RU2655123C1 - Ureterocystoanastomosis method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology in the treatment of stenosing and refluxing ureterohydronephrosis, requiring resection of the ureteral orifice with the creation of ureteral-cystic anastomosis. Method is performed out-of-the-bladder. After the ureter is cut off from the bladder, the muscle tunnel is formed bluntly from the incision, retreating 1.5–2 cm from the remaining mouth to the top of the bladder to prolapse of the mucosa and in the lower corner of the wound created. Stepping away from it by 5 mm creates a small hole in the mucosa. Through the lumen of the bladder, enter the terminal section of the ureter for 5–7 mm and fix the mucosa with microsurgical nodular sutures for 3, 6, 9, 12 hours. Above the fixed part of the ureter from the mucosa, a “clutch” is created by imposing on it one nodal suture of the submucosal layer. Ureter is fixed to the muscular membrane when the muscle wound is sutured.

EFFECT: method has both sphincter and valve properties.

1 cl, 13 dwg, 1 ex

Description

The invention relates to medicine, in particular to urology, and can be used in the treatment of stenosing and refluxing ureterohydronephrosis, requiring resection of the mouth of the ureter with the creation of a ureter-vesiculate anastomosis.

Congenital anomalies of the urinary tract leading to impaired urodynamics are the leading factors in the formation of urological diseases in children (N.A. Lopatkin, A.G. Pugachev, 1990).

This group of diseases includes vesicoureteral reflux and other types of supravesical obstruction of the ureters, such as stenosing and refluxing ureterohydronephrosis.

Reconstructive plastic surgery on the vesicoureteral fistula can lead to progression of the development of renal failure until death.

Despite the large number of currently developed methods for correcting vesicoureteral anastomosis, including conservative ones, to date, the choice of correction method remains debatable.

The advantage of surgical treatment is the quick recovery of urodynamics. In this regard, in the 60s of the last century, re-implantation of the ureters became a very common operation. Classical anti-reflux operations were developed for Politano-Leadbetter, Bairov, Bischoff, Cohen, Barry, Leach-Gregoire and others. Despite the large number of methods, the frequency of unsatisfactory results remains high (from 2 to 20% according to various authors).

The choice of the optimal type of surgical correction, taking into account the individual structural features of the ureter and the wall of the bladder, as well as the need for one or another type of modeling of the ureter, currently remains relevant.

Analogs Currently, in clinical practice with open surgery, the following types of operations are used, which can be divided into two groups: extravesical (Politano-Lidbetter, Cohen, Gilles-Vernet operation) and intravesical (ureterocystoanastomosis with antireflux protection according to the Lich Gregoire method, Barry operation ) Each of them has its advantages and disadvantages. In the presence of a megaureter, a classical modeling of the ureter according to Hendren is performed.

During the operation according to the method of Politano-Leadbetter (Pediatric Surgery: A Practical Guide / Edited by V.D. Tikhomirova. - M.: Publishing House Medical Information Agency, 2011, pp. 651-652, Pediatric Urology: A Manual for Doctors . - M .: GEOTAR-Media, 2009, A.G. Pugachev, p. 361) after mobilization of the front wall of the bladder and the application of holders, the bladder is widely opened in the longitudinal direction. Then, the affected ureter mouth is taken onto the holder and the terminal section is isolated with a bordering incision, mobilized and pulled into the bladder cavity 5-7 cm. The mucous membrane is opened 1-3 cm above the previously located mouth. With a special tool, a defect is created in the thickness of the muscular wall of the bladder, grabs are held by the handles previously applied to the wall of the mobilized ureter and the ureter is brought out into the bladder. A submucous tunnel is created with a length of at least 3 cm, a ureter is passed through it, where a new mouth is formed at the location of the old mouth. The defect in the muscle layer and mucous membrane is sutured. The newly created mouth is intubated with a polyvinyl chloride tube, which is removed through the urethra or through a separate puncture of the anterior wall of the bladder and the anterior abdominal wall. A permanent catheter is placed in the bladder; the bladder wound is sutured with a double-row suture. Establish insurance drainage. Layer closure of the surgical wound.

The advantages of this technique include a relatively low relapse rate. This technique has its drawbacks - the operation is performed completely intravesically, and when the ureter is made from peri-bubble fiber into the bladder, it can be inserted into the bladder cavity at an acute angle, which subsequently causes urodynamic disturbances. Damage to the peritoneum due to intravesical ureteral discharge is also possible. The vertical location of the ureter after reimplantation reduces the possibility of catheterization when the need arises (kidney block after removal of the endotracheal tube, urolithiasis, etc.). A wide opening of the bladder leads to the appointment of narcotic analgesics due to high trauma, lengthens the terms of catheterization of the bladder and, accordingly, the terms of inpatient treatment.

