RU2371102C1 - Inverting orthotopic ileocystoplasty technique in short mesoileum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, urology and can be used for treatment of the patients underwent cystectomy. An orthotopic intestinal U-reservoir of low pressure is formed of ileum. Herewith 55 cm of ileum is resected at a distance of 20-25 cm from ileocecal angle. The resected ileum is dissected along antimesentric edge throughout 40 cm. An afferent limb is preserved throughout 15 cm. A split part is folded symmetrically U-like so that an apex of U is directed caudad and maximally close to urethra stump. The adjoining edges are sutured. The opposite long sides are aligned so that ensuring a tube U-reservoir to be closed. The formed reservoir is turned out and unrolled in small pelvis between leaves of mesentery. It is unrolled so that posterior wall of the reservoir free from mesentery is arranged anteriad and its free pull-through in small pelvis additionally reduces the distance to stump of urethra by 3-4 cm. In low point of the reservoir, anastomosis with urethra is formed. Stented ureters are anastomosed with upper edge of afferent limb by the reflux technique. Ureteral stents are delivered outside through the reservoir along urethra. Inversely in neocyst cavity, a Foley's catheter is applied. The technique is simple and reliable; allows reducing surgically injured regions, avoiding conversion with applying more complex and expensive techniques of derivation in short mesoileum.

EFFECT: besides the technique ensures maximum life quality of the patients underwent cystectomy, reduces risk of complications due to pull-through of low point of the reservoir in small pelvis, forming antireflux protection.

10 dwg, 2 ex

Description

The invention relates to medicine, urology and can be used for surgical treatment of patients after removal of the bladder.

Until recently, radical cystectomy was considered as a disabling operation, associated with high mortality, the risk of severe postoperative complications and the subsequent short prognosis of patients' lives. This was due to both the imperfection of the technique of radical cystectomy and the imperfection of the methods of postoperative derivation of urine. The modern cystectomy technique and options for intestinal cystoplasty have fundamentally changed the attitude towards radical cystectomy and contributed to its popularization. Orthotopic bladder replacement is now the standard form of bladder replacement after cystectomy, in the absence of contraindications. The rationale for performing orthotopic bladder replacement is the simplicity of the surgical technique with a low risk of complications and good long-term functional results. The main goal of creating orthotopic reservoirs is medical and social rehabilitation of patients undergoing bladder removal. The main conditions for the rehabilitation of this category of patients are:

- creating an orthotopic reservoir with sufficient capacity and low pressure in it;

- protection of the upper urinary tract with an adequate antireflux mechanism.

For these purposes, the most commonly used segments of the ileum, ascending, transverse and descending colon, a combination of these segments, less often - the wall of the stomach.

The modern condition for the full social and psychological rehabilitation of patients should be considered the restoration of self-urination. In the mid-90s, orthotopic replacement of the bladder in most medical centers became the standard method for urine diversion, and in 90% of patients, an orthotopic bladder from the ileum is used to divert urine (JFMoutie 1997, R.E. Studer et al 1998 G. REHautmann et al 1999, 2001). The patent and medical literature describes a fairly wide variety of methods for replacing the bladder after radical cystectomy.

A known method of bladder plasty with a free musculocutaneous flap on a vascular pedicle (RF Patent No. 2141448, 2001.01.10), including performing a cystectomy, isolating two free musculocutaneous flaps on a vascular pedicle, forming an artifical bladder from a musculocutaneous flap, applying an uretroneo - and ureteroneocystoanastomoses. The method is characterized in that the selection of two free skin-muscle flaps is carried out in the thoracodorsal region on the right or left on a single vascular pedicle, consisting of parts of the dorsal artery and chest vein, the main skin-muscle flap has the shape of a clover leaf, and the additional one has an elongated ellipsoid form. Within the access area, parts of the artery and veins of the lower epigastric vessels are isolated, then vascular anastomoses with parts of the dorsal artery and chest vein are performed, anastomosis of the upper lobe of the main muscle-muscle flap with the posterior urethra on the Foley catheter pre-installed in the urethra is performed. Ureters with endotracheal tubes are passed through the flap wall into the cavity of the formed bladder, the ureters are fixed to the outer and inner walls of the formed bladder, then the edges of the petal flap are sewn together to obtain the cavity of the correct size. Both ureteral endotracheal tubes are brought out of the reservoir formed, a drainage tube is inserted into the cavity of the newly formed bladder and the wound in the suprapubic area is sutured with drainage left and an additional musculocutaneous flap is removed onto the anterior abdominal wall to allow control of the formed artifical bladder in the subsequent state . In this case, a fence is taken in the thoracodorsal region of the main musculoskeletal flap measuring 30 × 20 cm and an additional 15 × 4 cm.

The described method of cystoplasty has several disadvantages. The fence of skin-muscle flaps from the thoracic-dorsal region significantly increases both the time of the operation and its invasiveness. This significantly lengthens the period of medical and social rehabilitation of patients. The formed neocyst in comparison with the intestinal wall has insufficient extensibility, which leads to inadequacy of the accumulative and evacuation functions of the neocyst in the long term.

One of the important drawbacks is that the operation is technically complicated, it is very expensive, it requires the use of microsurgical technique, prolonged anesthesia with a change in the patient’s position during the operation from the supine position to the thoracotomy position and vice versa. The presence of ureteral drainages and additional drainage discharged through the neocyst wall necessitates their subsequent removal with additional hospitalization. Thus, at present, the described method of cystoplasty does not fully meet the tasks of social and medical rehabilitation of patients after undergoing radical cystectomy.

