RU2371114C1 - Adenomectomy technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to urology. Retropubic extravesical approach is ensured. At first, on one side between urethra and rectum, two lines of longitudinal sutures of length approx. 3 cm are applied on prostatic capsule. The prostatic capsule is dissected longitudinally between ligatures. Urethra and neck of urinary bladder are separated from adenomatous knots. Then the same manipulations are performed from the opposite side. Husking of adenomatous knots is carried out under visual control, palpation control of a Foley catheter cylinder in bladder and under finger control through rectum. Then adenoma bed is sutured from both sides. Two dual-lumen catheters are applied in Retzius's cavity on both sides. The catheters are delivered through separate punctures out of the operative wound. The catheters are attached to active aspiration within one day.

EFFECT: method allows preventing intraoperative and early postoperative haemorrhage, maximally preserving neck of urinary bladder and prostatic urethra, and preventing sclerosis of neck of urinary bladder and urethral stricture.

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Description

The invention relates to medicine, in particular to urology. In case of prostate adenoma, operations such as post-cylindrical extravesical adenomectomy, described by various authors, are used: VV Goldberg “Surgery of the prostate adenoma”. Riga: Lat. Gos. Publishing House, 1960, pp. 100-107; A.S. Portnoy "Surgical treatment of adenoma and prostate cancer." Leningrad: “Medicine”, 1979, p.138-141; L.G. Managadze, N.L. Lopatkin, O.B. Laurent, D.Yu. Pushkar, etc. "Operational urology - a classic and an innovation." Moscow: “Medicine”, 2003, pp. 266-267.

The disadvantages of these operations:

1. Bleeding from a wound, in some cases it is necessary to resort to plugging the wound.

2. During the first 24-36 hours, urine contains a large amount of blood, which leads to clogging of the catheter with blood clots.

3. Leakage of urine into the posterior space with the subsequent development of osteitis of the pubic bones.

4. Excision of the prostatic part of the urethra can subsequently lead to cervical sclerosis to urethral stricture.

The prototype of our invention is proposed by Millin (Millin) in 1945, posadilon extravesical (retropubic) adenomectomy (VV Goldberg "Surgery of the prostate adenoma. Riga. Lat. State Publishing House, 1960, p.102-103.). The technique of Millin’s operation is as follows. When approaching through the suprapubic space, the veins are ligated over the prostate gland. Then, using a long clamp with a gauze ball at the end, the front surface of the prostate gland is released. On both sides of it gauze rollers are introduced. The border of the prostate gland is palpated towards the bladder, after which a true and false prostate capsule, right down to the adenoma, are dissected transversely above the right lobe, 1 cm anterior to the bladder neck, with a long scalpel. In this case, there is severe bleeding, to eliminate which it is necessary to use an aspirator. The lower part of the capsule is separated with long scissors and the edges are gripped by clamps. The same actions are performed on the left lobe, with both sections connected. After separation of the lower as well as the upper part of the capsule, the adenoma is exposed. Through the lower and upper edges of the dissected capsule, the sutures of the holder are held and the urethra is cut off at the very top of the adenoma. Then, pulling the lower holders, the adenoma is pulled out with the index finger in the direction from the bottom up until it remains to hang only on the mucous membrane of the neck of the bladder. The circular muscle fibers at the exit of the bladder are pushed up and the cuff of the mucous membrane is cut across at the base of the adenoma. After a temporary tamponade of the bed, the capsules are stretched with holders, grab the lower edge of the cystic border of the bed of the adenoma and a large wedge of tissue is cut from it. Millin performs a wedge-shaped excision of the edge of the internal opening of the urethra that protrudes above the bed in order to prevent contracture of the bladder neck. Hemostasis is carried out by electrocoagulation. After the catheter is inserted into the bladder, the transverse wound of the capsule is carefully sutured with a continuous catgut suture. Drainage is introduced into the back-space. This operation has all of the above disadvantages.

The purpose of the invention: the prevention of bleeding during surgery and in the early postoperative period, the maximum preservation of the bladder neck and prostatic urethra, the prevention of sclerosis of the bladder neck and urethral stricture.

The method is as follows. The patient is laid on his back and attached to a position arched in the pelvis. Legs slightly apart and bend. Access to the posterior space is carried out by the lower midline incision by dilating the rectus abdominis muscles and dissecting the prebubble fascia. A Foley catheter is inserted into the bladder with 30 ml of fluid introduced into the balloon. After the bladder neck and posterior urethra are released under the palpation control of a catheter balloon, first on one side between the urethra and rectum two rows of longitudinal sutures of about 3 cm are placed on the prostate capsule, the prostate capsule is cut longitudinally between the ligatures, the urethra and the bladder neck are separated from adenomatous nodes; then the same manipulations are carried out on the opposite side, adenomatous nodes are husked under visual control, by palpation of a balloon of a Foley catheter in the bladder and under the control of a finger through the rectum, after which the adenoma bed is sutured on each side, two two-lumen are placed in the prebubble space catheters, remove them through separate punctures outside the surgical wound and attach to active aspiration during the day.

Thus, we preserve the bladder neck and the prostatic urethra as much as possible, prevent bleeding during surgery and in the early postoperative period, and prevent further sclerosis of the bladder neck and urethral stricture.

A specific example of our invention is an adenomectomy in a patient, Mustafin R.A., 69 years old, case history No. 12859.

Date of receipt 05.23.07.

Diagnosis: adenoma of the prostate gland II tbsp.

According to ultrasound, the size of the prostate adenoma is 74 × 62 × 75, V-183 cc. 05/31/07, an operation was performed on the posterior urethral-sparing adenomectomy. The patient was laid on his back and placed in an arched position in the pelvis. Legs are slightly spread and bent. Access to the posterior space was made by the lower midline incision by dilating the rectus abdominis muscles and dissecting the prebubble fascia. A Foley catheter was inserted into the bladder with 30 ml of fluid injected into the balloon. After releasing the bladder neck and posterior urethra under palpation control of a catheter balloon, two rows of longitudinal sutures about 3 cm long were first placed on the prostate capsule on one side between the urethra and rectum, the prostate capsule was cut lengthwise between the ligatures, the urethra and the bladder neck were separated from adenomatous nodes; then the same manipulations were performed on the opposite side, the adenomatous nodes were husked under visual control, by palpation control of a balloon of a Foley catheter in the bladder and under the control of a finger through the rectum, after which the adenoma bed was sutured on each side, two double-lumen was placed in the prebubble space catheters, brought them out through separate punctures outside the surgical wound and attached to active aspiration during the day.

During the operation, there was practically no strong bleeding from the wound, which allowed under the control of vision in order to maximize the preservation of the urethra and neck of the bladder to hatch adenomatous nodes on each side. In the early postoperative period, there was practically no admixture of blood in the washing fluid. The postoperative period was uneventful. The patient was discharged on day 14 with self-urination. One year after the operation during the follow-up examination of complaints and complications were not observed.

Claims (1)

A method of adenomectomy, including posterior extravesicular access, characterized in that first, on the one hand, between the urethra and rectum, two rows of longitudinal sutures of about 3 cm are applied to the capsule of the prostate, the capsule of the prostate is cut longitudinally between the ligatures, the urethra and the neck of the bladder are separated from adenomatous nodes, then the same manipulations are carried out from the opposite side, husking of adenomatous nodes is performed under visual control, by palpation control of a balloon of a Foley catheter in evom bubble and under the control of a finger through the rectum, and then sutured adenoma bed on each side, mounted in predpuzyrnom space flanked by two double-lumen catheter, lead them through separate puncture wound is operating and connected to an active aspiration during the day.