RU2279254C2 - Method for orthotopic intestinal plasty of urinary bladder - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: the present innovation deals with urinary bladder's plasty after its removal. It is necessary to develop a U-shaped intestinal reservoir out of ileal transplant, dissect the transplant along counter-mesenteric edge. In the triangle obtained one should bend a long arm along the middle and connect the edges to suture it from mucosal side with uninterrupted suture. Then it is necessary to coincide opposite long sides to obtain reservoir of U-shaped form. Then one should coincide and suture transplant's edges for the length of about 4-5 cm, anastomose ureters with a reservoir under development, form an urethral tube. Moreover, it is necessary to replace urethrally transplant's inferior lip, connect superior lip and two points of inferior one with triangular suture, form an urethral tube out of the fragment developed, introduce a Foley catheter into through urethra into the transplant and withdraw ureter devices in reverse direction, anastomose urethral tube and urethra, coincide transplant's edges with adapting suture. The innovation enables to prevent the failure of anastomosis between reservoir and urethra.

EFFECT: higher efficiency.

1 ex, 1 tbl

Description

The invention relates to the field of medicine for urology, in particular to methods for orthotopic intestinal plastic surgery of the bladder and can be used after operations to remove the bladder.

Known methods of orthotopic plastics aimed at diverting urine into the intestine date back to the mid-19th century. In 1852, Simon diverted urine from a patient with bladder exstrophy, moving the ureters to the rectum, thereby securing urine retention using the anal sphincter. Until 1950, this method of urine diversion was considered the leading one, for patients who required urinary diversion with retention. In 1886, Bardenheüer developed a technique and technique for partial and total cystectomy [1; 2; 3]. A known method of ureteroileocutaneostomy (Bricker) is the removal of urine on the skin through a mobilized fragment of the ileum. For a long time, this operation was the gold standard for urine diversion after radical operations on the bladder, but the solution to this problem is far from being resolved to date. The bladder removal method should result in the formation of a well-functioning urinary reservoir [4; 5; 3]. Otherwise, a number of complications associated with urinary incontinence develop, leading to a deterioration in the patient's quality of life.

Closest to the proposed method for technical implementation is a method of forming a U-shaped reservoir of low pressure from a fragment of the ileum, performed after radical cystectomy, including radical cystectomy, forming a reservoir of U-shaped from 60 cm of the terminal ileum after detubulation and reconfiguration of the intestinal transplant forming a hole at the lowest point of the graft to form an anastomosis between the stump of the urethra and the formed intestinal transp lanthate. However, in the case of destruction due to the severe pathological condition of the anatomical formations responsible for the retention of urine, complications of urinary incontinence are observed during the formation of the reservoir by this technique. Since one of the difficult stages of the operation, taking into account the anatomical features of the location of the urethra, is the formation of an anastomosis between the reservoir and the urethra, failure of the anastomosis leads to leakage of urine in the early postoperative period and the development of stricture of the enterocystourethral anastomosis in the late postoperative period [5], Table 1.

A new technical task is the prevention of intraoperative, postoperative complications and improving the quality of life of patients after operations related to the removal of the bladder.

The problem is solved by a new method of orthotopic intestinal plasty of the bladder, which consists in the formation of a U-shaped intestinal reservoir of low pressure from a graft of the terminal ileum and a channel for urine diversion, the channel being a urethral tube 5 cm long, which is formed from the distal lip of the intestinal reservoir for which they move the lower lip of the transplant towards the urethra and connect it to the upper lip at two points of its lower lip with an angular suture, forming a flap, with the edges of which the urethral tube is formed by a single-row serous-muscular suture, after which the mucosa of its distal end is turned out and fixed with separate sutures to the serous membrane of the graft, after which a three-way Foley catheter is passed through the urethra and the formed urethral tube, and out of the intestinal reservoir in the opposite direction external ureteral stents, then anastomose with 4-6 ligatures at 2, 4, 6, 8, 10, 12 hours, then the edges of the right and left knees of the graft are compared with adaptive L-shaped sutures, after which the front wall of the intestinal reservoir is fixed to the stumps of the pubic-cystic, pubic-prostatic ligaments or to the periosteum of the pubic with separate sutures from non-absorbable suture.

The method is carried out in the following way.