A known method of forming a urinary reservoir (Patent of the Russian Federation No. 2195881, 2003.01.10), which consists in mobilizing a loop of the small intestine, followed by suturing of the ureters intubated with catheters and forming a suspended enterostomy, characterized in that the left ureter is passed through the mesentery of the sigmoid colon, the medial walls are sutured the distal ends of the ureters between each other for 3-4 cm with separate sutures, catheters are passed through the small intestine, with separate sutures, the ureters are circularly sutured with the proximal edge of the small intestine Ki, pulling by catheters, immerse the line of sutures in the small intestine by 3-4 cm, impose a second row of sutures between the wall of the ureters and the wall of the small intestine, stitch the serum-muscle sutures of the wall of the small intestine between the ureters, fix the small intestine to the tissues of the retroperitoneal space and to the mesentery of the sigmoid colon with separate sutures.

The described method is an analogue of the method of conduction diversion of urine to the anterior abdominal wall, proposed by Bricker in 1950. As previously performed conduit techniques, the described method does not lead to the restoration of self-urination. Urine is constantly poured onto the skin of the anterior abdominal wall through a formed suspended enterostomy. The patient is forced to constantly use cutaneous urinals. This leads to a sharp deterioration in the quality of life of patients in comparison with orthotopic reconstruction, does not fully solve the problems of social and medical rehabilitation of patients after cystectomy.

A known method of orthotopic intestinal plasty of the bladder (Patent No. 2279254, 2006.07.10), including the formation of a U-shaped intestinal reservoir of low pressure from a transplant of the terminal ileum and a channel for urine diversion, characterized in that the intestinal transplant is dissected along the mesenteric reservoir edge, getting a rectangle having two short and two long shoulders. On one of the long shoulders in the middle, a point is distinguished around which the long shoulder is bent, the edges are combined and the side of the mucous membrane is sutured with a continuous through, twisting seam. Next, the opposite long sides are combined so that a tubular reservoir of a U-shape is obtained, the edges of the graft knees are aligned and sutured for 4-5 cm, the ureters are anastomosed with the formed reservoir with antireflux protection on the ureter external stents, then they form the urethral tube, for which they are moved towards the urethra, the lower lip of the graft, connect the upper lip and two points of the lower lip of the graft with a triangular suture so that a flap is formed by stitching the edges of which are single-row nodular form seam urethral tube 5 cm. Then the mucosa of the distal end of the tube turned inside out and fixed with sutures to graft serosa. A three-way Foley catheter is passed through the urethra and the formed urethral tube into the graft, external ureteric stents are removed in the opposite direction, the urethral tube with the urethra is anastomosed to 6 ligatures by 2; four; 6; 8; 10 and 12 hours 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, matching is done by adaptive L-shaped sutures and then fix the front wall of the intestinal reservoir to the stumps of the pubic-cystic, pubic-prostatic ligaments or to the periosteum of the pubic bones.

The disadvantage of this method is the need to carry out a rather complicated technical reconstruction with the need to form at the ends of the U-shaped reservoir two alternating ureteroreservuaroanastomoses in accordance with the antireflux technique, followed by the stage of formation of the urethral tube, which significantly increases the operation time. In addition, the proposed option for the formation of the "urethral tube", in fact, creates better conditions for suturing during anastomosis with the urethra. However, this does not reduce the degree of tissue tension in the anastomosis, and the need for multiple sutures in this area is potentially fraught with ischemic tissue in the anastomosis, which increases the risk of insolvency and subsequent obstruction, as demonstrated by the authors themselves in clinical observations.

A known method of heterotopic intestinal plasty of the bladder (RF Patent No. 2286098, 2006.10.27), including radical cystectomy and lymphadenectomy, mobilization of the ileum, followed by the formation of the urinary reservoir from it, the mechanism of urine diversion and modeling of the cutaneous stoma, mobilize to form the urinary reservoir the intestine for 55-60 cm, retreating 20 cm from the ileocecal angle, form an inter-intestinal anastomosis, then detubularize 50 cm of the transplant site, rotate it by 1 80 ° around the mesentery so that the detubularized area is located towards the right iliac region. Then, the detubularized area is first subjected to longitudinal and then transverse reconfiguration, forming a reservoir of low pressure, the ureters anastomose with the reservoir along its posterior wall on modeling catheters according to the Nesbit technique. The rest of the graft is narrowed by applying a Lambert suture at a distance of 0.5 cm from each other, after which the modeling catheters and the formed urine drainage tube are removed through a separate incision in the anterior abdominal wall, after the formation of the stoma, the exit site of the catheters is delimited from the abdominal cavity with several sutures between the anterior the wall of the reservoir and the parietal peritoneum of the anterior abdominal wall.

However, this method is applicable only for heterotopic derivation of urine, which, in comparison with orthotopic reconstruction, today does not comply with the principle of maximizing the patient’s quality of life. The patient is forced to constantly use a catheter to evacuate urine. This dramatically reduces the quality of psychosocial rehabilitation of patients due to reduced self-esteem and impaired social adaptation.

The method of heterotopic intestinal plasty of the bladder is described (www. UroBel.UroWeb.ru, July 20, 2007, S.A. Krasny, O.G. Sukonko, S.L. Polyakov, A.N. Volkov First experience with the new method formation of a continental heterotopic reservoir after cystectomy).

