RU2559139C2 - Method of surgical treatment of ureterohydronephrosis and device for its realisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to medicine, surgery. Endoscope is introduced into urinary bladder on urethra. Ureterocele is visualised. Cutting instrument is introduced into working channel of endoscope. Before dissecting ureterocele device for surgical treatment of ureterohydronephrosis is introduced into urinary bladder on urethra. Device consists of branches, connected with rigid tube, spoke-shaped metal movable element, and flexible casing. On the end of spoke forceps are placed. After distal end of forceps is visualised, casing is taken off from them. Uretrocele is gripped by forceps in medium part of anterior wall and cut transversally in the area of base for width, not exceeding 3 mm.

EFFECT: method of surgical treatment of ureterohydronephrosis makes it possible to improve treatment results, accuracy of dissection, avoid risk of vesicoureteral reflux development.

2 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to urology and pediatric surgery, and is intended for the treatment of ureterohydronephrosis formed on the background of ureterocele.

A known method for the surgical treatment of ureterohydronephrosis by longitudinal dissection of the anterior and upper walls of the ureterocele by exposing the mobile formation to an endoscopic knife, endoscopic scissors or a laser beam. The incision is performed from the neck of the bladder to the area of the bottom of the bladder, with a dissection of the upper and front walls of the ureterocele (1).

The main disadvantage of the longitudinal method of cutting the front and upper walls of the ureterocele is the high frequency of surgical complications - vesicoureteral reflux, which leads to the progression of urodynamic disorders. Complications arise due to the destruction of the valve mechanism of the ureter with a wide longitudinal section of the ureterocele.

There is also a known method of transverse dissection of the anterior wall of the ureterocele, including the formation of an aperture in the ureterocele through its wide dissection along the anterior wall from the lateral to the medial edge (2).

The disadvantages of this method are as follows. Due to the lack of fixation of the ureterocele during its dissection, there is a risk of performing an incision that is inadequate in length (excessively large or excessively small), which leads to surgical complications, such as vesicoureteral reflux with an excess length of the incision or relapse of the obstructive process in the ureter with a short incision due to intergrowths of ureterocele tissues. To achieve an adequate dissection of the tissue with an unsecured ureterocele, a considerable time is sometimes required to perform a transverse incision; an uneven, “ragged” or inconsequential incision is performed.

In addition, during transverse dissection of the ureterocele, the incision can very rarely be performed strictly linearly due to the free movement of the ureterocele in the bladder under the influence of a cutting tool, which can lead to dissection of the bladder tissue together with ureterocele tissues, a wave-like incision or excessive dissection of the anterior wall of the ureterocele with loss of valve ureter function. There is a high risk of performing an incision involving the upper wall of the ureterocele due to the impossibility of choosing the correct dissection zone on an unfixed ureterocele.

Closest to the claimed is a method for dissection of the ureterocele, in which an endoscope is inserted into the bladder, cystoscopy is performed, the ureterocele is visualized, its dissection area is determined, the cutting tool is carried out into the working channel of the endoscope until the distal end of the cutting tool appears in the field of view and the ureterocele is transected, focusing on the transition zone of the anterior wall of the ureterocele and the bladder mucosa, for a length equal to the width of the ureterocele (3).

The disadvantages of the method selected as a prototype are as follows.

1) A significant risk of developing vesicoureteral reflux due to the fact that:

A) wide dissection of the anterior wall of the ureterocele leads to the destruction of the natural antireflux mechanism;

B) an aperture of excess diameter is formed, which facilitates the casting of urine into the ureter and kidney in the postoperative period,

2) a high risk of recurrence of ureterocele and ureterohydronephrosis due to coalescence of the walls of the ureterocele with an insufficient length of the cut of its wall, a wavy cut or "loosened" edges of the cut, making the cut in the form of a "window".

The task of the invention is the prevention of surgical complications of surgery.

According to the invention, the problem is solved in that in the method of surgical treatment of ureterohydronephrosis, which consists in the fact that an endoscope is inserted into the bladder along the urethra, cystoscopy is performed, the ureterocele is visualized, its dissection zone is determined, the cutting tool is carried out into the working channel of the endoscope until the distal end of the cutting the instrument in the field of view and dissect the ureterocele, before dissection of the ureterocele, the device stated below is inserted through the urethra into the bladder, an endoscope is passed through the urethra, after visualization of the distal end of the forceps remove the protective device from them, after which the forceps capture the ureterocele in the middle part of the front wall and are transversely cut in the base region to a width not exceeding 3 mm.

