RU2373868C1 - Method of surgical treatment of ureter pelvic part constriction in patients with ablated or non-functioning opposite kidney - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to urology, can be used in surgical treatment of ureter pelvic part constriction in patients with ablated or non-functioning opposite kidney. Medial laparotomy is performed. Health ureter of opposite ablated kidney is mobilised. After that frontward of main vessels retroperitoneal tunnel is formed. Through tunnel ureter is passed on the side of narrowed ureter, where lower kidney pole, pelvis and ureter proximal part are exposed within the limits of healthy tissues. Crossed uretero-ureteroanastomosis "end-to end" is formed.

EFFECT: method allows to preserve anatomo-functional state of ureterovesical segment, including ureter orifice, which will eliminate probability of its narrowing or vesicouretral reflux, as well as to create anastomosis which is functionally reliable and available for adequate drainage with stent or intubator.

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Description

The invention relates to medicine, namely to urology, and can be used for surgical treatment of narrowing of the pelvic ureter in patients with a removed or non-functioning opposite kidney.

With extensive ureteral contractions, two types of cross anastomoses between the ureters are performed: transureteroureteroanastomosis with unilateral nephrostomy (TUUN) [1, 2, 3] and ureteroureteroanastomosis "end to side" [4, 5]. Moreover, TUUN is used for extended defects in the lower third of both ureters (for example, after removal of the bladder).

As a prototype, we have chosen a method for the treatment of narrowing of the pelvic ureter [4, 5]. The method is used for the defeat of the entire pelvic ureter. The method consists in isolating the unchanged proximal part of the affected ureter, conducting into the contralateral retroperitoneal space and performing an end-to-side cross anastomosis with the opposite ureter.

The disadvantages of the prototype method are:

1. The created end-to-side cross anastomosis is not functionally reliable and accessible for adequate drainage of the VMP, stent or intubator.

2. Since the natural anatomical and functional state of the ureterovesical segment is not preserved, the prerequisites for the occurrence of vesicoureteral reflux are created.

3. The development of insolvency or stricture of the cross ureteric anastomosis can lead to obstruction of both kidneys, including a healthy one, the occurrence of bilateral hydronephrosis and a decrease in renal function.

The technical result of the invention is the preservation of the anatomical and functional state of the ureterovesical segment, including the mouth of the ureter, which eliminates the likelihood of its narrowing or vesicoureteral reflux, as well as the creation of a functionally reliable and affordable anastomosis for stent or intubation, which will prevent the development of anastomosis his stenosis.

The technical result is achieved by the fact that during surgical treatment of narrowing of the pelvic ureter in patients with a removed or non-functioning opposite kidney, median laparotomy is performed, a healthy ureter of the opposite kidney is mobilized. Then, an retroperitoneal tunnel is formed anterior to the main vessels, through which this ureter is led to the side of the narrowed ureter, where the lower pole of the kidney, pelvis, proximal part of the ureter are separated within healthy tissues and an end-to-end cross ureteroureteroanastomosis is formed.

The method is as follows.

Median laparotomy is performed, the colon is removed medially, the parietal peritoneum of the lateral canal is opened, a healthy ureter of the opposite kidney is mobilized throughout the lumbar region before moving to the pelvic region, where the ureteric vessels should be preserved if possible. Further, an retroperitoneal tunnel is formed anterior to the main vessels, through which this ureter is led to the side of the narrowed ureter. The lower pole of the kidney, the pelvis and the proximal part of the ureter are isolated within healthy tissues. On the stent, ureteropyelo- or ureteroureteroanastomosis "end to end" is performed. If necessary, the kidney can be pre-drained or nephrostomy during the operation. Retroperitoneal space is drained on both sides.

Distinctive essential features of the proposed method are:

1. Using a healthy ureter of the opposite kidney.

2. Type of cross ureteroureteroanastomosis "end to end".

A causal relationship between the salient features and the result:

1. The use of a healthy ureter of the opposite kidney, in contrast to the prototype method, which uses the affected ureter of one of the two functioning kidneys, allows you to save the anatomical and functional state of the ureterovesical segment.

