RU2539012C2 - Method for minimally invasive treatment of urethral stricture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to urology, and can be used in treating urethral stricture. To this effect, a urethra bougienage is followed by introducing a stromal-vascular cell fracture of patient's fat in the number of thirty million into the sclerotic portion.

EFFECT: method provides the relevant minimally invasive treatment of the urethral strictures covering a pathogenetic unit of the cicatrical tissue formation.

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Description

The present invention relates to medicine, namely to urology, and can be used for minimally invasive treatment of urethral strictures.

Urethral stricture is one of the most complex urological diseases. The frequency of occurrence in the structure of diseases of the genitourinary system is about 6% [N.A. Lopatkin, 1999, G. Barbagli, 2004]. Patients with urethral strictures need long-term specialized treatment.

Currently, it is proved that the leading pathological mechanisms of the formation of adhesions of the abdominal cavity are: trauma to the urethra, impaired microcirculation and, as a result, the formation of scar tissue [L. Boccon-Gibod, 2006].

Until recently, the main methods of treating patients with urethral strictures were complex plastic surgeries, such as Holtsova-Marion, Solovova, Rusakova and others, most of which do not guarantee complete recovery. Poor results of treatment of patients with urethral strictures are often observed and reach 16-25% [S.P. Darenkov, 2005]. In addition to trauma and a long rehabilitation period, common complications after open surgery are suppuration of the postoperative wound, the occurrence of urinary fistulas, and urinary incontinence. Shortening of the penis, erectile dysfunction and impotence should be attributed to the negative consequences of operations on the urethra, which is associated with the inevitable trauma during surgery of the muscles, blood vessels and nerve endings of the perineum, as well as resection of the urethra [L. Boccon-Gibod, 2006]. All of the above leads to social maladaptation of this category of patients.

In connection with the development and implementation of new urotechnologies, recently minimally invasive methods of treating urological diseases have been given great importance. In this case, endoscopic benefits are largely less traumatic interventions. They include mainly internal optical urethrotomy, optical stricture restoration during an endoscope during transurethral surgery in the lower urinary tract, Otis urethrotomy, transurethral resection of urethral scar-sclerotic tissue [I.R. Saidov, 2000, A.G. Martov, 2001]. However, when observing patients in the long term, relapses are observed in 15-50% of cases. Meanwhile, the problem of endoscopic treatment of urethral strictures as a whole to date remains unresolved. Each of the existing methods of endoscopic treatment of urethral strictures carries certain disadvantages. That largely determines the relevance of developing new methods for minimally invasive treatment of urethral strictures.

A method for treating urethral strictures by performing internal optical urethrotomy (Dutkiewicz SA, Wroblewski M. Comparison of treatment results between holmium laser endourethrotomy and optical internalurethrotomy for urethral stricture. Int Urol Nephrol. - 2012. Vol. 3, No. 44. - p.17-24). The method is as follows: a cystoscope is inserted into the urethra and, under optical control, the urethral stricture is dissected with a blade or laser.

Disadvantages:

1. the method is applicable for non-extended strictures up to 1 cm, in the case of a greater length of the stricture, the method is not effective;

2. The implementation of this method is possible only under anesthesia, which increases the time spent in the hospital.

As the closest analogue, a method for treating urethral strictures by bougieumentation is taken (Voelkel H. Bougienage of urethral stricture with local use of steroids. Z Urol Nephrol. - 1970. Vol. 2, No. 63. - p. 49-53). The method is as follows: the introduction into the urethra of special curved metal bougie Benique, begin with the introduction of instruments easily passable in the stricture area and continue until bougie No. 20-22 according to Charrier.

Disadvantages:

1. Considering the fact that bougie only spreads sclerotically altered tissues without affecting regeneration, relapse accounts for more than 50% of cases;

2. Considering that bougienage is performed “blindly” - the risk of urethral damage is high.

Tasks:

1. to develop a method for the treatment of urethral strictures affecting the pathogenesis of stricture formation;

2. expand the indications for the use of minimally invasive treatment of urethral strictures.

