RU2408305C1 - Method of ortotopic iliocystoplasty in patients with meckel's diverticulum, freely located in abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for ortotopic ileocystoplasty in patients with Meckel's diverticulum, freely located in abdominal cavity. Meckel's diverticulum is laid caudad without its detubularisation. Iliac segment is detubularised on anti-mesenteric edge excluding base of Meckel's diverticulum, where detubularisation of ileum segment is carried out on its anterior surface closer to mesentery, forming flap, which will represent funnel-like narrowing passing into diverticulum. Anastomosis between Meckel's diverticulum and urethra is performed. During formation of anastomosis sutures are applied leaving knots outside lumen of reservoir and urethra.

EFFECT: method allows to form urinary bladder neck, provide possibility of extending reservoir to small pelvis, reduce risk of stone formation development.

1 ex, 4 dwg

Description

The invention relates to medicine, namely to oncourology, and may find application in performing orthotopic ileocystoplasty in patients with Meckel diverticulum, freely located in the abdominal cavity, in the surgical treatment of patients with bladder cancer.

It will be appropriate to cite the following anatomical remarks by Forg and Richard: “If we can give a general description of the formation, which is even larger than the rudimentary organ, is subject to very significant morphological variations, then we will readily say that the Meckel diverticulum is a vermiform appendix of the small intestine, which usually starts from lower ileum at least a meter away from the cecum. Most often, he moves away from the convex part of the intestinal loop ”(Mondor G. Emergency Diagnostics. Belly. Volume 1. St. Petersburg. - 1996 - ed. Gif. - S.201-202.).

With a wide variety of sizes, the Meckelian diverticulum occurs in three main forms:

1. A diverticulum attached to the navel, open or closed from the outside.

2. A diverticulum, fixed elsewhere in the abdominal cavity and attached either to internal organs, or, more often, to the mesentery.

3. A diverticulum freely located in the abdominal cavity.

The pathology of the Meckel diverticulum has been studied in sufficient detail.

Acute or chronic intestinal obstruction, acute diffuse or localized peritonitis, diverticulitis, diverticular hernias, umbilical-diverticular fistulas, tumors of diverticular origin, specific infections (tuberculosis, typhoid fever, etc.) - this is a list of the main lesions of Meckel diverticulum.

For acute peritonitis of diverticular origin, the same diverse symptoms are characteristic as for appendicitis. It is rightly pointed out that the Meckelian diverticulum is a worm-shaped process of the small intestine, which carries the danger of developing various serious pathological processes.

Currently, radical cystectomy is the method of choice for the surgical treatment of patients with invasive bladder cancer. Indications for surgery are:

invasive bladder cancer

- superficial cancer of a low degree of differentiation (stage T ₁ , G ₃ -G ₄ ) or cancer in situ,

- tumors that have shown resistance to intravesical therapy (stage T _a , G ₃ -G4 or cancer in situ),

- adenocarcinoma, squamous cell carcinoma, or bladder sarcoma.

Absolute contraindications include severe concomitant diseases and widespread bladder cancer with distant metastases.

Radical cystectomy in men implies the removal of a single bladder block with its peritoneum, perivesical adipose tissue, distal ureters, prostate, seminal vesicles, distal segments of the vas deferens with ampoules and lymph nodes. Urethral removal in case of radical cystectomy is indicated for patients with multifocal in situ cancer, involving the neck of the bladder and / or prostatic urethra. In women, radical cystectomy is known as anterior pelvic exenteration. This operation involves removal of the bladder with its peritoneum, the entire urethra, uterus, fallopian tubes, ovaries, anterior vaginal wall and pelvic lymph nodes. In most cases, only the anterior third of the vagina is resected, thus leaving enough wall for organ reconstruction.

The main issue that the surgeon has to solve after removing the bladder is the method of urine diversion. Derivation of urine over the past more than 100 years has passed certain stages of its development. To date, there are three options for urine diversion:

1. external urine diversion (ureterocutaneostomy; formation of “wet” growth: ileal conduit according to Bricker; continental skin urine derivation).

2. transplantation of the ureters into the sigmoid colon (bilateral uretero-sigmoid anastomosis according to Goodwin-Belt-Sorrentino, Mainz-pouch II, Atta).

