RU2294156C1 - Method for surgical therapy of urinary bladder's cancer - Google Patents

Abstract

FIELD: medicine, oncology.

SUBSTANCE: the present innovation deals with orthotopic plasty of urinary bladder after cystectomy. It is necessary to carry out cystectomy, cut a flap out of gastric body due to resecting greater curvature, suture in gastric defect, transpose the flap obtained into small pelvis to form an urinary reservoir and implant ureters into it; then the reservoir should be anastomosed with urethra, moreover, the flap should be cut out by resecting greater curvature of stomach together with adjacent departments of its anterior and posterior wall from cardial gastric department up to pyloric one at about 5-7 cm against pyloric sphincter. Flap's length corresponds to 20 cm, not less. Transplant should be descended into small pelvis so, that greater curvature to be the posterior wall of the reservoir formed. It is important to fix reservoir's mesentery towards parietal peritoneum., Inferior third of the flap should be folded upwards to suture its edges with those of the middle third of the transplant. One should finish the formation of closed reservoir of spherical shape due to suturing in the remained defect so, that all the lines of sutures to be at anterior wall of the reservoir developed being as an "inverted" letter "Y". In distal part of the cupula of the developed reservoir one should form a separate foramen being beyond the area of sutures to use it for applying reservoir-urethral anastomosis. The innovation enables to develop spherical low-pressure urinary reservoir that decreases the risk of vesico-ureteral reflux, frequency of urination and enuresis.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, more specifically to oncourology, and may find application in orthotopic cystoplasty of the bladder (MP) after cystectomy.

For muscle-invasive cancer of the bladder (RMP) or for high-grade rapidly recurring surface tumors that do not allow organ-preserving treatment, cystectomy is performed.

The main problem that has to be solved after radical cystectomy is the method of urine diversion. The success of reconstructive operations is determined, first of all, by the degree of retention of urine and the achievement by patients of social adaptation, therefore, the continental methods of urine diversion are considered the most optimal.

Currently, various sections of the gastrointestinal tract are used for derivation of urine, but anal diversion of the urine through the rectum, the creation of a rectosigmoid reservoir, as well as catheterized heterotopic conduits from the small intestine are most popular. Preference is given to orthotopic reconstruction of the bladder from the ileum and sigmoid colon, ileocecal segment and stomach, in which the patient is able to retain urine and self-urinate through the urethra.

Absolute contraindications to the creation of orthotopic MP is a tumor lesion of the neck of the bladder, urethral mucosa, as well as the presence of distant metastases. Relative contraindications recognized chronic renal failure and hydroureteronephrosis.

Due to significant problems arising from the use of intestinal segments associated with mucus formation, urine infection, stone formation, and metabolic acidosis, complete replacement of the bladder by the stomach was first proposed in 1953 in 5 dogs. According to the researchers, the gastric mucosa does not have absorption ability, has poor mucus formation, secretes chlorides, which prevent and eliminate metabolic acidosis; due to the acidic environment and lysozyme, it has bactericidal properties, and the presence of a powerful muscle wall makes it possible to create a sphincter that holds urine. In addition, the remaining part of the stomach completely restores its size and motor-evacuation function. The surgical technique consisted of a median laparotomy and longitudinal resection of most of the bottom and body of the stomach without slight curvature. Blood supply was carried out due to the right and left gastrointestinal vessels. The ureters were passed through the wall of the gastric segment and fixed to its mucosa [Sinaiko E.S. et al., Amer. J. Physiol. - 1954. - Vol. 179. - P.3]. In 1957-58 E.S.Sinaiko first performed heterotopic gastrocystoplasty in 2 patients suffering from bladder cancer complicated by hydroureteronephrosis. The segment of the stomach was cut out from its great curvature and was supplied by a.gastroepyploica dexstra.

Known orthotopic replacement of the bladder with the antrum-pyloric stomach, which later became known as antral gastrocystoplasty.

M.C.Adams et al. [Y.Urol. - 1988. - V.140. - P.1152-1156] performed orthotopic reconstruction of the MP with part of the stomach in 3 children. In all cases, a wedge-shaped segment of the middle part of the greater curvature of the stomach was used, which was supplied with blood by the right gastro-omental gland. The flap resection was carried out, not reaching the slight curvature in order to avoid vagotomy. The gastric transplant was displaced into the small pelvis through the holes in the mesentery of the transverse colon and small intestine. Its edges were sutured, and the distal part of the formed reservoir was sutured to the remaining part of the urethra. The ureters were implanted into the reservoir end to side. This allowed for natural urination.

