RU2332933C1 - Method of surgical treatment of bladder cancer in women - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: bladder with paravesical pacefollower is removed. Prior to cystectomy the urethra is ablated endoscopically by an electro resectoscope loop at 0.5-0.7 cm distally from the bladder.

EFFECT: averting relapses of the disease; improving postsurgical continention and reducing time of surgery.

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Description

The invention relates to medicine, in particular to oncology, and may find application in the surgical treatment of bladder cancer in women.

Radical cystectomy is performed for invasive muscle cancer of the bladder, superficially low-grade (T ₁ G ₃ ) cancer of the bladder, cancer in situ, not amenable to intravesical BCG therapy, multiple lesions of the bladder, which do not allow organ-preserving treatment.

In women, the standard volume of radical cystectomy is removal of the bladder with paravesical tissue, visceral peritoneum, uterus, fallopian tubes, anterior vaginal wall, urethra, and bilateral pelvic lymphadenectomy. A similar volume of surgical intervention is also called anterior extententration (Stenzl A., Nagele U., Kuczyk M., Sievert KD., Anastasiadis A., Seibold J., Corvin S. Cystectomy - technical considerations in male and female patients // Eur. Urol . Update Series - 2005. - Vol.3. - issue 3. - P.138-146).

The proximal urethra along with the external sphincter, the functional consistency of the muscles and fascia of the pelvic floor play the main role in the retention of urine in women.

Violation of the integrity of one of these structures can lead to the most painful complication - urinary incontinence - when performing orthotopic reconstruction of a new bladder from the small or large intestine. Therefore, any kind of traction during bladder removal should be excluded (Colleselli K., Stenzl A., Eder R., Strasser N., Poisel S., Bartsch G. The female urethral sphincter: a morphological and topographical study // J. Urol. - 1998. - Vol. 160. - P. 49-54).

After pelvic lymphadenectomy, ligation and crossing of the ureters, the ovarian leg is ligated and crossed at the next stage. The feasibility of ovarian removal in young women is disputed by many experts (Stein JP, Stenzl A., Grossfeld GD, Freeman JA, Esrig D., Boyd SD, Lieskovsky G., Bartsch G., Skinner DG The use of orthotopic neobladder in women undergoing cystectomy for pelvic malignancy // World J. Urop. - 1966 - Vol.14 - P.9-14; Stenzl A., Colleselli K., Bartsch G. Update of urethra-sparing approaches in cystectomy in women // World J. Urop. - 1967 - Vol.15 - P.134-138).

The uterus is pulled up, which is facilitated by preliminary flashing its top with a thick silk ligature. At the neck, a large Fedorov clamp is superimposed. The peritoneum on both sides of the bladder carefully peels down to the Douglas space.

Following this, round uterine ligaments intersect on both sides. Both bordering lines are connected by a transverse section of the peritoneum enveloping the cervix in the douglas space so that the peritoneal cover remains on the bladder and uterus. The next stage involves the intersection and ligation of the vessels of the uterus, ureters and lateral bundles of arteries represented by the superior cystic. Then, the pelvic fascia is exposed on both sides, and the vagina below portio vaginalis uteri is transversely opened with a scalpel.

The front wall of the vagina with two parallel incisions is cut longitudinally along the urethra towards the pelvic floor. The urethra is separated from the pubic symphysis. The final step is a circular cut-off of the vaginal wall with the external opening of the urethra. A single block removes the complex of the pelvic organs, consisting of the bladder, ovaries, tubes, uterus, urethra and the anterior wall of the vagina. The vaginal wound is sutured with a continuous suture using the remaining lower wall. The lumen of the absent urethra in the pelvic floor is sutured with non-absorbable suture material. A tampon is left in the vagina for 48 hours (Stenzl A., Nagele U., Kuczyk M., Sievert KD., Anastasiadis A., Seibold J., Corvin S. Cystectomy - technical considerations in male and female patients // Eur. Urol. Update Series - 2005. - Vol.3. - issue 3. - P.138-146).

