RU2667209C2 - Method of functional sparing capsule prostate vesicle cystectomy with orthotopic ileocystoplasty in surgical treatment of bladder cancer - Google Patents

Abstract

FIELD: medicine; surgery.SUBSTANCE: invention relates to surgery and may be useful for functional sparing capsule prostate vesicle cystectomy with orthotopic ileocystoplasty in the surgical treatment of bladder cancer. Two-sided pelvic lymphodissection, monoblock removal of the bladder with a tumor and prostate tissue is performed. Ileoneocyst is orthotopically cross-linked with the capsule of the prostate with the formation of an anastomosis with the urethra proximal to 3–4 cm.EFFECT: method allows to reduce the risk of urinary incontinence, erectile dysfunction.1 cl, 1 ex, 8 dwg

Description

The invention relates to medicine, more specifically to oncourology, and may find application in orthotopic bladder plastic surgery after radical surgical treatment of bladder cancer in order to maintain erectile function, urocontinence, and reduce the likelihood of inconsistency of urinary anastomoses.

Under anesthesia, bilateral pelvic lymphatic dissection is performed extraperitoneally with removal of the common, internal and external iliac, obstructive lymph nodes. Intraperitoneal with excision of the parietal peritoneum and urachus is the mobilization of the bladder with ligation and intersection of the upper and lower urinary bladder arteries with the allocation and preservation of the vas deferens. Mobilization of the neck of the bladder and the base of the prostate to the base of the seminal vesicles is performed. The bladder and prostate are secreted in the retia without crossing the Santorini venous plexus. Ligation of the lateral vascular legs of the prostate gland Vicryl - 0 is performed (Fig. 1, pos. 2).

The prostate capsule is dissected along the front wall in the transverse direction at the border with the neck of the bladder (Fig. 2, pos. 6) with preliminary ligation of the capsular veins on both sides of the intersection line (Fig. 2, pos. 5). The tissue of the prostate gland is digitally mobilized (Fig. 3, pos. 7). The urethra intersects in the lower third of the intraprostatic part without additional violation of the integrity of the capsule of the prostate gland. A clamp is applied to the Foley Ch No. 22 catheter. Monoblock (prophylaxis of intraoperative dissemination of the tumor) subcapsular prostatectomy with bladder and tumor is performed with preservation of the capsule of the prostate gland, adjacent seminal vesicles and vas deferens. Throughout, the right and left ureters are distinguished with the preservation of periurethral tissue. Having retreated 20 cm from the ileocecal angle, 70 cm of the ileum is mobilized on 2 vascular arcades. A double-row ileoileoanastomosis end-to-end 3–0 suture is formed. From the ileum loop with preliminary detubulation, the posterior wall of the W-shaped conduit is formed with stitching of Vicryl 3-0 through a single-row twisted seam through all layers. With the capsule of the prostate gland and ileoneocyst, 6 nodal single row Vicryl suture 3-0 are applied (3 anterior lip of the anastomosis, 3 posterior lip of the anastomosis) - ileoneocystic capsule anastomosis (Fig. 4, item 7, 8)

On the right side with the medial right knee of the conduit, through the mesentery of the sigmoid colon on the left with the medial left knee of the conduit, antireflux isoperistaltic ureteroileoanastomoses according to Le Due are formed with preliminary spatulation of the distal ends of the ureters and fixation of the latter to the ileal mucosa from the 4 nodes into 4 nodes ileum 2 interrupted sutures of Vicryl 3-0 outside. The ureters are stented to the renal pelvis with the passage of stents through the neocyst into the urethra. A 3-lumen Foley Ch catheter No. 22 is inserted into the neocyst cavity. Neocyst tightness is checked by introducing about 100 ml of furatsilin - it is tight (no leakage of fluid through the seams was detected). The distal ends of the stents are sutured with a nodal suture to the frenum of the penis. The front wall of the ileoneocyst is sutured with a vicry 3-0 single-row seam.

The method provides the creation of a spherical urinary reservoir of low pressure, preservation of the sphincter system of the urethra, including the capsule of the prostate gland, which reduces the frequency of urination, does not impair erectile function, and urine retention.

The invention relates to medicine, more specifically to oncourology, and may find application in orthotopic cystoplasty of the bladder after removal of the latter with a small percentage of incontinence and erectile dysfunction, inconsistency of urinary anastomoses.

In case of muscle-invasive cancer of the bladder or in case of high-grade, rapidly recurring superficial tumors that do not allow organ-preserving treatment, cystectomy is performed.

