RU2336035C1 - Method of enterocysto-urethral anastomosis - Google Patents

Abstract

FIELD: medicine; urology.

SUBSTANCE: sphincter cuff is formed. Thus seromuscular layer of urethral end of urethral tube is stripped, turned up and fixed to urethral tube wall. Edges of urethral end of uretic reservoir and installed sphincter cuff are sutured with proximal edge of urethra wall. Sutured in two lines. At first line suturing bougie brought through urethra is supplied with three channels equispaced in a circle and longitudinal to its body. Sutures are provided at 2, 6 and 10 o'clock of clock code. In each suturing needle is brought in addition through bougie channel. In suturing mucous membrane of urethra is moved to urethra lumen and fixed to urethra wall from inside. The second suturing line is carried out at 12, 4 and 8 o'clock of clock code. Thus bougie is removed from urethra and catheter is inserted into lumen of uretic reservoir. Stick is applied at distance 1-2 mm from edge of seromuscular layer and proximal edge of urethra.

EFFECT: method allows for lowered complications and simplified and reduced time of operative intervention.

6 dwg, 1 tbl, 1 ex

Description

The invention relates to the field of medicine, to urology, specifically to methods for forming an enterocysto-urethral anastomosis, and can be used in the case of an orthotopic variant of urinary diversion in the formation of an illein reservoir of low intraluminal pressure.

Bladder surgery is without a doubt one of the most difficult and difficult chapters in operative urology. The search for the ideal technique for reconstructing the urinary tract after cystectomy dates back to 1851, when Simon first performed a urine diversion in the intestine of a child with bladder exstrophy by anastomosing the ureters with the sigmoid colon. The next important step in bladder surgery was made in 1886 by Bardenheüuer, who proposed a technique for partial and total cystectomy. In 1898, Poggi and Tizzoni in an animal experiment performed orthotopic intestinal plasty of the bladder using a 7 cm fragment of the small intestine for plasty [1].

The next important step in bladder surgery involves the creation of intestinal urinary reservoirs of low intraluminal pressure. The technique of forming an anastomosis of the reservoir with the urethra, its reliability, in most cases prevents the development of specific complications in the postoperative period, providing a high level of quality of life for the patient. Indications for various options for urinary diversion occur after removal or loss of bladder function.

A known method of forming an enterocysto-urethral anastomosis, which consists in the following: three stitches of the holder are placed on the stump of the urethra at 3, 9 and 12 hours of the conditional dial, the mucous membrane and paraurethral tissue are captured in the stitch. The back wall of the urethra and the corresponding part of the fascia of Denonvillier are dissected and two threads are applied at 5 and 7 hours. The matching of the edges of the anastomosis is performed by tightening the threads connected to the opening of the reservoir on the 22Fr urethral catheter [2].

A known method of forming an anastomosis of the urinary reservoir with the urethra according to the Studer technique, the main steps are as follows: the hole for anastomosis in the reservoir is cut out at the lowest point of the reservoir, the opening width is up to 8-10 mm. Anastomosis is formed with 6 sutures of Vicryl 2/0 / suture from the side of the reservoir into the suture, the serous-muscular layer is captured, and from the side of the urethral stump, the needle is injected 4 mm from the caudal end of the stump, and the puncture is made in the mucous layer at the level of the resection line urethra [3, 4, 5].

Known methods have the following complications: urinary incontinence, anastomotic failure, anastomotic stricture, urinary hypercontinence, the formation of external and internal urinary fistulas (table) [7, 8, 9, 10, 11, 12].

Closest to the proposed is a method of forming an enterocysto-urethral anastomosis by suturing between the urethral edge of the urinary reservoir with the cuff-pulp located on it and the urethral stump. The disadvantages of the prototype are insufficiently reliable and longer-lasting technique for the formation of anastomosis, which increases the risk of ischemia in the anastomosis.

A new technical task is to reduce the number of complications due to the development of ischemia in the anastomosis, a simplification of the method, a reduction in the time of surgery.