Smooth muscle fibers of the outer and inner layer innervated by the autonomic nervous system are present along the entire length of the urethra. Autonomous nerve fibers innervating the smooth muscle of the urethral sphincter originate from the pelvic (hypogastric) plexus (Strasser N., Ninkovic M., Hess M., Bartsch G., Stenzel A. Anatomic and functional studies of the male and female urethral sphincter // World J. UroL - 2000. - Vol.18.- No. 5. - P.324-9; Baader B., Baader SL., Herrmann M., Stenzl A. Autonomic innervation of the female pelvis. Anatomic basis // Urologe A. - 2004. - Vol. 43. - No. 2. - P.133-40). The innervation of the volitional sphincter system is most likely carried out by the branches of n.pudendus (Gosling JA., Dixon JS., Critchley HO., Thompson SA. A comparative study of the human external sphincter and periurethral levator ani muscles // Br. J. Urol. - 1981 . - Vol.53. - No. 1. - P.35-41), although it is also believed that the fibers of the autonomic nervous system (Donker P., Droes J., Van Ulden B. Anatomy of the musculature and innervation of the bladder and the urethra. In: Chisholm G, editor. Scientific Foundations of Urology. London: Heinemann; 1976. p.3232). Nerve fibers originating from the pelvic plexus are located dorsolaterally from the rectum, pass the lower third of the ureter dorsally, then downward from the lateral vesicle and along the lateral walls of the vagina approach the neck of the bladder and urethra (Colleselli K., Stenzel A., Eder R. , Strasser H., Poisel S., Bartsch G. The female urethral sphincter: a morphological and topographical study // J. Urol. - 1998. - Vol.l60. - No. 1. - P.49-54). Thus, anterior ectentration with vaginal resection can lead to dissection of most, if not all autonomous nerves innervating the urethra, which can lead to urinary incontinence in patients in the postoperative period.

In the past few years, such radicalism remains controversial, since removal of the urethra does not allow orthotopic replacement of the bladder. In a number of previously published works (De Paepe M., Andre R., Mahadevia P. Urethral involvement in female patients with bladder cancer. A study of 22 cystectomy specimens // Cancer - 1990. - Vol.65. - P1237-42) simultaneous cancer of the urethra in women was observed in 36% of cases, although recent studies show that with careful selection of patients, the urethra can be preserved in order to perform orthotopic replacement of the bladder with subsequent application of urethrocystoanastomosis (Coloby P., Kakizoe T., Tobisu KI, Sakamoto MI Urethral involvement in female bladder cancer patients: mapping of 47 consecutive cysto-urethrectomy specimens // J. Urol. - 1994. - Vol. 152. - P.1438-42; Stein JP, Cote RJ, Freeman JA, Esrig D., Elmajian DA, Groshen S. Indications for lower urinary tract reconstructions in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens // J. Urol. - 1995. - Vol.l54. - P. 1329-33).

The generalized European experience confirms the validity of such tactics, in which the results of treatment of 102 women with preserved urethra during cystectomy are presented. Formed ideal orthotopic bladder anastomosed with left urethra. Five-year survival was 63% (Stenzl A., Jarolim L., Coloby P., Golia S., Bartsh G., Babjuk M., Kakizoe T., Robertson C. Uretra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors // Cancer - 2001. - Vol. 92. - N.7. - P.1864-71),

The most important prerequisite for the success of such interventions is the histologically confirmed absence of a tumor in the neck of the bladder and urethra. Oncological danger is associated with a possible local recurrence after removal of the bladder. In addition, when cutting off and separating the bladder from the urethra, the probability of the spread of tumor cells with urine and their local dissemination is high (Stenzl A., Colleselli K., Poisel S., Feichtinger H., Bartsh G. The use of neobladder in women undergoing cystectomy for transitional-cell cancer // World J. UroL - 1996 .-- Vol.l4. - P.15-21).

In recent years, bold attempts have been made to perform a cystectomy with laparoscopic techniques. So, Puppo P. et al. [Puppo P., Perachino M., Ricciotti G., Bozzo W., Gallucci M., Carmignani G. Laparoscopically assisted transvaginal radical cystectomy // Eur. Urol. - 1995 .-- Vol. 27. - N.1 - P.80-4] remove the bladder through an opening in the posterior wall of the vagina. Turk I. et al. [Turk I., Deger S., Winkelmann B., Schonberger B., Loening S.A. Laparoscopic radical cystectomy with continent urinary diversion (rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases // J.Urol. - 2001 .-- Vol. 165. - N.6. - Pt. 1. - P.1863-6] give the results of successful laparoscopic cystectomy followed by the creation of retention urine diversion. The drug and the complex of lymph nodes are removed by means of a laparoscopic sac through the vagina.

