RU2423927C1 - Method of urine derivation after radical cystectomy - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to urologic oncology and can be used for urine derivation after radical cystectomy. For this purpose after ablation of urinary bladder sigmoid colon is transected on the border of middle and lower thirds with sewing distal end of cut off part of colon tightly. Interintestinal anastomosis "end-to-side" is formed by means of circular suturing device. After that implantation of ureters into formed urine reservoir is performed through separate micro-cuts on the line of mesentery attachment. At the same time, additionally edges of ureters are sewn through cut in sigmoid colon on the line of their intersection with colon mucosa with further muff-like "covering" sigmoid colon with mesentery along 2.5-3 cm zone of ureter-sigmoid-anastomoses and distal ends of ureters, preliminarily intubated with uretral stents. After that, urine reservoir cut is sutured and fixed to anterior abdominal wall, through which ureteral stents are passed outside. ^ EFFECT: method makes it possible to reduce risk of post-operation complications development: anastomoses failure, attacks of acute pyelonephritis, ureter stricture and reduce operation time. ^ 1 ex, 1 dwg

Description

The invention relates to medicine, more specifically to oncology, and may find application in the treatment of invasive bladder cancer.

Tumors of the bladder (MP) constitute, according to WHO, 70% of all neoplasms of the urinary tract. In invasive cancer of the MP, as a rule, a radical cystectomy is performed. The main problem that has to be solved in this case is the derivation of urine. Various methods of urine derivation have been developed: its external diversion, the creation of intestinal reservoirs, which serve as MPs, providing the possibility of independent controlled urination, as well as the internal diversion of urine into the continuous intestine by creating a reservoir with transanal urination. Various operations are known for creating reservoirs from segments of the small or large intestine opening into the sigmoid or rectum. In this case, it is possible to obtain a partial separation of urine and feces, as well as to reduce the likelihood of developing gas or fecal reflux in the ureters. Such operations also include the creation of urinary reservoirs from the sigmoid colon segment. This type of urinary reservoir with transanal diversion of urine was first described in 1904 by Muscatello. Then it was modernized, supplemented with antireflux protection of the ureters and the creation of a large intestinal invaginate, located proximal to the large intestine anastomosis, performed on the type of "end to side" or "side to side".

The present invention relates to transanal urine diversion in patients suffering from malignant neoplasms of MP in stage T2-4NxMx, associated with concomitant diseases, with the formation of a urinary reservoir from a partially isolated section of the sigmoid colon created by its intersection and the application of end-to-side sigma-sigmoid anastomosis .

Closest to the proposed is the method described in the book Kucera J. [Urologische operationslehre, Leipzig, 1969, s.70-73], selected by us as a prototype. This method is carried out by forming the urinary reservoir by crossing the sigmoid colon at a distance of about 20 cm from the rectosigmoid colon, the distal end of the reservoir is drowned, the proximal end of the sigmoid colon is used to apply the end-to-side inter-intestinal anastomosis, the isolated ureters also anastomose from the sigmoid colon by type "end to side".

The advantages of the prototype include, in our opinion, the use of a sigmoid colon segment for the formation of the urinary reservoir. This is supported by the fact that the sigmoid colon is topically and genetically close to MP. Its segment secretes the least amount of mucus. When a segment of the sigmoid colon with the mesentery is excreted, the root of which is located in the left half of the pelvis, there is less risk of bowel obstruction compared with the same intervention, for example, on the small or cecum. Urine reabsorption is less pronounced in the mucous membrane of the sigmoid colon. When transplanting the ureters into it, their minimal displacement from their natural position occurs. All this distinguishes the prototype method from other known methods of forming a urinary reservoir. But still, the method is not without some drawbacks, which include:

- Insufficient reliability of the formed anastomoses: inter-intestinal - due to manual stitching of the intestine, ureterosigmoanastomoses - as a result of the use of single-row sutures. In some cases, this can lead to the failure of anastomoses with the development of peritonitis.

- The implantation of the ureters into the distal stump of the sigmoid colon performed by the authors does not provide their antireflux protection, which is associated with a risk of infection of the upper urinary tract.

