RU2527842C1 - Method for ureter implantation into urinary reservoir - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: serous and muscular layers are separated on a prepared urinary reservoir. A plate of the intestinal mucosa 3×1-2 cm is formed. A long incision of the length corresponding to the ureter section is performed in its distal portion. An interrupted suture is applied between the urinary reservoir mucosa and the stented ureter. An anastomosis is covered with mobilised serous-muscle flaps. The flaps are sutured together with interrupted sutures. The first suture covers the anterior wall of the ureter at 0.5-1 cm from the anastomosis.

EFFECT: method enables simplifying the surgical technique, reducing a risk of postoperative anastomosis inconsistency, vesicoureteral reflux, stenosis and stricture by forming the direct ureter-reservoir anastomosis and reinforcing its valve mechanism.

2 ex

Description

The invention relates to medicine, namely to surgery, and can be used to form ureteral-urinary reservoir anastomoses after cystectomy, anterior and total pelvic eviscerations.

A known method for implanting the ureter according to the Le-Duc-Carney technique, relating to antireflux anastomoses: after performing the resection stage of the operation (cystectomy, cystrostatectomy, anterior or total eviscerations), a urinary reservoir is prepared in which, after preliminary enterotomy, the mucous membrane is cut near the mesentery margin and organ along with submucosa (Wallace direct versus anti-reflux Le Due ureteroileal anastomosis: Comparative analysis in modified Studer orthotopic neobladder reconstruction; Katsumi Shigemura, Nozomu Yamanaka, Osamu Imanishi, Masuo Yamashita: Article first published online: 17 OCT 201 1, The Japanese Urological Association). The ureter is passed through the wall of the intestine freely without infringement, orienting it so that its vessels are located below, adjacent to the wall of the intestine. The mucous membrane of the latter is fixed to the adventitious ureter with interrupted sutures, without covering it from above. The edge of the ureter cut off in the form of a cone is sewn through the entire thickness to the mucous and submucous intestines with interrupted sutures. Anastomosis is strengthened from the outside with interrupted absorbable sutures between the adventitia of the ureter and the serous-muscular layer of the intestine.

The advantage of this method is its antireflux properties due to the tunneling method of forming an anastomosis, although 4.6% of patients have vesicoureteral reflux.

The disadvantages of this method are preliminary enterotomy, which increases the time of surgery and increases the risk of infectious complications, as well as postoperative complications in the form of strictures of uretero-enteroanastomoses, leading to ureterohydronephrosis, which was recorded in 9.6% of patients.

Also known is the method of implantation of the ureter, proposed by a team of authors P.A. Herzen (RF Patent for the invention No. 2170057): after performing the resection stage of the operation (cystectomy, cystrostatectomy, anterior or total evisceration), an opening is made in the wall of the urinary reservoir commensurate with the diameter of the lumen of the implanted ureter. The ureter is passed into the cavity of the urinary reservoir through the formed opening. Between the walls of the urinary reservoir and the ureter, extraluminal nodal sutures are applied. A cuff is formed from the wall protruding into the lumen of the ureter reservoir by eversion of these walls, a kind of tunnel is formed, mainly due to the screwing of the walls of the urinary reservoir. A ureteral catheter or ureteral stent is carried out from the cavity of the urinary reservoir into the lumen of the implanted ureter, the size of which is selected depending on the diameter of the lumen of the ureter. The above steps of the operation are carried out simultaneously. The operation ends with the removal of the ureteral catheters through the contraperture to the anterior abdominal wall, the installation of two double-lumen drainages in the small pelvis, single-lumen drainage in the abdominal cavity and layer-by-layer suturing of the surgical wound. According to the data presented by the authors of this method, postoperative vesicoureteral reflux is diagnosed in 1.4% of cases; postoperative obstruction of the ureter anastomosis was detected - 2.8%. The formation of urinary calculi in the urinary reservoir in the ureteral implantation zone was not detected (the maximum follow-up for patients was 60 months). As the closest analogue, we chose the method of implantation of the ureter, proposed by the team of authors of Moscow P.A. Herzen (RF Patent for the invention No. 2170057), which showed clear advantages over the known Le-Duc-Carney technique.

The objective of the invention is to simplify the technique of surgery, reduce postoperative complications, such as failure of the anastomosis, vesicoureteral reflux, stenosis and strictures of the anastomosis.

The problem is achieved in that in the method of implanting the ureter into the urinary reservoir on the prepared urinary reservoir in the longitudinal direction for 3 cm dissect the serous and muscle membranes, which are separated to the sides of the incision by 0.5-1 cm, forming a platform from the intestinal mucosa 3 × 1-2 cm in size, in the distal part of which a longitudinal incision is made corresponding to the cross section of the ureter, after which a continuous suture is applied between the mucosa of the urinary reservoir and the stent ureter, then the anastomosed ureter is covered with previously mobilized sero-muscular flaps, which are fixed with interrupted sutures, with the first suture being taken, which captures the front wall of the ureter at a distance of 0.5-1 cm from the formed anastomosis, immersing it in the lumen urinary reservoir.