3. orthotopic reconstruction of the bladder with self-urination in the urethra (gastrocystoplasty, ileocystoplasty according to Studer, Hautmann, VIP, Carney II, sigmocystoplasty).

Currently, ureterosigmoanastomosis is rarely used. Since this method of urine diversion is often complicated by the infectious and inflammatory process of the urinary tract and kidneys, often of a purulent nature. This method of derivation of urine can be used in patients with an expected short life expectancy due to neglect of the stage of bladder cancer.

Currently, preference is given to creating an orthotopic urinary reservoir with preserved urethral urination. When an orthotopic bladder reconstruction is planned for a patient, two important conditions must be met. First, the external sphincter should remain intact to ensure urine retention and controlled urination through the urethra. Second, the radicality of cancer surgery should not be compromised by the tumor tissue remaining in the urethra. If these two criteria can be met, the patient may be offered orthotopic reconstruction of the bladder after radical cystectomy.

One of the contraindications for this form of urinary diversion is renal failure. However, patients with impaired renal function due to obstruction of the ureters for decompression of the upper urinary tract can be performed percutaneous nephrostomy. Renal drainage subsequently leads to normalization of serum creatinine levels, which allows for orthotopic reconstruction.

The prototype of our proposed method is the method of orthotopic cystoplasty with a segment of the ileum according to Hautmann [Hautmann R.E., Egghart G., Frohneberg D., Miller K. The ileal neobladder // J.Urol. - 1988 .-- Vol. 139. - P.39-42; Hautmann R.E., Miller K., Steiner U., Wenderoth U. The ileal neobladder: 6 years of experience with more than 200 patients // J.Urol. - 1993 .-- Vol. 150. - P.40-45; Hautmann R.E., De Petriconi R., Gottfried H-W., Kleinschmidt K., Mattes R., Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup // J.Urol. - 1999. - Vol. 161 - P. 424-428]. The essence of the method is as follows. A midline incision is made from the pubic joint to the navel or slightly higher. Further, pelvic lymphadenectomy and standard radical cystectomy. The endopelvic fascia is opened, the puboprostatic ligaments are dissected, the dorsal venous complex is ligated. The urethra is cut off as close to the apex of the prostate as possible. The distal avascular mesenteric region between a is identified and dissected. ileocolica and terminal branches of the superior mesenteric artery. Thus, an ileal segment of approximately 60-70 cm is obtained. The distal 15 cm of the terminal ileum and the Bauginium valve are preserved. The ileum is dissected between the intestinal clamps. The continuity of the intestinal tube is restored by an end-to-end anastomosis. The defect in the mesentery is sutured. The resected ileum segment is moved to the pelvis and placed W-shaped. A silk suture is applied to the distal portion of the segment for ease of traction. Four fragments of the W-shaped segment are fastened to each other by 3 seams or Allis clamps. The entire iliac segment is opened strictly along the mesenteric margin. The formed ileum plateau is sutured with a continuous single-row 2-0 vicryl suture. In the center of the most caudal part of the ileum segment, an opening is created with a diameter of approximately the little finger. And on the Foley catheter pre-installed through the urethra, the iliac reservoir performs an anastomosis with the urethra. Commonly used is Vicryl 3-0. The seam goes from the inside of the iliac reservoir, then the urethra is stitched into the inside from the outside and returns more medially to the lumen of the anastomosis through the wall into the cavity of the reservoir. Thus, when tightened, the node appears in the lumen of neocystis. With easy catheter traction, the iliac reservoir directly matches the urethra. Usually 6 stitches are applied and they are tightened from the inside of the tank. Ureter implantation is performed after the urethroreservoir anastomosis. Ureteral implantation at this stage of the surgical intervention prevents the possibility of short cutting of the ureters or tension of the ureterreservar anastomoses. The ureters are implanted from the inside through small incisions in the neoplasm wall according to the method described by Carney and Le Duc [Carney M., Le Duc A. L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la opinie. Indications, technique operatoire, surveillance et resultats sur quatre-vingt-sept cas. // Ann.Urol. - 1979. - Vol.13. - P.114]. The mucous membrane is dissected and a deepening is created, a kind of mucous groove about 3 cm long. The ureters are fixed to the muscular membrane of the wall of the ileum by 2 sutures. The edges of the free mucosa are fixed laterally to the walls of the ureter with 2 or 3 sutures on each side. At the end of the anastomosis, the ureters for 3 cm lie in the mucosa of the groove on the muscle membrane of the neoplasm wall, which is a good antireflux mechanism. Mobilization of the right ureter is usually not necessary. The left ureter is passed through the mesentery of the sigmoid colon to the reservoir. The site of implantation of the ureters into the reservoir is chosen so that there is no tension and / or kinks. The ureteral intubators are brought out to the skin through the front wall of the neocystis. Uterine intubation usually lasts for 12 days. Then, the remaining portion of the front wall of the neo-bubble is also sutured with a continuous vicryl seam. According to a pre-installed Foley urethral catheter, usually 22 F, physiological saline is injected into the reservoir in order to determine the volume and exclude extravasation. When leaking, additional nodal seams are imposed. The urethral catheter is removed 18-20 days after cystography excludes leakage. Additionally, a 12 F cystostomy tube is installed, allowing control of the volume of residual urine after removal of the urethral catheter. At the end, two silicone drainages of 20 F are installed, one in the small pelvis, and the second - to the site of the ureterreservar anastomoses.