One of the main problems that have to be solved after a radical cystectomy is the method of urine diversion. The success of reconstructive operations is determined, first of all, by the degree of retention of urine and the ability to have a full sexual life with the achievement of social adaptation by patients, so the continental methods of urine diversion are considered the most optimal.

Currently, radical cystectomy with orthotopic cystoplasty is the method of choice for the surgical treatment of muscle-invasive bladder cancer.

In 1988, U.E. Studer proposed orthotopic replacement of the urinary bladder with an enteric low pressure reservoir [5, 6].

Methodology for the operation of U.E. Studer.

After cystectomy, a typical ileum resection is performed at a length of 60-65 cm, retreating 20-25 cm from the ileocecal angle. A mesentery is dissected at the distal and proximal borders of the electric knife resection in avascular spaces from the edge of the ileum in the direction of the mesentery root, by 1 / 2-2 / 3 of this distance (depending on the length and mobility of the mesentery). Restore the integrity of the gastrointestinal tract by applying the terminal double-row small-intestinal anastomosis. Sutured the proximal end of the resected ileum segment tightly.

Dissection of the intestinal segment from the distal end along the mesenteric edge for 40-45 cm is carried out while maintaining the tubular structure of the proximal segment - 20 cm. Symmetrical U-shaped folding of the detubularized part of the intestine (vertex U is directed caudally) is carried out with suturing of the posterior wall of the reservoir (single-row obvivnoy continuous serous - muscular - submucosal suture). Fold in the transverse direction a U-shaped posterior wall of the reservoir (the distal edge of the iliac plate is folded over and up) and the front wall of the reservoir is sutured with a single-row continuous twisted serous - muscular - submucosal suture.

Stented ureters are carried out into the abdominal cavity at the level of the proximal end of the adductor segment and anastomoses are performed with the adductor end-to-side adductor segment without antireflux protection.

The ureteral drainage is introduced through the adducting intestinal segment into the lumen of the reservoir and then discharged through the front wall of the reservoir to the anterior abdominal wall. In the wall of the intestine adjacent to the urethra, a hole is formed, passing the tip of the index finger, for applying an anastomosis with the urethra. An anastomosis with an urethra is performed. A Foley Ch catheter No. 22 is inserted into the neocyst cavity through the urethra. Additionally, a reservoirostomy is installed in the neocyst cavity, which is excreted together with the ureter catheters at the final stage of the operation on the anterior abdominal wall.

1 year after the operation, daytime retention is 92%, after 2 years nighttime retention is 80%.

In 1988, R.E. Hautmann proposed orthotopic replacement of the urinary bladder with an enteric low pressure reservoir [4].

Methodology for the operation of R.E. Hautmann is fundamentally different from the U.E. Studer is that from a longer segment of the ileum, a completely detubularized “W type” neocyst is formed with the formation of a cavity of lower pressure due to the larger volume.

1 year after the operation, daily retention is 96%, after 2 years, night retention is 88%.

As a result of improving diagnostic methods and increasing the incidence of bladder cancer, the number of young patients has increased, for whom, in addition to curing a serious illness, the quality of life after surgery is of great importance [2].

The most common problems in men who have undergone radical cystectomy with orthotopic cystoplasty are urinary incontinence and erectile dysfunction. It is believed that these problems do not depend on the cystoplasty method, but are associated with damage to the neurovascular bundles and / or removal of the prostate gland. Transitional cell carcinoma of the bladder rarely and slowly spreads outside the body, therefore, the implementation of nerve-sparing radical cystectomy seemed to many to be quite justified by surgical intervention [1].

In 1987, R.S. Walsh proposed a method of radical prostatctomy with preservation of the neurovascular bundles [7].

Performing nerve-saving cystectomy in men with preserving the prostate gland and, accordingly, sexual function and urine retention is still debatable.

The cause of social maladaptation in patients after radical cystectomy along with incontinence is erectile dysfunction. So, M.E. Gaspsrini et al. [3]. reported that after nerve-sparing cystoprostatectomy, potency persisted in 64%, and with prostate abandonment, in 82% of patients.

Thus, the decision on the appropriateness of radical cystectomy with preservation of prostate tissue should be considered from several perspectives: compliance of the operation with the principles of urine retention (continent), the nature of urination and the preservation of erectile function.

