RU2424774C1 - Method of treating vesicoureteral reflux in case of ureterohydronephrosis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to urology and can be used in case of vesicoureteral reflux in case of ureterohydronephrosis. Resection of adventitial-muscular layer of ureter wall is performed with isolation of mucosa. Monocryl thread is introduced into ureter lumen by sticking-in needle outside ureter, which is then passed out by means of flexible endoscopic clip. After that isolated section of mucosa is turned out, its edges are fixed to edges of adventitial-muscular wall, after which on the segment from distal end of ureter to the level of first sticking-in 6-8 through holes with 1-2 mm diameter are made at equal distance from each other. Distal sewn edge of ureter is tightened hermetically by means of loose end of ligature. It is turned into ureter lumen to the level of first needle sticking-in. It is fixed to internal ureter wall and in urine reservoir hole is created. Distal end of ureter is introduced into formed hole of urine reservoir to the level of first sticking-in, between walls of urine bladder and ureter extralumen interrupted sutures are applied. ^ EFFECT: method makes it possible to reduce concrement-formation, possibility of stricture development, perform prophylaxis of chronic pyelonephritis and chronic renal failure. ^ 2 ex, 4 dwg

Description

The invention relates to medicine, in particular to surgery, and can be used in patients with bladder cancer (MP) with ureterohydronephrosis, as well as for transplantation of an enlarged ureter in patients with cervical cancer, ovarian cancer, colon cancer, large uterine myoma, inflammatory tumor-like formations of the appendages with the formation of cicatricial strictures of the ureters.

Existing methods for the formation of a vesicoureteral anastomosis with an enlarged ureter have certain drawbacks - the formation of scar strictures in the anastomotic zone, vesicoureteral reflux, which is one of the main factors in the development of hydronephrotic transformation of the kidney. In this regard, there is a need to find new ways to create uretero-cystic anastomoses in case of ureterohydronephrosis.

A known method of treating congenital enlargement of the ureter in children, including resection of the distal stenotic parts of the ureter, modeling of the distal portion of the remaining ureter, suturing the walls of the ureter with the formation of a gradual transition from dilated to narrow parts, conducting the ureter through the submucosal tunnel of the MP and the creation of ureterovesical anastomosis (RU No. 225677) . However, the disadvantage of this method is the formation of a longitudinal fold due to suturing of the ureter walls with interrupted sutures, which leads to an increased risk of scarring of the distal ureter.

Closest to the claimed invention, in terms of features, is a method of implanting the ureter into the urinary reservoir (MR) by forming a tunnel from a full-layer wall of the MR by screwing it into the lumen of the MR, a cuff from the distal end of the implantable segment of the ureter by turning its walls and applying extra-luminal nodal sutures between the walls of the MR and the ureter (RU No. 2170057). Adopted as a prototype. The prototype method is successfully used in clinical practice, however, its use is not recommended for patients with an initial degree of ureterohydronephrosis due to the high risk of developing vesicoureteral reflux.

The invention is aimed at solving the problem of improving the quality of life of patients with ureteral stricture, malignant and benign neoplasms of the pelvic organs and developed ureterohydronephrosis, requiring resection of the pelvic ureter.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- the exclusion of the development of vesicoureteral reflux from the expanded ureter, which can subsequently lead to the development of chronic pyelonephritis and chronic renal failure;

- reduction of calculus formation, as well as a decrease in the frequency of scarring due to the absence of intraluminal vesicoureteral sutures;

- reducing the incidence of stricture in the area of the ureterocystic anastomosis;

- Improving the indicators of medical rehabilitation of patients after massive surgical interventions on the organs of the urinary system.

The specified technical (therapeutic) results in the implementation of the invention are achieved due to the fact that, as in the known method, the affected ureter is crossed, the antireflux valve is formed and the ureter is implanted in the MR.

