RU2199281C1 - Method for developing orthotopic bladder - Google Patents

Abstract

FIELD: medicine, urology. SUBSTANCE: ileum's segment is resected and put in the form of P- shaped arch. Left shoulder being 2-4 cm longer. Protruding end of arch is kept to be tabular and anastomozed with urethra. At developing posterior wall of reservoir one should apply serous-muscular sutures at reservoir's one third-half level. Intestinal edges are stretched and sutured with cross-sectionally sero-serous sutures leaving 1-1.5 cm against intestinal edge. Suturing line of posterior wall represents letter "Y". Ureters should be applied along suturing line. Reservoir's anterior wall is formed. The method enables to increase antireflux protection. EFFECT: higher efficiency of operation. 1 cl, 1 ex

Description

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

 Cystectomy is performed, as a rule, with invasive bladder cancer (RMP) or with highly malignant 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). When choosing a particular method, 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 derivation method is selected for each individual patient.

 An ideal way for urine diversion for a patient is the formation of an orthotopic bladder (MP), in which the patient can hold urine and optionally carry out an urination act. For this, sections of the small or large intestine are used, and in rare cases, part of the stomach is used. Currently, preference is given to the ileum, due to the anatomy of which one can create orthotopic urinary reservoirs of various configurations. Contraindications to the creation of orthotopic MP are tumor lesions of the neck of the MP and the mucosa of the prostatic urethra, i.e. those cases in which removal of the urethra is indicated.

 A known method of forming an orthotopic W-shaped MP, described in [H. Abol-Eneim and M.A. Ghoneim, British Journal of Urology, V.76, p. 558-564, 1995]. The method consists in resecting 40 cm of the distal ileum, laying it in a W-shape, dissecting along the mesenteric edge, forming the posterior wall by applying gray-serous sutures, in the lateral channels formed between the segments of the resected W-shaped intestine, laying the ureters and applying gray -serous sutures form tunnels, fix the ureters to the intestinal mucosa, after which the edges of the intestine are sutured together to create a reservoir. After the reservoir is formed, determine the most optimal place for anastomosis of the urethra.

This method has a number of positive properties, namely
- provides the creation of a sufficiently reliable, according to the authors of this work, a reservoir for the derivation of urine,
- gray-serous tunnels for the ureters protect their walls from contact with urine,
- resection of only 40 cm of the ileum makes the method less traumatic,
- the method is suitable for ureters of any size, because the tunnel can be created of any length and diameter.

 And yet, despite the positive aspects of the method, it is not without drawbacks, the main of which are as follows.

 As our experience shows, this method does not always ensure the retention of urine. In our opinion, this is due to the fact that with such a volume and configuration of the MP, there is a high hydrostatic pressure at the junction with the urethra, which leads to urinary incontinence.

 Rehabilitation of patients with this method of forming orthotopic MP lasts about a year.

Closest to the proposed is a method of forming an orthotopic MP described in [Camey M., Richard F., Botto H. Ileal replacement of bladder. In: King LR, Stone AR, Webster CD, eds. Bladder Reconstruction and Continent Urinary Diversion, 2 ^nd edn. Chicago: Mosby Year Book Inc. 1991: 389-410].

 The method consists in resecting 60 cm of the ileum, laying it in the form of a U-shaped arch, dissecting along the mesenteric edge, stitching the inner edges of the intestine with a continuous serous-muscular suture, forming the posterior wall of the reservoir. It creates submucosal tunnels for implantation of the ureters, which are passed through the wall of the intestine with subsequent fixation. By stitching the outer edges of the intestine, the formation of the reservoir is completed.

This method provides
- creating a reliable and sufficient capacity of the reservoir for the derivation of urine,
- sufficiently reliable retention of urine in case of safety of the external sphincter of the urethra,
- allows you to restore urination in a natural way.

 However, as our clinical experience shows, due to the insufficiency of the external urethral sphincter in the absence of other urinary retention mechanisms and high hydrostatic pressure in the prototype method, it does not provide reliable urine retention.

 The submucous tunnels for the ureters do not provide reliable antireflux protection, since the thin mucosa under which the ureter is held does not provide a reliable antireflux mechanism that protects the upper urinary tract from infection.

 In addition, 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. 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. These circumstances are the cause of such serious complications as obstructive uro and nephropathy.