- The absence of ureteral stents, as follows from the illustrations in the prototype illustrations, can increase the likelihood of insolvency of ureterosigmoanastomoses due to the lack of decompression of the anastomoses. And even in the case of using stents, but removing them outside through the rectum, which was accepted in those years and is used mainly at the present time, it can cause acute pyelonephritis in the early postoperative period due to retrograde infection of the upper urinary tract due to the dislocation of the intestinal flora along the stents in the tank. In addition, when stents are located in the rectum, the likelihood of their displacement during defecation and when the patient's position in bed increases.

The technical result of the present invention consists in increasing the viability of the formed anastomoses through the use of a circular stapler, double-row sealing of them and installation of urethral stents with their removal to the anterior abdominal wall.

This result is achieved by the fact that in the known method of urine derivation after radical cystectomy, including the formation of the urinary reservoir by crossing the sigmoid colon at the border of the lower and middle third of it, forming the stump of the sigmoid colon and applying an end-to-side sigmoid sigmoid anastomosis the level of the rectosigmoid colon, the subsequent excretion of the ureters and the application of ureterosigmoanastomoses, according to the invention, after the formation of a stump of the sigmoid colon, it is longitudinally dissected to the neural edge, taenia libera, extending 4–9 cm from the stump of the urinary reservoir 7–9 cm, the formation of sigmoid-sigmoid anastomosis is performed through this incision using a circular stapler, and ureterosigmoid anastomosis is applied by implanting the ureters into the formed urinary reservoir along the line attachment of the mesentery of the intestine at a distance of at least 3 cm between them after preliminary conducting the ureters through the oval holes made in the mesentery, and 5-6 cm from the stump, suturing between seros the intestinal membrane and the walls of the ureters and additional stitching through the incision in the sigmoid colon of the edges of the ureters along the line of their intersection with the intestinal mucosa with the subsequent “shelter” of the mesentery of the sigmoid colon over the 2.5-3 cm zone of ureterosigmoanastomoses and distal ends of the ureters previously intubated with urethral stents , after which the incision of the urinary reservoir is sutured and fixed to the anterior abdominal wall, through which the urethral stents are brought out.

The method of urine derivation that we create is based on the above advantages of the sigmoid colon for the formation of the urinary reservoir.

A known method of forming a urinary reservoir using a segment of the sigmoid colon formed by the type of "side to side" ["Continental heterotopic derivation of urine into a partially isolated segment of the sigmoid colon after cystoprostatectomy" Urology, 2009; 3: 48-51], the authors of which note the advantages of this method compared to the prototype we have chosen. However, this method is associated with the presence of additional sutures in the proximal end of the sigmoid colon, insufficient reliability of manual stitching when an intestinal anastomosis is applied, which can cause its failure and, as a result, serious complications, up to peritonitis. The application of an endo-intestinal inter-intestinal anastomosis eliminates the need for suturing in the proximal section of the crossed sigmoid colon, thereby preventing the possibility of additional complications.

Dissection of the sigmoid colon along the mesenteric margin allows, firstly, to use a circular suturing apparatus, thereby increasing the reliability of the formed sigmoid-sigmoid anastomosis (in the prototype, the use of a suturing apparatus is not possible), and secondly, it allows additional suturing of the sigmoid colon from the side of its lumen edges of the ureters along the line of their intersection when applying ureterosigmoanastomoses, which makes the anastomosis more hermetic.

Dissection of the sigmoid colon along the mesenteric margin also allows, if necessary, to eliminate the excess length of the ureters by resecting them from the side of the intestinal lumen to prevent excesses of the ureters with an excessively long length.

Dissection of the sigmoid colon to a length of 4-5 cm allows the formation of the ureter-intestinal anastomoses from a single access. This incision length provides, in addition, the freedom of surgical manipulation even with a 3 cm distance between implantable ureters.

Dissection of the sigmoid colon along the mesenteric margin, tenia libera, in addition, does not cause functionally significant damage to the circular smooth muscle muscles and saves the possibility of isoperistaltic contraction of the sigmoid colon used to create the urinary reservoir. Thus, without violating the physiological mechanisms of antireflux protection due to the fact that the sigmoid colon is isoperistaltically relative to the inter-intestinal anastomosis, reflux to the created urinary reservoir of intestinal contents is prevented without creating additional antireflux mechanisms and, therefore, infection of the upper urinary tract.