Closest to the proposed is a method of forming a bladder after cystectomy for bladder cancer according to the patent of the Russian Federation No. 2323102, MKI A61B 17/00: the method consists in the fact that after cystectomy a U-shaped orthotopic intestinal reservoir of low pressure from the ileum is formed. In this case, 55 cm of the ileum are resected at a distance of 20-25 cm from the ileocecal angle. The resected ileum is dissected along the mesenteric margin for 40 cm. The adductor segment is maintained for 15 cm. The detubularized part is folded symmetrically U-shaped so that the apex U is directed caudally and is as close as possible to the urethral stump. Stitch adjacent edges. Opposite long sides are combined in such a way as to obtain a tubular reservoir of a U-shape and sutured tightly. Invert and turn the formed reservoir in the small pelvis between the mesentery sheets. The turn is carried out so that the back wall of the reservoir, free from the mesentery, is located anteriorly and its free lowering into the small pelvis additionally reduces the distance to the urethral stump by 3-4 cm.Anastomosis with urethra is applied at the lower point of the reservoir. Stented ureters anastomose with the upper edge of the adductor segment using a reflux technique. The ureteral stents are brought out through the reservoir through the urethra. In the opposite direction, a Foley Ch No. 22 catheter is inserted into the neocyst cavity. The method is simple and reliable.

However, despite the positive aspects of the method, it has a serious drawback: the lack of full preservation of the sphincter mechanism of the urethra, which increases the risk of enuresis and sexual impotence, as well as the frequency of urination.

The technical result of the present invention is:

1) reducing the risk of urinary incontinence,

2) reducing the risk of erectile dysfunction,

3) a decrease in the risk of insolvency of the neocystic capsular anastomosis. This result is achieved in that in the proposed method of surgical

treatment of bladder cancer, which includes, after preliminary bilateral pelvic lymphadenectomy, monoblock removal of the bladder with a tumor and tissue of the prostate gland, a capsule of the prostate gland with adjacent seminal vesicles and vas deferens is preserved, ileoneocysts are orthotopically sutured to the prostate capsule and anastomosis is formed 3-4 times proximal by preserving the capsule of the prostate gland.

The essence of the method is illustrated by example.

Example

Patient K., born in 1962, was in 1 o / o GBU RO OKOD from 03.24.2016 with a diagnosis of bladder cancer T3NxM0.

In December 2015, a transurethral resection of a bladder tumor was performed at the 11th City Clinical Hospital in Ryazan. Directed to the GBU RO OKOD, the glass preparations were revised - histology No. 1552/26964 (revised January 15, 2016): picture of urothelial carcinoma G3, with ingrowth into the muscle layers of the wall.

With an MRI of the pelvic organs (01/25/2016), an endophytic volumetric formation with fuzzy uneven contours, sizes ~ 5.1 * 1.5 * 5.2 cm, is determined in the area of the apex of the bladder. The formation infiltrates the entire thickness of the wall, spreads into the surrounding fatty tissue . A crater-shaped postoperative defect with uneven contours is defined at the center of the formation. The walls of the bladder in the remaining sections are not thickened. Identified single iliac lymph nodes on the left with sizes up to 1.0 cm.

Conclusion: MP picture of the volume formation of the bladder after TUR. Regional lymphadenopathy (mts?). Signs of chronic prostatitis.

In GBU RO OKOD, 2 courses of neoadjuvant polychemotherapy were carried out according to the GC regimen (gemcitabine 2.0 g. On days 1 and 8, cisplatin 100 mg on day 1; course once every 28 days).

Inpatient and outpatient comprehensively examined.

Performed chest CT, irrigoscopy, TRUS - data for organic pathology not received.

Re-performed cystoscopy - without additional findings.

With spirography, ultrasound of the heart, sufficient functional capabilities of the body are determined. PSA control - 0.26 ng / ml.

Anamnaesis vitae: of the past illness notes colds.

Allergic history: denies allergic reactions to medications.

Status praesans: general condition is satisfactory. The consciousness is clear, the position is active. Proper physique, moderate nutrition. The skin is of normal color. In the lungs, vesicular breathing over all pulmonary fields, no wheezing. Heart sounds are clear, rhythmic, noises are not determined. Pulse - 78 in 1 minute, satisfactory qualities. Blood pressure -130/80 mm Hg The tongue is wet, clean. The abdomen is not swollen, participates in the act of breathing, with palpation is soft, painless in all departments. Tumor formations in the abdominal cavity are not determined. There are no symptoms of peritoneal irritation. The liver is not enlarged, the edge is smooth, even. The spleen is not palpable. Pasternatsky’s symptom is negative.

Physiological administration: stool, urination is normal, no dysuria.

The patient is somatically preserved. 03/30/2016, the patient was taken for surgery.