A device is known for the surgical treatment of ureterohydronephrosis by extracting stones from the bladder and ureter, consisting of jaws connected to a tube, inside of which there is a metal flexible movable element made in the form of a string, and a wire basket for capturing and removing stone is installed at its distal end ( 4, 5).

The disadvantage of this device is the impossibility of actively manipulating it in the bladder with the use of forces of different directions along the vector, which allows you to perform only traction force (traction), the inability to capture the tissue site.

A device for gripping and holding tissue is known, consisting of jaws connected to a tube, inside of which there is a metal movable element made in the form of a spoke, and forceps (6) are installed on the end of the spoke.

The disadvantage of this device is the inability to conduct it along the urethra into the bladder in addition to the working channel of the endoscope due to the high risk of trauma (puncture) of the urethra and surrounding tissues.

Closest to the claimed is a device for illumination, capture and resection of tissues during endosurgical interventions for cancer of the bladder in the form of a multi-channel fibroscope consisting of three channels, one of which is used for illumination, the other for conducting an endoscopic flexible instrument, such as biopsy forceps, and the third the channel is used to supply energy to the manipulation zone, for example, laser, through an optical fiber, a piezoelectric pulse through a flexible electrode or microwave ktricheskoy through the electrode manipulator. Thus, when manipulating in an illuminated area with affected tissue, two types of exposure to a cancer tumor can be used: mechanical (cutting tools, forceps, needles) and energy (laser, piezoelectric pulse, microwave electric exposure) (7).

The disadvantage of the device selected as a prototype is the impossibility of tensioning and shifting the fabric away from the cutting tool when it is captured by endoscopic forceps held along the working channel of a flexible fiber microscope, since the thrust vector in all channels of the prototype device is unidirectional. Using tension of the tissue with forceps towards the working end of the fiber endoscope will only lead to tissue getting out of focus, blurring the optical picture and worsening visualization.

The inventive method according to claim 1, dissection of the ureterocele is possible only when using the device according to claim 2 — endoscopic forceps with a protective casing, allowing tension of the captured tissue when dissecting the ureterocele away from the working end of the endoscope, which allows the dissection of the ureterocele during surgical treatment of ureterohydronephrosis using laser or mechanical energy with reliable fixed fixation of pathological dissected formation without deterioration of optical visual ation and the ability to freely manipulate the working end of the hard endoscope. In addition, the prototype device has a flexible controllable working end, the use of which, like the handle, in the treatment of ureterohydronephrosis by the claimed method is not required. Only a separate arrangement of rigid endoscopic instruments (the claimed endoscopic forceps with a protective casing and an operating endoscope) in the urethra and the bladder allows reliable, quick and minimal chance of complications developing endoscopic dissection of the ureterocele during surgical treatment of ureterohydronephrosis.

To implement the proposed method, a device is used, consisting of a jaw connected to a tube inside which a metal movable element is installed, while the tube is rigid, the metal movable element is made in the form of a spoke, a flexible casing is movably mounted on its distal end, and on the end of the spoke forceps.

Fixation of the ureterocele using the claimed device for the middle part of the anterior wall allows you to clarify the area of the proposed incision, to make an even linear section strictly along the zone of transition of the mucous membrane of the bladder into the anterior wall of the ureterocele, preserving the anterior and upper walls, which are an antireflux valve, as much as possible.

This method of performing a ureterocele incision can be safely performed only with the help of the claimed device, which is the key to the prevention of vesicoureteral reflux due to the complete preservation of the antireflux mechanism of the ureter.

A linear cross-section of the formation along the border of tissues of various elasticities and stiffnesses to a length of 3 mm allows the formation of a slit-like aperture that does not allow the edges of the dissected formation to converge again, which prevents the coalescence of ureterocele walls and the relapse of ureterohydronephrosis.

Only the presence of a protective casing, as an integral part of the claimed device, allows you to blindly pass the device along the urethra into the bladder para-instrumentally, without injuring the wall of the urethra and surrounding tissue. The use of other endoscopic devices, in addition to the claimed, will inevitably lead to significant trauma to the urethra and bladder, which is unacceptable.

A linear transverse incision of the ureterocele, carried out in the manner described, can only be performed if the formation and tension in the bladder are fixed and tension, which is possible only when using the inventive device.

The use of the inventive device - endoscopic forceps with a protective casing, significantly increases the efficiency and reduces the invasiveness of the operation, eliminates the risk of surgical complications of the intervention (recurrence of ureterocele, vesicoureteral reflux, trauma to the walls of the urethra).