 Resection in the prototype method of 60 cm ileum leads to metabolic disorders, the severity of which is directly proportional to the length of the resected segment of the small intestine.

 A large volume of the created reservoir and, therefore, a large area of the small intestinal mucosa lead to reabsorption of a large number of electrolytes, which is also associated with metabolic disorders.

 Based on the foregoing, it can be stated that insufficiency of the external urethral sphincter in the absence of other urinary retention mechanisms and high hydrostatic pressure does not provide reliable urine retention, submucosal tunnels are often the cause of ureteral stricture and by no means always provide their effective antireflux protection. All this leads to a long rehabilitation of patients after surgery.

 The technical result of the present invention is to increase the reliability of urine retention and antireflux protection and reduce the rehabilitation of patients by changing the method of formation of orthotopic MP.

 This result is achieved by the fact that the resected segment of the ileum is laid in the form of a U-shaped arch, the left shoulder of which is 2-4 cm longer, the intestine is dissected along the mesenteric edge, keeping the protruding end of the arch tubular, and anastomose it with the urethra. When creating the back wall of the reservoir at the level of the lower 1 / 3-1 / 2 of the formed reservoir, sero-muscular sutures are applied, then the remaining edges of the intestine are stretched and stitched transversely by gray-serous sutures, departing from the edge of the intestine so that the seam line of the back wall is the letter "Y". The ureters are laid along the line of gray-serous sutures, the edges of the intestine are stitched over them, creating gray-serous tunnels, after which the formation of the reservoir is completed by stitching the outer edges of the resected intestine together. To create a urinary reservoir of sufficient capacity, an optimal resection of 35-40 cm of the ileum is optimal.

 Resection of only 35-40 cm of the ileum and the subsequent formation of an orthotopic MP from it ensures the creation of a small but sufficient reservoir for urine diversion, which reduces the absorption of its components and thereby prevents the development of severe metabolic complications.

 Laying the resected intestinal segment in the form of a U-shaped arch, the left shoulder of which is longer than the right, makes it possible to leave the protruding end of the left shoulder undetubularized when cutting it, which ensures preservation of intestinal motility and, when anastomosing it with the urethra, provides more reliable retention of urine due to antiperistaltic waves of non-tubular part of the intestine and an increase in the functional length of the urethra.

 The formation of the posterior wall of the reservoir with a Y-shaped suture and its execution on the two upper segments of gray-serous makes it possible to create 2 extramural tunnels on them for implantation of the ureters, which eliminates the need to separate the mucosa from the muscle layer, which is associated with the risk of rupture of the mucosa with all the ensuing consequences, and the location of the ureters in the serous tunnels, where homogeneous tissues come in contact (the serous membrane of the intestine with the serous membrane of the ureters), reduces the possibility of cicatricial narrowing of the implanted ochetochnikov and provides reliable antireflux protection. In addition, the use of a Y-shaped suture to form a reservoir maximally approximates the shape of the created MP to the spherical one, which is the most physiological and leads to a fairly quick normalization of urodynamic parameters and, therefore, to quick rehabilitation of patients, which, according to our observations, is 2-3 months.

 The essence of the method is illustrated by example.

 EXAMPLE.

 B-th P., 69 years old, and / b N 9288, was routinely hospitalized in the urology department of the city multidisciplinary hospital (GMBP) N 2 (S-Pb) with complaints of difficulty in frequent urination, intermittent blood in the urine.

 From the anamnesis it is known that in December 2000, with complaints of difficulty urinating, he turned to a urologist at the polyclinic at the place of residence. An ultrasound examination of the bladder revealed a tumor formation. He was hospitalized in a hospital in Vyborg, where he was examined and, according to computed tomography and ultrasound examination of the pelvis and cystoscopy, was diagnosed with a bladder tumor. Due to the large size of the tumor and the impossibility of performing a transurethral resection, the patient was sent to St. Petersburg, to the hospital No. 2 for radical cystectomy.

Upon admission, the patient’s condition is relatively satisfactory, clear consciousness, normal skin integument, peripheral lymph nodes not enlarged, no edema. Hemodynamic parameters within normal limits, blood pressure 140/80 mm Hg On palpation - internal organs without features. Urination is frequent, urine stream is sluggish, urine mixed with blood. In the department the patient performed:
Electrocardiogram - sinus rhythm, heart rate 68 beats / min, deviation of the electrical axis of the heart to the left, blockade of the anteroposterior branch of the left leg of the bundle of His. Left ventricular hypertrophy.

