RU2639407C1 - Method of surgical rehabilitation of patients after cystectomy with bladder intestinoplasty in formation of uretero-reservoir anastomosis strictures - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: urinary reservoir is mobilized and the area of the uretero-reservoir anastomosis stricture is revealed. The ureter is mobilized 3-4 cm above the detected narrowing, the stricture is excised. The urinary reservoir wall defect is closed with a Z-shaped suture. An aperture is formed in the urinary reservoir wall, along the antiplatelet edge, commensurate with the ureter diameter. A serous-muscular suture is applied between the ureter wall and the reservoir wall at a distance of 5-10 mm from the opening edge. Two nodal intracorporeal sutures form the posterior wall of the anastomosis. The ureter is stented. Nodal intracorporeal sutures form the anterior wall of the anastomosis. The second serous-muscular suture is applied on the side opposite the first suture. The stent is removed from the ureter by reservoirroscopy after 3-4 weeks.EFFECT: elimination of uretero-reservoir anastomosis stenosis.1 ex, 18 dwg

Description

The invention relates to medicine, surgery, rehabilitation, can be used for strictures of the ureters in patients after cystectomy with intestinal plasty of the urinary reservoir.

The main treatment for muscle-invasive bladder cancer is radical cystectomy. When the bladder is removed in order to ensure an acceptable quality of life, intestinal plastic surgery of the bladder is performed with the formation of a dry or wet stoma, transrectal urination or preservation of urethral urination. With all variants of these methods of urine derivation, uretero-reservoir anastomoses are formed [1, 2].

Subsequently, after the recovery period in the absence of progression of the tumor process in some patients, the main threats to health and life are associated with impaired urodynamics in the created urinary tract, in particular during the formation of strictures of uretero-reservoir anastomoses [3].

The main reason for narrowing of the ureter is a cicatricial process due to leakage of urine, the development of inflammation. In the long term, ureteral strictures develop quite often, which dictates the need for monitoring and regular examination of patients after radical cystectomy, not only to exclude tumor progression, but also with the goal of assessing urodynamics and functional state of the kidneys.

The incidence of stricture of the ureterointestinal anastomosis during the formation of a conduit or reservoir can reach 10% [4, 5].

A known method of treating strictures of the uretero-reservoir anastomosis by open surgery aimed at excising the narrowed portion of the ureter and implanting the ureter into the urinary reservoir. At the end of the XIX century, the first successful reconstructive operations were performed with strictures of the ureter. Throughout the 20th century, many treatment methods have been proposed for narrowing of the ureters, open surgery was considered the "gold" standard of treatment.

The disadvantages of this surgical intervention are: 1). Surgical trauma due to a pronounced adhesive process in the abdominal cavity after cystectomy and changes in the normal anatomical structure of the digestive tract and urinary tract after the creation of the urinary reservoir and inter-intestinal anastomoses cause a high risk of complications, a long period of treatment and rehabilitation of patients.

2). The threat of intestinal injury with relaparotomy due to the same adhesive process.

Recently, another method of treating ureteral strictures is percutaneous interventions, which include puncture of the pyelocaliceal system of the kidney, passing the string through a narrowed section of the ureter to the urinary reservoir, further bougie-up or balloon dilatation with the installation of the ureteric stent. The disadvantages of such methods of treatment include the need for kidney puncture and the risk of bleeding, the intervention is performed under x-ray control with an X-ray load on the medical staff and the patient, the ureteric stent causes certain technical difficulties and the structure is not always overcome. Subsequently, after removal of the ureteric stent, the risk of recurrence of strictures of the uretero-reservoir anastomosis is high.

The development of medical technology in the late XX - early XXI centuries led to the widespread introduction of laparoscopic surgery, including in urology in the treatment of ureteral strictures. Methods of ureteroureteroanastomoses, ureteroterocystoanastomoses using laparoscopic techniques are described.