In FIG. 1 shows the inventive device, which consists of a jaw 1, movably connected to each other by a hinge 2, with a metal spring plate 3, through the upper part of the proximal jaw 4 and a rubber band 5 connected to the locking element 6, through a threaded connection 7 connected to the hollow tube 8 , inside of which a metal element in the form of a spoke 9 is movably fixed, through a hinge 10 connected to the tongs 11 with the gear element 12. On the tube 8, the swivel 10 and the tongs 11 with the gear element 12 is installed protective cover 13.

The method is as follows. An endoscope with a diameter of 3 mm is inserted into the urethra and carried into the bladder. After insertion through the instrument, cystoscopy is performed to determine the presence of a ureterocele, its localization and size.

The inventive device is carried out para-instrumentally through the urethra rectified by the endoscope into the bladder. Then, the distal end of the device with the protective casing 13 is visualized. After the device is visualized, under the control of vision, the protective casing 13 is moved proximally along the tube 8 until the forceps 11 with the toothed element 12 at the end are completely released.

Under visual control, the operator spreads jaws 1 on the swivel joint 2, dispensing dilution with a spring plate 3, transfers force through the upper part of the proximal jaw 4 to the movable metal element 9, passing through the sealing gum 5, the fixing element 6, through the threaded connection 7, the hollow tube 8 through the swivel 10, acting on the forceps 11 with the gear element 12 at the end, and performs the breeding of the forceps 11 (Fig. 2).

After visualizing the capture zone of the ureterocele, the operator, reducing the jaws 1 at the swivel joint 2, dosing the reduction by the spring plate 3, transfers the force through the upper part of the proximal jaw 4 to the movable metal element 9 passing through the sealing gum 5, the fixing element 6, through the threaded connection 7, the hollow tube 8, through the swivel joint 10, acting on the forceps 11 with the gear element 12 at the end, and performs the reduction of the forceps 11 with the gear element 12 for the upper part of the front wall of the ureterocele. After capturing the ureterocele, the distal end of the device is lifted upward, lowering the proximal end, using the muscle structure of the perineum as a support of the lever, and traction toward the urethra, forming a protrusion of the ureterocele in the form of a fold.

A cutting tool is passed into the working channel of the endoscope until it appears in the lower part of the field of view. Diagnose the ureterocele dissection zone, focusing on the clearly visible area of its base after capture and tension. Then, a straight linear cross section of the bladder mucosa and a section of the ureter tissue forming the ureterocele are performed into all layers until a slit-like aperture with even edges is formed, which includes an endoscope with a diameter of 3 mm.

After the introduction of the endoscope into the ureter, ureteroscopy is performed through the formed aperture, the transparency of the optical medium is evaluated, and the presence of calculi and sources of bleeding are excluded. The endoscope is removed from the ureterocele and the visualization of the incision zone, ureterocele and the distal end of the device holding the ureterocele in a fixed state is repeated.

Under visual control, the operator spreads jaws 1 on the swivel joint 2, dispensing dilution with a spring plate 3, transfers force through the upper part of the proximal jaw 4 to the movable metal element 9, passing through the sealing gum 5, the fixing element 6, through the threaded connection 7, the hollow tube 8 through the swivel 10, acting on the forceps 11 with the toothed element 12 at the end, and performs the breeding of the forceps 11 (Fig. 2), freeing the front wall of the ureterocele from capture, and then removes the device from the ureterocele 1-2 cm.

Before removing the device from the bladder, it is brought into a safety state: the operator, reducing the jaws 1 on the swivel joint 2, dosing the spring plate 3, transfers the force through the upper part of the proximal jaw 4 to the movable metal element 9 passing through the sealing gum 5, the fixing element 6, through the threaded connection 7, the hollow tube 8, through the hinge device 10 acting on the forceps 11 with the gear element 12 at the end, performs the reduction of the forceps 11 with the gear element 12. The protective casing 13, moving the tube 8 under the control of to the original position (fully protected by the distal portion of the tube 8, the hinge member 10, the forceps 11 with a toothed element 12, the distal end of the guard 13 is distal closure forceps 11 by 2 cm) (Fig. 1).

A device is removed from the bladder through the urethra, a cutting device is removed from the working channel of the endoscope, fluid is removed from the bladder, an endoscope is removed from the bladder through the urethra.

Example. Patient P.E.A., 3 years old, diagnosis: Complete doubling of the kidney on the right, ectopic ureterocele on the right 3 degrees, obstructive ureterohydronephrosis of the upper segment of the doubled right kidney, chronic secondary pyelonephritis, continuously recurrent course, infravesical obstruction. Received May 13, 2010 at the Urology Department of the Clinical Hospital SBEI HPE SPbSPMU with complaints of frequent exacerbations of pyelonephritis, constant leukocyturia, the absence of a normal stream during urination, the presence of residual urine, pain in the lumbar region on the right.