During Cohen’s operation (Pediatric Surgery: A Practical Guide / Edited by V. D. Tikhomirova. - M.: Medical Information Agency Publishing House, 2011, p. 655), a lower midline incision is made, tissues are dissected in layers, and the anterior peritoneal is opened bladder wall. A thin polyvinyl chloride tube is inserted into the ureters, fixed to the mucous membrane in the area of the mouth with one or two sutures. A bordering incision around the mouth of the ureter, departing from it by 1 cm, mobilize 4-5 cm of the distal ureter, pulling on the tube. Then, in parallel to the ureteric fold, a submucosal tunnel is made in the direction of the contralateral mouth. The distal section of the mobilized ureter is pulled into the canal and a new one with the help of nodal catgut sutures is formed somewhat lower and medial to the opposite mouth. The endotracheal tube is removed through the front wall of the bladder and through the front abdominal wall. The wall of the bladder is sutured with a two-row suture. The surgical wound is drained. A catheter is inserted into the bladder.

The advantages of this technique include a relatively low percentage of relapses and postoperative complications in the form of urinary leakage, the possibility of surgery simultaneously from two sides. This technique has its drawbacks - the operation is completely intravesical and it is not always possible to simulate the ureter, changing the location of the mouth after reimplantation reduces the possibility of catheterization if necessary (kidney block after removal of the endotracheal tube, urolithiasis, etc.). A wide opening of the bladder leads to the appointment of narcotic analgesics due to high trauma, lengthens the terms of catheterization of the bladder and, accordingly, the terms of inpatient treatment. In violation of the technique of surgery, it is possible to engage in the cicatricial process unchanged mouth of the ureter. Bladder hemotamponade may develop due to high trauma to the mucous layer of the bladder.

Operation Gilles - Vernet (Pediatric Surgery: A Practical Guide / Edited by V.D. Tikhomirova. - M.: Publishing House “Medical Information Agency”, 2011, pp. 655-656): the middle lower incision is exposed and the urinary tract exposed and opened. bubble on the front surface. The ureters are intubated. A transverse incision of the mucous membrane is made between the mouths of the ureters, the edges of which are separated upward and downward by 1.5-2 cm. Then, with the help of nodular catgut sutures, a fold of the muscle layer of the posterior wall of the bladder is formed in the region of the vesicoureteral triangle in the sagittal direction so that the mouths of the ureters as close as possible. After this, the mucous membrane is sutured longitudinally with catgut sutures. The endotracheal tubes are removed from the ureters. The bladder wound is sutured tightly with a two-row suture. The surgical wound is drained and sutured in layers. A permanent catheter is inserted into the bladder for 5-7 days.

The advantages of this technique include ease of implementation, low invasiveness, and the preservation of the anatomical location of the mouths of the ureters.

The disadvantages of this technique include a high percentage of recurrences of vesicoureteral reflux.

Lich-Gregoire Operation (Pediatric Surgery: A Practical Guide / Edited by V.D. Tikhomirova. - M .: LLC Medical Information Agency Publishing House, 2011, pp. 656-657): the bladder is exposed with a midline incision, and the bladder is exposed the terminal section of the affected ureter. From the place where the ureter flows toward the top of the bladder, its wall is cut to the mucous membrane with a 3-4 cm section, and the terminal section of the ureter is laid in the wound formed in this way. Then the muscle layer of the bladder is sewn over the ureter with nodal nylon sutures. The surgical wound is drained and sutured in layers before drainage.

The advantages of this technique include low invasiveness, the operation is performed without bladder, which allows to reduce the time of constant catheterization of the bladder. In this case, an autopsy of the mucous membrane is not performed, which reduces the risk of developing urinary leakage.

The disadvantages of this technique include the difficulty of performing in older children due to the low location of the mouth of the ureter.

