RU2545442C2 - Method of surgical treatment of ureterohydronephrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular urology. The lower cystoid of the dissected ureter is turned out in the form of an invaginate. An anastomosis of the ureter with the urinary bladder is formed. The mucous membrane of the urinary bladder is cut on the length of the formed invaginate. An external leaf of the ureter invaginate is cut to transfer into an internal leaf. A wall of the internal leaf is sutured with the muscular layer of the urinary bladder. Edges of the dissected external leaf of the ureter invaginate are sutured with edges of the dissected mucous membrane of the urinary bladder.

EFFECT: method ensures the ureter reimplantation in case of ureterohydronephrosis, makes it possible to reliably fix the invaginate in the urinary bladder, prevents rolling of the invaginate and bladder-ureter reflux.

1 ex, 1 dwg

Description

The invention relates to medicine, in particular surgery, urology, and can be used to treat ureterohydronephrosis with severe dilatation of the ureter.

A known method of surgical treatment of ureterohydronephrosis with the nipple method (Dewan P.A. Ureteric reimplantation: a history of the development of surgical techniques. BJU International 2000; 85: 1000-1006). The ureter is passed through the wall of the bladder near the initial ureter orifice and the lateral edge of the ureter wall is dissected for 2-2.5 cm. The end of the ureter removed into the bladder is turned out, the edges of the dissected wall are sutured. Formed invaginate (nipple), consisting of a doubled wall of the ureter, is sutured to the mucous membrane of the bladder.

The main disadvantage of this method is that the created invaginate can be screwed into the lumen of the bladder, resulting in vesicoureteral reflux, which leads to infection of the upper urinary tract, pyelonephritis, sclerosis of the parenchyma of the kidney, wrinkling, chronic renal failure, reflux nephropath .

A known method of reimplantation of the ureter Politano-Leadbetter (Politano V, Leadbetter Wf. An operative technique for the correction of vesicoureteral reflux // J. Urol. - 1958. - No. 79. - P.932-941). The ureter is cut off from the bladder, the formed hole is sutured. The bladder is dissected. An oblique submucous tunnel is created in the bladder, ending in the corner of the Lietto triangle on the reimplantation side. The cut off ureter is passed through a separate incision of the bladder wall inward and the created submucous tunnel.

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The distal end of the ureter is sutured to the edge of the submucosal tunnel and the wall of the bladder, leaving the lumen of the ureter.

The disadvantage of this method is the risk of complications: kink, obstruction of the ureter, ischemic damage to the mucosa.

Closest to the claimed is a method that includes resection of the ureter, intussusception in its lumen of the transverse circular wall duplicate and the formation of anastomosis of the ureter with the bladder (Description of the invention to author certificate. No. SU 1450825 A1. Lopatkin NA, Zhitnikova LN Method for the treatment of neuromuscular dysplasia of the ureters // Application 4194903, 02.23.1987).

The disadvantage of the method selected as a prototype is the insufficiently reliable fixation of the invaginate in the bladder and the possibility of screwing the invaginate back, resulting in vesicoureteral reflux.

An object of the present invention is to prevent vesicoureteral reflux.

The technical result of the present invention is achieved by the fact that in the method of surgical treatment of ureterohydronephrosis, including resection of the ureter, the formation of ureteral invaginate and the formation of anastomosis of the ureter with the bladder, characterized in that the lower ureter cystoid is inverted as an invaginate, dissect the bladder mucosa from the bladder towards the corner of the Lietto triangle along the ureter and the length of the formed invaginate; the lateral edge of the outer leaf of the ureteral invaginate is dissected before passing into the inner leaf; the wall of the inner leaf of the invaginate is stitched with the muscle layer of the bladder between the edges of the dissected mucosa, the edges of the dissected outer leaf of the invaginate are stitched with the edges of the dissected mucosa of the bladder.