The disadvantages of the prototype are:

1. During the formation of the urethral reservoir anastomosis, the superimposed 6 ligatures are tied from the inside of the reservoir. Thus, the knots of the threads are in the lumen of the neocystis, which is the trigger mechanism of stone formation, the so-called "stones on the ligature."

2. In some patients, the mesentery of the small intestine short and ileum anatomically cannot be reached to the pelvis and urethra. In such cases, it is technically impossible to form an orthotopic reservoir according to the Hautmann method, and surgeons have to choose another method of orthotopic or even heterotopic cystoplasty.

3. The risk of developing various serious pathological processes associated with the presence of Meckel's diverticulum, freely located in the abdominal cavity of the patient.

The technical result of the invention is the ability to perform orthotopic ileocystoplasty in patients with Meckel diverticulum, freely located in the abdominal cavity, with a short mesentery of the small intestine, as well as reducing the risk of stone formation on ligatures in neocystis when performing orthotopic cystoplasty and eliminating the risk of various serious pathological processes associated with the presence of Meckel's diverticulum.

The technical result of the invention is achieved by resecting the ileum and laying it in a W-shape, followed by detubularization along the mesenteric edge and creating a spherical neocystis, and in the presence of Meckel’s diverticulum freely located in the abdominal cavity, it is laid caudally, without detubularizing, at the base Meckel’s diverticulum, detubularization of the ileum segment is carried out along its front surface closer to the mesentery, forming a flap. During the formation of the urethroreservoir anastomosis, sutures are imposed leaving nodes outside the lumen of the reservoir and the urethra.

The method is as follows:

After a midline incision from the pubic joint to the navel or slightly higher (the navel is bypassed on the left), a standard radical cystectomy is performed. Then a standard extended lymphadenectomy. The distal avascular region of the mesentery between a is identified. ileocolica and terminal branches of the superior mesenteric artery. Figure 1 illustrates the isolation of the ileum segment with a length of about 60 cm (1) along with Meckel's diverticulum (2). The distal 15 cm of the ileum and the bauginium valve retain. The intestine is crossed between the intestinal clamps. Figure 2 shows the restoration of the end-to-end anastomosis of the continuity of the intestinal tube. The defect in the mesentery (3) is sutured with interrupted vicryl sutures (4).

During the formation of the urethroreservoir anastomosis, sutures are imposed leaving nodes outside the lumen of the reservoir and the urethra.

It is easier to transpose the ileal segment into the small pelvis to the urethra if silk ligature is applied along the mesenteric edge at the base of Meckel’s diverticulum. Ligature serves as a guide during transposition. Then, the isolated iliac segment is laid W-shaped. The entire iliac segment is opened strictly along the mesenteric margin with the exception of 5 cm around the traction suture at the base of Meckel’s diverticulum. A further stage of the operation is reflected in figure 3. The diverticulum does not detubulate (2). At this point, the intestine is opened along the front edge closer to the mesentery. A U-shaped flap is created (5), which subsequently is a funnel-shaped narrowing, passing into a diverticulum, thus reconstructing the neck as in a native bladder.

