RU2233611C2 - Method for visualization of transplant's collector system while performing reconstructive operations upon urinary tract in patients after renal transplantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: the present innovation deals with visualization of the superior urinary tract of renal transplant. For the purpose to find and isolate a transplant's pelvis and an ureter while performing reconstructive operations under conditions of pronounced fibrosis of retroperitoneal space one should apply the light from the structure of renal collector system due to the source visible radiation as He-Ne laser at 0.63 mcm wave length and emitting power of 20 mW at light guide's end. The method enables to decrease the risk for damaging in the main vessels and shorten duration of operative interference.

EFFECT: higher efficiency.

2 ex

Description

The invention relates to medicine, namely to transplantology.

A known method for determining the location of the pelvis during reconstructive operations on the transplant using hydraulic expansion of the collector system of the kidney by preliminary blocking the nephrostomy drainage 1-2 hours before surgery. In this case, the enlarged pelvis is determined by palpation (Trapeznikova MF, Kazimirov V.G., Perlin D.V., Urenkov SB, Urology and Nephrology, 1997, No. 6, pp. 20-24). This method has the following significant drawbacks: firstly, the complexity of palpation of the pelvis through a thick layer of coarse fibrous-altered tissue and the high probability of erroneous determination of the main vessels intimately adjacent to it, which resemble the pelvis and ureter in density. Secondly, the method is not applicable when performing an operation for necrosis of the ureter, when there is an external urinary fistula, due to the impossibility of hydraulic expansion of the collector system of the kidney. Thirdly, even a relatively short violation of the outflow of urine from the transplant can lead to pyelovenous reflux, and as a result to serious complications.

A known method of visualizing the pelvis of the graft by staining it through the introduction of a methylene blue solution through nephrostomy drainage (Shiff M., Littion B. Secondary ureteropuloscong in renal transplant recipient. J.of Urol., 1981, V / 126, P.723-725). This method has similar disadvantages. Firstly, visual determination of the pelvis is difficult through a thick layer of rough scarred tissue. Secondly, the use of the method for ureter necrosis, when there is an extravasation of urine, is ineffective in connection with the staining of the entire area of the urinary tract.

A patent search was conducted on the use of a laser to visualize urinary tract. No analogues found.

The objective of the present invention is to remedy these disadvantages by creating a reliable method for visualizing the pelvis, necessary for its search and isolation, when performing reconstructive operations on the urinary tract of the transplant, such as pyeloureterostomy, ureteroureterostomy, pyelovecicostomy, etc., under conditions of pronounced fibrous compaction of surrounding tissues and lack of permanent anatomical landmarks. For this purpose, it is proposed to visualize the pelvis by local illumination using a fiber through a nephrostomy drainage. The position of the working part of the fiber is corrected under the control of a fluoroscope. It is proposed to use a helium-neon laser with a wavelength of 0.63 μm and a power at the end of the fiber of 20 mW as a source of visible radiation. Radiation with the indicated characteristics has high penetration through dense fibro-altered tissues. An additional advantage of the method is the bacteriostatic effect of radiation, which also increases the safety of the operation.

The implementation of the method is shown in specific examples:

Example 1

Patient V., IB 13223, 29 years old, with a diagnosis of Chronic glomerulonephritis, chronic renal failure - terminal stage, allograft of a cadaveric kidney 04/13/1989.

He was urgently hospitalized on 09.25.1991 with complaints of high fever. During the examination, a significant decrease in kidney function (plasma creatinine 0.90 mmol / L), pronounced leukocyturia (up to 50-60 in the field of view) attracted attention. Ultrasound revealed a pronounced transplant hydronephrosis. Perforated nephrostomy. Antegrade pyeloureterography revealed a pronounced stricture of the distal ureter.