To solve the problem in a method of forming an enterocysto-urethral anastomosis by matching and stitching the edges of the urethral end of the urinary reservoir and the cuff-pulp located on it with the proximal edge of the urethral wall, two rows of sutures are applied, for the first row of sutures, between the urethral edge of the urinary reservoir and the proximal edge of the urethra, through the urethra, a bougie is carried out, equipped with three channels evenly spaced along the circumference, made longitudinally to its body, the sutures are placed at 2, 6 and 10 hours of the conditional dial, to complete each of the stitches, the needles are inserted into the urethra wall from the outside, through the corresponding bougie channel and adjacent tissues at a distance of 5-7 mm from its proximal edge, then the needle is passed through the mucosa into the bougie guide channel and removed from the urethral lumen, after that the needle is brought from the inside to the wall of the urethral part of the urinary reservoir and punctured outward 2 mm from its edge, then the needle is again immersed in the urethral lumen, it is passed through the urethral wall from the inside outwards, placing t the puncture is 2 mm from its proximal edge, after the other two sutures are made in the same way, the threads are tightened and the sutures are tied, while the urethral mucosa is moved into the urethral lumen and fixed to the urethral wall from the inside, then the second row of three sutures is performed, located at 12, 4 and 8 hours around the circumference according to the conditional dial, for which they remove the bougie from the urethra and insert a catheter into the lumen of the urinary reservoir, injecting the needle at a distance of 1-2 mm from the edge of the serous-muscular layer of the cuff and the proximal edge of the urethra.

The method is designed to form an anastomosis between the urinary reservoir from the ileum, created by forming a U-shaped reservoir of low pressure with an urethral tube.

Indications:

Cystectomy with distal resection of the urethra (large prostate gland, previous surgery in this area).

Multi-stage operations (difficulties in isolating the urethral stump, the risk of developing urinary incontinence).

CE in women with preservation of the urethra.

Benefits:

There is no need to isolate the urethra from scar tissue.

Elongation of the urethra (due to the urethral fragment of the reservoir).

A more reliable technique for the formation of an anastomosis (actually a two-row seam).

The formed cuff, as one of the mechanisms of urine retention.

Due to the peculiarities of the formation of the anastomosis, the probability of stricture is not higher than with standard techniques.

The method is as follows.

The position of the patient on the operating table with the extension in the sacral region. A mid-lower-mid-laparotomy is performed with excision of the postoperative scar, separation of adhesions, revision of the abdominal organs. The 26-28 Fr bougie is introduced into the urethra, the urethral wall is separated to the depth of no more than 4-5 mm over the end of the bougie by bordering sections (to prevent ischemia of the urethral tissue), then the proximal end of the urethra is excised, opening its lumen.

The ileum is used for plasty of the bladder, for this, stepping 20 cm from the ileocecal angle (mandatory preservation of the ileoocolic artery), a graft 60 cm long is cut on the vascular pedicle. Intestinal integrity is restored by applying an end-to-end anastomosis. Next, detubularization and reconfiguration of the selected area of the intestine is carried out with the modeling of a U-shaped graft with the formation of a urethral tube up to 5 cm long in a funnel shape, with preliminary implantation of the ureters (Figs. 1 and 2). The mucous membrane of the urethral end is grasped with a soft non-crushing clamp, stretched and the muscle-serous layer is peeled off for 8 mm at an acute level at the level of the submucosal layer and wrapped up so that a cuff is formed that is fixed with three serous-serous sutures to the proximal wall of the urethral tube (Fig. .3).

Next, proceed to the implementation of the anastomosis. Two rows of sutures are applied: the first connects the urethral edge of the urinary reservoir and the proximal edge of the urethra, the second - the edges of the serous-muscular layer of the cuff and urethra. This significantly reduces the number of complications due to the development of ischemia in the area of the anastomosis.

The first row of sutures is performed as follows: to increase the convenience and reliability of the manipulation, for example, bougie 1 (Fig. 4) is inserted into the urethra, equipped with channels 3 made at its working end 2 at an angle of 120 degrees to each other and arranged longitudinally to its body, playing the role of guides when suturing. Seams are placed at 2, 6 and 10 hours of the conditional dial. To complete each of the sutures, the needles are inserted into the urethral wall from the outside. through the corresponding canal of the bougie, through adjacent tissues at a distance of 5-7 mm from its proximal edge, then the needle through the mucous membrane is passed into the guiding canal of the bougie and removed from the lumen of the urethra. After this, the needle is brought from the inside to the wall of the urethral part of the urinary reservoir and punctured outward 2 mm from its edge. Next, the needle is again immersed in the lumen of the urethra, passed through the wall of the urethra from the inside out, having a puncture point 2 mm from its proximal edge. After the other two sutures are made in the same way, the threads are tightened and the sutures are tied, while the urethral mucosa is moved into the urethral lumen and fixed to the urethral wall from the inside.