Closest to the claimed method is a method for the surgical treatment of bladder cancer in women, which consists in removing only the bladder without excising surrounding tissues, lymph nodes and neighboring organs. This surgery is called a simple cystectomy [Pereverzev AS, Petrov SB Bladder tumors. Publishing house "Fact", Kharkov, 2002, p.159-160]. A simple cystectomy can be performed when the neoplasm is localized, for example, on the front or side walls of the bladder. The internal genital organs and vagina are preserved. The initial stages of mobilization of the bladder are standard, but the vessels going to the internal genital organs from the internal iliac artery must be preserved. The peritoneum is opened in the uterine-bubble recess, the vagina remains intact, and dissection continues in the well-vascularized plane between the bladder and the anterior wall of the vagina. Dissection of the bladder neck is performed, since in such patients, as a rule, orthotopic reconstruction is planned. Then the bladder is cut off approximately 0.5 cm below the neck.

With this technique of openly cutting off the bladder from the urethra, there is a possibility of the spread of tumor cells in the urine and subsequent local relapse [Turner WH., Danuser H., Moehrle K., Studer UE. The effect of nerve sparing cystectomy technique on postoperative continence after orthotopic bladder substitution // J.Urol. - 1997 .-- Vol. 158. - No. 6. - P.2118-22]. In addition to local tumor recurrence after the interventions, urinary incontinence is caused, which leads to patients becoming irritable, withdrawn, alienated, they leave work and limit themselves to the walls of the apartment.

The objective of the invention is to prevent relapse, improve the postoperative continent and reduce the time of surgery.

The technical result of the present invention is the elimination of local spread of tumor cells from the bladder and urethra, as well as the preservation of the sphincter mechanism.

This result is achieved by the fact that during surgical treatment of bladder cancer in women, including removal of the bladder by paravesical tissue, the urethra is cut off endoscopically with an electroresectoscope loop before retreating to cystectomy, retreating 0.5-0.7 cm distal to the neck from the bladder.

The method is as follows.

In a position with legs apart, a cystorezectoscope is inserted into the bubble. A bladder is examined. Then, with a loop of an electro-resectoscope under visual control, the bladder is cut off from the urethra 0.5-0.7 cm distal to the neck of the bladder. Cutting off the urethra occurs under direct visible control. The intactness from tumor lesions of the bladder neck and the entire length of the urethra is also visually monitored. Next, the Foley urinary catheter is inserted into the bladder. The patient fits horizontally. A cystectomy is performed. After performing orthotopic reconstruction with the intestinal segment, the abdominal cavity is drained with two silicone tubes and the wound of the anterior abdominal wall is sutured in layers. Ureteric intubators, removed one along the urethra, the second through the anterior abdominal wall, are removed on the 10-12th day after surgery, the urethral catheter on the 12-14th. After that, self-controlled urination through the urethra is restored.

Distinctive essential features of the proposed method are:

- clipping of the urethra before cystectomy;

- clipping endoscopically with an electro-resectoscope;

- the urethra is cut off, retreating 0.5-0.7 cm distal to the neck from the bladder;

When the urethra is cut off before cystectomy, there is no need to carry out any dissection around the urethra, which reduces the risk of postoperative incontinence, provides intraoperative mobility of the bladder neck region, which reduces the amount of dissection of the lateral walls of the vagina, bladder neck and, as a result, most fibers are preserved, going to the urethra and, accordingly, the sphincter mechanism. The separation of the drug (the bladder with the proximal part of the urethra) intraoperatively significantly simplifies the technique of surgery, since only cranial traction of the bladder from the small pelvis is performed, which, in turn, reduces the time of surgery.

Cutting off the urethra using an electroresectoscope leads to local hemostasis and thermal coagulation of possible micrometastases, which reduces the risk of local recurrence.

The value of the selected indentation of 0.5-0.7 cm distal to the neck from the bladder is explained as follows:

With an indentation of more than 0.7 cm, the external sphincter can be damaged, providing the mechanism of the continent; with an indentation of less than 0.5 cm, the area of electroresection can pass through the intramural section of the urethra, i.e. in the thickness of the bladder wall.