To increase the capacity of the gastric reservoir and reduce intracavitary pressure, a dissection of its serous-muscular membrane in mutually perpendicular directions is proposed [Hauri D., J. Urol - 1996. - Vol.156 - P.931-935].

Currently, the creation of an artifactal bladder from the stomach is considered as an alternative to ileocystoplasty. Gastrocystoplasty is indicated for patients with chronic renal failure complicated by metabolic acidosis; the inability to use a portion of the intestine with a short mesentery; chronic and surgical bowel diseases; irradiation of the pelvic organs. Absolute contraindications are diseases of the stomach and duodenum, previously operated stomach. Relatives include a small volume of the stomach, a short right gastro-omental artery, infection of the stomach with Helicobacter pylory.

Currently, antrum, greater curvature and the body of the stomach are used for orthotopic gastrocystoplasty. As a vascular pedicle, take the right, left or both gastrosalic arteries.

Closest to the proposed method is the formation of the bladder after cystectomy for cancer MP according to the patent of the Russian Federation No. 2204951, MKI A 61 B 17/00.

The method consists in a cystectomy with the formation of an orthotopic urinary reservoir with a graft from the body of the stomach on the feeding vascular pedicle, transplantation of the graft into the pelvis and creating a reservoir from it by suturing the edges of the flap with each other, followed by implantation of the ureters in the created reservoir and anastomosis with the urethra. In this case, the flap is cut out so that the base of the trapezoid is on a large curvature, the side opposite to the base is on a small curvature, and this side is located between the angle of the stomach and the left gastric artery 1-2 cm distal to its branch.

This method has a number of positive properties, namely:

- Allows you to form a reservoir in cases where the use of intestines for these purposes is excluded,

- Minor mucus formation due to the characteristics of gastric secretion,

- Reducing the risk of infectious and inflammatory complications due to the secretion of hydrochloric acid and lysozyme in gastric secretion,

- The minimum risk of intestinal paresis in the postoperative period.

However, despite the positive aspects of the method, it has a serious drawback: the lack of a spherical shape of the created reservoir can lead to critical fluctuations in intra-reservoir pressure, increasing the risk of vesicoureteral reflux, as well as the frequency of urination and enuresis.

The technical result of the present invention is to reduce the risk of vesicoureteral reflux, urination frequency and enuresis by creating a spherical reservoir of low pressure and sufficient capacity.

This result is achieved by the fact that in the known method for the surgical treatment of bladder cancer, including cystectomy, cutting out a flap from the body of the stomach on the feeding vascular leg by resection of the greater curvature of the stomach, suturing the stomach defect, transposition of the flap into the small pelvis, the formation of the urinary reservoir from it, implantation of ureters in it "end-to-side" and anastomosis with the urethra, according to the invention, the flap is cut out, resecting the greater curvature of the stomach with adjacent sections of the anterior and its posterior wall from the cardial part of the stomach to the pyloric, departing from the pyloric sphincter 5-7 cm, while the length of the flap is at least 20 cm, and the distance from the greater curvature to its dome is 7-8 cm, the resulting transplant is reduced into a small pelvis so so that the greater curvature is the back wall of the formed reservoir, the mesentery of the reservoir is fixed to the parietal peritoneum, after which the lower third of the flap is folded upwards and the edges are sutured with the edges of the middle third of the graft, and the formation of a closed reser a spherical-shaped wooar by suturing the remaining defect so that all the seam lines are located on the front wall of the formed reservoir and are a view of the inverted letter Y, then a separate hole is formed in the distal part of the dome of the formed reservoir outside the suture zone and used to apply a reservoir-urethral anastomosis.

Lowering the flap cut from the body of the stomach into the small pelvis in such a way that the greater curvature is located on the back wall of the formed reservoir, and fixing its mesentery to the parietal peritoneum, allow the flap to be reconfigured with the creation of a spherical reservoir and provide its natural stable position in the small pelvis. And cutting the flap along the greater curvature of the stomach body with a length of at least 20 cm and a height of 7-8 cm to the dome makes it possible to bend the lower third upwards to lower it to the edges of the middle third of the graft after lowering it into the small pelvis. With this closure of the flap, a Y-shaped seam is formed, which ensures the creation of a spherical reservoir of low pressure and sufficient capacity, which reduces the risk of developing vesicoureteral reflux, the frequency of urination and enuresis, and also reduces the possibility of pyelonephritis and progression of renal failure.

The location of all sutures on the front wall of the formed reservoir simplifies the subsequent implantation of the ureters through separate openings in the reservoir of the end-to-side type.