The novelty of the method lies in the fact that prior to the formation of the anastomosis, enterotomy is not performed, as with other methods of “tunnel” anastomoses: the anastomosis is superimposed according to the type of “direct” ureteropulmonary anastomosis. Immersion of the ureter is carried out in the depths of the urinary reservoir and along its plane. As a result of this, the valve mechanism of the ureter-urinary reservoir anastomosis is enhanced. The method is characterized by technical simplicity, which can significantly reduce operating time.

The method is as follows. After performing the resection stage of the operation (cystectomy, cystoprostatectomy, anterior or total evisceration), the serous and muscular membranes are dissected in a longitudinal direction for 3 cm with a scalpel in a prepared urinary reservoir, which are then separated from the incision by 0.5-1 cm, forming a mucosal area 3 × 1-2 cm in size. In the distal part of the formed area, the mucous membrane is cut longitudinally with a length corresponding to the cross section of the ureter. Next, a continuous suture is applied between the mucosa of the urinary reservoir and the previously stented ureter. Then, the anastomotic ureter is covered by previously mobilized sero-muscular flaps, which are fixed between them by interrupted sutures, and in the first place, a suture is taken that grasps the front wall of the ureter at a distance of 0.5-1 cm from the formed anastomosis, immersing it in the lumen of the urinary reservoir.

The invention is illustrated by the following clinical examples.

Example 1. Patient W, born in 1976 was admitted to the Moscow City Clinical Hospital 05/25/10 with complaints of constant pain in the lower abdomen, weakness, grayish vaginal discharge with a strong odor and an admixture of blood. Since 2006, she was treated at the Russian Oncology Center RAMS for cervical cancer III in Art. Chemotherapy was carried out (SOD 73.2 Gy, 5 courses according to the eloxatin + campto regimen). Since January 2009, the progression of the disease in the form of the appearance of paraaortic lymph nodes was noted - 7 chemotherapy courses were conducted according to the cisplatin + gemzar regimen. In December 2009, dirty vaginal discharge appeared. I applied for medical help at the Russian Oncology Center RAMS, where I performed magnetic resonance imaging of the pelvis and transrectal ultrasound. A cervical tumor was discovered that spreads to sr / 3 of the vagina, growing into the rectum and bladder with the formation of a rectal vaginal fistula. January 22, 2010 there was abundant spotting from the vagina. Diagnosed with Cervical Cancer IVA Art. (pT4NlM0), endophytic form, vaginal-parametric variant. Condition after chemoradiotherapy. Tumor decay. Rectal-vaginal fistula. Vaginal bleeding. 02/18/2010 the patient was operated on in the amount of total pelvic evisceration, ileo-pelvic lymphadenectomy, ureteroileocutaneostomy, sigmostomy. During surgery in the abdominal cavity and pelvis of the free fluid, no additional tumor formations were found. The uterus, bladder and rectum are represented by a single tumor conglomerate. Infiltration extends to the parametrium on both sides, reaching the iliac vessels on the left. The ureters are uniformly dilated throughout up to 1.5 cm, their patency is not impaired. Given the prevalence of the tumor process, partial colonic obstruction, the presence of recto-vaginal fistula, it was decided to perform total evisceration of the small pelvis. General, internal and external iliac vessels with fiber dissection prior to aortic bifurcation were distinguished. The ureters are taken on handles, mobilized and traced to the confluence of the bladder. The funnel and round ligaments were stitched and cut off on both sides. Separately processed vascular bundles of ligaments. Processed cardinal ligaments. Outside of the ureters, the uterine vessels are bandaged. The uterus, bladder and rectum are mobilized in a single unit. The uterus was extirpated with appendages to n / 3 of the vagina in the block with the bladder, rectum (cut off at the level of the muscles of the pelvic floor) by the ligamentous apparatus and pelvic-ileal tissue. An ideal conduit was formed from the terminal segment of the ileum about 15 cm long. Intestinal continuity was restored by a side-to-side anastomosis. The leading end of the resected ileum segment is sutured. Having departed from it by 4 cm, the serous and muscle membranes were dissected with a scalpel in the longitudinal direction for 3 cm, which were separated by 1.5 cm to the sides of the incision, forming a site from the mucous membrane 3 × 1 cm. In the distal part of the site, they were dissected the mucous membrane 0.5 cm long (corresponding to the cross section of the ureter). A continuous suture was applied between the mucous membrane of the urinary reservoir and the previously stented ureter. The anastomosed ureter was covered with previously mobilized sero-muscular flaps that were fixed with interrupted sutures. First of all, a suture was applied, which captured the front wall of the ureter at a distance of 1 cm from the formed anastomosis, immersing it in the lumen of the reservoir. Anastomosis with a second ureter was performed in a similar way. The outlet end of the ideal conduit was brought out onto the skin with the formation of a moist urostoma into which the Foley catheter was inserted, and the ureter catheters were fixed to the skin. A sigmostoma was formed in the left iliac region. Histology No. 3784-3808: in the cervix, in the cervical canal, myometrium - the growth of squamous cell carcinoma with necrosis of the tumor tissue. In the serous membrane of the bladder, vascular embolization by tumor cells, growth of squamous cell carcinoma throughout the entire thickness of the wall of the sigmoid colon. At the edges of the resections - without tumor growth.