A distance of 7-9 cm from the stump of the urinary reservoir for dissection of the sigmoid colon allows you to avoid bowel deformation when it is sutured at the level of previously formed ureteral anastomoses.

Implantation of the ureters into the formed urinary reservoir on the mesenteric margin of it ensures quick and reliable healing along the suture line of anastomoses, which, as you know, depends on the proper blood supply to the walls of the stitched organs.

The creation of oval holes made in the mesentery allows the ureters to pass to the urinary reservoir along the shortest path, while preventing the possibility of their bending.

The sleeve-like “shelter” of the ureterosigmoanastomosis zone of the mesentery of the sigmoid colon over 2.5-3 cm of the distal ends of the ureters additionally increases the tightness of these anastomoses.

The removal of ureteral stents to the outside through an isolated segment of the sigmoid colon eliminates, firstly, contact of the stents with the contents of the intestine, preventing the possibility of retrograde infection of the upper urinary tract, and secondly, it allows for controlled decompression of the created ureterosigmoid anastomoses and thereby avoiding urinary leakage in case of their failure. Fixation of stents on the anterior abdominal wall also excludes the possibility of their unintentional extraction. In debilitated patients, in whom prolongation of the terms of reliable healing of anastomoses can be expected, stents allow radiographic monitoring of the viability of anastomoses and the optimal timing of their removal. In addition, such fixation of stents provides patients with better tolerance of the postoperative period, without fear of the possibility of their unintentional displacement during bowel movements.

The essence of the method is as follows.

Under general anesthesia, a lower middle laparotomy is performed.

After radical cystectomy, lymphodissection is performed along the iliac vessels and mobilization of the ureters while preserving paraurethral tissue. Next, the colon is mobilized from its splenic angle to the upper ampullar part of the rectum and intersected with the Ethicon® TLH 30 stitching apparatus (Johnson & Johnson) at the border of the upper and middle third of the sigmoid colon with the closure of the distal end of the disconnected part of the intestine. The sigmoid colon is dissected along the mesenteric margin, departing from the stump 7–9 cm, for 4–5 cm. Then, an end-to-side inter-intestinal anastomosis is formed using the Ethicon® CDH 25 circular stapler (Johnson 6 Johnson) passed through a previously performed longitudinal section in the sigmoid colon. A “window” is formed in the mesentery of the small intestine, through which the right ureter is led to the reservoir, and the left ureter through the mesentery of the sigmoid colon. Ureters are intubated with ureteral stents up to 90 cm in length. Next, the ureters are implanted in the disconnected segment of the sigmoid colon through separate micro-incisions in the small section of the intestine not covered by the peritoneum (pars nuda) into the lumen of the reservoir, departing from the stump 5-6 cm. The ureter is located on the posterior semicircle - intestinal anastomosis fixing sutures are applied between the serous membrane of the intestine and the wall of the ureter, followed by a sleeve-like sealing of the mesentery of the intestine. The stump of the left ureter, protruding into the lumen of the reservoir, adapts to the desired length by resection, is longitudinally dissected, and the edge of the ureter along the incision line is anastomosed from the intestinal mucosa with a Prolen 5-0 thread. Similarly, a second anastomosis is applied at a distance of at least 3 cm from the previous one. Then, the previously made longitudinal section of the urinary reservoir is sutured in the longitudinal direction with a two-row suture. Next, the urinary reservoir is fixed to the front wall of the abdomen with the removal of the urethral stents out through punctures of the anterior abdominal wall with hemming them to the skin. The pelvic cavity is drained from the counter-holes in the right and left iliac regions for active aspiration. The abdominal cavity is sutured tightly.

The essence of the method is illustrated by examples.

EXAMPLE 1

Patient I., born in 1943, and b / w No. 2371, was admitted to the urology department of the Federal State Research Center for the Chemistry of the Russian Federation on 12.01.09, complaining of an admixture of blood in the urine, frequent, painful urination.

From the anamnesis it was known that for the first time an admixture of blood in the urine appeared in November 2008, on December 15, 2008, a repeated episode of hematuria. On December 16, the patient turned to a urologist at the clinic at the place of residence, where he underwent ultrasound of the kidneys and pelvis, according to which a neoplasm 6 × 8 cm in size was found on the left side wall with a transition to the posterior wall.

