RU2263519C1 - Method for restoring urodynamics of the upper urinary tract - Google Patents

Abstract

FIELD: medicine, physiotherapy.

SUBSTANCE: the present innovation deals with performing ureteric stimulation due to successive transmission of impulse onto contact surface of electrodes being isolated against each other. For this purpose during operation one should apply and fix a multi-contact electrode-catheter along the ureter, its loose end should be withdrawn outwards together with draining tube. Electrostimulation should be started sine the first day after operation to be conducted for 5-10 min with pauses between seances, affect with impulses at duration of 5-10 msec, at period of sequence being 20-30 msec grouped into a bundle at duration of 0.3-0.6 and frequency of repetition being 0.3-0.4 Hz, tension in impulse being 2-4 V, current power in impulse being 2-4 mA, the delay time for impulses supply between neighboring pairs of contact surfaces being 1-3 sec, pauses between seances correspond to 1.5-2 h, seances should be conducted for 3-8 d.

EFFECT: decreased traumatism of operation.

1 cl, 2 dwg, 3 ex

Description

The invention relates to medicine, namely to urology, and relates to methods for restoring the urodynamics of the upper urinary tract.

Closest to the proposed is a method of restoring the urodynamics of the upper urinary tract by stimulating the ureter by sequentially transmitting an impulse to isolated contact surfaces of the plate electrodes [1] laid in such a way that the first pair of electrodes is placed at the level of the projection of the renal pelvis and pelvis-ureter segment, 3rd — in the area of projection of the lower third of the left ureter, and 2nd — between the first and third pairs of electrodes, a prerequisite for performing Soba is a fractional intake of drinking water and chloride baths, which is unacceptable in the early postoperative period.

However, with this arrangement of electrodes, the stimulation is directed not only at the ureter, but also at the surrounding tissues and skeletal muscles. This helps to disperse the pulse and reduces the effectiveness of electrical stimulation.

A new technical task is to increase the efficiency of the method due to the possibility of restoring the tone, contractile and evacuation ability of the upper urinary tract in the shortest possible time, which significantly reduces the number of possible postoperative complications associated with impaired urodynamics.

The problem is solved in a new way to restore the urodynamics of the upper urinary tract, including stimulation of the ureter by sequentially transmitting a pulse to the contact surfaces of the electrodes isolated from each other, and during the operation, a multi-contact electrode-catheter is laid and fixed directly along the ureter, the free end of which is brought out together with a drainage tube, and electrical stimulation begins from the first day after the operation and is carried out twice a day for 5-10 minutes with the interruptions between sessions with pulses of 5-10 ms duration with a repetition period of 20-30 ms, grouped into a pack of 0.3-0.6 s duration and a repetition rate of 0.3-0.4 Hz, with a pulse voltage of 2-4 V, the current strength in the pulse 2-4 mA, the delay time for the supply of pulses between adjacent pairs of contact surfaces 1-3 sec. Also, pauses between sessions are 1.5-2 hours, and sessions are carried out for 3-8 days.

The method is carried out, for example, using an electric stimulator of an original design, the block diagram of which is shown in FIG. 1, where 1 is a power supply and control unit, 2 is a power supply, 3 is a stimulating pulse voltage generator 4 is a switch, 5 is a stimulating pulse delay unit , 6 - stimulating electrode-catheter, 7 - annular contact surfaces. Figure 2 schematically shows the design of the stimulating electrode-catheter, where 8 is a polyvinyl chloride tube, 9 are conductors for supplying stimulating voltage to the electrodes, 10 is an electrical connector for connecting the catheter electrode to the power supply and control unit.