The postoperative period is smooth. Sutures were removed on day 12. Ureteric catheters removed. On the urograms, there are no signs of ureterohydronephrosis, reservoir-ureter reflux and insolvency. The patient was discharged on the 18th day after the operation in satisfactory condition.

Example 2. Patient M, born in 1959 was admitted to the Moscow City Clinical Hospital on 01/18/10 with complaints of weakness, moderate pain in the lower abdomen, spotting from the genital tract. Sick since August 2008, when the examination was diagnosed with a cervical tumor. 4 courses of chemotherapy (gemzar) were carried out, followed by remote gamma therapy, after which nephrostomas were placed on both sides in connection with increasing hydronephrosis. Then brachytherapy and 6 chemotherapy courses were conducted in the taxol + carboplatin regimen. Since the fall of 2009, a deterioration has been noted - increasing weakness, weight loss, pain in the lower abdomen, periodically renewed spotting from the genital tract. She was hospitalized for further examination and to decide on further treatment tactics. When conducting multispectral computed tomography of the pelvis, a bladder tumor was detected with invasion of the cervix and uterine body. 02/12/10 the patient underwent anterior pelvic evisceration, ureteroileocutaneostomy. During surgery, no free fluid and additional tumor formations were found in the abdominal cavity and pelvis. In the area of the cervix with the transition to its body, a dense sedentary tumor is determined (up to 8.0 cm in diameter), infiltrating the posterior wall of the bladder, clutch-like covering the mouth of the ureters. The latter are uniformly expanded throughout to 1.5 cm, their patency is not impaired. Infiltration extends to the neck of the bladder and ligamentous apparatus of the uterus. Given the prevalence of the tumor process, it was decided to perform anterior evisceration of the pelvis. Common, internal and external iliac vessels with fiber dissection prior to aortic bifurcation were isolated. The ureters are taken on handles, mobilized and traced to the confluence of the bladder. The funnel and round ligaments were stitched and cut off on both sides. Separately processed vascular bundles of ligaments. Processed cardinal ligaments. Outside of the ureters, the uterine vessels are bandaged. The uterus and bladder are mobilized in a single unit. The uterus was extirpated with appendages in the cf / 3 of the vagina in the block with the bladder, ligamentous apparatus and pelvic-iliac tissue. An ileal conduit was formed from the terminal segment of the ileum about 15 cm long. Intestinal continuity was restored by a side-to-side anastomosis. The leading end of the resected ileum segment is sutured. Having departed from it by 4 cm, the serous and muscle membranes were dissected with a scalpel in the longitudinal direction for 3 cm, which were separated to the sides by 1 cm from the incision. As a result, a platform was formed from the intestinal mucosa 3 × 2 cm. the mucous membrane was cut into the distal part of the site by 1 cm (corresponding to the cross section of the ureter). A continuous suture was then applied between the mucosa of the urinary reservoir and the previously stented ureter. The anastomosed ureter was covered with previously mobilized sero-muscular flaps, which were fixed with interrupted sutures, with the first suture being inserted into which the front wall of the ureter was grasped at a distance of 0.5 cm from the formed anastomosis, immersing it in the lumen of the urinary reservoir. Anastomosis with a second ureter was performed in a similar way. The outlet end of the ileal reservoir is brought out onto the skin with the formation of a wet urostoma into which the Foley catheter is inserted. Ureteric catheters (stents) are fixed to the skin of the anterior abdominal wall. The postoperative period was uneventful. Sutures were removed on day 14, healing by first intention. On control urograms, there were no signs of failure of the anastomoses and reservoir-ureteral reflux, ureteral patency was complete. The patient was discharged on the 15th day after the operation in a satisfactory condition for undergoing chemotherapy on an outpatient basis. According to this technique, we operated on 16 patients. In no case did we observe strictures and failure of the anastomosis. Thus, the proposed method for implanting the ureter into the urinary reservoir allows one to avoid a number of dangerous complications, such as failure of the urinary-ureteral anastomosis, vesicoureteral reflux, stenosis and stricture of the urinary-ureteral anastomosis, thereby improving the survival rate of this category of patients and improving the quality of life.

Claims (1)

The method of implantation of the ureter into the urinary reservoir, characterized in that the serous and muscle membranes are dissected in the prepared urinary reservoir in the longitudinal direction for 3 cm, which are separated from the incision by 0.5-1 cm, forming a platform of intestinal mucosa of size 3 × 1-2 cm, in the distal part of which a longitudinal incision is made with a length corresponding to the cross section of the ureter, after which a continuous suture is applied between the mucosa of the urinary reservoir and the previously stented ureter ureter, then the anastomosed ureter is covered with previously mobilized sero-muscular flaps, which are fixed together by interrupted sutures, while first of all they impose a suture that captures the front wall of the ureter at a distance of 0.5-1 cm from the formed anastomosis, immersing it in the lumen of the urinary reservoir.