The patient was referred to the Federal State Research Center for Surgery for Consultation with an Oncologist.

The patient was examined: on December 23, a spiral computed tomography scan was performed, according to which data on the presence of a bladder tumor were confirmed, and it was suggested that the tumor would grow into paravesical tissue. On December 25, an examination cystoscopy of the bladder cavity was performed, which was difficult due to macrohematuria. A plucked biopsy was taken. The histological conclusion No. K-266401 papillary urothelial cancer of the bladder.

At the prehospital stage, the patient also underwent intravenous urography - a slight expansion of the pyelocaliceal system (CHS) of the kidney on the left was noted. According to irrigoscopy and fibrogastroduodenoscopy, pathological changes were not detected.

Based on the survey data, the diagnosis was established: Bladder cancer pT3bN0M0 (stage III). Given the presence of a bladder tumor, the stage of the disease and the patient's age, surgical treatment was recommended in the amount of radical cystectomy with derivation of urine into the large intestine reservoir formed from an isolated segment of the sigmoid colon. The patient was examined by a cardiologist before hospitalization, the risk of developing cardiovascular complications is regarded as average.

Upon admission to the urology department, the patient's condition is satisfactory, body temperature is 37.1 degrees, the skin is dry, pale. In the clinical analysis of blood - moderate anemia (erythrocytes 4.0 million, hemoglobin 118 g / l), leukocytosis (11.6 thousand × 10 ⁹ );

according to biochemical blood tests, no abnormalities were noted. In urinalysis, red blood cells cover all fields of vision.

After further examination and preparation on 01/28/09, under endotracheal anesthesia in combination with epidural anesthesia, the lower middle laparotomic access opened the abdominal cavity in layers. When revising the iliac and obturator lymph nodes, their increase was not detected. Performed pelvic lymphadenectomy on both sides. Both ureters were isolated before flowing into the bladder, crossed and intubated with 7 Fr. urethral stents. The bladder was mobilized and removed in a single block with the parietal peritoneum, prostate gland, seminal vesicles, ducts carrying ducts and perivezical tissue.

The next step was the mobilization of the sigmoid colon from the splenic angle to the mid-ampullar part of the rectum.

The sigmoid colon was crossed using the Ethicon® TLH 30 stitching apparatus (Johnson & Johnson) at the border of the upper and middle third with suturing of the distal end of the disconnected part of the intestine tightly. The length of the formed urinary reservoir was 25 cm.

Retreating from the stump by 3 cm, the isolated sigmoid colon segment was longitudinally dissected for 5 cm. The proximal end of the sigmoid colon was reduced to form an end-to-side anastomosis with the upper ampulla of the rectum using the Ethicon® CDH 25 circular stapler (Johnson & Johnson) conducted through a longitudinal incision in the gut. The right ureter is brought to the reservoir through the formed "window" in the mesentery of the small intestine, and the left - through the mesentery of the sigmoid colon. With the help of ureteral stents, the ureters were intubated. 5 cm away from the edge of the stump, ureters are implanted into the lumen of the reservoir through separate micro-incisions in pars nuda.

Fixing sutures were placed between the serous membrane of the intestine and the wall of the ureter on the posterior semicircle of the urethrointestinal anastomosis, followed by muft-shaped sealing of the mesentery of the intestine by applying purse string sutures.

The stump of the left ureter, protruding into the lumen of the reservoir, was adapted by resection. Anastomosis between the ureter and the intestinal mucosa is formed by suturing with a Prolen 5-0 thread. Similarly, a second anastomosis was applied at a distance of 3 cm (see drawing).

A defect in the urinary reservoir is sutured in the longitudinal direction by a double-row suture.

Then, the urinary reservoir was fixed to the anterior abdominal wall by the type of suspended sigmostomy with the removal of ureteral stents fixed on the skin through it.

Polyvinyl vinyl drainage is installed in the pelvic cavity. The surgical wound is sutured in layers tightly.

