RU2183425C1 - Method for creating ureterosigmoidostomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves transecting intestine at the rectosigmoid region of along the countermesenteric edge. Tunnel is built for implanting the ureter and creating rectosigmoid reservoir. The tunnel is built in extramural way. The posterior reservoir wall is formed by stitching seroserous sutures. The ureters are arranged on the built wall towards each other. The ureters are fixed on intestine wall. Intestine edges are sutured one to another. EFFECT: enhanced effectiveness of antireflux protection; reduced risk of ureteral stricture. 3 dwg

Description

 The invention relates to medicine, more specifically to oncourology, and may find application in supravesical derivation of urine after cystectomy.

 A cystectomy is performed, as a rule, with invasive bladder cancer or with high-quality, rapidly recurring superficial tumors that prevent organ-preserving treatment.

 The main issue that must be addressed after radical cystectomy is the method of urine diversion (derivation). This problem, most often, is solved by the formation of ureterical anastomoses that provide different options for urine diversion: 1) external abduction into the intestinal conduit with the formation of "dry" and "wet" growth; 2) the creation of intestinal reservoirs that perform the function of the bladder and provide the possibility of self-controlled urination (various options for orthotopic intestinal reconstruction of the bladder, anastomosed with the urethra; rectal bladder); 3) internal urine diversion into the "continuous" intestine (ureterosigmoanastomosis; Mainz-pouch II operation); [B.P. Matveev et al. Bladder cancer, M .: Verdana, 2001, p.139].

 When choosing a method of urine derivation after cystectomy, the stage of the disease, the general condition of the patient, his functional capabilities, the nature and severity of the concomitant pathology are taken into account. Taking into account these features, the most suitable and least traumatic urine diversion method is selected for each individual patient. The most optimal is the recovery after surgery of independent controlled urination, which largely determines the quality of life for patients.

 The present invention relates to the formation of a ureterosigmoanastomosis after a cystectomy with the creation of a low pressure reservoir that provides continental (i.e., retention) controlled urination through the rectum.

 Closest to the proposed is a method of forming a ureterosigmoanastomosis during surgery Mainz-pouch II [M. Fisch, R. Wammack, R. Hohenfellner. The sigma rectum pouch (Mainz poch II). // World. J. Urol.-1996.-Vol.14.-P.-68-72].

 This method consists in dissecting the large intestine along the antispasmodic edge in the region of the sigmorectal angle, stitching the lower edges of the dissected rectal and sigmoid segments in a side-by-side manner, thereby forming the posterior wall of the future reservoir, creating two submucous tunnels, and perforating the wall intestines, ureters, previously removed into the abdominal cavity, are implanted into the openings and implanted into the created submucosal tunnels, then the front wall of the created reservoir and phi are sutured siruyut it to promontoriumu.

 This method provides the creation of a sigmorectal reservoir with controlled urination through the rectum. The method allows to achieve a certain degree of separation of the flow of urine and fecal matter, reduce and significantly prevent one of the main complications of transplantation of the ureters into the intestine - intestinal-pelvis reflux. Moreover, the method is relatively simple to implement and allows you to achieve good long-term results.

 However, as practice shows, in the formation of submucosal tunnels in the intestine, frequent breaks of the thin mucosa occur when it is separated from the muscle layer. This leads to trauma to the intestinal wall and causes the formation of submucosal hematomas, on the site of which subsequently scar tissue is formed, which often leads to the development of narrowings (strictures) of the implanted ureter. In addition, it is possible to form stricture of the left ureter at the site of it under the root of the sigmoid colon. The development of ureteral strictures is also facilitated by the fact that when conducting them between the mucous membrane of the intestine and its muscle layer, heterogeneous tissues come into contact - muscle, mucous and serous. The thin mucous membrane under which the ureter is held does not provide a reliable antireflux mechanism that protects the upper urinary tract from infection. These circumstances are the cause of such serious complications as obstructive uro and nephropathy.

 Based on the foregoing, it can be stated that the creation of two submucous tunnels with perforation of the intestinal wall makes this method rather traumatic, and the created submucous tunnels are often the cause of stricture of the ureters and by no means always provide their effective antireflux protection.

 The technical result of the present invention is to increase antireflux protection, reduce the risk of stricture of the ureters and reduce the invasiveness of surgical intervention by creating a serous extramural tunnel for implantation of the ureters.

 This result is achieved by the fact that in the known method for the formation of ureterosigmoid anastomosis, including dissection of the intestine in the rectosigmoid section along the anti-spray edge, the creation of a tunnel for implantation of the ureters with the formation of a rectosigmoid reservoir, according to the invention, the tunnel is created extramurally, for which, prior to suturing, the reservoir forms an additional wall impose a series of gray-serous sutures and lay on them the ureters towards each other.