The operation is performed under endotracheal anesthesia. Median laparotomy, perform a typical radical cystectomy and lymphadenectomy. If the conditions for radical operation allow, preserve the neurovascular bundles, the ligamentous apparatus of the urethra, and the external striated sphincter. Mobilization of 60 cm of the terminal ileum is performed, retreating 20-25 cm from the ileocecal angle (Figure 1). With a sufficient length of the mesentery, as a rule, it is enough to cross the artery of the arcade vessels closest to the intestinal wall, but at the same time try to maintain direct vessels, while dissecting the mesentery to a length of 10 cm, which is sufficient for further actions. The free abdominal cavity is delimited from the possible ingestion of intestinal contents with 4 gauze napkins. Cross the intestinal wall at a right angle with preliminary ligation of the vessels of the submucosal layer. Gastrointestinal tract patency is restored by applying an inter-intestinal anastomosis between the proximal and distal ends of the intestine - end-to-end double-row nodal suture, so that the formed anastomosis is above the mesentery of a mobilized intestinal transplant. The proximal end of the graft is clamped with a soft clip and a silicone probe is inserted into the intestinal lumen, through which a warm 3% solution of boric acid is injected to remove intestinal contents. After that, release the proximal end of the graft from the clamp and straighten it evenly on the probe. Intestinal transplant is strictly scissored along the mesenteric edge with scissors. A rectangle having two short and two long shoulders is obtained from a fragment of the intestine. On one of the long shoulders, a point is strictly allocated in the middle, around which the long shoulder is bent, the edges are combined and from the mucosa side a continuous through, twisting (according to Reverden) suture is sutured (Figure 2). Opposite long sides are then combined so that a tubular U-shaped reservoir is obtained. This stage is the main in this method and it consists of a series of actions. The first action consists in matching and suturing for 4-5 cm the edges of the right and left knees of the resulting graft (Figure 3). The second action is the anastomosis of the ureters with an intestinal reservoir with antireflux protection on the ureteric external stents (Figure 4). The third action consists in the formation of the urethral tube by moving the lower lip of the graft towards the urethra, connecting the upper lip and two points of the lower lip of the graft with an angular suture, so that a flap is formed (Figure 5; 6), by suturing the edges of which the urethral tube is formed by a single-row interrupted suture. 5 cm long, the mucosa of the distal end of the tube is turned out and fixed with separate sutures to the serous membrane of the graft (Fig. 7). A three-way Foley catheter is passed through the urethra and the formed urethral tube into the graft, and external ureteric stents are removed from the reservoir in the opposite direction. The fourth action consists (in the application of an anastomosis) in the anastomosis of the urethral tube with the urethra, which is performed by 4-6 ligatures on 2; four; 6; 8; 10 and 12 hours of the conditional dial. The fifth action is to compare the edges of the right and left knees of the intestinal transplant to a triangular suture, given that the lower lip is shorter than the upper one, matching is done with adaptive knotted L-shaped sutures (Fig. 8). Sixth action - to prevent possible transplant displacement and deformation of the urethral tube with separate sutures from a non-absorbable suture, the front wall of the reservoir is fixed to the stumps of the pubic-cystic, pubic-prostatic ligaments or to the periosteum of the pubic bones. The dimensions and shape of the graft are generally shown in FIG. 9.

Justification of the method.

The main criteria for the surgical technique of radical cystectomy, under which the probability of urinary incontinence after the formation of the intestinal reservoir is minimal, is the maximum possible preservation of the anatomical formations of the urethra and neurovascular complexes. However, in a number of cases: with locally common forms of tumor lesions of the bladder, after previously undergoing surgical interventions on the pelvic organs, after radiation therapy of the pelvis, preservation of these formations becomes an impossible task, therefore, the likelihood of urinary incontinence increases significantly. In addition, one of the difficult stages of the operation, given the anatomical features of the location of the urethra, is the formation of an anastomosis between the reservoir and the urethra. Anastomotic failure leads to early urine leakage and the development of stricture of enterocystourethral anastomosis in the late postoperative period. The reduction of these complications is possible in the case of favorable conditions for the formation of anastomosis, which are created during the formation of the urethral tube. The formed reservoir does not interfere with the passage and tightening of the ligatures from the formed tube. The formation of the urethral tube from the graft wall allows you to maintain adequate blood circulation in the wall of the urethral tube, and also to prevent possible transplant displacement and deformation of the urethral tube, it is fixed with separate sutures from a non-absorbable suture to the anterior wall of the reservoir to the stumps of the pubic, pubic-prostatic ligaments or to the periosteum pubic bones. The result is a triple urine retention mechanism.

Example: Patient A., 43 years old. I went to the urology department in the order of planned care with a diagnosis of bladder cancer, the condition after combined treatment. In the patient’s history at the time of admission, the diagnosis was established 6 years ago. During the follow-up, the following operations were performed: resection of the bladder and two times TUR of a tumor of the bladder. Two courses of systemic and intravesical chemotherapy, one course of remote radiation therapy. At the time of admission, clinically shriveled (effective bladder volume not more than 50 ml), severe pain, urinary frequency up to 25 times a day. The diagnosis is histologically confirmed. Conducted instrumental examination methods: ultrasound of the abdominal organs, CT of the pelvic organs, isotope osteoscintigraphy, chest x-ray - data for distant metastases were not received. Given the relapse of the disease, the changes that developed in the bladder, which significantly worsened the quality of life of the patient, it was decided to perform a radical operation. However, given the nature of the developed complications, it was decided to perform a two-stage treatment option. The first step is to perform a radical cystectomy with ureterocutaneostomy, and the second step is an orthotopic intestinal plasty of the bladder. The first stage of the operation was performed without serious complications; after a three-month rehabilitation, the patient underwent orthotopic plastic surgery of the bladder. Given that during the first stage of the operation, there was no possibility of preserving the neurovascular bundles and the external striated sphincter and urethral ligamentous apparatus, the option of forming the intestinal reservoir with an additional urine retention mechanism, the U-shaped low-pressure reservoir with the formation of the urethral, was chosen as the plastic option. tube. The operation was performed without technical difficulties, without complications in the early postoperative period. The ureteral catheters were removed on the 10th day, and the urethral catheter on the 21st day. Up to 3 months after surgery, bedwetting continued (at the same time that the patient strictly complied with all the recommendations). Subsequently, adequate urination was restored. The patient returned to his previous job. During the staged examination after 12 months, an intestinal reservoir capacity of up to 400 ml was reached at a maximum urine flow rate of 20 ml / s (Figure 10). When conducting retrograde urethrography, a typical structure of the urinary reservoir is noted (Fig. 11; 12).