A feature of the proposed method lies in the fact that they perform resection of the adventitio-muscular layer of the ureter wall with the release of the mucous membrane over 2-3 cm from the distal edge of the resected ureter. At a distance of 3-4 cm from the selected area of the mucosa, a monocrylic filament is inserted into the ureter lumen by injecting an atrovmatic needle outside the ureter, which is brought out using a flexible endoscopic clamp. The selected section of the mucous membrane is turned outward, its edges are fixed to the edges of the adrenal-muscular wall. From the distal end of the ureter to the level of the first injection, 6-8 through holes with a diameter of 1-2 mm each are made at an equal distance from one another. The distal sheathed edge of the ureter is tightened tightly with the free end of the ligature. Screw it into the lumen of the ureter to the level of the first needle injection, fix it to the inner wall of the ureter. A hole is created in the MR that is commensurate with the diameter of the implantable ureter, the distal end of the ureter is inserted into the formed MR hole to the level of the first injection, and extraluminal nodal sutures are placed between the walls of the MR and the ureter.

The invention consists in the technique of forming a kind of mouth of the ureter containing the antireflux valve. A feature of the method for the formation of neoureterocystanastomosis is the technique of screwing and fixing the distal ureter into its lumen and the creation of a natural antireflux valve that narrows its initial section and prevents the outflow of urine from the MP into the pelvis.

The inventive method for the treatment of vesicoureteral reflux with ureterohydronephrosis can improve the quality of life of patients with MP cancer with ureterohydronephrosis. The method can also be used for resection and transplantation of an enlarged ureter in patients with cervical cancer, ovarian cancer, rectal cancer, large uterine fibroids, inflammatory tumorous formations of the appendages with the formation of obstruction of the ureters.

The method is as follows.

Under combined anesthesia or under conditions of epidural anesthesia, a lower middle laparotomy or extraperitoneal access to the pelvic organs and ureter is performed. According to the generally accepted method, cystotomy is performed. The affected ureter is crossed, departing 2.0 cm from the wall of the MP or the upper border of the cicatricial stricture of the ureter, and is excreted for 7-9 cm with the surrounding tissue.

At a distance of about 2-3 cm from the distal edge of the resected ureter, the adventitio-muscular layer of the ureter wall is resected with the mucous membrane secreted for a given length.

At a distance of 3-4 cm from the selected area of the mucosa, an atraumatic needle with a monocrylic thread is injected. A flexible endoscopic clamp (hitch) is introduced into the ureteric lumen, with the help of which a needle with the working end of the thread is brought out of the ureteric lumen. Next, the thread is reintroduced into the ureter lumen with the formation of a free loop and an injection is made from the lumen into the full-layer wall of the ureter immediately below the allocated mucous membrane, a needle is injected externally into the proximal edge of the mucous membrane on the same side, and a puncture is made into the ureter lumen. The resulting free loop is pulled. Thus, the selected area of the mucous membrane is turned outward and fixed to the adrenal-muscular wall. With this technique, the ureter is sutured along its perimeter.

From the distal end of the ureter to the level of the first injection, 6-8 through holes with a diameter of 1-2 mm each are made at an equal distance from one another. It is optimal to make two consecutive rows of these holes. Then, using the free end of the ligature, the distal sheathed part of the ureter is pulled tightly, screwed into the ureter at the site of the first needle injection and fixed to one of the walls.

A radiopaque drainage (ureteric stent, the diameter of which is selected depending on the width of the ureteric lumen) is introduced into the lumen of each ureter (into one of the formed openings of the sutured stump) and is carried out to the level of the renal pelvis.

A hole is formed in the wall of the MP or formed MR, commensurate with the diameter of the lumen of the lumen of the implanted ureter. A fragment of the ureter is passed through the formed opening into the MR cavity to the level of the first injection. Between the walls of the MP (MR) and the ureter, extraluminal nodal sutures in the amount of 3-4 pcs.

A Foley catheter No. 18 or 20 is inserted into the cavity of the MP (reservoir) and the cavity of the MP (reservoir) is sutured tightly with two rows of continuous sutures on an atraumatic needle. The small pelvis is drained with one or two double-lumen silicone drains supplied to the suture area on the MP wall or the pelvic lymphadenectomy area. The retroperitoneal space is drained with one double-lumen silicone drainage supplied to the ureter anastomosis zone.

The pelvis is thoroughly washed with antiseptic solutions and dried with napkins. The surgical wound is sutured in layers.

Drainage from the retroperitoneal space is removed for 4-5 days if there is no discharge on it, from the small pelvis drainages are removed alternately for 6-8 days with an interval of 2 days. The urinary catheter is removed 12-14 days after surgery to prevent vesicoureteral reflux against the background of the stent. Ureteric stents are removed 3-6 months after surgery.

