RU2174368C1 - Method for creating epicystocutaneostoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves opening muscular layer of the urinary bladder. Urinary bladder mucous membrane is conducted through all layers of the anterior abdominal wall in the area of the musculus rectus abdomini. Mucous layer of the urinary bladder is opened. The mucous membrane is turned with its inner layer outside and sutured to skin. Catgut sutures are put in over the muscular layer of the urinary bladder. The muscular layer is sutured to the musculus rectus abdomini. EFFECT: reduced risk of traumatic complications. 3 dwg

Description

 The invention relates to medicine, namely to urology and can be used to divert urine when it is impossible to urinate naturally.

 In urological practice, a bladder drainage technique, epicystostomy, has long been used. (Goryunov V.P. Acute urinary retention - "Urology and Nephrology", 1994, N 4 pp. 44-48; Weinberg Z.S. Emergency Urology, M., 1997, p. 158-160; N. Lopatkin. Guide to Urology. M., 1998, pp. 54-70, 503-519).

 A skin incision 6-8 cm long is carried out along the midline above the pubis. The subcutaneous tissue and the anterior vaginal wall of the rectus abdominis are dissected; the rectus muscles are moved apart along the midline, the transverse fascia is incised in the transverse direction. Open the pre-bladder fiber, the peritoneum folding fold is pushed up and the front wall of the bladder is exposed, on which two sutures are placed - holders. The wall of the bladder is lifted using sutures - holders and dissect it in the transverse direction. Through this hole, a rubber or polyvinyl chloride tube is inserted into the bladder with side holes 2 to 2.5 cm deep, which are fixed to the bladder wall with catgut sutures. Layered sutures are placed on the wound to the drainage tube, which is fixed to the skin. According to the installed tube, urine from the bladder flows into the urinal. This cystostomy is an “Open” way to divert urine from the bladder using a drainage tube.

 But this method of urine diversion has a number of complications: the development of microcystitis, detrusor retraction and stenosis of the ureter orifice; deterioration of urodynamics of the upper urinary tract; maintaining a chronic infection in the urinary system; the need for frequent replacement of the drainage tube due to its obstruction with purulent plugs, fibrin flakes and salts.

 Investigations of a number of authors (Levin AF, Choice of the method of urinary diversion in children. - “Urology and Nephrology”. 1991, N 1, pp. 22-25, Gusev P.V. Features of the clinic, diagnosis and treatment of decompensated forms of urodynamic disorders in of infravesical obstruction in children. Abstract of diss. candidate Ufa, 1999, 18 pp.) with epicystostomy, profound changes (hemorrhagic, bullous, fibrous, etc.) were revealed from the bladder, most often in the region of the Lietot triangle and the mouth of the ureters. The constant presence of the drainage tube grossly violates the reservoir and evacuation function of the bladder.

 A known method of forming a fistula of the bladder, experimentally developed by A. Litvinenko (Drainage-free fistula of the bladder. Author. Cand. Diss. Orenburg, 1971. P. 14), the essence of which is to cut a flap from the wall of the bladder, form a tube and bring it to the skin. Clinical use of this fistula showed that the patchwork tube undergoes cicatricial changes very quickly due to a violation of the blood supply to the bladder wall.

 The prototype of the invention is a method of forming a urinary fistula developed by A. Akhunzyanov (Method of cystocutaneostomy surgery in children. - Questions of pediatric urology. Abstracts of the report. All-Union Scientific and Practical Conference of Children's Surgeons. Tallinn, 1991, 0.14-15). However, the disadvantage of this method is the formation of a fistula from all layers of the wall of the bladder, when stretched, fixed to the aponeurosis of the rectus abdominis muscles and narrowing the base with a purse string suture, circulatory disturbance, cicatricial degeneration and stenosis of the formed fistula occur.

 The technical result is a reduction in the invasiveness of the method, the prevention of postoperative complications due to the formation of a permanent drainage lip-like fistula and the formation of an artificial sphincter from own tissues of the bladder and fibers of the rectus abdominis muscle.

 In FIG. 1 shows the extension of the mucous membrane of the bladder; in FIG. 2 sectional view of a conical tube; in FIG. 3 - sectional epicystocutaneostomy formed.

 The method of forming epicystocutaneostomy is as follows.

 A layer-by-layer incision is made of the skin and subcutaneous tissue along the midline above the symphysis, up to 7-8 cm long, the rectus abdominis muscles are stupidly removed to the sides, the transverse fascia, prevesical tissue, and the transitional fold of the peritoneum are opened upward and the front wall of the bladder is exposed. Lateral from the middle by 1.5-2.0 cm on the wall of the bladder impose a suture-holder, behind which the wall is lifted and a longitudinal muscle layer is cut up to 1.5-2.0 cm long to the submucosal-mucous layer. Then they take the mucous-submucous membrane of the bladder on the stitch-holder, pull it in the form of a cone-shaped tube 1 up to 6.0-6.5 cm long, 1.0-1.5 cm in diameter, blunting the muscle layer 2. On the muscle layer impose 2 half-net catgut suture 3, but the threads are not cut (Fig. 1,2). 1.5-2.0 cm lateral from the midline with a scalpel point, a through puncture is made through the rectus abdominis muscle, sharpened branches of Kellian's mirror are inserted into this wound, and from the retroperitoneal space the formed tube is brought out of the mucous-submucous layer of the bladder, outside treated with a powdered preparation "Alloplant" (TU 42-537-88). The ends of the threads from the half-mesh sutures are sewn to the fibers of the rectus abdominis muscle from its inner surface along the edges of the formed fistulous tube. Layered sutures, an aseptic dressing are applied to the wound of the anterior abdominal wall. An incision up to 0.8-1.0 cm in length is made at the top of the extracted conical tube from the mucous membrane of the bladder, the mucous membrane is turned out and sutured to the skin with four six sutures with an atraumatic needle and a chrome-plated catgut. The wound around these sutures is treated with an antibiotic ointment. A rubber tube 0.8 cm in diameter is inserted into the bladder through this fistula for 7-10 days and is removed after wound healing. The fistula created in this way functions independently, the muscle layer of the bladder and the fibers of the rectus abdominis muscle serve as the "sphincter" of the fistula (Fig. 3).