After normalization of the transplant function and stabilization of the general condition of the patient 10.10.1991 produced reureterocystostomy with intubation of the ureter. After x-ray control 02.11.1991 nephrostomy and intubating drainage removed. The patient was discharged from the hospital with good transplant function (plasma creatinine - 0.12 mmol / l).

After a little more than six months 05/20/1992 the patient was again hospitalized. During the examination, an increase in plasma creatinine up to 0.32 mmol / L attracted attention. Ultrasound revealed a pronounced expansion of the pyelocaliceal system and the upper third of the ureter of the graft. Perforated nephrostomy. When antegrade pyeloureterography revealed stricture of the lower half of the ureter.

After normalization of transplant function 06/11/1992, end-to-end pyeloureterostomy was performed with the recipient's own ipsilateral ureter. The ureter of the graft was selected among the scarred tissues using its illumination with a helium-neon emitter through a light guide inserted through the nephrostomy. The postoperative period was uneventful.

The nephrostomy and intubating drainage were removed on 07/13/1992 after ultrasound and x-ray control. The patient was discharged from the hospital with satisfactory graft function. During the subsequent observation period, the transplant function remains satisfactory. In urine tests, no significant changes were noted. With control ultrasound, the pyelocaliceal graft system was not expanded.

Example 2

Patient M., IB No. 0138, 40 years old, with a diagnosis of Chronic pyelonephritis. CRF, cadaveric kidney allotransplantation on the left, transplantectomy (acute rejection) in 1997. Programmed hemodialysis.

Repeated transplantation was performed on August 16, 1999 from a cadaveric donor with retroperitoneal fibrosis. Transplant processing was accompanied by technical difficulties due to a pronounced cicatricial process in the kidney gate. The graft function is delayed with the restoration of diuresis on the 27th day. At the next ultrasound on September 22, 1999, a volumetric fluid formation was found at the lower pole of the graft, 5 × 6 cm in size. The formation was punctured under ultrasound control. The biochemical composition of the resulting fluid corresponded to urine. Percutaneous nephrostomy performed, drainage of the urinary tract. With antegrade pyeloureterography, a massive extravasation of contrast was observed in the middle third of the ureter. The graft function remained satisfactory.

After control fistulography (there was practically no leakage cavity), the drainage was removed. However, despite the adequate function of the nephrostomy, an external urinary fistula continued to exist for a long period. In order to restore the urinary tract transplant on 12/21/1999, a transplant pyeloureterostomy was performed with the recipient's own ureter according to the “end to side” type of laparotomy access.

Performed a lower middle laparotomy. The parietal peritoneum is wedge-shaped along the lateral canal above its ureter and graft.

Own ipsilateral ureter of the recipient is mobilized from the intersection with iliac vessels for 8-10 cm in the distal direction. To isolate the pelvis of the graft, a light guide was introduced previously parallel to the nephrostomy drainage under the control of a fluoroscope. A helium-neon laser was used as a light source. The graft pelvis is dissected longitudinally for about 2 cm.

The ureter of the recipient is anastomosed “end to side” with the pelvis of the graft. The defect of the parietal peritoneum over the graft is sutured. The nephrostomy was removed after x-ray control after 3 weeks. The stent was removed 5 weeks after surgery. The graft function remained stable.

The present invention can significantly reduce the complexity of performing reconstructive operations on the graft urinary tract in case of urological complications after a kidney transplant, significantly reduce the risk of damage to the great vessels, shorten the duration of the intervention and improve its results.

Claims (1)

A method for visualizing the upper urinary tract of the renal transplant by introducing through the nephrostomy passage a fiber connected to a source of visible radiation, characterized in that for reconstruction and reconstruction of the pelvis and ureter of the graft during reconstructive operations under conditions of pronounced retroperitoneal fibrosis, the structure of the kidney collector system is illuminated using source of visible radiation, helium is used as the latter - a neon laser with a wavelength of 0.63 microns and radiation guide output at the fiber end 20 mW with a high penetrating power through dense scar-modified tissue.