The method is as follows. At the end of the operation on the kidneys or ureter, a multi-contact electrode-catheter 6 is placed along the ureter and fixed with thin catgut ligatures. The free end of the catheter electrode 6 with connector 10 for connection to the power supply and control unit 1 is brought out through the corner of the wound along with the drainage tube. From the first day after surgery, they begin to stimulate. The catheter electrode 6 is connected to a power supply and control unit 1, which provides a pulse electrical stimulating signal. The impact on the muscle structure of the ureter is carried out with pulses of 5-10 ms duration with a repetition period of 20-30 ms, grouped in a pack of 0.3-0.6 s duration and a repetition rate of 0.3-0.4 Hz, with a pulse voltage of 2- 4 V, current 2-4 mA, with a delay time of the supply of pulses between adjacent pairs of electrodes 1-3 s. The treatment session is carried out twice a day for 5-10 minutes with pauses between sessions of 1.5-2 hours for 3-8 days. Sequential excitation of individual sections of the ureter leads to the appearance of a peristaltic wave from the pelvis to the cystic region. As a control of restoration of the function of the upper urinary tract, for example, antegrade or excretory ureteropyeloscopy is performed and, in the presence of a stable therapeutic effect, the stimulation is stopped, the catheter electrode is removed.

The switch 4 provides switching of the pulse during the transition from one pair of annular contact surfaces 7 to another. This allows you to apply a stimulating impulse sequentially to adjacent pairs of annular contact surfaces from the first to the second, from the second to the third, etc. along the ureter. Thus, an excitation wave similar to the natural peristaltic wave arises and is maintained in the smooth muscles of the ureter. The delay unit 5 allows you to synchronize the stimulating pulses supplied along the ureter, with the speed of the excited peristaltic wave.

The proposed stimulation mode is optimal for obtaining a stable therapeutic effect and is selected on the basis of a study of literature, well-known stimulation techniques and clinical observations of 21 patients. When implementing the method, we periodically (not earlier than 2 days from the start of electrical stimulation) recorded an electroureterogram, as well as performed excretory or antegrade ureteropyeloscopy with video recording to monitor the effectiveness of the electrical stimulation. There were 14 patients with ureteral stones (11 men and 3 women), 1 patient (1 man) with hydroureteronephrosis due to neuromuscular dysplasia of the urinary system. 3 people (2 men and 1 woman) with hydronephrosis due to an additional vessel; 3 people (3 men) with hydronephrosis due to stricture of the ureteropelvic segment (LMS). The age of patients is from 16 to 52 years. At the age of 16 to 20 years - 2 people, from 21 to 30 years - 6 people, from 31 to 40 years - 11 people, from 41 to 52 years - 2 people.

A patient with ureteral stones underwent lumbotomy on the corresponding side, ureterolithotomy, and the installation of a stimulating catheter electrode. The disease duration from the moment of clinical manifestations was from 1 to 3 days - 9 people, from 3 to 7 days - 3 people, more than 7 days and up to 14 days - 2 people. In the postoperative period, all patients underwent electrical stimulation according to the described technique. In 13 patients, the function of the upper urinary tract (UMP) was restored within 3 to 5 days, which was confirmed by periodic recording of electroureterograms and excretory ureteropyeloscopy. In 1 patient in the postoperative period (on the 2nd day) there was an episode of gastric bleeding that was not associated with stimulation, in connection with which electrical stimulation was not performed, the stimulating catheter electrode was removed on the 4th day.

One patient with hydroureteronephrosis due to neuromuscular dysplasia of the urinary system underwent lumbotomy, resection of the pelvis, plastic of the ureteropelvic segment using the Lopatkin method, nephrostomy. The disease was 9 years old. The function of the upper urinary tract was restored on the background of stimulation on the 8th day.

Three patients with hydronephrosis caused by additional vessels were performed: the 2nd - ligation of the additional vein, ureterolysis, the first - nephropexy.

The duration of the disease ranged from 1 year to 4 years. In all patients, against the background of electrical stimulation, the restoration of VMP function occurred in a period of 3 to 5 days.

Three patients with hydronephrosis due to stricture of the ureteropelvic segment were performed: 2nd - operation according to the Calp de Vird method (plastic of the ureteropelvic segment with the wall of the pelvis), one - pyeloneostomy of the ureter. The duration of the disease ranged from 6 months to 2 years. Urodynamics recovered on the background of stimulation in all patients, in the period from 3 to 5 days.