The iliac plateau is sutured with a continuous 2-0 vicryl seam. Then, a dissector is inserted into the diverticulum, and a hole with a diameter of the little finger is created in its distal part for the future anastomosis with urethra. 6 vicryl sutures (3-0 vicryl) are applied from the inside out. (A Foley catheter, usually 22 F), is inserted transurethrally through this “new neck” of the bladder into the cavity of the reservoir. Then, on the Foley catheter, an urethroreservoir anastomosis is performed. Vicryl sutures are placed on the urethra from the inside out. Thus, when tying the nodes of the anastomosis are outside the lumen of the reservoir and the urethra.

The next step of the operation is illustrated in FIG. 4. Ureters are implanted after the reservoir (6) has been moved to the small pelvis and anastomosis has been performed between the Meckel diverticulum (2) and the urethra. The ureters are implanted outside the neocystis through a small incision in the ileum wall according to the method described by Carney and Le Duc. The implantation site is chosen so that the ureters lie without tension and excesses. At the site of transplantation, the mucous membrane of the ileum wall is dissected and a groove is created in the mucosa for 3 cm. The ureters are fixed to the muscle membrane of the neoplasm wall with 2 vicryl sutures. Then the edges of the mucosa are fixed laterally to the ureter wall with 2 or 3 sutures on each side. Upon completion of the formation of anastomosis, 3 cm of the distal part of the ureter lie in the mucosal groove on the muscle membrane of the neoplasm, thus creating a good antireflux mechanism. Mobilization of the right ureter is usually not necessary. The left ureter is passed through the mesentery of the sigmoid colon to the reservoir. Ureters are intubated with polyvinyl chloride tubes, usually within 12 days. The ureteral intubators are removed through the front wall of the reservoir and then separately through the front abdominal wall. Next, close the front wall of the tank. Through the urethral catheter, the tightness of the joints of the reservoir is checked. In case of leakage, additional nodal vikrilny seams are imposed. The urethral catheter is held for 14-16 days, before its removal, a cystogram is performed to exclude the extravasation of the contrast medium. After installing drainage in the pelvis and to the site of the ureterreservar anastomoses, the wound is sutured in layers.

Distinctive features of the invention are:

- in the presence of Meckel's diverticulum, freely located in the abdominal cavity, it is laid caudally;

- Meckel’s diverticulum does not detubulate;

- at the base of Meckel’s diverticulum, the ileum segment is detubularized along its front surface closer to the mesentery, forming a flap;

- during the formation of the urethroreservoir anastomosis, the sutures are imposed leaving nodes outside the lumen of the reservoir and the urethra.

A causal relationship between the distinctive essential features and the achieved result:

In some cases, patients have a short mesentery of the small intestine, and the isolated segment of the ileum does not reach the urethra. Meckel’s diverticulum is a kind of worm-shaped process of the small intestine, serves as a kind of “insertion” between the urethra and the orthotopic reservoir. Thus, he eliminates this drawback and makes technically feasible orthotopic plastic surgery.

The sutures during the formation of the urethral reservoir anastomosis are superimposed outside the lumen of the urethra and neo-bubble, thus, the node appears outside the anastomosis, which reduces the likelihood of stone formation on the ligatures in the neocystis. This result is achieved by the fact that with the claimed method, the diverticulum is not excised, but is an integral part of the reservoir. An undetubularized diverticulum is a continuation of the spherical reservoir and is located caudally in relation to it. It serves as a kind of “insertion” between the urethra and neocystis proper.

If the diverticulum is non-tubular and the ileum segment is detubularized at the base of the Meckel diverticulum, an U-shaped flap is created on the front surface of the ileum closer to the mesentery, which later takes the form of a cone-shaped funnel, which becomes a diverticulum. Thus, Meckel’s diverticulum serves as the new physiological neck of neocystis, which is as close as possible to the shape of the natural neck in the native bladder.

Resecting the ileum segment with Meckel’s diverticulum, the anatomical substrate is eliminated, which carries the danger of developing various serious pathological processes.

The essence of the method is illustrated by an example from clinical practice.

Example.

Patient T., 56 years old, and / b No. 32949 - SB, was re-hospitalized, as planned, on October 31, 2008, to the urology department of the city multidisciplinary hospital (GMPB No. 2, S-Pb) with complaints of periodic admixture of blood in the urine, pain in the lower abdomen.