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Thanks to fixation on the outer and inner wall of the invaginate to the muscle and mucous layers of the bladder, the possibility of screwing the invaginate is minimized. Due to the stitching of the inner wall of the invaginate through all layers to the muscle wall of the bladder with a contraction of the bladder, the ureter also contracts, while the invaginate is tightly fixed to the bladder and does not change the internal trajectory when filling and emptying the bladder. Due to this, the risk of screwing intussusception and the occurrence of vesicoureteral reflux is minimized.

In FIG. 1. shows a method of fixing the invaginate to the wall of the bladder: 1 - the outer leaf of the invaginate of the ureter; 2 - an internal leaf of an invaginate of an ureter; 3 - the mucosa of the bladder; 4 - muscle layer of the bladder.

The method is as follows. The ureter in the lower third is mobilized by extraperitoneal access, the intramural part is isolated and cut off from the bladder. The resulting defect is sutured. Dissect the bladder. The lower cystoid of the ureter is inverted in the form of an invaginate (nipple). The lateral edge of the outer leaf 1 of the ureter invaginate is dissected before passing into the inner leaf 2. The mucous membrane 3 of the bladder is dissected from the bottom of the bladder towards the corner of the Lietto triangle along the ureter and the length of the formed invaginate. The walls of the inner leaf 2 of the ureteral invaginate are sutured with the muscle layer 4 of the bladder between the edges of the dissected mucosa 3 of the bladder with separate sutures. The edges of the dissected outer leaf 1 of the ureter invaginate are sutured with the edges of the dissected mucosa 3 of the bladder.

Example. Patient R. (source of illness No. 19673, d. 05.11.2007), received treatment at the urology department of St. Petersburg State Medical University for bilateral ureterohydronephrosis. Anamnesis: ureteropyeloectasia from 2 sides was noted antenatally, during the examination revealed obstructive ureterohydronephrosis from 2 sides. Subsequently, the patient was repeatedly operated. 03/21/2008 - ureterocutaneostomy from 2 sides. 04.21.2009 re-implantation of the ureters according to Politano-Ledbetter from 2 sides, closing of the ureterocutaneostomy on the right. During the follow-up examination, signs of obstruction of the right ureter persisted, stenting of the right ureter was performed. 03/16/2010 reimplantation of the right ureter with the nipple method. During the control examination revealed vesicoureteral reflux of the V degree.

10/04/2010 reimplantation of the right ureter by the claimed method. The diameter of the ureter is 1.5 cm, the length of the invaginate is 3.5 cm.

During the follow-up examination according to ultrasound, ureteral invaginate is visualized in the bladder, with cystography of vesicoureteral reflux it was not detected, with excretory urography there was a positive dynamics in the form of contraction of the right ureter and pyelocaliceal system of the right kidney.

Final diagnosis: Bilateral ureterohydronephrosis. Condition after repeated surgical treatment.

The inventive method allows reliable fixation of ureteral invaginate in the bladder, which prevents the screw intussusception and, thus, the occurrence of vesicoureteral reflux, wrinkling of the kidney, and chronic renal failure.

The risk of acute pyelonephritis is reduced, which reduces the duration of antibiotic therapy and the rehabilitation period.

This method makes it possible to reduce the number of postoperative complications. An additional advantage is the visualization of invaginate during ultrasound.

Claims (1)

A method of surgical treatment of ureterohydronephrosis, including resection of the ureter, the formation of ureter invaginate and the formation of an anastomosis of the ureter with the bladder, characterized in that the lower ureter cystoid is turned out as an invaginate, the bladder mucosa is dissected from the bottom of the bladder and the urine runs in the direction towards the corner the length of the formed invaginate; the lateral edge of the outer leaf of the ureteral invaginate is dissected before passing into the inner leaf; the wall of the inner leaf of the invaginate is stitched with the muscle layer of the bladder between the edges of the dissected mucosa, the edges of the dissected outer leaf of the invaginate of the ureter are stitched with the edges of the dissected mucosa of the bladder.

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