According to this method, at the first stage, a radical cystectomy with pelvic lymphatic dissection is performed, with a lesion of the urethra, a urethrectomy is performed.

An isolated ileum segment of 60-65 cm is used to form the reservoir. To avoid subsequent serious digestive and metabolic disturbances, the terminal section of the small intestine is preserved (20-25 cm). Retreating 20-25 cm from the ileocecal angle, the mesentery of the small intestine is dissected for 10-15 cm with the preservation of A. Ileocolica. The proximal incision of the mesentery is shorter (5-8 cm), so that at least 2 vascular arcades feeding the isolated segment of the intestine remain intact. In order to facilitate the detection of intestinal vessels, transmitted side light is used.

The small intestine is dissected along the line of incisions of the mesentery between the soft intestinal pulp or using staplers. Intestinal continuity is restored by applying a small-intestinal anastomosis of the end-to-end type, for which a single or double row suture with Vicryl or Polysorb 3-0 or 4-0 sutures is used, and a hardware suture can also be used. The hole in the mesentery is sutured on both sides. An isolated section of the small intestine is washed from the contents, after which the operation of forming a reservoir is performed.

An isolated segment of the intestine on the mesentery is dissected lengthwise along the mesenteric margin, leaving the terminal segments unchanged (10 cm long). The detubularized (dissected) segment of the intestine is laid in the form of the letter W, the adjacent edges of the incisions are sutured together by continuous twisted seams with overlapping Vicryl or Polysorb 3-0 thread. Then the front wall of the tank is sutured. The ureters anastomose with the distal end of the isolated intestine, the proximal end is used to form the valve and stoma.

The use of this technique, the same as described above, does not lead to the restoration of self-urination.

The closest to the claimed method of inverting orthotopic ileocystoplasty orthotopic ileocystoplasty according to Camey II, Hemi-Kock and the Studer method.

Orthotopic ileocystoplasty according to Camey II

Initially, urinary retention and urination function during this operation were problematic: from 20 to 80% of patients had daytime and 20 to 100% nightly incontinence - urinary incontinence (Roehrbom CG, Teigland CM, Sagalowsky AI. Functional characteristics of the Camey ileal bladder. J Urol 1987; 138: 739-42). Upper urinary tract remained intact in 95% of patients, and reflux was absent in 85% of patients.

An important subsequent modification in the operation "Camey II" was the detubularization and reconfiguration of the intestinal segment, which led to a decrease in peristaltic contractility of the walls of the reservoir and a decrease in pressure in its lumen. For this, along the mesenteric margin, the iliac segment (65 cm long) was dissected and folded U-shaped. The inner edges were sewn together. The ureters were implanted at the edges of the reservoir (at the apex and warp U) according to the Le Duc-Camey technique (Le Due A, Camey M, Teillac P. An original antireflux ureteroileal implantation technique: long-term follow up.J Urol 1987; 137: 1156- 8). The lowest point of the middle part of the ileal segment anastomosed with the urethra (Fig. No. 1-a - the ileum is folded in a U-shape, the back wall is sutured with a continuous twisting seam through all layers, an anastomosis hole with an urethra is formed in the middle of the long arm; places for future implantation are marked with marks ureters;

Fig. No. 1-b - the ureters are implanted into the wall of the reservoir according to the Le Due technique, the formation of the urethro-reservoir anastomosis is completed; arrows indicate the direction of the final folding of the walls of the tank before its final closure).

Day urine retention after this surgery is 96% and only 22% of patients have bedwetting (Camey M, Botto H, Richard E. Complications of the Camey procedure. Urol Clin North Am. 1988; 15: 249-55 .; Ramon J, Leandri P, Rossignol G, Botto H. Orthotopic bladder replacement using ileum: techniques and results. In Webster GD, Kirby R, King LR, Goldwasser B (eds). Reconstructive Urology. Oxford: Blackwell Scientific Publications, 1993; 445-57. ) Adequate urination control is achieved within 4-6 months. The frequency of reflux in the upper urinary tract is approximately the same.

Orthotopic ileocystoplasty by Hemi-Kock

The orthotopic reservoir Kock (a) is called the “Hemi-Kock pouch” operation, which is a modification of the original continental reservoir with a skin stoma according to Kock (y), with inlet and outlet invagination valves (Skinner DG, Lieskovsky G, Boyd S. Continent urinary diversion. J Urol 1989; 141: 1323-7 .; Kock NG, Ghoneim MA, Lycke KG, Mahran MR. Replacement of the bladder by the urethral Kock pouch: functional results, urodynamics and radiological features. J Urol 1989; 141: 1111-16 .). With orthotopic plastic surgery according to Kock (y) with an anastomosis to the urethra, there was no need for an outlet valve. The only leading invagination valve acts as a mechanism for antireflux protection of the upper urinary tract.