The aim of the invention is to reduce the incidence of postoperative complications due to a more gentle surgical intervention when performing laparoscopy compared with open surgery, reducing the time of the postoperative period and rehabilitation of patients with strictures of uretero-rezervuarnoy anastomoses.

The goal is achieved due to the following factors:

- less trauma to the anterior abdominal wall (4-5 trocar wounds instead of mid-lower middle laparotomy);

- better visualization of tissues during laparosocopy, which allows precise separation of adhesions, always present after previously performed cystectomy with intestinal plasty, and delicate suturing during the formation of a new uretero-reservoir anastomosis;

- the application of two serous-muscular sutures between the ureter and the urinary reservoir in order to reduce the load on the sutures of the uretero-reservoir anastomosis and the prevention of anastomosis failure.

The method is as follows.

After applying pneumoperitoneum, a laparoscope and laparoscopic surgical instruments are inserted into the abdominal cavity. After revision of the abdominal cavity, adhesions present in the area of the forthcoming plastic surgery are dissected. They mobilize the urinary reservoir while preserving the supply vessels of the mesentery. The stricture area of the uretero-reservoir anastomosis is revealed. The proximal ureter is mobilized 3-4 cm above the detected narrowing. The stricture is excised, the defect in the wall of the urinary reservoir is sutured with a Z-shaped suture. In the wall of the urinary reservoir along the mesenteric edge, an opening is made that is commensurate with the diameter of the ureter, FIG. 1. A sero-muscular suture is applied between the wall of the ureter and the wall of the urinary reservoir at a distance of 5-10 mm from the future anastomosis (Fig. 2, 3), which ensures the immobility of the ureter relative to the conduit, which creates the convenience of forming an anastomosis, eliminates the need to use a tool to hold the ureter in the desired position, reduces the number of necessary laparoscopic instruments.

Using 2 nodal intracorporeal sutures form the posterior wall of the anastomosis (Fig. 5, 6, 7). The ureteric stent is placed in the ureter to the renal pelvis (Fig. 8). The distal part of the stent with curl is placed in the cavity of the urinary reservoir (Fig. 9). The formation of the anastomosis is completed by applying 2 or 3 (depending on the diameter of the ureter) nodal intracorporeal sutures to the front wall of the created anastomosis (Fig. 10, 11, 12, 13). A second serous-muscular suture is applied between the ureter and conduit on the side opposite to the formed anastomosis from the first serous-muscular suture (Figs. 14, 15). An insurance (trapping) drainage is brought to the area of operation through the closest of trocar openings, which is removed on the 2-3rd day of the postoperative period. A stent from the ureter is removed with reseruaroscopy 3-4 weeks after surgery.

In the Moscow City Oncological Hospital No. 62 (MGB No. 62), the proposed method for forming uretero-reservoir anastomoses was used in 4 patients with strictures after Bricker surgery.

Clinical example.

Patient L., 66 years old, has been under observation at the Moscow City Hospital No. 62 since 2010. In 2010, she was diagnosed with Cancer of the bladder. T2N0M0. Complete doubling of the left kidney. Incomplete doubling of the right kidney.

04/07/2010, performed a radical cystectomy, Bricker operation. Histological examination: low-grade urothelial cancer (Grade 3) of the bladder, invading the inner layer of the muscle membrane. She was discharged in satisfactory condition, after discharge she returned to her usual lifestyle. With regular follow-up examinations in 2010-2012. data for progression, impaired urodynamics in the upper urinary tract were not detected (photo 1).

In January 2013, right-sided hydronephrosis was detected.

01/28/2013 performed antegrade installation of the external ureteric stent on the right under ultrasound and x-ray control. 07.24.2013 drainage from the right ureter removed. Examination in February 2014 revealed a right-sided ureterohydronephrosis again (photo 2).

02.17.2014, urethral-reservoir anastomosis on the right was performed, antegrade stenting of the right ureter was performed in connection with a relapse of stricture of the right ureterreservar anastomosis, right-sided hydronephrosis. The stent of the right ureter independently retreated in July 2014. In connection with exacerbation of pyelonephritis (hyperthermia, pain in the right side), percutaneous puncture nephrostomy on the right was performed on August 21, 2014, an urethro-reservoir anastomosis on the right was performed, antegrade stenting of the right ureter was performed.

