RU2256410C2 - Method for transplanting ureter into intestine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves exposing ureter with fibromuscular layer around juxtavesical part and urinary bladder wall area around the orifice of 7-15 mm large diameter. Microsurgical techniques are used in preparing and retaining superior urinary bladder artery branches coming to the ureter and periureteral loop nerves. The ureter is transplanted to intestine.

EFFECT: enhanced effectiveness in mobilizing ureter with muscular contracture apparatus, blood supply and innervation being retained.

Description

The invention relates to medicine, namely to surgery, and can be applied at the reconstructive stage of evisceration when creating a urinary reservoir.

There is a method of transplanting the ureter into the rectosigmoid colon, in which the ureter is mobilized below the iliac vessels, intersected, anastomosed with the intestine with 2 rows of sutures and peritonized with a peritoneal graft (M.A. Podgorbunsky, G.M. Abalmasov // Urology and Nephrology - 1968. - No. 5. - P.40-44).

A significant disadvantage of this method is the lack of valve apparatus at the level of anastomosis, a high probability of urine reflux and the development of pyelonephritis.

As a prototype, we have chosen a method for the formation of ureterosigmoanastomosis, which provides for the creation of an antireflux mechanism by conducting the distal section of the mobilized ureter in the submucous tunnel of the colon wall (N.A. Lopatkin, A.G. Pugachev, S.I. Alferov // Urology and Nephrology. - 1994. - No. 1. - P.39-41).

The method has the following disadvantages:

1) the possibility of using the natural antireflux mechanism at the level of the vesicoureteral connection is excluded;

2) there is no sufficient antireflux reliability;

3) a unified technique is used in the absence of clear criteria for intraoperative assessment of the adequacy of the functioning of the antireflux valve in each individual case;

4) there are anatomical limitations of the application of the method, when insufficient thickness of the intestinal wall does not allow the formation of a reliable submucosal canal;

5) no attention is paid to the preservation of small arterial branches and nerves.

The aim of the present invention is the development of such a method of mobilization of the ureter, in which you can save a natural closure apparatus, blood supply and innervation.

This goal is achieved by the fact that the ureter is secreted together with the fibromuscular layer around the juxtavesical part and a section of the bladder wall with a diameter of 7-15 mm around the mouth, the branches of the upper urinary bladder artery and nerves around the ureter loop are dissected using the microsurgical technique, the ureter is transplanted into the intestine while maintaining blood supply and innervation.

The invention "A method for transplanting the ureter into the intestine" is new because it is unknown in modern medicine and surgery in particular.

The novelty of the invention lies in the fact that the ureter is mobilized together with the portion of the urinary bladder triangle and the fibromuscular layer, while maintaining blood supply and innervation.

There are no similar methods in the available literary sources in Russia, the CIS countries and foreign countries.

The invention "A method for transplanting the ureter into the intestine" is industrially applicable, since it can be used in the surgical treatment of locally advanced forms of cancer of the rectum and female genitalia in oncological institutions.

The method was carried out as follows.

During evisceration at the stage of drug mobilization, the ureters were isolated from the surrounding tissues up to the bladder, solving the question of their involvement in the pathological process. At the same time, using the microsurgical technique, the branches of the upper urinary bladder artery and nerves around the ureteric loop from the upper inferior hypogastric plexus reaching the healthy ureter were dissected and preserved. Performed a vertical cystotomy, made an audit of the area of the bladder triangle. In the absence of infiltration by a tumor of one of the ureters, it was catheterized with a thin silicone tube, which was fixed to the mouth with a purse-string suture with a synthetic absorbable thread. Around the mouth outlined the borders of the flap with a diameter of 7-15 mm. A hook-shaped scalpel, pulling by the tube, cut the mucous membrane and muscle layers of the urinary bladder along the perimeter of the intended flap. Then, the ureter was isolated along with its fibromuscular layer. The ureter was wrapped in a cloth moistened with 0.5% chloramine solution or saline. At the reconstructive stage, an anastomosis was formed between the ureter and the urinary reservoir.

Example.

Patient A., 53 years old, was admitted to the TAO RNII with a diagnosis of colorectal cancer, clinical group 2. When examined according to excretory urography, a significant decrease in left kidney function was noted. After preliminary preparation, an operation was performed. With laparotomy, it was revealed that in the mid-ampullar part of the rectum there is a dense tuberous tumor measuring up to 7 cm in diameter. No distant metastases were found. During the mobilization of the rectum, it was found that the tumor sprouts the posterior wall of the bladder in the region of the bladder triangle, the left ureter is expanded to 1 cm in diameter, and the right one has normal sizes. It was decided to perform abdominal-perineal extirpation of the rectum, prostatvesiculectomy, cystectomy (pelvic evisceration). The mobilization of the rectum, bladder, prostate and seminal vesicles, ureters on both sides was performed, while the supply vessels were centrally ligated and crossed. The left ureter is bandaged and crossed at the bladder. The right ureter is isolated with preservation of small branches of the upper urinary bladder artery, nerves of the upper and lower hypogastric plexuses using microsurgical technique. A cystotomy was performed with a vertical incision of 5 cm, during the audit it was found that the tumor infiltrates the mouth of the left ureter and urethra, the right ureter is not affected. The right ureter is catheterized with a thin silicone tube, which is fixed to the mouth with a purse string suture with a synthetic absorbable suture 4/0. Around the mouth, pulling the tube, layerwise dissection of the mucous membrane and muscle layer of the urinary vesicle triangle with a hook-shaped scalpel, a flap with a diameter of 1 cm was cut. The ureter with its fibromic ocular layer was isolated. The ureter is covered with a cloth moistened with a 0.5% solution of chloramine. The removal of the drug. At the reconstructive stage, an artificial urinary reservoir was formed from an isolated segment of the sigmoid colon. An anastomosis was applied between the left and right ureters according to the end-to-side type. A ureterosigmostomy with the right ureter was performed. The distal end of the colon is sutured tightly and subsequently removed to the anterior abdominal wall as an unnatural anus. Performed drainage of the abdominal and pelvic cavities. The wound is sutured in layers tightly.

The postoperative period was uneventful, without complications. The patient was discharged on day 16. The drainage of the abdominal cavity and pelvis is removed in the period from 9 to 15 days. After 5 months. after surgery, according to excretory urography, the function of the right kidney is not impaired, the left is reduced, the patient is in good health.

The technical and economic effectiveness of the method consists in the fact that mobilization of the ureter together with the portion of the urinary bubble triangle and the fibromuscular layer, while maintaining blood supply and innervation, allows the formation of a reliable uretero-intestinal anastomosis that prevents urine reflux and the development of pyelonephritis. Thus, the long-term results of treatment improve, the quality and life expectancy of patients increase.

Claims (1)

A method for transplanting the ureter into the intestine, including mobilizing the ureter with a part of the urinary bladder triangle, characterized in that the ureter is secreted together with the fibromuscular layer around the juxtaesical part and a section of the bladder wall around the mouth with a diameter of 7-15 mm, using a microsurgical technique, dissecting and preserving those going to the ureter branches of the upper urinary bladder artery and nerves around the ureteric loop, the ureter is transplanted into the intestine.