RU2407463C1 - Method of surgical treatment of extended strictures and obliterations of ureter - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to urology and can be applied for surgical treatment of extended strictures and obliterations of ureter. Cicatricial stenosed part of ureter is dissected. Proximal and distal ends of ureter are sewn on their posterior surface in form of semi-circle. Anterior walls of ureter ends are cut in longitudinal direction. Patch from autotransplant of skin mucosa is sewn into formed defect. ^ EFFECT: method allows to increase extension of corrected stenoses, reduce risk of recurrence development. ^ 1 ex, 1 dwg

Description

The invention relates to medicine, in particular to urology, and can be used for surgical correction of strictures and obliterations of the ureter, up to 5 cm long.

The fundamental principle for the treatment of ureteral obliteration requires maximum excision of the obstructive cicatricial ureter and restoration of continuity and adequate clearance of the ureter.

A surgical method is known for treating ureteral strictures by suturing into a longitudinally dissected narrowing of a “patch” from an autograft of the mucous membrane of the cheek and enveloping the site of graft implantation with an omentum for better revascularization. (J.H. Naude Buccal mucosal grafts in the treatment of ureteric lesions. - B.J.U. International. - 1999. - Vol.83. - P.751-754.)

The disadvantage of this method is that it can only be used for narrowing of the ureter while maintaining the lumen of the latter. This method cannot be used for obliteration. Enveloped with an omentum at the site of implantation can lead to the development of circular stenosis due to scarring of the omentum. In this case, repeated surgery on the ureter (in case of relapse) is sharply complicated due to the numerous cicatricial fusion of the ureter with the omentum.

Closest to the proposed is a method of surgical treatment of extended strictures and obliterations of the ureter, including excision of the scar-stenotic part with the subsequent connection of the proximal and distal ends of the ureter. (Kang D.V. Reconstructive surgery of the ureter. - M.: Medicine, 1973. - P.106). The proximal and distal ends of the ureter are connected end-to-end.

However, it was established that this is not always possible, since matching the ends of the ureter without tension is possible only if there is a defect of the latter not more than 3-5 cm.

Surgical experience shows that from the place of obliteration of the ureter, cicatricial changes in the wall of the latter extend in the proximal and distal directions by at least 1.5-2.0 cm. In this regard, when resecting the maximum allowable 5 cm of the obliterated ureter and applying an anastomosis “end to end” "There is a stitching of deliberately narrowed ends of the ureter, with cicatricial changes in the wall. This subsequently leads to relapse of stricture and obliteration.

In accordance with this task, aimed at expanding the functionality of the method by increasing the length of the correctable stenosis of the ureter, as well as increasing the effectiveness of treatment by reducing the number of postoperative relapses.

The problem is solved in that in the method of surgical treatment of extended strictures and obliterations of the ureter, including excision of the scar-stenotic part with the subsequent connection of the proximal and distal ends of the ureter, it is suggested that after excision the proximal and distal ends of the ureter are sewn along their posterior surface in the form of a semicircle, then longitudinally dissect the front walls of the ends of the ureter, and sew a patch from the autograft of the mucous cheek into the defect that has formed.

The drawing schematically shows the sequence of operations.

The method is as follows.

Surgical access is carried out depending on the affected ureter - to the upper third, middle third, or lower third. The operation is performed under endotracheal anesthesia. After isolation of an extended stricture or obliterated portion of the ureter, the latter is excised. The maximum possible obliteration is 5 cm. Then, the proximal and distal ends of the ureter are sutured along the posterior semicircle with separate atraumatic sutures. The front walls of the proximal and distal segments of the ureter are longitudinally dissected throughout the scarred or narrowed part. In this case, the incision should be with some margin and go into healthy tissue by 0.5 cm. This is done in order to better revascularize the graft that is filed into this zone. After this, the ureter is intubated with a urethral stent No. 8. The total length of the defect in the anterior wall of the ureter is measured. According to the generally accepted method, an autograft of the mucous membrane of the cheek is oval. Graft revascularization occurs from the mesenteric zone of the descending and sigmoid colon with plastic surgery of the left ureter and from the mesenteric zone of the cecum and ascending colon with plastic surgery of the right ureter. The pelvic ureters carry out revascularization due to the parietal peritoneum, which has great plastic capabilities. That is why it is important to place the graft on the front wall of the ureter. In this way, the gland wraps around the operation area, which prevents the adhesion process. Given that the graft is reduced after the fence, its length should be 1 cm longer than the length of the defect. After this, the graft as a patch is sutured with separate sutures with an atraumatic suture material by the epithelium into the ureter lumen. Then, on the sides of the graft on the front wall impose the final seams of the ureteric anastomosis. An insurance drainage is retroperitoneally brought to the place of operation. Uterine stenting is carried out for 3 months. Insurance drainage is removed after the cessation of wound discharge.

A specific example of the method.

Example 1

Patient K., 56 years old, case history No. 795

Diagnosis: Iatrogenic obliteration of the middle third of the left ureter. Puncture nephrostoma on the left. Condition after remote lithotripsy of the stone of the middle third of the left ureter, contact ureterolithotripsy of the stone of the middle third of the left ureter, complicated by perforation of the ureter.

The patient underwent surgery as follows. Under endotracheal anesthesia, retroperitoneal access was made to the obliterated ureter by an incision according to Bergman-Irael. In retroperitoneal tissue, a pronounced sclerotic process. The cicatricial obliterated segment of the ureter 5 cm long is excised. However, the proximal and distal parts of the ureter on the cut do not bleed and are narrowed for 1.5 cm each. The posterior semicircle of the ureter was stitched with separate atraumatic vicryl sutures No. 4/0. The ureter is intubated with ureteral stent No. 8. The front surface of both segments of the ureters is dissected for 2.0 cm in the longitudinal direction until active bleeding from the edges of the incision appears, which indirectly indicated the adequacy of blood circulation in the wall. According to the generally accepted technique, an autograft of the mucosa of the cheek is oval in shape with a length of 5 cm. Then, the autograft has been sutured with the mucous epithelium inside with separate No. 4/0 Vicryl sutures. Then, seams were placed on the sides of the autograft to complete ureteroureteroanastomosis in the anterior semicircle. The insurance drainage through the counter-puncture in the lumbar region was brought to the operation site. After stent removal, excretory urography was performed after 3 months. Uterine patency restored.

The proposed method is technically simple, non-dramatic, provides a reduction in postoperative relapse.

Claims (1)

A method for the surgical treatment of extended strictures and obliterations of the ureter, including excision of the scar-stenotic part with the subsequent connection of the proximal and distal ends of the ureter, characterized in that after excision, the proximal and distal ends of the ureter are sewn along their posterior surface in the form of a semicircle, then the anterior ones are cut in the longitudinal direction the walls of the ends of the ureter, and a patch from the autograft of the cheek mucosa is sewn into the resulting defect.

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