To solve the tasks after performing urethral bougienage, a regeneration catalyst is introduced into the area of cicatricial deformity of the urethra - the stromal-vascular fraction of the patient's own adipose tissue. The stromal-vascular fraction of adipose tissue cells is stromal and vascular vascular cells, pericytes, leukocytes, fibroblast-like multipotent cells and hematopoietic stem cells. The content of stem cells is from 1 to 5%.

In relation to the closest analogue of the claimed method has the following technical result. The application of the proposed method for minimally invasive treatment of urethral strictures by performing urethral bougienage with injection of the stromal-vascular fraction of the patient’s own adipose tissue allows adequate minimally invasive treatment of urethral strictures, with exposure to the pathogenetic link in the formation of scar tissue, to exclude the possibility of urethral injury during bougienage.

The method is as follows. On the day of surgery, the patient in an outpatient setting under local anesthesia takes adipose tissue by syringe liposuction in a volume of up to 100 ml to isolate the stromal-vascular fraction of the patient's own adipose tissue cells. Next, the main stage of manipulation begins: bougieument and introduction of the catalyst. Probing is performed according to the standard method of Cook's bougie under optical control to avoid injury to the urethra. Bougienage is performed up to No. 24 according to Charrier, then, under optical control, a stromal-vascular fraction of the patient’s own adipose tissue cells is injected at 4-6 points using the Laborie endoscopic injector, depending on the length of the stricture. The total number of introduced cells is 30 million. At the end of the main stage, a Foley catheter No. 20 according to Sharyer is placed in the bladder, the last is removed 3 days after the manipulation and self-urination is restored.

The distinctive advantages of the proposed method is its pathogenetic orientation, based on the catalytic effect of the stromal-vascular fraction of the patient’s own adipose tissue cells on the processes of neovascularization, reduction of fibrosis and regeneration.

The inventive method of minimally invasive treatment of urethral strictures has been tested experimentally and clinically. At the experimental stage, under aseptic conditions under anesthesia, two series of male minipigs (20 animals each) reproduced urethral stricture by electrocoagulation for 2 cm in the bulbous section of the urethra (own method). The stricture treatment was started 3 months after modeling, in the first series (control), urethral boughening was performed according to the standard method, in the second series (experimental), after staging, the stromal-vascular fraction of adipose tissue cells was injected into the stricture zone. On the 30th day after the operation, the animals underwent urethrography and urethroscopy, and photo and video protocols were performed.

At the clinical stage, 10 patients with urethral stricture from 1 to 2.5 cm long performed urethral boughening with the simultaneous introduction of the stromal-vascular fraction of the patient’s own adipose tissue. All patients were discharged on day 2 without complications. When observing patients for 12 months (after surgical treatment) based on clinical and instrumental examination, data for urethral stricture were not found.

Clinical example

Patient B., 30 years old, was admitted to the hospital with complaints of difficulty urinating with a sluggish stream in the history of perineal injury. On examination: satisfactory condition. According to uroflowmetry, an obstructive type of urination with Qmax is 4 ml / sec. According to the urethrogram, a stricture of the urethral bulbous section with a length of ~ 2 cm was diagnosed with a stricture of the urethral bulbous section. The patient underwent urethral surgery with a simultaneous injection of the stromal-vascular fraction of the patient’s own adipose tissue, a urethral catheter was inserted into the bladder, the latter was removed on the 3rd day after the manipulation, and self-urination was restored. After manipulations on the urethra, the patient was repeatedly examined. 12 months after surgery, the condition is satisfactory, no complaints, no data for urethral stricture.

Thus, the application of the proposed method allows for the pathogenetic treatment of urethral stricture up to 2.5 cm long.

Socio-economic importance

The developed method can significantly reduce the risk of recurrence of urethral stricture when using a minimally invasive technique, to improve the immediate and long-term results of treatment of urethral pathology.

Claims (1)

A method of treating urethral stricture, which consists in introducing a thirty million million stromal-vascular fraction of a patient’s own adipose tissue as a regeneration catalyst in a sclerotically altered part of the urethra after augmentation of the last urethra.