For an orthotopic neocyst, Kock resected 60 cm of the ileum. A proximal 16 cm is used for a typical formation of an invagination valve. The distal 44 cm is opened along the mesenteric edge, laid U-shaped, and the adjacent edges are sutured to form the posterior wall of the reservoir. Then the distal edge of the iliac plate is folded onto itself and up. The distal edge along the suture line at the lowest point of the reservoir is left open for anastomosis with the urethra. The ureters anastomose with the lead loop above the invagination valve according to the reflux technique (Fig. No. 2-a - the final fixation of the invagination valve to the tank wall by flashing with the TA-55; prolene mesh for subsequent stabilization of the valve is inserted into the formed mesenteric window Deaver (a); arrow the direction of the transverse folding of the tank before its final closure is indicated;

Fig. No. 2-b - the final view of the reservoir Hemi Kock: the ureters are implanted in the adducing tubular segment above the level of the invagination valve; the valve is stabilized using a circularly fixed prolene mesh; the tank is finally sutured in the transverse direction.

The disadvantages of this operation are the need to separate the mesentery from the intestinal wall for 7 cm, the use of synthetic material and staplers when forming the valve, which can disrupt the nutrition of the intestine with subsequent violation of the retention mechanism. To form one valve, a stapler with four cassettes is used. The migration of metal clips into the lumen of the tank can lead to the formation of calculi.

The number of early and late p / operative complications is 12 and 24%, respectively. As for other methods of orthotopic ileocystoplasty, characteristic complications are the failure of the reservoirs and reservoir-urethral anastomoses, pyelonephritis and stricture of the reservoir-urethral anastomosis. Late complications in Hemi-Kock surgery are mainly associated with a leading invagination valve. According to Skinner D.J. 4.1% of 295 patients had neocyst stones, while 2.4% had stenosis of the adrenal valve. Disinvagination of the valve leads to reflux in the upper urinary tract and lengthening of the adducting segment of the intestine.

Night retention was achieved in 75-86% of patients. Reflux occurs in 17% of patients.

Orthotopic ileocystoplasty by Studer

In 1988, Studer proposed orthotopic replacement of the bladder with a small bowel reservoir of low pressure, which is a simplified version of Hemi Kock orthotopic cystoplasty (Studer UE, Ackermann D, Casanova GA, Zingg EJ. Three years' experience with an ileal low pressure bladder substitute Br Br J Urol 1989; 63: 43-52; Studer UE, Danuser H, Thalmann GN, Springer J, Turner H. Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: Long term results of a prospective randomized trial. J Urol 1996; 156: 1913-17.). The essence of the fundamental difference is that the Kock (a) invagination valve is not formed in the adducting small intestinal segment of the neocyst. The novelty is due to the fact that the Kock (a) intussusception valve has been replaced by an undetubulated adrenal iliac segment 20 cm long that prevents reflux into the upper urinary tract.

Studer Operation Technique

After cystectomy, a typical ileum resection is performed at a length of 60-65 cm, retreating 20-25 cm from the ileocecal angle. A mesentery is dissected at the distal and proximal borders of the electric knife resection in avascular spaces from the edge of the ileum in the direction of the mesentery root, by 1 / 2-2 / 3 of this distance (depending on the length and mobility of the mesentery). Restore the integrity of the gastrointestinal tract by applying the terminal double-row small-intestinal anastomosis. Sutured the proximal end of the resected ileum segment tightly.

The intestinal segment is dissected from the distal end along the mesenteric edge for 40-45 cm while maintaining the tubular structure of the proximal segment - 20 cm. Symmetric U-shaped folding of the detubularized part of the intestine (vertex U is directed caudally) with suturing of the posterior wall of the reservoir (single row continuous serous-muscular-submucosal suture). The U-shaped posterior wall of the reservoir is folded in the transverse direction (the distal edge of the iliac plate is folded over and up) and the front wall of the reservoir is sutured with a single-row continuous twisted serous-muscular-submucosal suture (Fig. No. 3-a - the detubularized part of the ileum is folded U -shaped, the leading segment 20 cm long is saved for use as an antireflux mechanism; the arrow indicates the direction of the transverse folding of the reservoir before its final closure.

Fig. No. 3-b is the final view of the Studer reservoir: the ureters are implanted in the adducting tubular segment; the tank is finally sutured in the transverse direction. The reservoir is lowered into the pelvis and rotated so that the bringing elbow reaches the retroperitoneal space on the right, and the position of the lower wall of the reservoir adjacent to the urethra ensures that the urethro-iliac anastomosis is performed without tension.

Carrying out stented ureters into the abdominal cavity at the level of the proximal end of the adductor segment and performing anastomoses with adducting intestinal segment end-to-side without antireflux protection.

The ureteral drainage is introduced through the adducting intestinal segment into the lumen of the reservoir and then discharged through the front wall of the reservoir to the anterior abdominal wall. The implementation in the wall of the intestine adjacent to the urethra, holes, passing the tip of the index finger, for applying an anastomosis with the urethra. An anastomosis with an urethra is performed. Introduction to the neocyst cavity through the urethra of the Foley Ch catheter No. 22. Additionally, a reservoirostomy is installed in the neocyst cavity, which is excreted together with the ureter catheters at the final stage of the operation on the anterior abdominal wall.

1 year after the operation, daytime retention is 92%, after 2 years nighttime retention is 80%. The method does not have the risk of stone formation on stapling brackets, since small intestinal invaginate is not formed as during Hemi-Kock surgery.

At present, it has become possible and extremely important to choose exactly the method of urine derivation that will allow the operation to be performed with the least number of immediate and long-term complications and will ensure the best quality of life for the patient after the operation (Hautmann RE Urinary diversion: ileal conduit to neobladder // J Urol. - Vol. 169, 2003 .-- P. 834-842). It should be noted that over the past decade, most surgeons have given Studer surgery the choice of orthotopic ileocystoplasty option and its popularity continues to grow. However, the results of this technique significantly deteriorate if the presence of a short mesentery of the small intestine is detected intraoperatively, which causes tissue tension along the urethrointestinal anastomosis. This situation is still a contraindication to Studer surgery, which forces the surgeon to resort to alternative cystoplasty options.