This method of treatment was used in 5 patients, all men. The average age was 55.6 years (from 48 to 66). Three patients were operated in a multistep manner, and two patients underwent surgery in one step. The duration of observation reaches 18 months. In all patients, urine retention day and night. One patient, 66 years old, up to 4 months after surgery, could not completely empty the reservoir, which required regular catheterization of the urinary reservoir, and subsequent independent adequate urination was restored. One patient, 53 years old, 6 months after surgery developed a stricture of the vesicourethral anastomosis. This complication was eliminated by optical urethrotomy. The most common complication is erectile dysfunction, observed in 4 patients.

Thus, the proposed method can be successfully used in a contingent of patients suffering from lesions of the bladder requiring a radical operation, during which it is not possible to preserve the anatomical structures responsible for urine retention, options for orthotopic plastic surgery of the bladder with additional urinary retention mechanisms are shown, one of which is the formation of the urethral tube according to the proposed method.

Table 1 The list of complications after the formation of urinary reservoirs from various sections of the gastrointestinal tract (excluding cardiovascular and pulmonary complications) R P one Urine leakage 2-14% 2 Urinary incontinence 0-14% 3 Intestinal failure 0-3% four Sepsis 0-3% 0-3% 5 Acute pyelonephritis 3% eighteen% 6 Wound infection 7% 2% 7 Wound event 3-7% 8 Gastrointestinal bleeding 2% 9 Abscess 2% 10 Intestinal obstruction 6% eleven Intestinal bleeding 2% 10% 12 Intestinal obstruction 3% 5% 13 Ureteral obstruction 2% 6% fourteen Parastomal hernia 2% fifteen Entero-ureteric anastomosis stenosis 6% 6-17% 16 Entero-urethral anastomosis stenosis 2-6% 17 Stone formation 7% eighteen Overstretching of the tank 9% 19 Metabolic acidosis 13% twenty Reservoir necrosis 2% 21 Volvulus 7% 22 Reservoir stenosis 3% 23 Intestinal fistula <1% 24 External intestinal fistula 2% 2%

Literature

1. Matveev B.P., Figurin K.M., Koryakin O.B. Bladder cancer Moscow. Verdana, 2001.

2. Kucera J. Blasenersatz - operationen. Urologische operationslehre. Lieferung 2. 1969; 65-112.

3. Julio M. Pow-Sang, MD, Evangelos Spyropoulos, MD, PhD, Mohammed Helal, MD, and Jorge Lockhart, MD Bladder Replacement and Urinary Diversion After Radical Cystectomy Cancer Control Journal, Vol. 3, No. 6.

4. Matveev B.P., Figurin K.M., Koryakin O.B. Bladder cancer Moscow. Verdana, 2001.

5. Hinman F. Operational urology. M. "GEOTAR-MED", 2001 (prototype).

Claims (1)

A method of orthotopic intestinal bladder plasty, comprising forming a U-shaped low pressure intestinal reservoir from a transplant of the terminal ileum and a urine drainage duct, characterized in that the intestinal transplant is dissected along the mesenteric edge to form a reservoir, producing a rectangle having two short and two long shoulders, on one of the long shoulders in the middle there is a point around which the long shoulder is bent, the edges are combined and from the side of the mucosa continuous They are sutured with a portable, twisted seam, then the opposite long sides are combined so that a tubular reservoir of a U-shape is obtained, the edges of the graft knees are compared and sutured for 4-5 cm, the ureters anastomose with the formed reservoir with antireflux protection on the ureter external stents, then form the urethral tube, for which the lower lip of the graft is moved towards the urethra, the upper lip and two points of the lower lip of the graft are connected with a triangular seam so that a flap is formed by means of a stitch the edges of which the urethral tube is 5 cm long is formed by a single-row nodal suture, then the mucosa of the distal end of the tube is turned out and fixed with separate sutures to the serous membrane of the graft, a three-way Foley catheter is passed through the urethra and the formed urethral tube, the external ureteric stents are removed, the ureteric stents are removed in the opposite direction, anastomose the urethral tube with the urethra with 6 ligatures of 2; four; 6; 8; At 10 and 12 o’clock of the conditional dial, the edges of the graft are compared to a triangular suture, taking into account that the lower lip is shorter than the upper one, the matching is done with adaptive nodal L-shaped sutures and then the front wall of the intestinal reservoir is fixed to the stumps of the pubic-cystic, pubic-prostatic ligaments or periosteum of pubic bones.

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