Electrical stimulation is carried out by pulses of 5-10 ms duration, since it was found that the optimal duration of the stimulating pulse for smooth muscles is 1.5-10 ms [2]. The repetition period of pulses grouped into a burst of 0.3-0.6 s duration is 20-30 ms, that is, from 10 to 30 pulses are sent during the burst time (on average 20). This mode of sending pulses makes it possible to send the exciting pulse to the depolarization phase with a higher probability, i.e. at the moment when the muscles of the ureter are as ready to contract as possible. The practice of using autonomous gastrointestinal electrical stimulators shows that the listed parameters of stimulating impulses are adequate and are successfully applied [3 - p. 25]. The frequency of sending bursts of pulses is 0.3-0.4 Hz. It is proved that the limiting frequency of electrical stimulation is the frequency of 0.3-0.4 Hz. If stimulation is carried out with a frequency of 1 impulse in 4 seconds, then the ureter responds with a reduction for each stimulation; with a larger pause between pulses, for example, 1 pulse in 5 seconds or less, an alternation of spontaneous and evoked potentials occurs [4]. This frequency is due to the duration of the period of absolute refractoriness, which is on average 3 seconds [5 - p. 42]. The current flowing through the tissues brought into contact with the electrodes does not exceed - 2-4 mA. The current strength was selected based on the occurrence of peristaltic contractions in response to stimulation, which were recorded during electroureterography, as well as on the basis of subjective sensations of patients arising during stimulation, from mild severity to moderate compression and twitching in the projection of the ureter. Our studies showed that the resistance of the tissue site adjacent to the contact surfaces lies in the range of 800-1200 Ohms. Therefore, to ensure the indicated magnitude of the stimulation current, the pulse voltage generator must provide a voltage of 2-4 V on the contact surfaces. Adjacent pairs of contacts on the stimulating electrode-catheter are located at a distance of 30-50 mm. Considering that the speed of propagation of the excitation wave along the ureter is on average 20 mm per second [5 - p. 27], the delay time between actions through adjacent pairs of contacts is chosen within 1-3 s, i.e. the excitation wave manages to travel the distance from one contact to another. Stimulation is carried out twice a day, as this ensures the persistence of developing effects, which is confirmed by our clinical observations. The duration of each session is 5-10 minutes, since on the basis of theoretical data and clinical observations it was found that stimulation of 5 minutes, although it provokes a response of the upper urinary tract, but the effect is unstable and longer treatment is required to restore normal function of the upper urinary tract (see example 1). When exposed for more than 10-15 minutes, the body adapts to the procedure, which can lead to a decrease in the therapeutic effect [6 - p. 96]. The pause between the sessions was chosen on the basis that the duration of the aftereffect during the procedure in the smooth muscles of the gastrointestinal tract is on average 1.5-2 hours [3 - p. 8]. Given the similarity of the functional properties of smooth muscle elements, we decided to use the same pause duration when performing electrical stimulation of the ureter. The duration of treatment is 3-8 days, and the duration of each session, their number and pauses between sessions in each case, is determined by the attending physician depending on the degree of impaired tonus of the upper urinary tract and patient tolerance of the procedure [6 - p. 33]. However, observations of patients found that stimulation of less than 3 days does not give a sustainable therapeutic effect, and more than 8 is inappropriate. The process of restoring peristalsis and tonus of the upper urinary tract was periodically monitored by recording the bioelectric activity of the ureter and performing excretory or antegrade ureteropyeloscopy. At the end of treatment, the electrode-catheter was removed.

Example 1 (extract from the medical history): Patient V., 27 years old, was admitted to the urology department with complaints of pain in the lumbar region of varying intensity, of a constant nature, sometimes in the form of attacks of renal colic. Attacks are accompanied by nausea and high blood pressure.

During the examination: ultrasound - the left kidney is larger than the right, the calyx and pelvis are enlarged, the thickness of the parenchyma is normal, the mobility of the kidney is significantly reduced. On a series of excretory urograms: the left kidney is enlarged, the calyx and pelvis are enlarged, the cavities have clear, even edges. On the ureterograms, a transverse break of the shadow is visible in the region of the pelvic-ureteric segment (characteristic of an additional vessel). To clarify the functionality of the kidney, a radioisotope study and dynamic scintigraphy were performed. The function of the left kidney is preserved, but sharply reduced. Clinical diagnosis: Additional vessel of the left kidney. Primary open hydronephrosis of stage II on the left. Chronic left-sided pyelonephritis.