Under anesthesia during the revision of the pelvic organs, no visual pathology was revealed. Bilateral pelvic lymphadenectomy was performed extraperitoneally with removal of the common, internal and external iliac, obstructive lymph nodes. Mobilization of the bladder with ligation and intersection of the upper and lower urinary bladder arteries with isolation and preservation of the vas deferens was performed intraperitoneally with excision of the parietal peritoneum and urachus. The mobilization of the neck of the bladder and the base of the prostate to the base of the seminal vesicles was performed. The bladder and prostate are isolated in the retia without crossing the Santorini venous plexus. Ligation of the lateral vascular legs of the prostate gland Vicryl - 0 was performed. The capsule of the prostate gland was dissected along the front wall in the transverse direction at the border with the neck of the bladder with preliminary ligation of the capsular veins on both sides of the intersection line. Digitally mobilized prostate tissue. The urethra is crossed in the lower third of the intraprostatic part without additional violation of the integrity of the capsule of the prostate gland. A clamp is placed on the Foley Ch No. 22 catheter. A monoblock (prophylaxis of intraoperative tumor dissemination) subcapsular prostatectomy with a bladder and a tumor with preservation of the capsule of the prostate gland, adjacent seminal vesicles and vas deferens was performed. The right and left ureters with preservation of periurethral tissue are highlighted throughout. Having retreated 20 cm from the ileocecal angle, 70 cm of the ileum was mobilized on 2 vascular arcades. Formed end-to-end ileoileoanastomosis with 3–0 Vicryl suture. From the ileum loop with preliminary detubulation, the posterior wall of the W-shaped conduit is formed with stitching of Vicryl 3-0 through a single-row twisted seam through all layers. With the capsule of the prostate gland and the ileoneocyst, 6 nodal single row Vicryl suture 3-0 (3 anterior lip of the anastomosis, 3 posterior lip of the anastomosis) - ileoneocystocapsuloanastomosis. Extraperitoneally to the right with the medial right knee of the conduit, through the mesentery of the sigmoid colon to the left with the medial left knee of the conduit, antireflux isoperistaltic ureteroileoanastomoses according to Le Due with preliminary spatulation of the distal ends of the ureters and fixation of the latter to the ileal mucosa from the 4 intestines 3 nodes ileum 2 interrupted sutures of Vicryl 3-0 outside. The ureters are stented to the renal pelvis with stents through the neocyst into the urethra. A 3-lumen Foley Ch catheter No. 22 was inserted into the neocyst cavity. Neocyst tightness was checked by administering about 100 ml of furatsilin - it is tight (no leakage of fluid through the joints was detected). The distal ends of the stents are hemmed with a nodal suture to the frenum of the penis. Vicryl 3-0 was wrapped in a single-row seam through all layers of the front wall of the ileoneocyst.

Histology No. 15780-81, 16047-76 (04/05/2016): no tumor growth was detected along the edge of the resection of the prostate gland and the prostatic part of the urethra. Against the background of severe fibrosis and calcification of the bladder wall with the presence of giant cell granulomas, there is a focus of urothelial carcinoma, G-3, with invasion in the near-bubble tissue. Therapeutic pathomorphism of the III degree. In the prostate gland, stromal glandular hyperplasia with foci of high IDU. At the edges of the ureter resection (No. 4-5), tumor growth was not detected. In 10 lymph nodes - No. 2 and in 12 - No. 3 - histiocytosis of sinuses, no metastases were detected.

The postoperative period was uneventful.

When control reservoirography was performed on 04/11/2016, ileoneocysts were contrasted, a capsule of the prostate gland with a balloon of a Foley Ch catheter No. 22 filled in the bed of the removed prostate gland - no streaks of contrast medium were detected (Fig. 5, 6, pos. 8, 9).

Ureteral stents removed on day 12. Drains removed on the 12th and 14th day.

04/18/2016 performed intravenous pyelography - without features. Catheter Foley Ch No. 22 removed.

In the general blood test, biochemical blood tests without features from 04/19/2016 (hemoglobin 124 g / l, blood creatinine - 97 mmol / l, protein - 68 g / l, blood potassium - 4.6 mmol / l, blood sodium - 138 mmol / L, blood chlorides - 97 mmol / L, blood iron - 10.3 mmol / L, blood calcium - 2.14 mmol / L).

Urinates on his own, full day and night urination control.

04/20/2016, the patient in satisfactory condition was discharged under the supervision of an oncourologist at the place of residence.

In the postoperative period, 2 courses of adjuvant polychemotherapy were carried out in GBU RO OKOD according to the GC regimen (gemcitabine 2.0 grams on days 1 and 8, cisplatin 100 mg on day 1; course once every 28 days).

During the control examination after 2 months. after surgery, the patient's condition is satisfactory. Urinary incontinence is not noted.

