of the internal sphincter, the muscular and adventitious membranes of the intestine were crossed, thus penetrating into the pelvic cavity. The distal end of the small intestine was captured and lowered to the perineum in the canal between the sphincter of the rectum and the separated mucosa of the anal canal. Sutures were made between the reduced small intestine and perianal skin along its anterior semicircle and the separated mucosa of the anal canal along its posterior semicircle. From the side of the abdominal cavity, it was drained and the wound of the abdominal wall was sutured.

 A total of 5 patients were operated on. In all patients, the postoperative period was uneventful. Life expectancy was 38.5 months. All patients were examined 3, 6, 9, 12, 24 months after surgery. The capacity of the newly formed bladder averaged 180-200 ml, all patients held urine. No evidence of an ascending urinary tract infection.

 Thus, the advantage of the method is the reliable restoration of the reservoir function of the bladder and the mechanism of urine retention.

LITERATURE
1. Shepilov V.I. Bladder cancer -M.: Medicine, 1983.- 192 p.

 2. Schilling A., Friesen A., Greenwald V.A. A new technique for surgical treatment of bladder cancer and its immediate results // Bulletin of Surgery. - 1994. - N 1-2. - from. 82-90.

 3. Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M .: Medicine, 1972. - 376 p.

 4. Managadze L. G., Chigogidze T. G., Rodionov I. A., Gotsadze D. T. Methods of supravesical urinary diversion and cystoplasty // Urology and Nephrology. - 1994. - N 3. - p. 45-49.

Claims (1)

 The method of enterocystoplasty, including cystectomy, intersection of the small intestine, restoration of intestinal continuity, catheterization of the ureters, characterized in that in the formation of an artificial bladder using a T-shaped loop made from part of the ileum by suturing its mesenteric edge with nodular gray-serous sutures, then, holes are formed between the stitched portions of the ileum in the avascular zone of the mesentery, the ureters are inserted into these holes together with the catheters placed in them, fixing each of them to the intestine, after which the ileum is dissected throughout the entire T-shaped loop, the ureters are placed in the lumen and form a small intestinal reservoir, then the distal end of the intestine is lowered to the perineum, the latter being placed in the channel between the sphincter of the rectum and the separated mucosa of the anal canal.

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