RU2612189C1 - Method of ureterosigmostomy in case of urinary bladder cancer - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: invention relates to medicine, surgery. Midline laparotomy is performed. Reservoir is formed from rectosigmoidal part of large intestine. Both ureters are implanted into abducting part of intestine in isoperistaltic way. Ureters are passed through formed submucosal tunnels. Intestine mucosa is dissected in form of chutes, each with diameter 1.5-2.0 mc and 2.0-2.5 cm long. Ends of ureters are dissected on 2.0-2.5 cm and laid into formed chutes. Spatulated ends are sewn to intestinal wall, taking grip of muscular layer. After formation of anterior wall of reservoir it is fixed to parietal peritoneum. Wound is sewn layer-by-layer.

EFFECT: invented method reduces frequency of development of hyperchloraemic acidosis, ensures increase of reservoir tightness, reduces risk of development of stenosis of ureterosigmoanastomosis and reflux into upper urinary tract in discharge of urine into intestine after ablation of urinary bladder caused by cancer.

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Description

The invention relates to medicine, namely to urology, and is used to divert urine into the intestine after removal of the bladder.

To date, cystectomy is the only radical way to fight muscle-invasive bladder cancer. However, having saved a person from a cancerous tumor, cystectomy can lead to serious complications that reduce the quality and duration of his life. Most of these complications are consequences of various methods of urine diversion. There is no universal way to urine derivation, for each there are certain indications. In 2015, the European Society of Urology recommends three alternative methods for urinary diversion after cystectomy: abduction on the anterior abdominal wall (ureterocutaneostomy), ileum or colonic reservoir, and various forms of retaining reservoir; diversion through the urethra, which includes various versions of the gastrointestinal reservoirs connected to the urethra, orthotopic replacement of the bladder; urine diversion into the rectum or sigmoid colon, for example, uretero (ileo) rectectomy (EUA GUIDELINE - 2015 - English. Bladder Cancer - Muscle invasive and metastatic, http://www.uroweb.org/guidelines/online-guidelines/).

The prototype of our technique is the ureterosigmostomy of Mainz pouch P. The operation technique of Mainz pouch II is as follows. An incision is made of the parietal peritoneum along the Toldt line on the left and on the right, ureters are found. They are isolated and intersected as distally as possible. The left ureter is stretched behind the mesenteric to the right. The rectosigmoid segment of the intestine is dissected antimesenterically with an electric knife along the free tape of the sigmoid colon proximal and distal 10-12 cm. The intestine is placed in the form of an inverted letter V. The medial edges of the intestine anastomose by type of side to side with a double-row continuous suture. The ureters are implanted according to the antireflux technique in parallel to the right and left of the middle suture. The back wall of the reservoir in the area of the cranial end of the continuous suture is fixed to the cape of the sacrum or m.psoas. The front wall of the reservoir is sutured with either single-row serous-muscular interrupted sutures or a double-row suture. (Managadze L.G. et al. Operational Urology. Classics and Innovations: A Guide for Physicians. - M.: Medicine, 2003, 524-544).

Numerous methods have been developed for antireflux implantation of the ureter into the intestine. So the most popular among domestic and foreign surgeons are the following: Ricard (1909), Coffey I (1911), Coffey II (1927), Nesbit (1948), Cordonnier (1949), Leadbetter (1951) and Goodwin-Gallo (1953), Le Duc-Camey (1979) (Urinary Diversion. Scientific Foundations and Clinical Practice. GD Webster, B. Goldwasser. Copyright © 2004 Informa Healthcare. P. 707).

The main disadvantages of the Mainz - pouch II ureterosigmostomy are the following.

1. The incidence of hyperchloremic acidosis (the main metabolic disorder in Mainz ureterosigmostomy - pouch II) reaches 31-63% (D'Elia G, Pahernik S, Fisch M et al. Mainz Pouch II technique: 10 years' experience. BJU Int. 2004 ; (93): 1037-1042; Tollefson MK, Elliott DS, Zincke H, Frank I. Long-term outcome of ureterosigmoidostomy: an analysis of patients with> 10 years of follow-up. BJU Int. 2010 Mar; 105 (6 ): 860-3. Epub 2009 Aug 13).

2. Anastomotic stenosis develops in 5-31% of cases (Le Due A, Camey M, Teillac P. An original antireflux ureteroileal implantation technique: long-term follow-up. J Urol 1987; 137: 1156-8; Helal M, Pow Sang J, Sanford E, Figueroa E, Lockhart J. Direct (nontunneled) ureterocolonic reimplantation in association with continent reservoirs. J. Urol 1993; 150: 835-7).

3. The frequency of reflux of the contents of the reservoir into the upper urinary tract is 10–25% (Kristjansson A, Engellau L, Willner J, Mansson W. Reflux, stricture and glomerular filtration rate after two antireflux techniques in continent urinary reconstruction using the right colon. Scand J Urol Nephrol 1997; 31: 425-9).

4. Insufficiency of ureterosigmoid anastomosis occurs in 2-3.5% of cases (Oncourology. National leadership. Edited by Academician of RAMS V.I. Chissov, Prof. B.Ya. Alekseev, Prof. I.G. Rusakov. - M .: GEOTAR-Media, 2012 .-- 688 p.).

