RU2525222C2 - Diagnostic technique and method for determining surgical approach to ureteric strictures of tuberculous and non-specific genesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically urology. A multicenter biopsy of the ureter in its lower, middle and upper one-third is performed. If observing total fibrosis, a substitutive ureteroplasty is carried out. A focal nature of pathological changes requires an endoscopic correction of the strictures. In case of active tuberculosis, anti-tuberculosis therapy is conducted. A method and technique provides selecting an approach to treating ureteric strictures of unobvious genesis. They enable diagnosing tuberculous and scar involvements of the ureter in patients with nephrotuberculosis.

EFFECT: providing early diagnosing of tuberculosis, reducing a risk of complications.

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Description

The invention relates to medicine, namely to urology, and can be used to diagnose tuberculosis and cicatricial lesions of the ureter in patients with nephrotuberculosis.

The spread of specific inflammation to the ureter with the formation of strictures complicates the course of nephrotuberculosis in 30-60% of cases [1, 2, 3]. Among all ureteral strictures, the proportion of specific reaches 9% [4]. It is rarely possible to verify the diagnosis bacteriologically because of the complete or partial block of the affected kidney. Urethroscopy with a biopsy of the ureter should be undertaken in cases where the etiology of stricture is not obvious. Messages about the application of the methodology for morphological confirmation of tuberculosis are single [4], and to determine the tactics of surgical treatment are absent.

Closest to the proposed method is a biopsy of the pelvic ureter using a flexible urethroscope. This method allows in 75% of cases to establish the etiology of stricture, however, in every fourth case, the procedure is uninformative due to the small amount of material. However, caution must be exercised in evaluating these limited samples if there is no clinical suspicion of a tumor [5].

The objective of the invention is the diagnosis of tuberculosis and cicatricial lesions of the ureters.

The technical result that will be achieved from the use of this invention is to improve the accuracy of diagnosis.

The technical result is achieved by the fact that in the method for the diagnosis and surgical treatment of ureteral strictures of tuberculosis and non-specific genesis, including ureteroscopy and multifocal biopsy of the lower third of the ureter, additional biopsy samples are taken from the middle and upper third of the ureter. If focal fibrosis is detected, endoscopic correction of the scarred area is performed; in the case of diagnosis of total fibrosis, ureteroplasty is performed, and if active tuberculosis is detected, anti-tuberculosis therapy is performed.

The essence of the invention lies in the fact that under visual control a biopsy is performed from all anatomical departments of the ureter, providing a sufficient amount of material for histological examination, which allows to recognize the etiology of its lesion, as well as to assess the severity and prevalence of fibro-inflammatory changes in it.

Previously, a similar biopsy method has not been used.

From an analysis of the scientific, technical and patent literature of the total biopsy specimen collection from all anatomical departments of the ureter, which can significantly improve the accuracy of diagnosis of tuberculosis and cicatricial lesions of the ureter in patients with nephrotuberculosis, it is not revealed, which allows us to conclude that the claimed technical solution meets the criteria of "novelty" and "inventive level".

The invention is as follows.

Figure 1 and 2 presents the necessary tools for the implementation of ureteroscopy with a biopsy. Figure 1 shows the equipment for retrograde endoscopic access to the ureter. From top to bottom, from left to right: ureter catheter with open end No. 5 Fr (yellow), coaxial dilator No. 8-10 Fr (blue), pusher stent (red), curved vascular catheter No. 5 Fr (light blue), endoscopic fiber optic cable , polytetrafluoroethylene-coated conductor string (PTFE), hydrophilic conductor string, extra-rigid PTFE coated conductor string, combination of hydrophilic and PTFE coated strings, transition valve, flexible cystoscope, flexible ureteroscope.

The method is as follows. Under spinal anesthesia, cystoscopy is performed with a flexible instrument, through the working channel of which one of the string conductors is held. The latter is administered through the mouth into the affected ureter. A cystoscope is removed without a conductor string through which a flexible ureteroscope is inserted into the bladder and then into the ureter. Inspect all of its departments with the simultaneous collection of biopsy samples from the lower (pelvic), middle and upper third of the ureter using flexible forceps. Biopsies are placed in a 10% formaldehyde solution and stained with hematoxylin-eosin. The operation is completed by internal drainage of the kidney with a self-retaining stent.

Example 1. Patient K., 41 years old, was admitted to the department in January 2010 with complaints of frequent peremptory urination, constant, aching pain in the lumbar region. Sick for more than 5 years. Multiple examinations in various urological hospitals revealed stricture of the left ureter, but did not allow to establish the etiology of the disease. 02.02.2010, urethroscopy with multifocal ureter biopsy was performed according to the described procedure. At the same time, the stricture was dissected with a holmium laser. The postoperative period is without complications. A morphological study of biopsy specimens revealed the tuberculous nature of the inflammation. Against the background of the installed stent, intensive anti-tuberculosis therapy was started. The stent was removed after 1 month. With an annual examination of 2 years, the urodynamics of the upper urinary tract are not impaired, and renal function is satisfactory.