 One of the areas of our professional activity in urology is performing radical cystectomies for bladder cancer. In this case, there were frequent cases of the need to remove during surgery, except for the bladder, and the urethra when it is affected by a tumor. Derivation of urine in these cases was carried out by the formation of ureterosigmoanastomosis according to Mainz-pouch II. Two years ago, during an operation, one of the patients found that the right ureter was sharply expanded and implanting it into the submucosal tunnel of the sigmoid colon was dangerous and impractical due to the high likelihood of subsequent development of the intestinal-ureteral reflux with the intestinal flora being thrown into the kidney. Given this fact, we tried to implant the enlarged right ureter into the serous extramural tunnel for greater antireflux protection. Since during the formation of the sigmorectal reservoir (Mainz-pouch II operation) it is possible to create only one extramural tunnel (there are only two “knees” of the intestine), we decided to place both ureters in it, refusing to transplant and the left ureter into the submucous tunnel, as is done in the original version of the operation. The ureters were implanted in one serous extramural tunnel towards each other.

 As a result of performing such a modified version of the Mainz-pouch II operation, the patient in the postoperative period and to date (more than 2 years) has no complications: no expansion of the ureters and pyelocaliceal systems of both kidneys was noted; for the entire period after surgery, there was no exacerbation of pyelonephritis; renal function is not impaired (this case is presented in more detail in Example 1).

 This fact interested us and, if necessary, the formation of ureterosigmoanastomosis, we began to further use it in our clinical practice. To date, surgical intervention has been performed in this way in 8 patients with consistently good results - in none of them we have observed intestinal-ureteric refluxes and strictures of the ureters in the anastomotic zone.

 The achievement of the positive results we obtain is explained as follows. The use of gray-serous sutures when stitching the lower edges of the dissected rectal and sigmoid segments of the intestine provides the ability to create a serous extramural tunnel for implantation of the ureters. This eliminates the need for separation of the mucosa from the muscle layer, associated with the risk of rupture of the mucosa with all the ensuing consequences. The extramural location of the tunnel allowed us to significantly reduce the invasiveness of the operation, since there was no need for additional perforation of the intestine.

 In addition, when the ureters are located in the serous tunnel, homogeneous tissues come into contact (the serous membrane of the intestine with the serous membrane of the ureters), which reduces the possibility of cicatricial narrowing of the implanted ureters and provides effective antireflux protection.

 The formation of a serous extramural tunnel for ureteral implantation is known from the literature. Such implantation of the ureters is performed during orthotopic reconstruction of the bladder from the ileum or heterotopic plastic with the creation of conduits (using the ileum or cecum with the distal ileum). During these operations, two serous extramural tunnels are formed between dissected bowel loops [Abol-Enein H., Ghoneim M.A. A novel uretero-ileal reimplantation technique: The serous lined extramural tunnel. A preliminary report. // J. Urol. 1994. Vol. 151. - P.-1193]. Such methods of urine diversion are far from possible in all patients with severe concomitant pathology due to the duration and high invasiveness of the operation. The method of choice in such patients is the Mainz-pouch II operation, which, in turn, is not without serious flaws that we indicated in the description (prototype method). In this regard, for the first time we introduced into Operation Mainz-pouch II a new variant of transplantation of the ureters that we proposed into the created sigmorectal reservoir. As clinical observations have shown, our proposed method for the formation of ureterosigmoanastomosis is technically relatively simple, does not require a long time, and at the same time reduces the risk of developing strictures of transplanted ureters and increases their antireflux protection.

 The essence of the method is as follows. After removal of the bladder, the large intestine is dissected along the anti-mesenteric margin to a length of 20 cm, with the same distance distal and proximal to the rectosigmoid angle. The lower flaps of the dissected intestine are sutured together by gray-serous sutures, forming the back wall of the created reservoir. Intubated ureters are laid towards each other on the formed back wall of the reservoir and are firmly fixed with 2-3 sutures. The next step is stitching the walls of the intestine over the implanted ureters and thereby complete the creation of a serous extramural tunnel. The ureteral intubators are led out through the rectum. At the last stage, the front wall of the created reservoir is sutured and fixed to the promotorium. As a result, both ureters are located intraperitoneally. The abdominal cavity is drained with two silicone tubes and the wound of the anterior abdominal wall is sutured in layers. Ureteric intubators are removed 12-14 days after surgery, after which independent controlled urination through the rectum is restored.

 The essence of the method is illustrated by example.

 EXAMPLE 1

 Patient K., born in 1931 (IB 256-C), was admitted to the urology department of the city multidisciplinary hospital in St. Petersburg on 02/09/99 with complaints of blood in the urine, frequent, painful urination, pain in the right lumbar region, chills.