Figure 1-4 presents the sequence of execution of the anastomosis.

Figure 1 presents a diagram of the allocation and inversion of the ureteral mucosa, where: 1 - the level of resection of the adventitio-muscular layer of the ureter, 2 - the selected mucous membrane of the ureter, 3 - farcop (flexible clamp), 4 - monocrylic thread on an atraumatic needle.

Figure 2 presents a diagram of the eversion of the ureteral mucosa by applying intraluminal sutures, where: 5 - an injection of the needle from the lumen of the ureter, 2 - the mucous membrane of the ureter, 6 - the injection of the needle into the lumen of the ureter, 7 - injection and injection of the needle from the mucous membrane of the ureter, 8 - lining of the mucosa around the perimeter.

Figure 3 presents a diagram of the formation of the antireflux valve, where: 9 - inverted mucous membrane of the ureter, 10 - through holes of the ureter wall, 11 - screwing the formed cone of the ureter and fixing it to the wall of the ureter, 3 - hitch.

Figure 4 presents the final view of the antireflux vesicoureteral anastomosis, where: 12 - the ureteric stent in the lumen of the ureter, 13 - extraluminal sutures between the adventitio-muscular wall of the ureter and MP (MR).

The inventive method for the treatment of vesicoureteral reflux with ureterohydronephrosis is used in the Moscow Scientific Research Institute P.A. Herzen in 16 cases in patients with malignant tumors of the pelvic organs (MP, lower third of the ureter, cervix, rectum and sigmoid colon) against the background of ureterohydronephrosis of the second and third degree.

Clinical examples.

1. Patient K., 29 years old, was treated with a clinical diagnosis of cervical cancer ICT T1bN0M0. In the history of the patient, a comprehensive treatment was performed in the amount of expanded hysterectomy with ovarian transposition and subsequent intracavitary radiation therapy.

The patient in connection with a central relapse in the pelvic cavity with invasion of the posterior wall of the MP performed removal of the recurrent tumor with resection of the MP and the right ureter. The ureter is implanted in the MP using the proposed technique. The observation period is 23 months. The patient has no signs of vesicoureteral reflux and hydronephrotic transformation of the kidney.

2. Patient B., 63 years old, was treated with a clinical diagnosis of cancer of the MP T1NxM0, a tumor in the area of the mouth of the left ureter. Performed transurethral electroresection MP. In the process of dynamic observation, the development of ureterohydronephrosis due to cicatricial stricture of the intramural part of the left ureter was revealed. The ureter is implanted in the MP using the proposed technique. Within 12 months of observation, the patient has no signs of ureterohydronephrosis.

In the postoperative period of management of patients operated using this method, a number of advantages were revealed:

- the formation of urinary calculi in the area of implantation of the ureter is not detected,

- postoperative vesicoureteral reflux was not detected in any patient (maximum observation period 23 months).

From the above data it follows that this method of treating vesicoureteral reflux with ureterohydronephrosis has advantages over known methods and meets the necessary criteria for patentability.

Claims (1)

A method of treating vesicoureteral reflux in case of ureterohydronephrosis, including crossing the affected ureter, forming an antireflux valve and implanting the ureter into the urinary reservoir, characterized in that the adventitio-muscular layer of the ureter wall is resected with mucous membrane secreted for 2-3 cm from the distal edge of the ureter, at a distance of 3-4 cm from the selected area of the mucosa, a monocrylic thread is inserted into the ureter lumen through an atraumatic needle outside the ureter, which is brought out using a flexible endoscopic clamp, the selected section of the mucous membrane is turned outward, its edges are fixed to the edges of the musculoskeletal wall, 6-8 through holes with a diameter of 1-2 mm are made from the distal end of the ureter to the level of the first injection each at an equal distance from one another, pull the distal sheathed edge of the ureter tightly with the free end of the ligature, screw it into the lumen of the ureter to the level of the first needle injection, fix to the inner wall of the ureter, a hole is created in the urinary reservoir, commensurate with the diameter of the implantable ureter, the distal end of the ureter is inserted into the formed opening of the urinary reservoir to the level of the first injection, between the walls of the urinary reservoir and the ureter extraluminal nodal sutures are applied.

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