Thus, one of the drawbacks of the small intestine is limited opportunities in relation to orthotopic plastic surgery, since a number of patients have mesenteric vessels short for unimpeded lowering of the ileum segment into the small pelvis and application of anastomosis between the intestinal bladder and the urethra without tension ( Zinman LN, Ill W. Bihrle // Bladder Reconstruction and Continent Urinary Diversion / Eds LR King, AR Stone, GD Webster - 2nd Ed. - St. Louis, 1991. - P. 68-87.).

To solve the same problem with orthotopic ileocystoplasty, other authors propose an additional formation of the urethral tube from the reservoir wall (the method of orthotopic intestinal bladder plasty according to RF patent No. 2279254, 10/11/2004). Thus, even the minimal tension in the anastomosis zone between the intestinal reservoir and the urethra that arises due to the insufficient length of the mesentery of the small intestine remains a serious problem and is the main reason for the failure of the anastomosis with the formation of urinary leakage, peritonitis, sepsis, intestinal obstruction, urinary fistula with the need for repeated operations, increased risk of mortality. This makes the surgeon, in case of tension in the anastomosis, change the intraoperative plan of the operation, refuse orthotopic reconstruction, perform additional bowel resections, use additional staplers, resort to other, more complicated options for urine derivation (heterotopic, conduit, abduction into the continuous intestine and etc.), which are obviously worse in comparison with orthotopic derivation. This unnecessarily delays the time of the operation, increases its cost, increases the amount of surgical injury, p / operative to / day, the risk of complications and mortality.

The above disadvantages are eliminated in the claimed invention.

The direct prototype of the proposed operation, we consider the operation by Studer. We improved it for cases when an insufficient length of the ileum mesentery is revealed intraoperatively for unimpeded reduction of it into the small pelvis and application of a reservoir-urethral anastomosis without tension.

The objective of the invention is to provide a simple method that does not require additional costs, does not increase the time of surgery and the amount of surgical trauma, which makes it possible to safely perform orthotopic small intestinal reconstruction of the bladder, as the most preferred, in conditions of insufficient length of the mesentery of the small intestine.

The problem is solved in that the method of inverting orthotopic ileocystoplasty with an insufficient length of the vessels of the mesentery of the small intestine, after cystectomy, includes a typical resection of the ileum of 55 cm at a distance of 20-25 cm from the ileocecal angle, cutting it along the mesenteric edge for 40 cm, leading the segment is maintained for 15 cm, restoring the integrity of the gastrointestinal tract by applying (manual or hardware) inter-intestinal anastomosis, the formation of an artifact orthotopic reservoir low pressure, the application of ureterone- and urethrocystoneoanastomoses, in addition, for this, longitudinal U-shaped detubularizing ileocystoplasty is performed with longitudinal stitching of the walls of the reservoir and preservation of the tubular leading segment, while the detubularized part is folded symmetrically U-shaped so that the apex U is directed vertically so that the apex U is directed to subsequent inverting positioning of the reservoir in the small pelvis, which ensures maximum approximation of the reservoir wall to the urethral stump, by applying an urethro-reservoir ary anastomosis without tension.

A new technical result is a reduction in the risk of complications, an increase in the quality of life of patients due to a more pronounced (in comparison with similar methods) lowering of the lower point of the reservoir into the pelvis and ensuring unhindered application of the urethral reservoir anastomosis. In addition, antireflux protection is provided. The operation does not require additional complex, more time-consuming, longer, with excessive surgical trauma reconstructive techniques (additional resection of the small intestine, additional mobilization of the mesentery with the risk of impaired adequate blood supply, the formation of special "urethral tubes" from the tank wall, etc.). Thus, the time of surgery and the volume of surgical trauma do not increase.

The proposed method does not require additional costs for staplers, suture material, instruments, long-term anesthetic aid, etc., i.e. the operation does not increase the cost of surgical treatment.

The operation involves minimal resection of the small intestine (no more than 55 cm).

The inventive technique allows the surgeon not to change the plan of operation and the method of intestinal plasty of the bladder, and therefore, helps to prevent unreasonably high additional costs for its implementation. Thus, the operation not only does not lead to an increase in the cost of surgical treatment, but also significantly reduces its cost in the presence of short vessels of the ileum mesentery, avoiding conversion.

The operation involves exclusively transurethral drainage of the neocyst. In contrast to similar operations with the installation of cystostomy drainage, the patient is relieved of the need for re-hospitalization for its removal, which eliminates the additional costs of patient rehabilitation and minimizes the time of rehabilitation itself

The operation allows you to restore self-urination as early as possible, which is extremely important for the subsequent increase in the capacity of orthotopic neocyst.

A significant difference of the proposed method from the prototype is that the prevention of tissue tension in the area of the reservoir-urethral anastomosis is achieved by longitudinal rather than transverse stitching of the reservoir and its inverting positioning in the small pelvis for maximum approximation of the reservoir wall to the urethral stump and application of the urethral reservoir anastomosis without tension. The proposed operation will allow not to refuse the most effective variant of cystoplasty - orthotopic due to the insufficient length of the mesentery of the small intestine.