The set of distinctive essential features is new and allows you to save the sphincter mechanism, as well as to exclude the local spread of tumor cells from the bladder and urethra, which prevents relapse, improves postoperative continent and reduces the time of surgery.

The essence of the method is illustrated by example.

Example

Patient K., 42 years old, № and / b 30565-СО, was hospitalized in a planned manner on October 28, 2004 to the urology department of the city multidisciplinary hospital (GMPB No. 2 (S-Pb) with complaints of a periodic admixture of blood in the urine with clots and difficulty and frequent urination for 3 months.

Upon admission, the patient's condition is satisfactory, clear consciousness, skin integument of normal color, peripheral lymph nodes are not enlarged, no edema. Hemodynamic parameters within normal limits, blood pressure 125/70 mm Hg On palpation - internal organs without features. Urination is difficult, urine mixed with blood. In the clinic, the patient performed:

Electrocardiogram: sinus rhythm, heart rate 82 beats / min. Incomplete blockade of the right bundle branch block. Local disturbance of intraventricular conduction.

Fluorography - without pathological changes.

Computed tomography of the bladder: a bladder of sufficient volume, a pathological volumetric formation is visualized on the back and left side walls, the walls of the bladder in the base area are 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 posterior wall and the left side wall, hyperechoic tissue formation of 35 × 30 mm is visualized.

Cystoscopy: on the back and left walls, departing 2-2.5 cm from the neck of the bladder, a tumor formation is visualized on a wide base with a diameter of about 3.0 cm, protruding into the lumen of the bladder.

Blood test: Lake. - 7.0 × 10/9, erythritol - 4.0 × 10/12, hemoglobin - 130 g / l, platelets - 250 thousand, lymphocytes - 33, monocytes - 8, neutrophils - 59, stab-nuclei - 2, eosinophils - 2, basophils - 1, ALT - 30 mmol / l, ACT - 27 mmol / l, total protein - 72 g / l, urea - 4.9 mmol / l, creatinine - 100 mmol / l, bilirubin total. - 8.2 μmol / L, glucose - 4.9 mmol / L, prothrombin - 102%.

Urinalysis: yellow, slightly cloudy, specific gravity 1017, acid reaction, protein 0.010 g / l, white blood cells 8-10 in n / a, red blood cells 30-40 in n / a, flat epithelium 0-1-2 in n / sp., mucus ++. Urine cultures did not give rise.

TUR (transurethral resection); a bladder biopsy was performed on October 13, 2004 - a moderately differentiated transitional cell carcinoma of the bladder with signs of invasion of the muscle layer.

Given the presence of muscle-invasive cancer in the patient, the absence of severe somatic diseases, it was decided to perform a cystectomy with the formation of an orthotopic urinary reservoir by the ileum segment using the Studer method.

November 2, 2004, the patient was taken for surgery. Under endotracheal anesthesia and spinal anesthesia, a cystorezectoscope is inserted into the bladder. Endoscopically under visual control 0.5 cm distal to the bladder neck with a loop of a resectoscope around the circumference of the urethra is cut off from the bladder. The patient is moved to a horizontal position. Laparotomy 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. Retreating 25 cm from the ileocecal angle, a segment of the ileum was taken. The ileal reservoir is created from an isolated ileal segment 55 cm long. The integrity of the edges of the ileum mesentery, through which the mesentery of the reservoir passes, is restored by interrupted vicryl sutures (3-0). The continuity of the intestinal tube was restored by serous-muscular single-row interrupted sutures (3-0 vicryl). Both ends of the intestinal segment from which the reservoir was formed were closed with a continuous serous-muscular suture. The distal end of the ileal segment is opened along the mesenteric margin. Then the left ureter is transferred to the right side in front of the aorta and the vena cava, above the inferior mesenteric artery. The ends of the ureters are obliquely cut for 1.5 cm. Then, two longitudinal incisions were made 1.5 cm parasredin from the mesenteric margin at the most proximal end of the non-tubular part of the 14 cm afferent tubular segment. The incision for the right ureter was located approximately 1 cm distal to the incision for the left ureter. The ureters were implanted with continuous sutures using the Nesbit technique, end-to-side. A continuous suture was started at the cranial / proximal end of the anastomosis. At the proximal end, a small amount of tissue was included in the suture on both sides in order to prevent narrowing of the lumen of the ureter. Towards the distal end, the amount of tissue trapped in the suture was gradually increased to compensate for the possible tension of the ureter. We pay special attention at the beginning of the anastomosis. In this case, the wall of the ureter should lie between the mucosa and the seromuscular layer of the wall of the afferent tubular segment. This prevents fistula formation due to mucosal prolapse. Intubators were installed in the ureters. In order to prevent their loss, catgut sutures were fixed to the tank wall. This made it possible to close the formed channel in the tank wall after removal of the ureteral intubators on the 12th day after the operation.