Filling the urethral opening in the distal part of the reservoir and forming the urethral reservoir anastomosis outside the suture zone avoids angulation at the site of the anastomosis and significantly reduces the risk of scarring.

The essence of the method is illustrated by example.

Example.

Patient P., 53 years old, No. I / b 35041-s / o, was hospitalized on a planned basis on December 5, 2004, in the urology department of the city multidisciplinary hospital (GMDB) No. 2 (S-Pb) with complaints of a periodic admixture of blood in the urine with clots and difficulty urinating for 2 months.

Upon admission, the patient's condition is satisfactory, clear consciousness, skin integument of usual color, peripheral lymph nodes are not enlarged, no edema. Hemodynamic parameters within normal limits, blood pressure 130/80 mm Hg On palpation - internal organs without features. Urination is difficult, urine mixed with blood. In the department the patient performed:

Electrocardiogram: sinus rhythm, heart rate (HR) 72 beats / min., Horizontal position of the electrical axis of the heart. Left ventricular hypertrophy.

Fluorography - without pathological changes.

Computed tomography of the bladder: a bladder of sufficient volume, a 54 × 46 mm volume pathological formation is visualized on the right side wall, the wall of the bladder in the base area is thickened. Lymph nodes of the pelvis are not changed.

Ultrasound examination: abdominal organs without pathology, no metastases. The kidneys are unchanged. The bladder contains 200 ml of urine; in the projection of the right side wall, a hyperechoic tissue formation of 57 × 53 mm is visualized. The prostate gland is not enlarged, dimensions 32 × 35 × 33 mm.

Cystoscopy: along the right contour, 2 cm away from the neck of the bladder, a tumor formation is visualized on a wide base with a diameter of about 5 cm, protruding into the lumen of the bladder.

Blood test: Lake. - 5.3 × 10/9, erythro. - 4.6 × 10/12, hemoglobin - 164 g / l, platelets - 230 thousand, lymphocytes - 32, monocytes - 7, neutrophils - 65, stab stabs - 4, eosinophils - 2, basophils - 1, ALT - 33 mmol / l, AST - 29 mmol / l, total protein - 69 g / l, urea - 8.5 mmol / l, creatinine - 0.148 mmol / l, total bilirubin. - 6.2 μmol / L, glucose - 4.3 mmol / L, prothrombin - 103%.

Urinalysis: light yellow, slightly turbid, specific gravity 1017, acid reaction, protein 0.015 g / l, white blood cells 8-10 in n / a, red blood cells 20-30 in n / a, flat epithelium 0-1-2 in s / sp., mucus ++. Urine cultures did not give rise.

TUR (transurethral resection) bladder biopsy is a highly differentiated transitional cell carcinoma of the bladder with signs of invasion of the muscle layer. The histological conclusion No. 183429-22 of 12.12.04: highly differentiated transitional cell carcinoma of the bladder with invasion of the muscle layer, without signs of metastasis to the lymph nodes.

Given the presence of muscle-invasive cancer, renal failure, but the absence of severe somatic diseases, it was decided to perform a cystectomy with the formation of an orthotopic urinary reservoir part of the stomach. For this, fibrogastroscopy was performed previously to the patient - no deviations from the stomach and duodenum were detected, the size of the stomach made it possible to cut out a flap of sufficient size from it to form a urinary reservoir from it.

12/13/04, the patient was taken for surgery. Under endotracheal anesthesia and spinal anesthesia, a laparotomy was performed. The ureters are isolated in the lower third to the juxtavesical section, cut off from the bladder and intubated. The bladder with phased hemostasis is extraperitonized, isolated with paravesical tissue (the prostate and seminal vesicles are preserved) and cut off at the base of the prostate. Performed pelvic lymphadenectomy.