Prototype. The prototype of our method is Barry surgery (Himan F. “Operational Urology: Atlas.” Second Edition. GEOTAR-Med, 2015, p. 819-820): the bladder is exposed with a midline incision. After exposure of the bladder, the bladder is filled with saline. Using a suture, the bladder is diverted in the medial direction. An electric knife with two parallel sections, spaced 3 cm apart, dissects the serous and muscular membranes of the bladder. The adventitia and detrusor are dissected with a scalpel to the submucosal layer, forming 2 cuts 2 cm long. A submucous tunnel 2 cm wide is formed with a curved clamp between these cuts. If the mucous membrane is accidentally slightly damaged, the edges of the defect are raised with tweezers and sutured with a fine absorbable thread. If the defect is large, it is sutured with a continuous seam. Vascular tweezers capture the mucous membrane of the bladder through a distal incision. The clamp is removed and emptied from the outlet knee of the adapter. A small oval hole is cut out in its mucosa. The ureter is passed through the submucosal tunnel. The end of the ureter is obliquely cut, dissected lengthwise and fixed to the hole in the bladder wall with three sutures with a synthetic absorbable thread: one suture is applied at the top of the oblique section, the other two in the direction of 9 and 3 hours. The fourth suture captures the entire thickness of the wall at the end of the ureter; threads, without cutting, are charged into bent needles. One end is drawn through the entire thickness of the wall of the bladder and a needle is punctured 1 cm distal, the other needle captures the serous and muscle layers of the bladder. The ends of the thread are tied. The distal hole in the wall of the bladder is sutured with a synthetic absorbable suture 4-0, without trapping the mucous membrane into the suture. Stents do not use. A vacuum drain is installed, which is removed when the amount of discharge is reduced. The urethral catheter is removed after 5 days.

The benefits of this technique include a low relapse rate. The disadvantages of this technique include a high risk of developing urinary leakage with insufficient fixation of the terminal ureter, a high probability of damage to the mucous membrane during the creation of the tunnel.

Currently, there are many methods of antireflux surgery, each of which has its own advantages and disadvantages. At the same time, there is no effective technique that would, along with the prevention of recurrence of vesicoureteral reflux, reduce the invasiveness of the operation and reduce the risks of postoperative complications.

The objective of the invention is the creation of sphincter-valvular antireflux ureterocystoanastomosis.

The novelty of the invention lies in the fact that form ureterocystoanastomosis, which has both sphincter and valve properties.

SUMMARY OF THE INVENTION Disclosure of the invention is that a complexly functioning sphincter-valve structure of the ureter-vesical anastomosis is created without a bubble. Reducing the invasiveness of the operation and the risk of postoperative complications is achieved by the fact that the operation is carried out extravascularly and contains minimal actions that traumatize the operated structures of the urinary tract. The midline incision is performed to expose the bladder and terminal portion of the affected ureter extraperitoneally. The affected ureter is cut off at the place where it flows into the bladder, the stump of the ureter is stitched and ligated. Retreating by 1.5-2 cm from the remaining stump of the ureter to the top of the bladder, the wall of the bladder is cut up to the prolapse of the mucous membrane (on the filled bladder). A fissure wound is formed with a length equal to four diameters of the affected ureter, by preparing the muscle layer with a blunt method. Then, in the lower corner of the created wound, retreating 5 mm, create a small hole in the mucous membrane. The stump of the ureter is immersed in the lumen of an empty bladder by 5-7 mm and its open end is fixed to the mucous membrane of the bladder along the perimeter with four microsurgical sutures with atraumatic suture 6/0 at 3, 6, 9, 12 hours. After that, a “sleeve” is created over the fixed part of the ureter from the mobilized mucous membrane with one nodal microsurgical suture of the submucosal layer with absorbable atraumatic suture material 6/0, which will be an additional element of antireflux protection, an obstacle to leakage of urine and the formation of urinary leakage. Due to mobility and good nutrition of the mucous membrane, the risk of stenosis of the formed mouth is reduced. Establish insurance drainage to the site of the anastomosis and a permanent catheter into the bladder. Layer wound closure is performed before drainage. The catheter is removed 7-10 days after surgery.

The technical result is achieved by creating a functionally effective valve mechanism by forming an extended ureteral invaginate in the lumen of the bladder and creating a muscle sphincter due to tunneling of the muscle layer of the bladder wall, as well as improving postoperative healing of the anastomosis through the use of microsurgical stapling technique. The longitudinal direction of the created muscle tunnel, taking into account the myoarchitectonics of the bladder, further enhances the sphincter properties of the anastomosis. The created ureteral invaginate with a “sleeve” from the mucous-submucosal layer enhances the valvular function of the anastomosis, and the presence of a pronounced vasculature of the submucosal layer improves the healing conditions of the anastomosis and reduces the likelihood of cicatricial processes. The created invaginate is able to perform the active function of the created muscle sphincter, but also the passive valve function, which ensures unidirectional passage of urine.

Bubbly surgery reduces the likelihood of complications: infection of the wound, cicatricial changes, stenosis, reduces the severity of the operation.