To create a reservoir, the two medial edges of the open distal part of the iliac segment were folded in the form of a U-shape and sewn with a single-row gray-muscular continuous suture (2-0 vikril). Then the lower part of the formed U-shaped structure was folded to the upper part, as a result of which a reservoir formed of a spherical shape, consisting of four folded iliac segments. After closing the lower half of the front wall and part of the upper half, the surgeon’s finger was inserted inside the reservoir in order to determine the most caudal part of the reservoir, where a hole of 10 mm in diameter was made outside the seam line. After installing the Foley catheter, an anastomosis with an urethra was performed using 6 gray-muscular sutures (3-0 vicryl). Until the reservoir was completely closed, one ureteral intubator was passed through the wall of the most distal part of the afferent tubular segment, the other was removed with the urinary catheter along the urethra. Drainages are installed in the pelvic cavity on both sides.

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 intubators were removed on the 12th day, the urethral catheter on the 14th. Independent urination was restored, the patient did not notice urine leakage, she got up at night after 2 hours. After the operation, intravenous urography was performed: renal function was satisfactory, the abdominal cavity systems and ureters were not expanded. According to the results of descending cystography, a reservoir of 300 ml. 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 125 g / l, platelets 300 thousand, lymphocytes 30, monocytes 06, neutrophils 61, p / 4, s / nuclear 42, eosinophils 3, basophils 0, ALT 21 mmol / L, ACT 30 mmol / L, total protein 70 g / L, creatinine 97 μmol / L, glucose 4.0 mmol / L.

Urinalysis: light yellow, cloudy, beats. weight 1015, neutral reaction, protein 0.018, white blood cells 15-20 in n / a., flat epithelium 0-2 in n / a, mucus ++.

November 16, 2004 the patient in satisfactory condition was discharged under the supervision of an oncourologist at the place of residence. Dynamic observation, uroseptic administration is recommended. Control examination after 4 months.

During the control examination 4 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 18 ml / s, the average is 12.7. With cystometry, intravesical pressure at the first urge to urinate is 19 cm of water. Art., and the maximum - 40 cm of water. The patient does not note day and night enuresis. The frequency of urination in the daytime does not exceed 7 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, 7 cystectomies in women have been performed for RMP by the claimed method in the Department of Urology of the City Multidisciplinary Hospital No. 2 of St. Petersburg. The operation time was 60 ± 8.1 min. No tumor recurrence was observed in any patient within 2-3 years after surgery. All operated women have night and day urine retention.

Simple cystectomy (prototype method) was performed by the authors of the proposed method in 27 women. The age of the patients was from 22 to 78 years. The average age is 55.3 ± 10.7 years. The operation time was 82 ± 7.5 minutes. Tumor relapse at various times after surgery within 1.5-3 years developed in 15 patients, which amounted to 55.6% of the total number of patients operated. 23 patients (85.2%) had daytime urinary retention, but nightly retention was observed only in 13 people (48.1%).

Thus, the claimed method, in contrast to the prototype, prevents relapse, improves the postoperative continent and reduces the time of surgical intervention.

The inventive method provides:

- local hemostasis and thermal coagulation of possible micrometastases, which prevents the risk of local recurrence;

- the preservation of most fibers going to the urethra and, accordingly, the sphincter mechanism, which positively affects the psycho-emotional state of patients and preserves their social status;

- a significant simplification of the operation technique, since only cranial traction of the bladder from the small pelvis is performed, which, in turn, reduces the time of surgical intervention;

Claims (1)

A method for the surgical treatment of bladder cancer in women, including the removal of a bladder with paravesical tissue, characterized in that the urethra is cut off endoscopically with an electroresectoscope loop prior to cystectomy, retreating 0.5-0.7 cm distal to the neck from the bladder.