The method is as follows:

Before the stage of suturing the tank, the technique does not fundamentally differ from the Studer operation, except for some points:

- not 60-65 cm of the ileum are resected, but 55 cm.

- detubularization of the distal end of the resected segment is performed over 40 cm, and the proximal tubular end is maintained over 15 cm, not 20 cm.

The detubularized part of the intestinal transplant is folded symmetrically U-shaped (the vertex U is caudally directed), the adjacent edges are sutured with a single-row continuous continuous seam through all layers from the mucosa side (Polysorb 3/0), forming the posterior wall of the reservoir. Then the reservoir is folded not in the transverse, but in the longitudinal direction by combining the opposite long sides so that a tubular reservoir of a U-shape is obtained (Fig. No. 4 - the detubularized part of the ileum is folded U-shaped, the leading segment 15 cm long is stored for use in as an antireflux mechanism; arrows indicate the direction of longitudinal folding of the reservoir before its final closure), which are sutured tightly with a single-row twisted continuous serous-muscular-submucosal suture with side of the serous membrane of the intestine (Fig. No. 5 - view of the reservoir after its final suturing in the longitudinal direction). Longitudinal stitching of the U-shaped reservoir provides closer adherence of the lower point of the reservoir to the urethral stump (3-4 cm) in comparison with the transverse folding with the Studer technique. However, in most cases, with a short mesentery, this does not ensure the absence of tension in the anastomosis with the urethra. To further reduce the lower wall of the reservoir into the pelvis, the inverting positioning of the formed reservoir in the pelvis is performed. To do this, “turn” the formed U-shaped reservoir between the leaves of the mesentery upward, starting from the top “U” (Fig. No. 6 - the beginning of the inverting positioning of the formed reservoir in the small pelvis by “turning” between the leaves of the mesentery upward, starting from the top of “U "). After completion of full invert positioning (Fig. No. 7 - continuation of “inversion” between the mesentery sheets, the arrow indicates the direction of continued inverting movement) and rotation of the reservoir together with the leading tubularized segment (Fig. 8 is the final stage of inverting positioning of the reservoir: the reservoir rotates together with a leading tubularized segment (indicated by arrows), the back wall of the reservoir, free of the mesentery, is located anteriorly and even more freely below is introduced into the small pelvis, reducing the distance to the stump of the urethra by another 3-4 cm (Fig. 9 - view of the reservoir after completion of the inverting positioning: the posterior wall of the reservoir, free from the mesentery, is located anteriorly and is freely reduced to the small pelvis; at the lowest point a hole adjacent to the urethra is formed, passing a tip of the index finger.) There is no bending of the mesentery, it freely retards under the tank. And the tank itself is not “pulled” by the vessels of the mesentery in the sagittal plane to a transverse folding it. This moment is very important for the subsequent unhindered expansion of the reservoir (increase in its capacity) in the postoperative period.

Next, at the lowest point of the reservoir adjacent to the urethra, a hole is formed that passes the tip of the index finger, an anastomosis with an urethra with interrupted sutures is applied through all layers, Polysorb 2/0, at 2, 4, 6, 8, 10, and 12 hours of the conditional dial. On the urethra, a Foley Ch catheter No. 20-22 is placed in the neocyst cavity. Stented ureters are performed retroperitoneally and inserted through the incision of the parietal peritoneum into the abdominal cavity at the level of the upper edge of the adducting tubularized segment. According to the Wallace method (Y-type anastomosis), the ureters anastomose with the open end of the intestine of the leading segment of the reservoir. Until the anastomosis is completely sutured, the ureteric stents are brought out through the urethra.

1. For this purpose, at the end of the Foley catheter Sp # 20-22, inserted through the urethra into the intestinal neocyst and passed through the leading intestinal segment, ureteral drainages Ch No. 6-7 are fixed (so that their ends are inserted into the lumen of the Foley catheter, which prevents injury to the reservoir and the area of the urethro-reservoir anastomosis during conduction) and a temporary conductor (polyvinyl chloride tube Ch No. 7), which are led out through the urethra following the removed Foley catheter.

2. The ureteral drainage is disconnected from the Foley catheter and held, and the Foley catheter is carried out along the urethra into the reservoir in the opposite direction by traction for the temporary conductor. The temporary conductor is removed, the Foley catheter balloon is inflated to 10.0-15.0 ml, and under visual and manual control, the drains in the reservoir are finally positioned.

3. Ureteric stents are fixed to the Foley catheter at the meatus.

4. The Foley catheter is fixed to the frenulum penis (or to the labia majora) (Perepechay V.A. Rationale for orthotopic sigmocystoplasty for bladder repair: Dis ... Ph.D. Medical Sciences. - Rostov-on-Don, 2000 .; Kogan M. I., Perepechay V.A. Modern diagnosis and surgery of bladder cancer. - Rostov-n / D, 2002. - 242 p.). The ureteral-reservoir anastomosis is finally sutured.

5. Additional cystostomy drainage is not installed. Thus, the reservoir is sutured tightly and drained exclusively transurethrally (Fig. No. 10 - the final view of the completed inverting orthotopic ileocystoplasty: an anastomosis with an urethra is performed; a Foley catheter is installed along the urethra in the neocyst cavity; the ureters are anastomosed with the leading segment using the Wallace method (anastomosis) ; ureteral stents are removed through the urethra), which minimizes the time required to restore self-urination in the operative period.