When CT 09.09.2014: Condition after surgery from 03/31/10: incomplete doubling of the right kidney with signs of ureteral stricture in the fusion zone, right-sided hydronephrosis, condition after nephrostomy. Dynamic nephroscintigraphy 09/18/2014: the accumulative-excretory function of the left kidney is preserved, the accumulative function of the right kidney is preserved, the decrease in excretory function due to gross violations of urodynamics from the pyelocaliceal systems (CLS) of both halves of the doubled kidney. On December 18, 2014, a stent of the right ureter was changed.

02/24/2015 Laparoscopic reimplantation of the right ureter into the Briker reservoir was performed. The uretero-reservoir anastomosis is formed in accordance with the method of the invention.

The postoperative period was uneventful. 04/02/2015 stent of the right ureter removed. Subsequently, the patient felt satisfactory, exacerbations of pyelonephritis were not observed. With excretory urography 04/06/2015: on the right, the CLS is expanded, on the left, the CLS is clearly not expanded. Kidney function saved. Excretory urography 10/14/2015: the right kidney kidney line doubled, the right ureter partially doubled, the excretory function is preserved - the contrast enters the urinary reservoir at the 7th minute of the study (photo 3).

Thus, the claimed method of forming a uretero-reservoir anastomosis is an effective method of treating strictures of this localization and has significant advantages over the known methods of open surgical intervention and percutaneous bougienage of ureteral strictures and drainage performed for the same purpose.

Information sources

1. Valiev E.I., Laurent O. B. The problem of urine diversion after radical cystectomy and modern approaches to its solution // Practical Oncology. - 2003. - No. 4. - S. 231-234.

2. Matveev V.R. Bladder cancer. Clinical oncology. - M .: Verdana, 2003 .-- 406 p.

3. Sitdykov E.N., Sitdykov M.E. The basics of rehabilitation of patients with bladder cancer. - Kazan, 1994 .-- 144 p.

4. Hautmann R.E., DePetriconi R., Gottfried H.W. et al. The ilealneodladder: complicacies and functional results in 363 patients after 11 years of follow-up // J. Urol. - 1999. - Vol. 161. - P. 422-428.

5. Studer U.E., Stenzl A., Manss W. et al. Bladder replacement and urinary diversion // Eur. Urol. - 2000. - Vol. 38. - P. 1-11.

Claims (1)

A method of forming a uretero-reservoir anastomosis in case of strictures after cystectomy with intestinal plasty of the urinary reservoir, including laparoscopic access, excision of the narrowed part of the ureter and laying of the uretero-reservoir sutures of the new anastomosis, characterized in that they mobilize the urinary reservoir while preserving the feeding vessels of the mesentery, - a reservoir anastomosis, mobilize the ureter 3-4 cm above the revealed narrowing, excise stricture, a defect in the wall of the urinary reservoir and sutured with a Z-shaped suture, then a hole is made in the wall of the urinary reservoir along the mesenteric edge, commensurate with the diameter of the ureter, a first serous-muscular suture is made between the wall of the ureter and the wall of the urinary reservoir at a distance of 5-10 mm from the future anastomosis, using two nodular intracorporeal sutures form the posterior wall of the anastomosis, a ureteric stent with a curl is placed in the ureter to the renal pelvis so that the curl is placed in the cavity of the urinary reservoir, two or three knots are applied new intracorporeal suture on the anterior wall of the created anastomosis, a second sero-muscular suture is applied between the ureter and the wall of the urinary reservoir on the side opposite to the formed anastomosis from the osseous-muscular suture, trapping drainage is brought to the operation area through the closest of trocar holes, in the postoperative period The catching drainage is removed for 2-3 days, the stent from the ureter is removed by reservoiroscopy 3-4 weeks after surgery.

Images