 From the anamnesis it was established that for the first time an admixture of blood in the urine was noticed three months ago (November 1998), but he did not attach any importance to this and did not go to the doctors. Three days before admission to the hospital (02/06/99), an admixture of blood in the urine reappeared. The next day, the patient noted the appearance of dull pain in the right lumbar region and an increase in body temperature to 38.0 degrees. I did not seek medical help this time either, took painkillers (analgin) and antipyretic drugs (aspirin) with a short-term effect. Over the next two days, the patient's condition worsened: an admixture of blood in the urine persisted, pain in the right lumbar region intensified, body temperature remained (38.0-38.8 degrees), and chills appeared. 02.09.99, the patient sought medical help at the clinic at the place of residence and was urgently hospitalized in a urological hospital.

 Upon admission to the hospital, the patient's condition is regarded as moderate. The body temperature is 38.8 degrees, the skin is dry, hot to the touch, the blowing on the lower back is sharply painful on the right, an enlarged, painful right kidney is palpated. In the clinical analysis of blood - moderate anemia (red blood cells 3.9 million, hemoglobin 112 g / l), leukocytosis (14.6 thousand) with a shift in the leukocyte formula to the left (10 stab neutrophils); according to biochemical blood tests, no abnormalities were noted. In urinalysis, red blood cells and white blood cells cover all fields of vision. An ultrasound examination of the bladder revealed an unshifted exophytic formation with uneven contours 4.0 cm in diameter located on the right side wall. Discontinuity of the bladder wall in the area of the base of the formation was noted. Ultrasound of the prostate gland showed an increase in its volume (86.0 cc), other pathological changes in the prostate gland were not detected. Ultrasound of the kidneys revealed a sharp expansion of the pyelocaliceal system on the right (calyx up to 1.5 cm, pelvis - 3.8 cm), expansion of the upper third of the right ureter to 1.2 cm. Pathology from the left kidney, adrenal gland and liver were not detected. The patient underwent urgent intravenous urography (40.0 ml of a 76% solution of urographin). According to the X-ray examination, a slowdown in the excretion of contrast medium by the right kidney, an expansion of the cavity system of the right kidney and right ureter was found. The expanded right ureter is traced to the bladder. On the descending cystogram, a filling defect of about 4.0 cm in diameter, located on the right side wall, is determined. On chest radiographs, lung pathology was not detected. Based on the data of the examination of the patient upon admission to the hospital, a preliminary diagnosis was made: a bladder tumor (cancer?), Right-sided hydroureteronephrosis, exacerbation of chronic pyelonephritis.

 In order to restore an adequate outflow of urine from the right kidney to the patient, a puncture nephrostomy on the right was performed on 09.02.99 under ultrasound and X-ray control and intensive antibacterial therapy was started (cefazolin 1.0 i / m 4 times a day, metrogyl 100.0 iv 4 times a day , ciprofloxacin 0.5 2 times a day), hemostatic (aminocaproic acid 100.0 iv, dicinone 2.0 iv 3 times a day, transfusion of a single-unit erythrocyte mass 220.0 ml) and detoxification (5% glucose solution, 0.9% sodium chloride solution) therapy. From 02.10.99, the patient's condition improved: body temperature returned to normal, pain in the right lumbar region disappeared, but moderate hematuria continued. In blood tests dated February 11, 1999, the level of leukocytes decreased to 8.2 thousand, the number of stab neutrophils was normalized, the level of red blood cells and hemoglobin remained the same (erythrocytes - 3.8 million, hemoglobin 110 g / l). On February 12, 1999, the patient underwent computed tomography (CT) scan of the pelvic area, which confirmed the presence of a bladder tumor located on the right side wall, and the tumor sprouted into paravesical tissue. 02.15.99, under epidural anesthesia, urethrocystoscopy was performed. In the bladder on the right side wall, a coarse villous tumor 4.0 cm in size is determined on a wide base. At the top of the tumor are ulceration sites with bleeding vessels. In the neck of the bladder and in the prostatic urethra, additional non-villous formations from 0.5 to 0.7 cm in diameter were found. TUR-biopsy of tumors of the bladder and urethra and coagulation of bleeding vessels were performed. According to the histological examination (histology 1236-42 of 02.23.99), transient cell bladder cancer of the middle degree of differentiation (T3aG2) was detected.

 Based on the examination (history data; laboratory data; ultrasound of the bladder, kidneys, liver; CT scan of the pelvic area; iv urography; chest x-ray; urethrocystoscopy and TUR-biopsy of the tumor), the final diagnosis was established: transitional cell carcinoma of the urine bubble T3aG2N0M0. The course of the disease was complicated by the germination of a tumor in the mouth of the right ureter with the development of hydroureteronephrosis and exacerbation of chronic pyelonephritis.