In the postoperative period, mucus is washed according to the Foley catheter - 3 r / day. Ureteric drainage is removed on the 8-12th day. On the 10-14th day, the urethral catheter is removed, self-urination is restored, and then after a day - two patients are discharged from the hospital.

The performance of the proposed method is confirmed by clinical examples.

Example 1

Patient P-in, 38 years old, turned to the urology department as planned with complaints of episodic macrohematuria for 8 months. A comprehensive examination established the diagnosis: primarily multiple, transitional cell carcinoma of the bladder T2amN0M0G4. The diagnosis was verified based on a TUR biopsy. Data for distant and regional lymphoid metastases were not received. Given the unfavorable prognostic factors (the stage of the process, the anaplastic structure of the tumor, the extremely high degree of aggressiveness, the maximum risk of recurrence and progression, the initially multiple tumor, the size of the tumor more than 3 cm in diameter, etc.), and also taking into account the patient’s age, it was decided to perform radical surgery in the scope of cystectomy, orthotopic enterocystoplasty by Studer. The stage of radical cystectomy was performed without technical difficulties, with a minimum blood loss of 150.0 ml. The length of the ileum mesentery was evaluated intraoperatively as sufficient to carry out the planned urine derivation technique. A typical small bowel resection 55 cm long was performed at a distance of 20 cm from the ileocecal angle. The resected intestinal segment is dissected from the distal end along the mesenteric edge for 40 cm while maintaining the tubular structure of the proximal segment - 15 cm. The detubularized part is symmetrically folded in a U-shape (vertex U is directed caudally), the posterior wall of the reservoir is sutured with a single-row, continuous continuous suture through all layers (Polysorb 3/0). The rear wall of the tank according to the Studer method is folded in the transverse direction and fixed with Alice clamps. The reservoir is lowered into the small pelvis for the final assessment of the possibility of unimpeded application of the anastomosis with the urethra. In this case, the presence of significant diastasis between the wall of the reservoir and the stump of the urethra was revealed, which causes tissue tension in the planned anastomosis. In this regard, it was decided to apply the claimed method of inverting orthotopic ileocystoplasty.

After removing the clamps, Alice performed longitudinal suturing of the reservoir with a single-row continuous continuous twisted serous-muscular-submucosal suture (Polysorb 3/0). An inverting positioning of the formed reservoir in the small pelvis was performed, after which an anastomosis was placed between the reservoir wall and the urethra without any tension, interrupted sutures through all layers, Polysorb 2/0, at 2, 4, 6, 8, 10, and 12 hours of the conventional dial . Stented ureters are retroperitoneally inserted through the incision of the parietal peritoneum and inserted into the abdominal cavity at the level of the upper edge of the adducting tubularized segment, anastomosed with the open end of the intestine of the advancing reservoir segment according to the Wallace method (Y-type anastomosis). Before the anastomosis is completely sutured, the ureteric stents are brought out through the formed reservoir through the urethra to the outside, in the opposite direction along the urethra, a Foley Ch No. 20 catheter is installed in the neocyst cavity.

The operation was carried out without technical difficulties, without the use of additional consumables, without increasing the operating time, without changing and complicating the technique and type of derivation of urine.

There were no complications in the postoperative period. Ureteric catheters removed on the 10th day. On the 12th day, the urethral catheter was removed, self-urination was restored. When examined after 3 months, the neocyst capacity is 390.0 ml, the maximum urination rate is 22 ml / sec, the full day urine retention, the full night urine, with one forced mix. The patient returned to his previous job. The maximum social and medical rehabilitation has been achieved.

Example 2

Patient G-ya, 43 years old, turned to the urology department in a planned manner with complaints of the presence of stranguria, macrohematuria for 1.5 years. Treated about hr. prostatitis. As a result of the examination, the diagnosis was established: transitional cell cancer of the bladder T2bN0M0G2, bilateral hydronephrosis. The diagnosis was verified based on a TUR biopsy.

A patient typically undergoes a radical cystectomy. Planned implementation of orthotopic sigmocystoplasty. Intraoperatively revealed the presence of a short sieve intestine of its mesentery, as well as an insufficiently mobile ileal mesentery. In order not to change the intraoperative variant of urine derivation to heterotopic or others, not to use much more traumatic, lengthy and complicated technical methods using the ileocecal angle, ascending, transverse and colon intestines or stomach, it was decided to use the method of inverting orthotopic ileocystoplasty.

A small bowel resection 55 cm long was performed at a distance of 20 cm from the ileocecal angle. The resected intestinal segment is dissected from the distal end along the mesenteric edge for 40 cm while maintaining the tubular structure of the proximal segment - 15 cm. The detubularized part is symmetrically folded in a U-shape (vertex U is directed caudally), the posterior wall of the reservoir is sutured with a single-row, continuous continuous suture through all layers (Polysorb 3/0). The reservoir was stitched longitudinally with a single-row continuous twisted serous-muscular-submucosal suture (Polysorb 3/0) by combining the opposite long sides so that a tubular U-shaped reservoir was obtained. An inverting positioning of the formed reservoir in the small pelvis was performed, after which an anastomosis was placed between the reservoir wall and the urethra without any tension, interrupted sutures through all layers, Polysorb 2/0, at 2, 4, 6, 8, 10, and 12 hours of the conventional dial . Stented ureters are anastomosed with the open end of the intestine of the inferior segment of the reservoir according to the Wallace method (Y-type anastomosis). Before the anastomosis is completely sutured, the ureteric stents are brought out through the formed reservoir through the urethra to the outside, in the opposite direction along the urethra, a Foley Ch No. 20 catheter is installed in the neocyst cavity.