After opening the stuffing bag, the stomach was mobilized and the vascular leg of the graft was formed by ligation and intersection of the vascular trunks going from the right gastrointestinal arteries and veins to the pyloric section of the stomach. Then, a hemispherical resection of the stomach was made along a large curvature between the cardial and pyloric sections with adjacent sections of the anterior and posterior wall of the stomach 22 cm long and from a large curvature to the dome of the flap 8 cm high, as a result of which part of his body became isolated and mobile. Nasogastric and nasojejunal probes were installed and the remaining part of the stomach was sutured in the transverse direction with a two-row vikrilovy seam. The gastric transplant is carried out through the mesocolon and mesentery of the ileum into the pelvic cavity so that the greater curvature becomes the posterior wall of the formed reservoir. The mesentery of the reservoir is fixed to the parietal peritoneum. Then the lower 1/3 of the flap, having a triangular shape, is bent up and connected with the edges of its middle 1/3 with 2 continuous seams, as shown in Fig. 1. When suturing the remaining defect, all seam lines were placed on the front wall of the reservoir in the form of an inverted letter Y. In the distal part of the formed dome, a special hole was made for the anastomosis with the urethra and a reservoir-urethral anastomosis was made (Fig. 2). The ureters are intubated and implanted into the wall of the tank by the type of "end to side". One ureter intubator is removed through the urethra, the opposite ureter is drained by an internal stent. Drainages are installed in the pelvic cavity on both sides, and drainage to the stuffing box has been installed. The wound is sutured in layers. In the postoperative period, antibiotic therapy, infusion and detoxification therapy were carried out. The postoperative period was uneventful, the ureteral intubator was removed on the 12th day, the urethral catheter and ureteral stent on the 14th. Independent urination was restored, the patient did not notice any urine leakage, he got up at night after 2 hours. Before discharge, intravenous urography was performed: renal function was satisfactory, abdominal renal system and ureters were not expanded (Fig. 3). According to the results of a downward cystography - a spherical reservoir with a volume of 300 ml (figure 4). When mixing cystography data for vesicoureteral reflux was not obtained. Blood test: White blood cells - 7.2 10/9, red blood cells - 4.3-10 / 12, hemoglobin 127 g / l, platelets 327 thousand, lymphocytes 34, monocytes 11, neutrophils 52, p / 6, s / nuclear 40, eosinophils 5, basophils 0, ALT 28 mmol / L, ACT 27 mmol / L, total protein 68 g / L, creatinine 0.86 μmol / L, glucose 4.4 mmol / L.

Urinalysis: light yellow, cloudy, beats. weight 1019, neutral reaction, protein 0.018, white blood cells 15-20 in n / a., flat epithelium 0-2 in n / a., mucus +.

December 28, 2004 the patient in satisfactory condition was discharged under the supervision of an oncourologist at the place of residence. Dynamic observation is recommended, 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, pyelocaliceal systems are not expanded. The bladder on the cystogram is rounded, there is no vesicoureteral reflux. The volume of the tank is 500 ml. With uroflowmetry, the maximum urination rate is 19 ml / s, the average is 12.3. With cystometry, the intravesical pressure at the first urge to urinate is 20 cm water column, the maximum is 41 cm water column. The patient does not note day and night enuresis. The frequency of urination in the daytime does not exceed 8 times, at night it rises to urinate no more than 1 time.

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

To date, 3 surgical interventions have been carried out with the formation in all cases of an orthotopic bladder by the proposed method after cystectomy for RMP.

The proposed method in comparison with the known has several significant advantages, namely:

1. Reduces the risk of vesicoureteral reflux, the frequency of urination and enuresis by creating a spherical reservoir of low pressure and sufficient volume. The exclusion of reflux, respectively, reduces the possibility of pyelonephritis and the progression of renal failure.

2. Reduces the possibility of infectious and inflammatory complications, mucus formation, which is due to the characteristics of the gastric reservoir.

3. Avoids angulation at the site of the anastomosis, and also reduces the risk of scarring due to the formation of a reservoir-urethral anastomosis outside the suture zone, in the area of the base of the neocystis.

The method was developed in the Department of Urology of the city multidisciplinary hospital No. 2 of St. Petersburg and underwent clinical testing of 3 patients with positive results.

Claims (1)

A method for the surgical treatment of bladder cancer, including cystectomy, cutting a flap from the body of the stomach on the feeding vascular pedicle by resection of the greater curvature of the stomach, suturing the defect in the stomach, transposing the flap into the pelvis, forming a urinary reservoir from it, implanting the ureters and anastomosing it with urethra , characterized in that the flap is cut out, resecting the greater curvature of the stomach with adjacent sections of its front and back walls from the cardial section of the stomach to the pyloric, dull from the pyloric sphincter 5-7 cm, while the flap length is at least 20 cm, the resulting graft is lowered into the small pelvis so that the greater curvature is the back wall of the formed reservoir, the mesentery of the reservoir is fixed to the parietal peritoneum, after which the lower third of the flap is folded upward and stitch its edges with the edges of the middle third of the graft, complete the formation of a closed reservoir of a spherical shape by suturing the remaining defect so that all the seam lines are located on the front wall of the th e vessel, and is a view of an inverted Y, then in the distal part of the dome formed by a separate reservoir forming hole outside the seams and use it for superposition of reservoir-urethral anastomosis.

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