 Fluorogram - within the age-related changes.

 Computed tomography of the bladder - a bladder of sufficient volume, a volumetric pathological formation is visualized on the posterior left side wall, which well accumulates a contrast drug during angiography up to 80-85 units. The dimensions of the formation are 47 x 23 mm, the wall of the bladder at the base of the neoplasm is thickened, fragmented.

Ultrasound examination - abdominal organs without pathology, no metastases. The kidneys are unchanged. The bladder contains 250 ml of urine, in the area of the left side wall, a hyperechoic tissue formation is visualized, filling 1/3 of the lumen of the bladder. The prostate is not enlarged, dimensions 30x39x30 mm, volume 18 cm ³ .

 Cystoscopy: on the left side, departing from the neck 1.5-2.0 cm, a tumor formation is visualized on a wide base with a diameter of about 4 cm, protruding into the lumen of the bladder.

 Blood test: Lake. - 7.6x10 / 9, erythro. - 5.6x10 / 12, hemoglobin - 152 g / l, platelets 206 thousand, lymphocytes 30, monocytes 4, neutrophils 63, stab 6, segmented 5, eosinophils 2, basophils 1, ALT 43 U / l, ACT 31U / l, total protein 58 g / l, urea 5.3 mmol / l, creatinine 99 μmol / l, bilirubin total 5.5 μmol / L, glucose 5.2 mmol / L, prothrombin 109%.

 Urinalysis: light yellow, slightly cloudy, specific gravity 1020, acid urine reaction, protein 0.025 g / l, white blood cells 10-12-17 in n / a, red blood cells var. 6-8-12 in n / a., Flat epithelium 0-1-2 in n / a., Mucus ++. Urine cultures did not give growth.

 Based on the examination, a diagnosis was made: a bladder tumor. Histological diagnosis - Highly differentiated invasive transitional cell carcinoma of the bladder.

 Given the presence of muscle-invasive cancer in the patient and the absence of severe somatic diseases, it was decided to perform radical cystectomy with the formation of an orthotopic urinary reservoir from an isolated segment of the ileum.

 04/05/2001, the patient was taken for surgery. Under endotracheal anesthesia and spinal anesthesia, a lower middle laparotomy was performed. The ureters are isolated in the lower third to the juxtasical section, cut off from the bladder and intubated. The bladder with phased hemostasis is extraperitonized, isolated with paravesical tissue, seminal vesicles and the prostate, cut off from the urethra, removed and sent for histopathological examination. Performed pelvic lymphadenomectomy. An expert diagnosis of the histological preparation revealed that the tumor grows only in the inner muscle layer of the bladder wall, no metastases to the lymph nodes were detected. Histological conclusion 36733 - 36751 of 04/11/01: Highly differentiated transitional cell carcinoma of the bladder with invasion of the muscle wall. Chronic cystic cystitis. Prostate adenoma. Chronic prostatitis. Hyperplasia of the lymph nodes. Seminal vesicles without features.

 During surgery, stepping back from the ileocecal angle of 30 cm, a segment of the ileum of 40 cm in length was taken, resected on the feeding vascular pedicle with the mesentery. Intestinal integrity restored anastomosis end to end. The resected isolated segment of the intestine is folded in the form of a U-shaped arch so that its left shoulder was 3 cm longer. After this, the intestine was dissected along the mesenteric edge, leaving the protruding end of the left shoulder undetubularized. After that, the back wall was formed, for which the lower half was sutured with a continuous-nodal seam, and the upper half was stretched over the edges so that the back wall took a Y-shape. Using gray-serous sutures on the upper segments of the Y-shaped suture, a bed 2 cm long was formed for laying the ureters. The ureters were carried into the reservoir, laid on serous beds and fixed on the wall of the intestine. Sutures were placed over the ureters with the capture of their walls. A Foley catheter was installed, anastomosis of the undetubularized part of the urethral reservoir was performed. The front edges of the intestine were stitched together with continuous-nodal sutures. The left ureteral intubator was withdrawn along the urethra, and the right through the contraperture on the anterior abdominal wall. The pelvis was drained with 2 drains through contra-holes. The wound was sewn in layers. In the postoperative period, antibiotic therapy, infusion and detoxification therapy were carried out. The postoperative period was uneventful, the intubators were removed on the 12th day, and the urethral catheter on the 14th. Independent urination was restored, the patient didn’t notice urine leakage, he got up 3-4 times at night. Before discharge, intravenous urography was performed: renal function is satisfactory, the renal cavity system and ureters are not expanded. With downward and retrograde cystography, the reservoir is round in shape, its volume was 220 ml. When mixing cystography data for vesicoureteral reflux was not obtained. Blood test: White blood cells - 7.2x10 / 9, red blood cells - 4.3x10 / 12, hemoglobin - 126 g / l, platelets - 354 thousand, lymphocytes 34, monocytes 11, neutrophils 50, p / nuclear 10, s / nuclear 40, eosinophils 5, basophils 0, ALT 28 U / L, ACT 27 U / L, total protein 71.9 g / L, creatinine 98 μmol / L, glucose 5.0 mmol / L.