Operation performed: ligation and intersection of the accessory vein. For the purpose of treatment according to the proposed method, the plastic is completed by the installation of a four-contact electrode-catheter along the ureter and fixed to it with separate catgut sutures. The free end of the electrode is brought out through a separate puncture along with a drainage tube. On the first day after surgery, stimulation of the ureter is started. Stimulation was carried out 2 times a day with a duration of each session of 5 minutes with pauses between sessions of 2 hours. On the first day, the intrapulmonary pressure was 180-190 mm water column; after stimulation, the pressure decreased by 10-20 mm water column. On the fifth day, the pressure in the pelvis was 80-120 mm Hg, stimulation was stopped. After antegrade pyelography, drainage and electrode were removed. On day 12, the patient was discharged from the hospital.

Example 2 (extract from the medical history): Patient M., 34 years old, was admitted to the urology department with complaints of unbearable pain in the right lumbar region with radiation to the right iliac region, nausea.

With ultrasound, the right kidney is larger than the left, pyeloectomy and calicoectasia are expressed, the pelvis-ureteric segment is enlarged. Intravenous urography - the function of the right kidney is reduced, the release of contrast medium is slowed down, pronounced hydronephrosis on the right, in the projection of the upper third of the ureter, the calculus has a shadow of calculus up to 0.5-0.7 cm, the ureter is above the calculus expanded to 1.0 cm. Clinical diagnosis: Urolithiasis. Stone of the upper third of the right ureter.

The operation was performed: lumbotomy, ureterolithotomy on the right. In order to conduct treatment according to the proposed method, the operation is completed by bringing the three-contact electrode to the pelvis laid and fixed along the ureter. The free end of the catheter electrode with a connector for connecting to the power supply and control unit is brought out through the lower corner of the surgical wound.

On the first day after surgery, stimulation of the ureter began twice a day with a duration of each session of 10 minutes, the interval between sessions of 1.5 hours. Peristalsis and tone of the urinary tract recovered on the third day. The restoration of the evacuation ability of the urinary tract has been proven by pharmacoechography and excretory pyeloureteroscopy with urography. On the fourth day drainage and electrode were removed. The patient in satisfactory condition on the eighth day was discharged from the hospital.

Example 3 (extract from the medical history): Patient B., 16 years old, was admitted to the urology department with complaints of minor aching pain in the right lumbar region.

From the anamnesis: from 1995 to 1998, he was operated on 8 times for: Neuromuscular dysplasia of the urinary system. Bilateral hydroureteronephrosis. Chronic pyelonephritis. Chronic renal failure.

On examination: ultrasound - the right kidney is 128 × 42 mm, the left is 107 × 46 mm. Mobility is preserved, the contours are clear, even. To the left in the projection of the lower, middle and upper groups of calyxes are calculi up to 7 mm in the projection of the pelvis - up to 13 mm. On the right are expanded all groups of cups from 16 to 23 mm. In the region of the lower pole of the right kidney, anechogenic formation of 93 × 48 mm. The mouth of the ureter is dilated. Conclusion: pronounced diffuse changes in both kidneys. Stones of the left kidney. Hydronephrotic transformation of the right kidney.

Excretory urography: - both kidneys are deformed, the contours are not clearly defined. CLS on both sides is sharply deformed. The cavity system is contrasted with 7 min in the form of separate contrasting fragments, ovoid in shape. Extended to the left (9 × 5 cm) to the right (9 × 15 cm). After 120 minutes, traces of contrast are preserved in the CLS. The ureters are not traced. Shadows suspicious of calculi are not determined. Conclusion: Hydronephrotic transformation of both kidneys. Condition after surgery on both kidneys for hydronephrosis.

Retrograde urography: Right - CLS sharply expanded (up to 150 × 90 mm), deformed. The right ureter is expanded to 20 mm. On the left - the CLS is expanded, deformed (in the form of a cavity 90 × 50 mm). The left ureter is crimped. Conclusion: Bilateral hydroureteronephrosis.

Clinical diagnosis: neuromuscular dysplasia of the urinary system. Bilateral stage III hydroureteronephrosis. Chronic pyelonephritis, latent course. Urolithiasis disease. Stones of the left kidney. Chronic renal failure.