With X-ray computed tomography with contrast (06/16/2016), the urinary tract was visualized, including a neocyst with a capsular anastomosis, seminal vesicles, and a capsule of the prostate gland. Renal function is satisfactory, pyelocaliceal systems are not expanded (Fig. 7, 8, item 11).

In the general blood test, biochemical blood tests without features from 06/17/2016 (hemoglobin 138 g / l, blood creatinine - 96 μmol / l, protein - 73 g / l, potassium blood - 4.9 mmol / l, blood sodium - 142 mmol / l, blood chlorides - 95 mmol / l, blood iron - 10.1 mmol / l, blood calcium - 2.22 mmol / l).

Recommended dynamic monitoring, follow-up examination after 3 months.

Rehabilitation of the patient is completed.

The proposed method in comparison with the known has several significant advantages, namely:

1. reduce the risk of urinary incontinence,

2. reduced risk of erectile dysfunction,

3. Reducing the risk of insolvency of the neocystocapsular anastomosis.

The method was developed in 1 oncology department of GBU RO OKOD of the city of Ryazan, it is used with positive results.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 Ligation of the lateral vascular legs of the prostate

1 - transition zone of the base of the prostate gland and bladder neck

2 - ligature on the left lateral vascular pedicle of the prostate

3 - seminal vesicles

4 - rectum

FIG. 2 Dissection of the capsule of the prostate gland at the border with the neck of the bladder

5 - ligatures on capsular veins

6 is a transverse section of the anterior wall of the capsule of the prostate gland.

FIG. 3 Finger prostate tissue

7 - capsule of the prostate gland

FIG. 4 Formation of ileoneocystokalsuloanastomosis

7 - capsule of the prostate gland

8 - ileoneocyst

FIG. 5. Contrasting of neocisg with capsuloneocystanastomosis (direct projection):

8 - ileoneocyst

9 - contours of the capsule of the prostate gland filled with a balloon of a catheter Foley Ch No. 22 filled in the bed of the removed prostate gland

10 - the external contour of the sigmoid colon

FIG. 6. Contrasting of the neocyst with capsuloneocystanastomosis (lateral projection):

8 - ileoneocyst

9 - contours of the capsule of the prostate gland filled with a balloon of a catheter Foley Ch No. 22 filled in the bed of the removed prostate gland

10 - the external contour of the sigmoid colon

FIG. 7 3D - reconstruction of the urinary tract (front view):

7 - capsule of the prostate gland

8 - ileoneocyst

11 - pyelocaliceal systems of the right and left kidneys (not expanded)

FIG. 8 3D - reconstruction of the urinary tract (rear view):

3 - seminal vesicles

7 - capsule of the prostate gland

8 - ileoneocyst

11 - pyelocaliceal systems of the right and left kidneys (not expanded)

List of sources of information

1. Nechiporenko A.Z., Lobkov L.N., Gagalinsky V.A. et al. Multiple cancer of the urethra after extirpation of the bladder // Urology and Nephrology. 1983. - No. 2. - S. 67-68.

2. Shimkus E.M., Chebanov V.A., Shimkus S.E. Cystectomy for bladder cancer // VIII plenum of the All-Union Society of Urology; abstracts of reports. Vilnius, 1988 .-- S. 170.

3. Gaspsrini M.E., Hinmann F.J., Presti J.C., Schmidt R.A., Carrol P.R. Continence after radical cystoprostatectomy and total bladder replacement: a urodynarnic analisis // J. Urol. - 1992. - V. 146. - P. 1861.

4. Hautmann R.E., Egghart G., Frohneberg D. et al. The ileal neobladder // J. Urol. 1988. - Vol. 139, No. 3. - P. 39-42.

5. Studer U.E., Ackermann D, Casanova GA, Zingg EJ. Three years' experience with an ileal low pressure bladder substitute. Br. J. Urol. 1989; 63: 43-52.

6. Studer U.E., Danuser H., Thalmann G.N., Springer J., Turner H. Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: Long term results of a prospective randomized trial. J Urol. 1996; 156: 1913-17.

7. Walsh P.C., Quinlan C.M., Morton R.A., Steiner M.S. Radical retropubic prostatectomy. Improved anastomosis and urinary continence // Urol. Clin. N. Amer. - 1987. - V. 17. - R. 679.

Claims (1)

A method of functionally sparing capsuloprostat vesicles preserving cystrostatectomy with orthotopic ileocystoplasty in the surgical treatment of bladder cancer, including after preliminary bilateral pelvic lymphadenectomy, monoblock removal of the bladder with a tumor and prostate tissue, characterized in that ileoneocystosis is orthoptosis with capsulotomy 4 cm

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