 Urinalysis: light yellow, cloudy, specific weight 1018, neutral reaction, protein 0.025 g / l, white blood cells 20-25-30 in n / a, flat epithelium 0-1-2 in n / a, mucus + .

 April 23, 2001 the patient in satisfactory condition was discharged under the supervision of an oncourologist at the place of residence. Recommended dynamic observation, taking uroseptics. Control examination after 3 months.

 During the control examination 3 months after the operation, the patient's condition is satisfactory. Urinary incontinence is not noted. Renal function is satisfactory, the pyelocaliceal system is not expanded. The bladder on the cystogram is rounded, there is no vesicoureteral reflux. The volume of the tank is about 250 ml. With urofluometry, the maximum urination rate is 17 ml / s, the average is 10.5 ml / s. With cystometry, intravesical pressure at the first urge to urinate 21 cm of water. century, and the maximum - 45 cm water column

 Conclusion: The patient's condition is satisfactory, urodynamic indicators are normal. Rehabilitation of the patient is completed.

 To date, 9 surgical interventions have been carried out with the formation of an orthotopic MP in all cases with our proposed method after removal of the MP due to RMP.

The proposed method in comparison with the known has several significant advantages, namely:
1. Provides reliable retention of urine due to the preservation of intestinal motility in the undetubularized part of the left shoulder of the U-shaped segment of the intestine due to antiperistaltic waves in it and an increase in the functional length of the urethra.

 2. Provides effective antireflux protection and reduces the risk of developing strictures of transplanted ureters by creating serous extramural tunnels for them.

 3. Rehabilitation of patients in the proposed method takes 2-3 months in connection with a fairly quick normalization of their urodynamic indicators by creating a urinary reservoir shape that is close to spherical and reducing metabolic disturbances, while in the prototype method, patient rehabilitation is about of the year.

 Thus, we have developed a method for the formation of an orthotopic intestinal reservoir from the smallest ileum, close in shape to spherical, with reliable mechanisms for protection against reflux and urinary incontinence.

 The method was developed in the Department of Urology of the city multidisciplinary hospital N 2 in St. Petersburg and underwent clinical testing in 9 patients with positive results.

Claims (2)

 1. The method of forming an orthotopic bladder, including resection of the segment of the ileum, laying it in the form of an arch, dissecting the intestine along the mesenteric edge, forming the back and front walls of the reservoir by stitching the edges of the intestine together, creating tunnels for the ureters, implanting them with fixation to the intestinal wall and the subsequent connection of the formed reservoir with the urethra, characterized in that the resected segment of the intestine is laid in the form of a U-shaped arch, the left shoulder of which is 2-4 cm longer, when the intestines are cut and the protruding end of the arch is kept tubular and anastomosed with the urethra, and when the posterior wall of the reservoir is formed, first sero-muscular sutures are placed at the level of the lower 1 / 3-1 / 2 of the formed reservoir, after which the remaining intestinal edges are stretched and sutured transversely by gray-serous sutures, departing 1-1.5 cm from the edge of the intestine, while the line of sutures of the posterior wall is the letter Y, ureters are laid along the line of gray-serous sutures and the edges of the intestine are sutured above them.  2. The method according to claim 1, characterized in that the size of the resected segment is 35-40 cm.