Then perform the second row of three sutures located at 12, 4 and 8 hours around the circumference according to the conditional dial (figure 5), making an injection at a distance of 1-2 mm from the edge of the serous-muscular layer of the cuff and the proximal edge of the urethra. To do this, remove the bougie from the urethra and a 14Fr catheter is inserted into the lumen of the urinary reservoir (Fig.6).

To prevent torsion, kinking of the urethral tube with anastomosis, the anterior wall of the reservoir with two sutures is fixed to the periosteum of the pubic bones. The urethral catheter is removed from 12 to 16 days after surgery, 2 days after removal of the cystostomy catheter.

Example.

Betenekov A.P., 58 years old, has been observed at the Scientific Research Institute of the TSC since 2004 with a diagnosis of Bladder Cancer T2N0M0, condition after combined treatment. Histology No. 9095-9119 of 05.25.06. Transitional Cr, moderately differentiated.

An anamnesis of the disease since 2003, when the first episode of macrohematuria occurred; first sought medical attention with complaints of bladder bleeding in 2004. During the examination: in the general blood test - a moderate decrease in hemoglobin to 105 g / l; in the biochemical analysis of blood, an increase in creatinine level to 115 mmol / l was noted, in the general analysis of urine - completely erythrocyte masses. Cystoscopically determined the presence of copiously bleeding villous tumor formation, located circularly in the neck of the bladder, more on the left, because of which the mouth of the left ureter was not visualized. Ultrasound examination of the abdominal organs revealed no data for distant and regional metastasis. An X-ray examination of the chest organs of the pulmonary pathology was not established. With iv excretory urography, data for impaired passage of urine from the upper urinary tract have not been established.

At the initial examination, the diagnosis was established: transitional cell carcinoma of the bladder T2-3? NxM0, about which the patient was given 2 courses of systemic x / t according to the M-VAC scheme in preoperative mode. Against the background of chemotherapeutic treatment, local progression of the process was noted, with no signs of systemic progression. During the control cystoscopic examination, further spread of the tumor to the left side wall of the bladder was established. In this regard, on May 18, 2005, the patient underwent surgical treatment in the amount of radical cystectomy, bilateral urethrocutaneostomy, and bilateral pelvic lymphatic dissection. Macro drug: bladder with prostate gland and seminal vesicles. In the removed cellulose, there is clearly no metastatic lymph node; cellulose tissue on the left with edema and inflammation. On a section - the neck and the left side wall of the bladder are occupied by a tumor, possibly sprouting the left mouth of the ureter. Conclusion: bladder cancer, T2-4? No-xM0. After a planned histological examination, the final stage of the tumor process, T2N0M0, was established. Within 6 months after surgical treatment during the follow-up examination, data for local recurrence and systemic progression of the tumor process were not obtained.

09/27/2006, the patient underwent the stage of reconstructive plastic surgery in the volume of orthotopic intestinal plasty of the bladder with a fragment of the ileum of the ileum reservoir of low pressure with a cuff from the serous-muscular layer, the urethral tube and enterocysto-urethral anastomosis, according to the proposed method.

The position of the patient on the operating table with the extension in the sacral region. The surgical field was processed according to Grossikh-Filonchikov. Under THES, a median laparotomy, revision of the abdominal cavity was performed. In the projection of the bladder, a tumor-like formation of stony consistency on the right wall in the prostate gland. Manipulation in the abdominal cavity is significantly difficult due to the large amount of fatty tissue. The peritoneum from the navel is cut out by a triangle with the capture of urachus, vas deferens and the wall of the bladder. Both ureters are located below the iliac vessels and are crossed, intubated with silicone catheters. The ureters are thin, 10 Fr. catheters are difficult to hold. With some technical difficulties, due to the large size of the bladder and the severity of paravesical tissue, mobilization of the lateral walls of the bladder with ligation of the upper and lower vesical vascular complexes was performed. The internal pelvic fascia was dissected on both sides, the pubic-prostatic ligaments were ligated and crossed, and the dorsal venous complex was treated. The 28 Fr bougie was inserted into the urethra, the urethral wall was highlighted at the depth of 5 mm above the end of the bougain (to prevent ischemia of the urethral tissue), then the proximal end of the urethra was excised and its lumen opened. The complex - the bladder with paravesical tissue, prostate, seminal vesicles and the adjacent peritoneum is removed. A lymphadenectomy was performed, on both sides, no clearly enlarged lymph nodes were detected, the proximal border at the level of bifurcation of the iliac arteries.