Due to the formation of the muscle tunnel near the previous mouth of the ureter, muscle pulp is created, and a part of the terminal part of the ureter protruding into the lumen of the ureter creates a valve mechanism. A sphincter-valve structure is created in the complex, which provides the areflux properties of the created ureterocystoanastomosis.

The proposed method for creating an extravesical invagination uretero-cystic anastomosis, along with a low invasiveness of the operation and a minimal risk of postoperative complications, has high antireflux properties due to the combination of the proposed techniques, each of which is necessary, and all together are sufficient to implement the proposed method.

The method is as follows.

1. Perform a suprapubic lower incision of the anterior abdominal wall on the affected side (Fig. 1).

2. The bladder and terminal portion of the affected ureter are exposed extraperitoneally (Fig. 2).

3. The affected ureter is cut off at the place where it flows into the bladder, the stump of the ureter is stitched and ligated (Fig. 3).

4. Retreating by 1.5-2 cm from the remaining stump of the ureter to the top of the bladder, dissect the wall of the bladder before prolapse of the mucous membrane (on the filled bladder). A fissure wound is formed with a length equal to four diameters of the affected ureter (Fig. 4).

5. In the lower corner of the created wound, retreating by 5 mm, create a small hole in the mucous membrane (Fig. 5).

6. An open stump of the ureter is immersed in the lumen of an empty bladder by 5-7 mm and fixed along the perimeter to the mucous membrane of the bladder with four microsurgical sutures at 3, 6, 9, 12 hours (Fig. 6).

7. Above the fixed part of the ureter from the mobilized mucous membrane and submucosal layer, a “sleeve” is created with one microsurgical suture of the submucosal layer (Fig. 7).

8. After creating the “sleeve” with one suture, the ureter is fixed to the muscle layer to prevent it from falling out of the bladder when the bladder is full (Fig. 8).

9. The muscle layer of the bladder is sutured with separate sutures above the ureter so as not to compress the ureter (Fig. 9).

Usage example. The method is performed in a child, 2 years old.

From the anamnesis it is known: from birth, registered with a urologist at the place of residence, regarding congenital ureterohydronephrosis on the right. The child underwent a complete comprehensive examination.

According to intravenous urography - on the left, kidney function at 10 minutes, collective cavities are not expanded, urodynamics are not broken. By 120 minutes, complete contrast evacuation. On the right, the function is reduced, the maximum contrast at 60 minutes, the counter-excretory function is reduced, the collective cavities are enlarged, the ureter is enlarged all the way up to 20 mm. by 120 minutes, the contrast remains in the collecting cavities (Fig. 10).

According to ultrasound, the enlargement of the size of the right kidney with a marked expansion of the ureter, the pelvis is expanded, the calyx is enlarged to 12 mm.

There were no renal attacks.

Under intubation anesthesia, UCAA operation was performed on the right with the modeling of the ureter with the creation of a “sleeve” and fixation of the ureter using the first suture. The course of the postoperative period without features. Primary healing. The catheter was removed on the 9th day. According to the ultrasound - positive dynamics - reduction of cavities. Discharged home under the supervision of a pediatrician in satisfactory condition.

An application example is presented graphically:

1. Stage of extraperitoneal discharge of the ureter. The expanded ureter is taken on a holder (Fig. 11).

2. The stage of wound formation - grooves on the anterior-lateral wall of the bladder prior to prolapse of the mucous membrane (Fig. 12).

3. The position of the ureter in the formed wound of the bladder, after creating a “sleeve” from the mucous membrane, before the first fixing suture, before suturing the muscle layer (Fig. 13).

Claims (1)

A method of ureterocystoanastomosis performed intravesically after cutting off the ureter from the bladder by forming a muscle tunnel and introducing the end of the ureter into the lumen of the bladder, characterized in that the muscle tunnel is formed in a blunt way from one incision made 1.5-2 cm apart from the remaining mouth of the ureter to the top of the bladder prior to the prolapse of the mucous membrane and in the lower corner of the created wound, departing from it by 5 mm by pulling the muscle layer, a small hole is created in the mucous membrane, through the terminal section of the ureter is inserted into the lumen of the bladder by 5-7 mm and is fixed to the mucous membrane with four microsurgical interrupted sutures around the perimeter at 3, 6, 9, 12 hours, a “sleeve” is created over the fixed part of the ureter from the mobilized mucous membrane by applying one microsurgical nodal suture of the submucosal layer, and the ureter itself is fixed to the muscle membrane when suturing a muscle wound.

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