We first proposed a method that reduces the incidence of hyperchloremic acidosis, which increases the tightness of the reservoir in the early postoperative period, reduces the incidence of stenosis of ureterosigmoanastomoses and reflux in the upper urinary tract in the long-term postoperative period.

The proposed method is illustrated by figures 1, 2, 3, 4, where 1 is the sigmoid colon; 2 - free tape of the sigmoid colon; 3 - a seam of the posterior wall of the intestinal reservoir; 4 - submucosal tunnel; 5 - spatulation of the end of the ureter; 6 - the right ureter; 7 - a seam of the anterior wall of the intestinal reservoir; 8 - fixation of the intestinal reservoir to the parietal peritoneum.

The method is as follows. Mid-median access laparotomy. In the area of the left and right iliac fossa, the parietal sheet of the peritoneum above the ureters is dissected. The latter are secreted to the juxtavesical section, intersected and intubated by polyvinyl chloride tubes. A parietal sheet of the peritoneum is sutured to the ureters. The sigmoid colon (1) is distinguished, folded in the form of an inverted letter V and dissected along the free tape of the sigmoid colon (2) by 15 cm (Fig. 1). The walls of the dissected intestine, facing posteriorly, are sutured together by two rows of continuous absorbable sutures 4-0 (3) (Fig. 2). After the formation of the posterior wall of the reservoir, the left ureter is passed through the mesentery of the sigmoid colon to the outside, and then in the mesentery passes extraperitoneally and is isoperistaltically implanted into the outlet knee of the intestine. Moreover, it is first carried out in a submucosal tunnel formed in the intestinal wall (4). The edges of the mucous membrane are carefully sutured with interrupted sutures with adventitia of the ureter. Then the intestinal mucosa is dissected in the form of a trench 1.5-2.0 cm wide (corresponding to the circumference of the ureter) and 2.0-2.5 cm long (with a longer extent, trophism of the distal end of the ureter may be disturbed, a smaller one would entail risk of developing stenosis). The end of the ureter undergoes wide spatulation along the front surface (2.0-2.5 cm - respectively the length of the gutter) (5), fits into the gutter and firmly stitches with the intestinal wall, capturing its muscle layer. The right ureter is carried out retroperitoneally through the mesentery of the sigmoid colon and, having retreated 2 cm from the mouth of the left ureter, is isoperistaltically implanted (6) (Fig. 3). The front wall of the reservoir is sutured with a 2-row continuous suture (7), and then the reservoir itself is fixed to the parietal peritoneum (8) (Fig. 4), which prevents the failure of the ureterosigmoanastomosis, as well as the bend of the ureters into the small pelvis.

This method of forming a urinary reservoir is used in 62 patients with bladder cancer. Clinically pronounced hyperchloremic acidosis during the follow-up period up to 5 years developed in 7 people (11%), stenosis in 3 patients (4.8%), reflux in 3 (4.8%), ureterosigmoanastomosis failure in 2 people (3.2% )

Clinical example. Patient Sh., 62 years old, was under treatment with a diagnosis of Bladder cancer T3aNOMO. Condition after three transurethral bladder resections. Relapse of a tumor in the bladder. October 15, 2013 performed a cystectomy with ureterosigmostomy by the proposed method. Drainage from the abdominal cavity was removed on the 4th day, from the pelvic cavity - on the 7th day. The drainage tube from the rectum was removed on the 7th day. Ureteric intubators removed on the 12th day after surgery. There are no postoperative complications. After removing the drainage, the patient began to urinate through the rectum: first, the frequency of urination was every 40-60 minutes, after 3 months the interval increased to 2-3 hours, and the frequency of nightly urination was 1-2. No urinary incontinence. Control examination 11 months after the operation showed no signs of impaired urodynamics of the upper urinary tract. Tank capacity 138 ml.

In the postoperative period of management of patients operated on by the claimed method, the following advantages are revealed in comparison with the prototype:

1) The implantation of the ureters into the outlet segment of the intestine is isoperistaltically, which prevents urine regurgitation in the adducting section of the colon and thereby reduces the likelihood of its absorption and the development of hyperchloremic acidosis.

2) The formation of a submucosal tunnel during implantation of the ureter prevents the development of reflux.

3) Wide spatulation of the distal end of the ureter prevents stenosis of ureterosigmoanastomosis.

4) Fixation of the intestinal reservoir to the parietal peritoneum at the site of the formation of the ureterosigmoanastomosis prevents the failure of the ureterosigmoanastomosis, as well as an excess of the ureter into the pelvis.

This gives reason to apply this method in the clinic according to the indications of the corresponding category of patients.

Claims (1)

The method of ureterosigmostomy for bladder cancer, including median laparotomy, the formation of a reservoir from the rectosigmoid colon of the colon by dissecting it along the free sigmoid colon tape 10-12 cm and the intestine in the form of an inverted letter V, the medial edges of the intestine anastomose with each other side-by-side type with a double-row continuous suture, characterized in that both ureters are implanted in the outlet section of the intestine isoperistaltically, submucous tunnels are formed through which the wire ureters of the ureters, the intestinal mucosa are dissected in the form of gutters, each with a diameter of 1.5-2.0 cm and a length of 2.0-2.5 cm, the ureters are dissected to a length of 2.0-2.5 cm and laid in formed gutters, sew them to the wall of the intestine, capturing the muscle layer; then form the front wall of the intestinal reservoir and fix the latter to the parietal peritoneum; the wound is sutured in layers.

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