Example 2. Patient K., 48 years old. He was admitted to the department in May 2011 with a diagnosis of urinary tuberculosis: polycavernous tuberculosis of the right kidney, tuberculous papillitis of the left kidney, tuberculosis of the ureters; strictures of the lower parts of both ureters; ureterohydronephrosis on both sides; nephrosclerosis; non-functioning right kidney; Chronic renal failure, compensated stage. Long-term anti-tuberculosis therapy did not lead to a regression of violations of the outflow of urine from the kidneys. 01/20/12 performed urethroscopy with multifocal biopsy of the ureter on the left according to the described method. According to a morphological study, total organ wall fibrosis was detected in all biopsy specimens; no specific changes were detected. A decision was made to replace the ureter. 03/14/12. - left ileourethroplasty on the left. The postoperative period is without complications. Ureteric drainage removed on day 12. Observation during the year did not reveal changes in the upper urinary tract and impaired function of the only functioning kidney.

In 2008-2011 In the urology department of the Federal State Budgetary Institution “Ural Research Institute of Phthisiopulmonology of the Ministry of Health and Social Development of the Russian Federation” ureteropyeloscopy with multifocal biopsy of the UMP wall was performed on 11 patients with kidney and ureter tuberculosis (7 women and 4 men). In a number of other cases, the study was not possible due to severe stenosis of the ureter mouth. During the procedure, strictures that served as an obstacle to the advancement of the ureteroscope through the ureter were dissected with a cold knife. In a morphological study of biopsy samples (light microscopy) in 27.2% of patients, the lumen of the vessels of the microvasculature was widened. The severity of cell infiltration varied. Inflammatory infiltrate in 90.9% of patients consisted of lymphocytes, plasma cells, macrophages, fibroblasts. Sites of atrophy and hyperplasia of the epithelium were detected in 54.5% of cases, submersible growth of urothelium (acanthosis) - in 9.1%, proliferative activity with elements of dysplasia - in 63.6%.

A morphological study of urinary tract biopsy samples revealed vascular congestion, edema of varying severity, elements of sclerosis, accumulations of fibroblasts, diffuse lymphoid-histiocytic infiltration, characteristic of the sclerosing process (Fig. 2), in 8 (72.7%) patients, granulosa inflammation with giant multinucleated Langhans cells - in 2 (18.2%) of them (Fig. 3). In 3 (27.3%) patients, lymphoid-histiocytic infiltration and accumulations of focal fibroblasts were noted. In general, total fibrotic changes in the wall of the upper urinary tract were detected in 72.7%, focal - in 27.3% of patients.

All patients with hydroureteronephrosis were candidates for ureteroplasty to restore adequate passage of urine and maintain or restore kidney function. It should be noted that ureteroscopy with or without ureterotomy in 3 (almost ⅓) cases, corresponding to the morphological picture of focal fibrosis of the UMP wall, contributed to the regression of retention changes. At the same time, with common fibro-inflammatory changes in the ureter wall, the performed manipulation from a therapeutic point of view was ineffective.

Thus, urethropyeloscopy with multifocal ureter biopsy for nephrotuberculosis can reveal the nature and prevalence of fibro-inflammatory changes in its wall, and in some cases confirm the specific nature of the lesion. The focal nature of pathological changes in the wall of the VMP allows you to limit yourself to endoscopic methods for correcting strictures. With common fibro-inflammatory changes in the ureter wall, we consider endoscopic treatment to be futile; in these cases, replacement ureteroplasty (Boari surgery or intestinal plastic surgery) is absolutely indicated. Figure 4 presents the algorithm of surgical tactics depending on the etiology of stricture and the prevalence of fibro-inflammatory changes in the ureter.

The proposed method for diagnosing and determining the tactics of surgical treatment of ureteral strictures of tuberculosis and other genesis in comparison with the known has several significant advantages:

- the method is technically simple and can be widely used in specialized urological hospitals;

- does not require open surgical access to the ureter;

- increases the likelihood of early diagnosis of tuberculosis and reduces the risk of complications;

- allows you to determine the surgical tactics depending on the etiology of stricture and the prevalence of fibro-inflammatory changes in the ureter.

Compared with the prototype of the claimed invention has 100% information content. Fibrosis is considered total when it is detected in 2 or more anatomical departments of the ureter, in the 1st department - focal.

LITERATURE

1. Zuban O.N., Ants A.N., Volkov A.A. Surgical treatment of nephrotuberculosis in modern epidemiological conditions // Bulletin of Surgery named after I.I. Grekov. - 2008. - No. 1. - S. 92-95.

2. Tkachuk V.N., Yagafarova R.K., Al-Shukri S.Kh. Genitourinary tuberculosis. A guide for doctors. - St. Petersburg: SpetsLit., 2004 .-- 320 p.

3. Yagafarova R.K., Vakhmistrova T.I. Tuberculosis of the kidneys, ureters and bladder // Extrapulmonary tuberculosis. - ed. prof. Vasilieva A.V. - SPb, 2000. - S.276-289.

4. Gulwani N., Jain A. Primary papillary mucinous adenocarcinoma of the ureter mimicking genitourinary tuberculosis // Patholog. Res. Int. - 2010 .-- Vol.16.

5. Tavora F., Fajardo D.A., Lee T.K. et al. Small endoscopic biopsies of the ureter and renal pelvis: pathologic pitfalls // Am. J. Surg. Pathol. - 2009 .-- Vol.33 (10). - P. 1540-1546.

Claims (2)

1. A method for choosing the treatment strategy for ureteral strictures of non-obvious genesis, which consists in conducting a multifocal biopsy of the ureter in its lower, middle and upper third, and when revealing total fibrosis, ureteroplasty is performed, and with focal nature of pathological changes, they are limited to endoscopic methods for correcting strictures. 2. The method according to claim 1, characterized in that when detecting active tuberculosis, anti-tuberculosis therapy is carried out.

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