There were no complications in the postoperative period. Ureteric catheters removed on the 12th day. On the 14th day, the urethral catheter was removed, self-urination was restored. When examined after 3 months, the neocyst capacity is 370.0 ml, the maximum urination rate is 26 ml / sec., Daytime urine retention is full, nighttime urine retention is complete, with one forced mikition. Maximum social and medical rehabilitation achieved

According to the proposed method of inverted orthotopic ileocystoplasty, we operated on 19 patients. Of these, 8 intraoperatively revealed the presence of a short ileal mesentery, which is offset by the technique of inverting orthotopic ileocystoplasty. Cases of insolvency of the reservoir or reservoir-urethral anastomosis were not noted.

The average capacity of the neocyst after removal of the urethral catheter is 110 ml, b / w 3 months - 350 ml, b / w 12 months - 490.0 ml. The maximum pressure in the tank does not exceed 40 cm water column (average 30 cm H ₂ O). Daytime retention - 94.7%, nightly retention with one forced night miktsii - 79.0%. Thus, the obtained functional results are not inferior to those with similar generally accepted methods.

In our practice, we did not encounter cases where, using the inverting orthotopic ileocystoplasty technique, tissue tension would be maintained in the area of the anastomosis with the urethra. However, it should be assumed that this situation is possible with excessively short vessels of the mesentery of the small intestine. The universality of the proposed method in this situation lies in the possibility of conversion with the transition to a heterotopic derivation. An already formed inverted iliac neocyst can be used for this purpose. In this case, the ureters are implanted into the wall of the reservoir according to the antireflux technique, and the adducing tubularized segment is used to form a retention valve according to one of the known methods.

The advantages of the proposed method of inverting orthotopic ileocystoplasty with a short ileum mesentery are as follows.

1) The operation is simpler and less laborious and expensive to provide in comparison with other methods of orthotopic intestinal reconstruction of the bladder today.

2) The proposed operation allows you to eliminate tissue tension in the anastomosis between the intestinal reservoir and the urethra and thereby prevent the most serious complications associated with the failure of the reservoir-urethral anastomosis (peritonitis, intestinal obstruction, sepsis), and therefore, eliminate the need for repeated operations.

3) Despite the insufficient length of the mesentery of the ileum, the proposed method allows you to safely perform orthotopic small intestinal reconstruction of the bladder as the most preferred and not switch to the less preferred - heterotopic, derivation into the continuous intestine, urine excretion on the skin, etc.

4) The minimum operation time and the amount of surgical trauma, exclusively transurethral drainage of orthotopic neocysts (suturing it tightly), minimize the patient’s stay in the hospital and make the patient’s rehabilitation as short as possible - urination is restored by 10-14 days and the patient is discharged from the hospital.

5) The proposed method allows you to perform ileum-intestinal orthotopic replacement of the bladder with short vessels of the ileum mesentery. Thus, even with the revealed intraoperative anatomical “contraindications”, the proposed operation allows not to refuse orthotopic cystoplasty as the most preferred by medical and social criteria. Therefore, the operation allows you to expand the indications for orthotopic small intestinal cystoplasty for cases when an insufficient length of the mesenteric vessels of the small intestine is revealed intraoperatively. As a result, this surgical technique provides the best quality of life for patients in this category after cystectomy.

6) Earlier removal of drains and the earliest possible restoration of self-urination allows you to achieve social rehabilitation of the patient with the restoration of adequate urine retention volume and quality of self-urination in the shortest possible time - no more than 1-3 months.

The universality of the proposed technique is as follows: if the surgeon, after performing the inverting orthotopic formation of the small intestinal reservoir, has the slightest doubt about maintaining tissue tension in the anastomosis with the urethra, the formed reservoir can be easily converted to heterotopic. In this case, the leading segment is used to form the retaining valve, and the ureters are transplanted directly into the tank wall according to the antireflux technique. This allows us to recommend this treatment method for widespread use in urological practice.

Claims (1)

The method of inverting orthotopic ileocystoplasty with a short ileum mesentery, which consists in the formation of a U-shaped orthotopic intestinal reservoir of low pressure from the ileum, characterized in that 55 cm of the ileum are resected at a distance of 20-25 cm from the ileocecal angle, dissected by an anti-mesenteric margin 40 cm long, the leading segment is maintained for 15 cm, the detubularized part is folded symmetrically U-shaped so that the vertex U is directed caudally and maximally at is close to the urethral stump, the adjacent edges are sutured, then the opposite long sides are combined so as to obtain a tubular U-shaped reservoir and sutured tightly, after which the formed reservoir is turned out and turned in a small basin between the mesentery sheets so that the back wall of the reservoir , free from the mesentery, is located anteriorly, and its free reduction into the small pelvis additionally reduces the distance to the stump of the urethra by 3-4 cm, anastomosis with urethra and walls are placed at the bottom of the reservoir th e ureters anastomose with the upper edge leading segment reflux procedure ureteral stents outputted through the reservoir through the urethra to the outside in the opposite direction in the cavity is set neotsista Foley catheter.

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