Retreating 20 cm from the ileocecal angle, a graft 60 cm long was cut out from the ileum, it was detubularized and reconfigured with a U-shaped graft to form a urethral tube up to 5 cm long with a funnel shape. The urethral part of the urinary reservoir is formed in such a way that a 12-14 Fr. catheter should pass freely into the lumen. The mucous membrane of the urethral end is captured by a soft non-crushing clamp, stretched and peeled in an acute way at the level of the submucosal layer. The muscular-serous layer is wrapped up for about 8 mm, so that a cuff is formed, which is fixed by three serous-serous sutures to the proximal wall of the urethral tube.

Anastomosis was performed according to the proposed method: the sutures were laid in two rows to reduce the likelihood of developing ischemia in the area of the anastomosis. The first row of seams - three seams were placed at 2, 6 and 10 hours of the conditional dial. The needle was injected outside the urethra, through adjacent tissues at a distance of 5-7 mm from the urethral wall, and the needle was injected through its lumen outward at a depth of about 5 mm. To facilitate the removal of the needle to the outside, a metal bougie of size 25 Fr was used with three channels deposited on its distal part, arranged uniformly around the circumference, respectively, 2, 6, and 50 hours. The needle was passed through the mucosa so that it fell into the corresponding guide channel of the bougie, and was removed from the urethral lumen to the mucosa at a distance of 2 mm from the urethral edge of the urinary reservoir. Then the needle was again immersed in the urethral lumen, passed through the urethral wall from inside to outside so that its injection point was located at a distance of 2 mm from the proximal edge of the urethra, while tightening this suture, the mucous membrane of the urethral tube was moved into the urethral lumen and fixed to the urethral wall from the inside. Two other seams from this row were similarly made. Next, a second row of 3 seams was performed. To do this, the bougie was removed from the urethra, a 14Fr catheter was inserted into the lumen of the urinary reservoir. The injections were carried out at 12, 4, 8 hours of the conditional dial. The needle was drawn between the serous-muscular edge of the cuff of the urinary reservoir and the proximal edge of the urethra at a distance of 1-2 mm from the edge on one and, accordingly, on the other hand. To prevent torsion, kinking of the urethral tube with anastomosis, the anterior wall of the reservoir with two sutures is fixed to the periosteum of the pubic bones.

Anastomosis of ureters with a transplant according to Nesbit on modeling catheters. The ureteral drainage tubes and the Petzer catheter are removed through the front wall of the graft. Control of tightness and hemostasis. Two tubular drainage through the iliac region into the pelvis. Suturing of the surgical wound. Aseptic dressing.

The urethral catheter was removed 16 days after surgery (2 days after removal of the cystostomy catheter).

In total, according to the proposed method, 15 patients were operated on.

Complications associated with the failure of the anastomosis, the formation of external and internal urinary fistulas, the development of strictures were noted.

Thus, the application of the proposed method avoids the complications caused by the development of ischemia in the area of the anastomosis, and also significantly reduces the time of surgery.

List of sources of information

1. Peacemakers S.R. Experimental data on the transplantation of the ureters into the intestine. / S.R. - S. - Petersburg: Slovo, 1909. - 86 p.

2. Fish M. Implantation of the ureters by the creation of extramural tunnels during operations Mainz-spider I and II / M. Fish, G. Abol-Enain, R. Hohenfeller // Operational Urology. Classics and innovations. / Edited by L.G. Managadze. - A guide for doctors. - M .: Medicine, 2003. - Ch. 6.25. - S.638-645.

3. Studer U.E. Replacing the bladder with a segment of the ileum with an afferent tubular segment. / W.E. Studer, Danuser G.J., Tsing F.J. // Operative urology. Classics and innovations. / Edited by L.G. Managadze. - A guide for doctors. - M .: Medicine, 2003. - Ch. 6.21. - S.614-620.

4. Burkhard F.C. Orthotopic urinary diversion: using an ileal lowpressure bladder substitute with an afferent tubular segment. / F. C. Burkhard, U. E. Studer / Atlas of the Urologic Clinics of North America / - 2001, October. - Vol. 9; 2. - P.57-73.