 Given the presence of invasive cancer of moderate differentiation, without regional and distant metastases, the patient was offered radical cystectomy with removal of the urethra. The patient categorically refused from the proposed method of urine diversion in the form of intestinal conduit with the conclusion of a urinostomy on the skin of the anterior abdominal wall. When planning the operation, it was decided after cystectomy to perform the patient ureterosigmoanastomosis according to our proposed option Mainz-pouch II (sigmorectal reservoir).

 02/25/1999, under endotracheal anesthesia in combination with epidural anesthesia with a lower middle incision, the abdominal cavity was opened in layers. When revising the iliac and obturator lymph nodes, their increase was not detected. Performed pelvic lymphadenectomy on both sides. Both ureters are isolated from the adult vessels to the inflow into the bladder, removed into the abdominal cavity, crossed and intubated with silicone tubes. It turned out that the right ureter was expanded to 1.0 cm in diameter, its wall was thinned. With phased hemostasis, the bladder was mobilized and removed in a single unit with the parietal peritoneum, prostate gland, seminal vesicles, ducts carrying out the ducts and perivesical tissue. From the perineal access, the urethra was excreted along the entire length from the external sphincter to the glans penis. The urethra is removed. The sigmoid colon is dissected to a length of 20 cm along the antispracheal margin distally and proximal to the rectosigmoid angle. Given the marked expansion of the right ureter, it was decided to implant it into the created sigmorectal reservoir by creating a serous extramural tunnel. For this purpose, the dissected intestine is U-shaped, its lower edges are stitched together by gray-serous sutures, departing from the edge of the intestine by 1.0-1.5 cm. The right ureter is placed on the created posterior wall of the reservoir formed and is fixed to the intestinal wall by three interrupted sutures. The left ureter is placed towards the right and is also fixed to the wall of the intestine. The edges of the intestine located above the ureters are stitched together by a continuous suture and thereby the creation of a serous extramural tunnel is completed. Ureter intubators are brought out through the rectum. The front wall of the formed intestinal reservoir is sutured with double-row serous-muscular sutures. The formed reservoir is fixed to the promontorium with three interrupted sutures. The abdominal cavity is drained by two polyvinyl chloride tubes, brought out through the contraperture. The surgical wound is sutured in layers tightly, iodine, aseptic sticker.

 The postoperative period was uneventful, on the 14th day (March 11, 1999), the ureteral intubators were removed after the operation, after which the patient recovered independent urination through the rectum. On the 18th day after the operation (March 15, 1999), the patient in satisfactory condition was discharged for outpatient treatment.

 Examined after 12 and 18 months (March and September 2000) after surgery: the patient urinates through the rectum 4-6 times a day, does not notice any leakage or urinary incontinence, clearly differentiates urination. Over the entire period after surgery, exacerbations of chronic pyelonephritis were not observed. Ultrasound and X-ray examination showed no expansion of the ureters and pyelocaliceal systems of both kidneys. Kidney function is not impaired. The patient continues to be observed to the present.

 We have applied the proposed method for the formation of ureterosigmoanastomosis to date in 8 patients (all patients underwent radical cystectomy for invasive bladder cancer) with positive results - in none of them we observed intestinal-ureteral refluxes and strictures of the ureters in the anastomotic zone.

 The proposed method in comparison with the known has several advantages.

 1. The frequency of development of strictures of transplanted ureters is significantly reduced, since when creating an extramural tunnel, scar tissue does not develop at the site of implantation of the ureters, as is often the case when creating a submucous tunnel.

 2. Provides effective antireflux protection by reducing the extramural tunnel, the wall of which contains the muscle layer. When implanting the ureters into the submucosal tunnel in this type of operation, more than half of the patients in the long-term period have one- or two-sided intestinal-renal reflux with frequent exacerbations of chronic pyelonephritis due to reflux of the intestinal flora, development and progression of renal failure.

 3. Reduces the invasiveness of surgical intervention due to the lack of need for perforation of the intestinal wall, while implantation of the ureters into the submucosal tunnels requires additional perforation of the intestinal wall for their passage into the holes formed.

 The method was developed in GMPB 2 together with TsMSCH-122 and TsNIRRI and passed clinical testing in the urology departments of these hospitals in 8 patients with positive results.

Claims (1)

 A method of forming a ureterosigmoid anastomosis, including dissection of the intestine in the rectosigmoid region along the anti-mesenteric edge, creating a tunnel for implantation of the ureter with the formation of a rectosigmoid reservoir, characterized in that the tunnel is created extramurally, for which the back wall of the reservoir is first formed by superposing the gray-serous glands from the edges of the intestines 1.0-1.5 cm, the ureters are placed on the created wall towards each other, fix them to the wall of the intestine and stitch the edges of the intestine located above the ureters between oh.

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