Upon admission, the patient's condition is satisfactory, clear consciousness, skin integument of usual color, peripheral lymph nodes are not enlarged, no edema. Hemodynamic parameters within normal limits, blood pressure 120/85 mm Hg On palpation - internal organs without features. Urination is free, urine is mixed with blood. In the clinic, the patient performed:

Electrocardiogram: sinus rhythm, heart rate 79 beats / min. Local disturbance of intraventricular conduction. Incomplete blockade of the right bundle branch block.

Fluorography - without pathological changes.

Computed tomography of the bladder: a bladder of sufficient volume, a pathological volume of 35 × 35 mm is visualized on the posterior and right lateral walls, the walls of the bladder in the base area are thickened. Lymph nodes of the pelvis are not changed.

Ultrasound examination: abdominal organs without pathology, no metastases. The kidneys are unchanged. The bladder contains 200 ml of urine; in the projection of the posterior wall and the right lateral wall, hyperechoic tissue formation of 35x35 mm is visualized.

Cystoscopy: on the back and right walls, departing 2-2.5 cm from the neck of the bladder, a tumor formation is visualized on a wide base with a diameter of about 3.5 cm, protruding into the lumen of the bladder.

Blood test: Lake. - 7.5 × 10/9, erythro. - 4.2 × 10/12, hemoglobin - 135 g / l, platelets - 350 thousand, lymphocytes - 31, monocytes - 7, neutrophils - 58, stab - 2, eosinophils - 2, basophils - 1, ALT - 27 mmol / l, ACT - 25 mmol / l, total protein - 77 g / l, urea - 4.5 mmol / l, creatinine - 90 mmol / l, total bilirubin. - 7.7 μmol / L, glucose - 4.0 mmol / L, prothrombin - 100%.

Urinalysis: pink, slightly turbid, specific gravity 1015, acidic reaction, protein 0.010 g / l, white blood cells 8-10 in n / a, red blood cells 30-40 in n / a, flat epithelium 0-1-2 in n / sp., mucus ++. Urine cultures did not give rise.

TUR (transurethral resection); a bladder biopsy was performed on July 30, 2008 (i / b 23189 СО). Histology No. 164299-58 of 07/31/2008: "Moderately differentiated transitional cell carcinoma with clear cell metaplasia and invasion of the muscle layer." Given the presence of muscle-invasive cancer in the patient, the absence of severe somatic diseases, it was decided to perform a cystectomy with the formation of an orthotopic urinary reservoir by the ileum segment.

11.11.2008, the patient was taken for surgery.

Under endotracheal anesthesia and spinal anesthesia, a lower middle laparotomy was performed. Bandaged and crossed vas deferens. The ureters are isolated in the lower third to the juxtavesical section, cut off from the bladder and intubated. Performed a radical cystoprostat vesiculectomy. During the audit of the abdominal organs, the patient revealed Meckel diverticulum, as well as a short mesentery of the small intestine, that is, the length of the mesentery is insufficient to transpose the ileum segment to the urethra. Retreating 15 cm from the ileocecal angle, a 60 cm ileum segment was taken, including Meckel’s diverticulum. The iliac reservoir is created from an isolated iliac segment according to the Hautmann method in our modification. The integrity of the edges of the ileum mesentery, through which the mesentery of the reservoir passes, has been restored by knotted vicryl sutures (2-0). The continuity of the intestinal tube was restored by serous-muscular single-row interrupted sutures (3-0 vicryl). A silk ligature was applied along the mesenteric margin at the base of Meckel's diverticulum. Ligature serves as a guide during transposition. Then, the isolated iliac segment was laid W-shaped. The entire iliac segment was opened strictly along the mesenteric margin with the exception of 5 cm around the traction suture at the base of Meckel’s diverticulum. The diverticulum is undetubularized. At this point, the intestine was opened along the front edge closer to the mesentery. A U-shaped flap was created, which later became a funnel-shaped narrowing, turning into a diverticulum. Thus, the neck was reconstructed as in a native bladder.