The postoperative period was uneventful. Pelvic drainage was removed on the 4th day (02/01/09), and the ureteric stents were removed on the 11th day (02/08/09), after which the patient had urine emptying with impurities of feces. On the 15th day after the operation (02/12/09), the patient in satisfactory condition was discharged for outpatient treatment.

Within 12 months, the patient is regularly observed at the Federal State Institution of Science and Medicine.

She feels well and has no complaints. The frequency of urination through the rectum 6 times a day (at night 1-2 times). Over the entire period after surgery, exacerbations of chronic pyelonephritis were not observed.

During the follow-up examination in July 2009 and January 2010, according to ultrasound and CT scan of the pelvis and abdominal cavity, data for the presence of tumor recurrence were not obtained, renal HRS was not expanded. According to extratory urography, the urinary reservoir is filled with contrast medium at 40 minutes.

The proposed method to date, since 2008, has been clinically tested in 19 patients (all underwent radical cystectomy for invasive bladder cancer) with the formation of all of them urinary reservoir from a segment of the sigmoid colon. Insolvency of sigmoid-sigmo and ureterosigmoid anastomoses, intestinal-ureteric refluxes and any other serious complications were not observed in patients. Only in one patient up to 12 months a stricture of one ureterosigmoanastomosis was revealed, which was eliminated by balloon dilatation. One patient’s erection required repeated suturing of the abdominal wall in the early postoperative period. In 2 patients, adhesive intestinal obstruction (not associated with failure of the urinary reservoir) was noted, which required relaparotomy. One patient died of disease progression. To date, all other patients are alive and continue to be observed.

The proposed method in comparison with the known has several advantages.

1. Greater reliability of anastomoses due to the use of a circular stapler when applying sigmo-sigmoid anastomosis, while manual stitching can cause intestinal ischemia in the anastomosis zone and lead to its failure, and the reliability of ureterosigmoid anastomoses due to their double-row sealing: suturing between the serous membrane of the intestine and the walls of the ureters and additional stitching through an incision in the sigmoid colon of the edges of the ureters along the line of their intersection with the intestinal mucosa, as well as the subsequent “shelter” of the brow the sigmoid colon of the ureterosigmoanastomosis zone and the distal ends of the ureters, which is not used in methods known to us.

2. Prevention of infection of the upper urinary tract due to the removal of urethral stents out through an isolated segment of the sigmoid colon, which excludes their contact with the contents of the intestine, as well as due to the location of the sigmoid colon isoperistaltically with respect to the inter-intestinal anastomosis, as a result of which the intestinal contents are refluxed into the created urinary reservoir of intestinal contents.

3. Reducing the time of surgery due to the use of staplers (about 2 times at this stage), as well as the lack of the need to create additional antireflux mechanisms.

The method was developed in the surgical department of FGU RSCRHT and was clinically tested in 19 patients with a positive result.

Claims (1)

A method of urine derivation after radical cystectomy, including the formation of a urinary reservoir by crossing the sigmoid colon at the border of the lower and middle third of it, forming a sigmoid colon stump and applying an end-to-side sigmoid-sigmoid anastomosis at the level of the rectosigmoid colon, followed by excretion of the ureters and the imposition of ureterosigmoid anastomoses, characterized in that after the formation of a stump of the sigmoid colon, it is longitudinally dissected along the mesenteric edge, taenia libera, for 4-5 cm, sludge fifth from the stump of the urinary reservoir 7-9 cm, the formation of a sigmoid-sigmoid anastomosis is carried out through this incision using a circular stapler, and the application of ureterosigmoid anastomoses is performed by implanting the ureters into the formed urinary reservoir along the line of attachment of the mesentery of the intestine at a distance of at least 3 cm between them after preliminary ureters through oval holes made in the mesentery and 5-6 cm from the stump, with sutures between the serous membrane of the intestine and the walls of the ureters and additional stitching through the incision in the sigmoid colon of the edges of the ureters along the line of their intersection with the mucous membrane of the ureter followed by a clutch-like “shelter” of the sigmoid colon mesentery over 2.5-3 cm of the ureterosigmoanastomosis zone and the distal ends of the ureters previously intubated with urethral stents, followed by a section of the urinary reservoir sutured and fixed to the anterior abdominal wall, through which the urethral stents are brought out.

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