 Example. (Patient G., 81 years old, case history No. 8403/687 was delivered on an emergency basis at 7.30 a.m. on June 9, 2000 to the Department of Urology, BSMP No. 22, Ufa with complaints about the inability to urinate during the day. Upon receipt, the patient's condition moderate severity, normal skin and mucous membranes, nutrition is satisfactory, vesicular breathing in the lungs is somewhat weakened in the lower sections, heart sounds are muffled, rhythmic, pulse is 80 in 1 min, blood pressure is 140-80 mm Hg, the stomach is moderately swollen in the lower sections , on palpation, pain below the navel is determined, the bladder is enlarged in volume and protrudes above the bosom by 5-6 cm. Pasternatsky’s symptom is negative on both sides. Upon rectal examination, a significant increase in the size of the prostate gland was 5.0 x 4.0 cm, it has a tight elastic consistency, the surface is smooth, the median groove is smooth, painless. He was diagnosed with benign prostatic hyperplasia, complication of acute urinary retention, catheterization of the bladder with a metal catheter with great difficulty, and about 1000 ml of urine was released. Clinical and laboratory examination of the patient. Complete blood count: Er. 4.7 • 10 / l, HB 130 g / l, L-7.0 • 10 / l. General analysis of urine: turbid, protein - 0.066%, leukocyte. 4-5-6 p / sp. Er. 8-10 p / sp. Ultrasound: the prostate gland is enlarged, 61.5 cm of heterogeneous density, increased echogenicity.

 The patient refused the proposed adenomectomy operation due to the severity of the condition.

 It was decided to apply an epicystocutaneostomy according to the method developed by us, to which the patient agreed. Under epidural anesthesia after processing the surgical field, a layer-by-layer incision was made of the skin, subcutaneous tissue, up to 10 cm long, in the midline 2-3 cm higher than the symphysis, after opening the white line, the rectus abdominis muscles are bluntly laid apart, the fascia and prebubular tissue are opened, transitional the peritoneal fold is pushed up and the front wall of the bladder is exposed. Laterally from the middle by 1.5-2.0 cm, a “suture-holder” of catgut was placed on the bladder wall, behind which the bladder wall was raised and the muscle layer was longitudinally dissected up to 1.5-2.0 cm long to the submucosal mucous layer. Then, the mucous membrane was taken onto the “suture-holder”, elongated in the form of a cone-shaped tube up to 6 cm long with a diameter of up to 1.0 cm, freeing it bluntly from the muscle layer. On the actual muscle layer of the bladder 2 half-net catgut sutures were applied, leaving the ends of the threads free. 2.0-2.5 cm to the right of the lower middle wound, a through puncture was made through the right rectus muscle through the right rectus muscle, branches of the Kellian mirror were introduced into this wound, and a formed tube from the mucous membrane of the bladder was brought out from the retroperitoneal space, having been treated externally with a powder preparation Alloplant. The edges of the muscle layer of the bladder for the left strands from the half-mesh seams are sewn to the fibers of the posterior surface of the right rectus muscle. The wound on the anterior abdominal wall is sutured. An incision up to 0.8 cm long was made at the top of the extracted conical tube, the mucous membrane was turned out and sewn with a chrome catgut to the skin. The wound is treated with 10% antibiotic ointment. Through the “lip-shaped” fistula of the bladder thus formed, the urethral catheter No. 15 according to the Charrier is inserted into the cavity of the last, fixed to the skin with silk ligatures. 100 ml of furatsillin solution was introduced into the bladder via a catheter. Within 8 days, urine was removed from the bladder along the catheter, after the wound healed along the edges of the fistula, the catheter was removed. In the next 5 days of monitoring the patient, the functioning of the fistula of epicystocutaneostomy was noted. urine was administered by the patient himself using a urinary catheter as urine accumulated in the bladder.

 06/26/2000, patient G. was discharged home in satisfactory condition. On examination, the outer opening of the epicystocutaneostomy is in satisfactory condition, the skin around the fistula without signs of maceration.

 September 20, 2000, during the follow-up examination, the patient notes the good functioning of the formed urinary fistula. Through epicystocutaneostomy, urine is excreted by catheter.

 By the developed method of epicystocutaneostomy, 4 patients were operated on with a good clinical result, which gives us the right to offer this method for widespread use in a urological clinic.

Claims (1)

 A method of forming an epicystocutaneostomy by stretching the wall of the bladder in the form of a cone-shaped tube and fixing it to the anterior abdominal wall, characterized in that they open the muscle layer of the bladder, stretch the mucous membrane and pass it through all layers of the anterior abdominal wall in the region of the rectus abdominal muscles, open the mucous membrane of the urinary bladder bladder, turn and hem to the skin, and apply catgut sutures to the muscle layer and hem to the rectus abdominis muscle.

Images