A Foley catheter 22 F was transurethrally inserted into the cavity of the reservoir through the “new neck” of the bladder. Then, a urethroreservoir anastomosis was performed on the Foley catheter. Vicryl sutures were placed on the urethra from the inside out. Thus, when tying the nodes of the anastomosis were outside the lumen of the reservoir and urethra. Next, implantation of the ureters is carried out. The ureters are implanted from the inside through small incisions in the neoplasm wall according to the technique described by Carney and Le Duc. The left ureter was passed through the mesentery of the sigmoid colon to the reservoir. The right ureter was intubated with a polyvinyl chloride tube; a stent was installed in the left ureter. The right ureter intubator was brought to the skin through the front wall of the neocystis. Then, the remaining portion of the front wall of the neo-bubble was also sutured with a continuous vicryl seam.

The wound is sutured in layers. In the postoperative period, antibiotic therapy, infusion and detoxification therapy were carried out. The postoperative period was uneventful, the ureteric intubators and stent were removed on the 12th day, the urethral catheter on the 18th. Independent urination was restored, the patient did not notice any urine leakage, he got up at night after 2 hours. After the operation, intravenous urography was performed: renal function was satisfactory, the abdominal cavity systems and ureters were not expanded.

According to the results of descending cystography, a reservoir of 300 ml. When mixing cystography data for vesicoureteral reflux was not obtained. Blood test: White blood cells - 6.2 × 10/9, red blood cells - 4.4 × 10/12, hemoglobin - 127 g / l, platelets - 350 thousand, lymphocytes - 31, monocytes - 07, neutrophils - 63, p / i - 3, s / nuclear - 43, eosinophils - 2, basophils - 0, ALT - 20 mmol / l, ACT - 31 mmol / l, total protein - 72 g / l, creatinine - 100 μmol / l, glucose - 4 1 mmol / L.

Urinalysis: light yellow, cloudy, beats. weight 1017, neutral reaction, protein 0.015, white blood cells 10-15 in n / a., flat epithelium 0-1 in n / a, mucus ++.

November 30, 2008, the patient in satisfactory condition was discharged under the supervision of an oncourologist at the place of residence. Dynamic observation is recommended, taking uroseptics. Control examination after 2 months.

During the control examination 2 months after the operation, the patient's condition is satisfactory. Urinary incontinence is not noted. Renal function is satisfactory, pyelocaliceal systems are not expanded. The bladder on the cystogram is rounded, there is no vesicoureteral reflux. The volume of the tank is 400 ml. With uroflowmetry, the maximum urination rate is 19 ml / s, the average is 14.7. With cystometry, the intravesical pressure at the first urge to urinate is 18 cm water column and the maximum is 38 cm water column. The patient does not note day and night enuresis. The frequency of urination in the daytime does not exceed 7 times, at night it rises to urinate no more than 1 time.

Conclusion: the patient's condition is satisfactory, urodynamic indicators are normal. Rehabilitation of the patient is completed.

To date, 4 cystectomy in men for bladder cancer of the proposed method.

The proposed method, in comparison with the prototype, has a number of significant advantages, namely:

- the ability to perform orthotopic ileocystoplasty in patients with Meckel diverticulum, freely located in the abdominal cavity, with a short mesentery of the small intestine;

- reducing the risk of stone formation on ligatures in neocystis when performing orthotopic cystoplasty;

- elimination of the risk of developing various serious pathological processes associated with the presence of Meckel's diverticulum.

The method was developed in the Department of Urology of the city multidisciplinary hospital No. 2 of St. Petersburg and passed clinical testing of 4 patients with positive results.

Claims (1)

Method of orthotopic ileocystoplasty in patients with Meckel’s diverticulum freely located in the abdominal cavity, which consists in resection of the ileum and laying it in a W-shape, its detubulation with the creation of a neocystis of a spherical shape and the formation of a urethroreserve anastomosis, characterized in that if the patient has a divulus of uterus freely located in the abdominal cavity, it is laid caudally without its detubularization, the ileal segment is detubularized along the anti-mesenteric edge, except the base of the Meckel’s diverticulum, where the ileum segment is detubularized along its front surface closer to the mesentery, forming a flap, which will be a funnel-shaped narrowing that turns into a diverticulum, anastomosis is performed between Meckel’s diverticulum and the urethra, while the anastomosis forms, nodes outside the lumen of the reservoir and urethra.

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