2. The formation of the cross ureteroureteroanastomastosis "end to end", in contrast to the prototype method, during which an anastomosis is formed "end to side", allows you to save the mouth of the ureter, which eliminates the likelihood of its narrowing or vesicoureteral reflux, and also create a functionally reliable and available for adequate drainage of the urinary tract with an anastomosis stent or intubator.

The set of distinctive essential features allows you to save the anatomical and functional state of the ureterovesical segment, as well as create anastomosis that is functionally reliable and accessible for adequate drainage of the UMP with a stent or intubator, which prevents the development of its stenosis.

Examples of clinical performance.

Example 1. And / b No. 8672, patient M. 56 years.

The patient was admitted to the clinic of urology 01/20/2005, with complaints of pain in the right lumbar region. From the anamnesis it is known that ureterolithotomy on the right was performed in 1973, in 1984 - a resection of the lower third of the right ureter with removal of the stone and ureterocystoanastomosis, in 1993 - a nephrectomy on the left due to calculous pyonephrosis. An objective examination of the patient's condition is satisfactory, body temperature 37.5 ° C, blood pressure 150/100 mm RT. Art., the abdomen is soft, moderately painful, its lower pole is determined in the projection of the right kidney. Complete blood count: hemoglobin - 137 g / l, red blood cells - 4.0, white blood cells - 10.3, ESR - 25 mm / h. General analysis of urine: turbid, specific gravity - 1010, urine reaction - alkaline, white blood cells and red blood cells cover all fields of view. Biochemical blood tests: urea - 9.8 mmol / L, creatinine - 142 mmol / L, sugar - 4.87 mmol / L, total bilirubin - 14.7 mmol / L. On the survey x-ray of the urinary tract, the shadows of a coral-shaped stone are projected in the projection of the right kidney and three stones in the proximal part of the ureter of the removed left kidney, which is visible on the urogram (Figure 1). On the excretory urogram, the expansion of the cavity system of the right kidney and the abdominal ureter (Figure 2).

Diagnosis: Urolithiasis, recurrent stones of the right kidney, postoperative stricture of the right ureter, right hydroureteronephrosis. Stones of the left ureter stump, chronic pyelonephritis, chronic renal failure stage II. 02/03/05. - operation nephrolithotomy, nephrostomy, ureterolysis in the upper third of the right. The postoperative course is smooth, was discharged for outpatient treatment. 03/23/05. - re-hospitalization. The condition is satisfactory, nephrostomy drainage is functioning, there is no independent urination. With antegrade pyeloureterography, the CHS of the right kidney and the lumbar ureter are expanded, the contrast agent does not enter the bladder.

04/01/05 performed median laparotomy, resection of the stump of the left ureter with removal of stones. After that, the left ureter is held in the right retroperitoneal space, where ureteureteroanastomosis between the proximal part of the right and the distal part of the left ureter is made on the stent (Figure 3). No complications were observed in the postoperative period, the wound healed by primary intention. After stent removal on the 14th day, antegrade pyeloureterography on the right was performed: the abdominal cavity system was moderately enlarged, VMPs were well passable throughout. During the follow-up examination after 26 months, the patient's condition is satisfactory, with ultrasound, moderate pyelokalikoectasia, blood creatinine 124 μmol / L. Currently, the patient continues to work, satisfied with the quality of life.

After 2.5 years, we again had the opportunity to perform this kind of surgical intervention. We give this observation too.