The operation was performed - lumbotomy on the right, resection of the pelvis, plastic of the pyelourethral segment according to the Lopatkin method. Nephrostomy Installation of an antireflux stent. Appendectomy. In order to conduct treatment according to the proposed method, the operation is completed by installing a four-pin stimulating electrode along the ureter and is fixed to it with separate catgut sutures. The free end of the electrode is brought out through a separate puncture along with a drainage tube.

Stimulation was carried out from the 4th day after the operation, (since the first three days moderate hematuria continued), twice a day, the duration of each session was 10 minutes with an interval between sessions of 2 hours. Stimulation was performed with blocked nephrostomy drainage. Intrapulmonary pressure was monitored around the clock every 2 hours, as well as before and after electrostimulation. On the first day after the operation, the intrapulmonary pressure was 30-55 mm aq, with a subsequent increase to 180-220 mm aq. After stimulation, the pressure decreased by 20-30 mm aq. On the ninth day after surgery (fifth day from the start of stimulation), the intrapulmonary pressure was 90-120 mm aq. After performing antegrade pyelography of the nephrostoma on the 12th day after the operation, it was blocked, electrical stimulation was stopped. Electrical stimulation was carried out for 8 days. On the 13th day, the nephrostomy was removed, on the 14th day, the stimulating electrode was removed. On day 19, the patient was discharged from the hospital in satisfactory condition.

Stimulation was performed twice a day, the duration of each session was 5-10 minutes with pauses between sessions of 1.5-2 hours. The duration of treatment was on average 3-8 days, while the duration of each session, their number and pauses between sessions in each particular the case is determined by the attending physician depending on the degree of violation of the tone of the upper urinary tract and patient tolerance of the procedure. The recovery of peristalsis and tone of the upper urinary tract was periodically monitored by recording the bioelectric activity of the ureter or antegrade or excretory ureteropyeloscopy with urography. At the end of treatment, the electrode-catheter was removed.

Thus, the proposed method for restoring the urodynamics of the upper urinary tract allows you to quickly restore the tone, contractility and evacuation ability of the upper urinary tract, which significantly reduces the number of possible postoperative complications associated with impaired urodynamics. The method is less traumatic and can significantly reduce the time of treatment and rehabilitation of patients.

Sources of information

1. AC SU 1725920, A1, BI from 04.15.92 (prototype).

2. Ed. Utyamysheva RI, Vrany M. Electronic equipment for stimulation of organs and tissues. Moscow .: Energoatomizdat - 1983.p-310.

3. Pekarsky V.V., Agafonnikov V.F., Dambaev G.Ts., Popov O.S., Martusevich A.G. Autonomous electrical stimulators of the human and animal body. Tomsk - 1995.p-25, p. 8.

4. Bakunts S.A., Muradyan K.M. On the effect of electrical stimulation on the function of the ureters. // Journal of Experimental and Clinical Medicine. Volume XVII, No. 6 1977. pp. 9-10.

5. Bakunts S.A. Physiology of the ureters. Leningrad - 1970.p-42, p.27.

6. Bogomolov V.M., Ponomarenko G.N. General physiotherapy. Moscow - St. Petersburg, 1997. p. 96, p. 33.

Claims (2)

1. A method for restoring the urodynamics of the upper urinary tract, including stimulation of the ureter by sequentially transmitting an impulse to contact surfaces isolated from each other, characterized in that during the operation, a multi-contact electrode-catheter is laid and fixed directly along the ureter, the free end of which is brought out together with a drainage tube, and electrical stimulation begins from the first day after the operation and is carried out twice a day for 5-10 minutes with pauses between sessions of impulses 5-10 ms in duration, with a repetition period of 20-30 ms, grouped in a pack of 0.3-0.6 s in duration and a repetition frequency of 0.3-0.4 Hz, with a pulse voltage of 2-4 V, current in a pulse of 2-4 mA, the delay time for the supply of pulses between adjacent pairs of contact surfaces 1-3 s. 2. The method according to claim 1, characterized in that the pauses between sessions are 1.5-2 hours, and the sessions are carried out for 3-8 days.

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