5. Studer U.E. Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. / U. E. Studer, H. Danuser, V. W. Merz, J. P. Springer et al. // J. Urol. - 1995, Jul - Vol. 154. - P. 49-56.

6. Vasilchenko M.I. New variants of intestinal bladder plastic surgery in the experiment. / M.I. Vasilchenko, Sergienko N.F., L.B. Belyaev, V.I. Zagarova // Urology. - 2001. - No. 5. - S.7-12 (prototype).

7. Elmajian D.A. The kock ileal neobladder: updated experience in 295 male patients / D. A. Elmajian, J..P. Stein, D. Esterig et al. // J. Urol. - 1996, Sept. - Vol. 156. - P.920-925.

8. Steven K. The orthotopic Kock ileal neobladder: functional results, urodinamic features, complicapions and survival in 166 men. / K. Steven, A.L. Poulsen // J. Urol. - 2000, Aug. - Vol. 164. - P.288-295.

9. Stein J.P. The orthotopic T - pouch ileal neobladder; experience with 209 patients. / J.P. Stein, M.D. Dunn, M.L. Quek et al. // J Urol. - 2004, Aug. - Vol. 172. - P.584-587.

10. Regalado Pareja R. Orthotopic bladder replacement: II. Functional results and complications in patients with Studer-type ileal neobladder. / R. Regalado Pareja, J. Huguet Perez, C. Errando Smet, B.X. Lima // Arch Esp Urol. - 1997, Apr. - No. 50 (3). - P.234-241.

11. Studer U. Ileal bladder substitute: antireflux nipple or afferent tubular segment? / U. Studer // Eur Urol. - 1991 .-- Vol.20. - P. 315-326.

12. Hautmann R. E. The ileum bladder: complications and functional results in 363 patients over 11 years of observation. / R. E. Hautmann, R. De Petriconi, X.V. Gottfried, K. Kleinschmidt / International Medical Journal. - 2000. - No. 2. Electronic Journal - The mode of access to the journal. - http://www.medi.ru/.

Table Tank related Elmaji an D. A 1993 n-295 Steven K. 2000 n-166 Stein J.P. 2004 n-209 Regalad on Pareja R1997 n-100 Studer 1993 n-100 Hautmann R.H. 2000 n-363 Stricture of ileo-urethral anastomosis 1 (0.3%) 1 (0.6%) 6 2 2 (1.5%) Intestinal fistula - 1 (0.3%) External fistula of the tank 1 (0.3) 4 (1,1) Urethral stricture 3 Chronic urinary retention 5 Fistula of the reservoir with the vagina 3

Claims (1)

A method of forming an enterocysto-urethral anastomosis by matching and stitching the edges of the urethral end of the urinary reservoir and the cuff-bag located on it with the proximal edge of the urethral wall, characterized in that the serous-muscle layer of the urethral end of the urethral tube of the urinary tank is peeled off when the cuff-bag is formed. wrapped up and fixed to the wall of the urethral tube, then two rows of sutures are applied, with the first row of sutures between the urethral edge of the urinary reservoir and A bougue is inserted through the urethra with the proximal edge through the urethra, equipped with three channels evenly spaced around the circumference and made longitudinally to its body, the sutures are placed for 2, 6 and 10 hours of the conditional dial, for each of the stitches the needles are inserted into the urethra wall from the outside, through the adjacent tissue at a distance of 5-7 mm from its proximal edge, then the needle is passed through the mucosa into the bougie canal and removed from the urethral lumen, after which the needle is brought from the inside to the wall of the urethral tube of the urinary reservoir and they are poured outward 2 mm from its edge, then the needle is again immersed in the urethral lumen and passed through the urethral wall from the inside out, having a puncture point 2 mm from its proximal edge, after the other two seams are made in the same way, the threads are pulled and the sutures are tied, with this mucous membrane of the urethra is moved into the lumen of the urethra and fixed to the wall of the urethra from the inside, then perform the second row of three sutures, placing them at 12; 4 and 8 hours around the circumference of the conditional dial, for which they remove the bougie from the urethra, insert a catheter into the lumen of the urinary reservoir and inject the needle at a distance of 1-2 mm from the edge of the serous-muscular layer of the cuff and the proximal edge of the urethra.

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