Example 2. And / b No. 27443, patient M., 50 years old, was hospitalized in the urology clinic on September 17, 2007 with complaints of dull pain in the lower back on the right, weakness. From the anamnesis it is known that on 20.03.1991 in Odessa a pyelolithotomy was performed on the right, however, only one was removed from the three stones of the cavity system of the right kidney. The examination also revealed incomplete doubling of the left kidney. In the future, it was planned to conduct DLT, however, the patient was re-hospitalized due to renal colic, since one of the remaining calculi descended into the ureter. When trying to retrogradely push a stone into the abdominal system of the kidney at the Kiev Research Institute of Urology, the ureter in the lower third was damaged. Therefore, on May 24, 1991, a secondary lumbotomy was performed with renal decapsulation and pyelonephrostomy. Some time later, on 02.10.1991, indirect ureterocystanastomosis was performed according to Boari on the right. In April 1992, another attack of renal colic, examination revealed a stone of the lower third of the right ureter, 04/07/1992 transurethral ureterolithoextraction was performed on the right. During the same hospitalization, the patient developed purulent pyelonephritis on the left, the kidney was revised, its decapsulation and drainage. However, in December 1994, left nephrectomy was performed due to secondary nephrosclerosis. After this hospitalization, the patient was not observed. Over the past few months, I began to notice growing dull pain in the lower back on the right. Ultrasound revealed a sharp expansion of the right kidney kidney disease. When examining the department in laboratory indicators, attention is drawn to an increase in creatinine to 237 μmol / l, urea to 15.1 mmol / l, CF 34.4 ml / min. Performed infusion excretory urography, spiral computed tomography with intravenous contrast, which visualizes the narrowing of the pelvic ureter, a pronounced expansion of its lumbar region and the cavity system of the kidney (Figure 4). With cystoscopy, there are no changes in the bladder; on retrograde ureterography on the left, the expanded ureter remaining after nephrectomy is clearly visualized (Figure 5). In order to decompress the right kidney on September 26, 2007, a percutaneous puncture nephrostomy was performed on the right. After improving the general condition and biochemical parameters of blood, the patient is re-hospitalized for surgical treatment. Given the extent of stricture of the right ureter and the unchanged left ureter, it was decided to use it to replace a defect in the right ureter. 10.25.2007, the patient was taken for surgery. Performed a lower middle laparotomy, first left ureter, and then right throughout the lumbar. One of the ureters on the left above the area of their connection is resected and bandaged. After that, the left ureter is held in the right retroperitoneal space, where ureteureroanastomosis between the proximal part of the right and the distal part of the left ureter is performed on the stent (Figure 6). No complications were observed in the postoperative period, the wound healed by primary intention. Before stent removal, excretory urography was performed on day 14. The function of the right kidney is timely, the abdominal system is slightly expanded (Fig.7). During the follow-up examination after 2 months, the patient's condition is satisfactory, with ultrasound, moderate pyelokalikoectasia, blood creatinine 124 μmol / L. Currently, the patient continues to work, satisfied with the quality of life.

The inventive method in comparison with the prototype preserves the anatomical and functional state of the ureterovesical segment, including the mouth of the ureter, which eliminates the likelihood of its narrowing or vesicoureteral reflux. The method also creates anastomosis that is functionally reliable and accessible for adequate drainage of the VMP with a stent or intubator, which prevents the development of its stenosis.

Literature

1. Komyakov B.K., Guliev B.G. Surgery of extended narrowing of the ureters. St. Petersburg: Dialect, 2005.

2. Lopatkin N.A., Goldguber G.V. Lower ureteroureteroanastomosis with unilateral nephrostomy. Urol. and nephrol. 1985; 3: 23-25.

3. Komyakov B.K., Prokhozhev A.Yu. Supravesical derivation of urine is a palliative method for the treatment of patients with inoperable bladder cancer. Herald of Surgery named after Grekov 1998; 3: 18-21.

4. Pereverzev. Clinical urogynecology. Kharkov: Fact, 2000.

5. Frank J.J., Smith J.A. Surgery of the ureter. In: Campbell's urology, (7 th ed.). Philadelphia: W.B. Saunders Co. 1998; 3: 3062-3084.

Claims (1)

A method for surgical treatment of narrowing of the pelvic ureter in patients with a removed or non-functioning opposite kidney, which consists in performing a median laparotomy, mobilizing a healthy ureter of the opposite kidney, and then creating a retroperitoneal tunnel anterior to the main vessels through which this ureter is passed to the side of the narrowed ureter where the lower pole of the kidney, the pelvis, the proximal part of the ureter within the healthy tissues are isolated and a ureteroureter cross is formed nastomoz "end to end".

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