Ultrasound revealed pyeloectasia and urerectasia on the right, a rounded formation in the bladder, residual urine up to 70 ml were visualized, with intravenous urography, expansion and tortuosity of the additional ureter, expansion of the cavity system of the upper segment of the right doubled kidney were noted. With cystography, difficulty urinating due to the introduction of part of the ureterocele into the internal opening of the urethra and the formation of infravesical obstruction was noted. Radionuclide research - a sharp inhibition of the rate of excretion of the drug from the kidney.

The operation was performed: cystoscopy, endoscopic dissection of an ectopic ureterocele on the right according to the claimed method.

The immediate result was evaluated after 7 days: there was a significant increase in the urine stream during mycotomy, with ultrasound there was no residual urine, the round formation in the bladder was determined as residual tissue, the size of the pelvis and ureter were significantly reduced.

Long-term result: evaluated during examination after 24 months: for the period of observation of exacerbations of pyelonephritis and leukocyturia was not, urinates freely, painlessly. Ultrasound of the bladder without pathological changes, there is a residual deformation of the collecting complex of the upper segment of the doubled right kidney without its expansion, the additional ureter is not visualized, there is no residual urine, intravenous urography is a significant reduction in the cavity system and ureter of the upper segment of the doubled right kidney, there is no shadow of the ureterocele, radionuclide nephroscintigraphy - normalization of the rate of capture and distribution of the radiopharmaceutical (technetium 99 m) in the parenchyma of the upper segment is doubled Noah right kidney, the normalization rate of excretion. With cystography, the bladder is rounded, there is no bladder-ureter reflux into the additional ureter. Parents of the child are satisfied with the treatment, the girl is fully socially adapted.

The proposed method allows to improve the results of surgical treatment of ureterohydronephrosis by optimizing the procedure for dissection of the ureterocele at the site of the incision and the length of the incision, simplifying the dissection of a fixed ureterocele.

The method provides linear cross-sectional dissection under conditions of ureterocele fixation, which prevents an excessively large length of the dissection zone and avoids such surgical complications as vesicoureteral reflux.

In addition, the linear cross-section of the ureterocele according to the claimed method allows to prevent coalescence of the walls of the ureterocele due to the exclusion of a cut of critically small length and / or "loosening" of the edges of the cut, which significantly reduces the risk of recurrence of ureterohydronephrosis and repeated surgical intervention.

Information sources

1. Effectiveness of Primary Endoscopic Incision in Treatment of Ectopic Ureterocele Associated With Duplex System / Adorisio O., Elia A., Landi L. et al. // Urology. - Vol. 77 (1). - 2011 .-- P. 191-194.

2. Transurethral Puncture for Ureterocele - Which Factors Dictate Outcomes? / Di Renzo D., Ellsworth P.I., Caldamone A.A. Chiesa P.L. // J. Urology. - Vol. 184. - 2010 .-- P. 1620-1624.

3. Technique Using a Percutaneous Nephroscope and Nephroscopic Scissors Transurethrally for Treatment of Complicated Orthotopic Ureterocele in Adult Women / Isen K. // Urology. - Vol. 79. - 2012. - P. 713-716.

4. Patent US2004097964 A1 publ. 05/20/2004.

5. Patent DE 102010007998 A1 publ. 08/18/2011.

6. Patent US 20120078289 A1 publ. 03/29/2012.

7. Design and Performance Evaluation of a Minimally Invasive Telerobotic Platform for Transurethral Surveillance and Intervention / Goldman R.E., Bajo A., MacLachlan L.S. et al. // IEEE transactions on biomedical engineering. - 2013 .-- Vol. 60. - No. 4. - P. 918-925.

Claims (2)

1. A method of surgical treatment of ureterohydronephrosis, which consists in introducing an endoscope into the bladder, performing a cystoscopy, visualizing the ureterocele, determining its dissection area, holding a cutting tool into the working channel of the endoscope until the distal end of the cutting tool appears in the field of view and is transversely dissected ureterocele, characterized in that before the dissection of the ureterocele, the device according to claim 2 is inserted through the urethra into the bladder, an endoscope is inserted through the urethra, after visualization of the distal end of the forceps a protective device is removed from them, after which a ureterocele in the middle part of the front wall is grasped with forceps and transversely cut in the base region to a width not exceeding 3 mm. 2. Device for surgical treatment of ureterohydronephrosis, consisting of jaws connected to a tube, inside which a movable element is installed, characterized in that the tube is rigid, the metal movable element is made in the form of a spoke, a flexible casing is movably mounted on its distal end, and on the end knitting needles set.

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