RU2711110C1 - Method for surgical treatment of extended strictures and ureter obliterae and pelvic-ureteral segment accompanying its tuberculosis involvement - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, specifically to urology. Cicatrical-stenosed portion is excised and the ulcer mucosa autograft is applied. Involved part of the ureter is completely removed from the surrounding cellulose and resected by the pelvic-ureteral segment. Buccal-labial flap is cut out of the oral cavity with width of 2.0 cm, a buccal end is used to fix the flap to the ureter, which is dissected on its front surface by 1 cm, with a continuous suture with monocryl 4/0. Transplant is fixed with internal epithelial single monocrylic 4/0 sutures to the ventral surface of the lumbar muscle by 1/3 of its diameter starting from the buccal edge of the flap and not reaching 2 cm until the end of the labial edge. Internal drainage stent N6 is inserted; the flap is closed above the stent by a continuous external monocrysal suture 4/0, not reaching 1 cm to the end of the labial edge. Flap is fixed by the labial end with continuous monocryl 4/0 sutures to the pelvis tissue and performing nephrofixation to the lumbar muscle.EFFECT: method is less traumatic and provides reducing the number of postoperative recurrences, enables to replace a pyelourethral segment and an upper one-third of the ureter at a considerable extent.1 cl, 2 ex

Description

The invention relates to medicine, in particular to urology and may be applicable for the surgical treatment of extended strictures and ureteral obliteration in patients with urinary tuberculosis, post-tuberculosis lesions of the upper urinary tract (UMP) and recurrent strictures after previously unsuccessful reconstruction of the ureters.

Treatment of obstruction of the upper urinary tract due to strictures of the ureters of various origins, localization, and extent remains a difficult problem in urology (Onopko V.F., 2011; Laurent O.B., 2012; Zuban O.N., Skornyakov S.N. et al., 2014 ; Yarovoy S.Yu., 2016). Surgical treatment of extended strictures and obliteration of the upper urinary tract using their own urinary tract is the most preferable option to restore their patency. However, the possibilities of such operations are significantly limited due to tissue deficiency in the upper urinary tract (Nishimura Y. et al, 2017; Srivastava D. et al., 2017).

In the structure of the causes of the formation of ureteral strictures, the share of urinary system tuberculosis (TMS) reaches 9.0 - 12.3% (Traenzg E. et al. 2005; Gulwani N., Jain A. 2010). With tuberculous damage to the kidneys, a specific process is first localized in the papilla of the renal pyramid. Then the lesion spreads to the calyx, pelvis, ureter and bladder. Further rash of tuberculous tubercles occurs on the mucous membranes of the urinary tract. The tubercles are necrotic, disintegrate and turn into ulcers, around which perifocal infiltration develops. With the healing of tuberculous inflammation, the ulcers are caseinified and scarred. Narrowing of the lumen of the urinary tract causes the development of pronounced disorders of intrarenal urodynamics, pelvis-renal reflux, which in turn contributes to the spread of the polycavernous process in the stroma and parenchyma of the kidney. Urine stasis also leads to an increase in intrapulmonary pressure, renal parenchyma atrophy and inhibition of renal function. These changes together create the conditions for the progression of a specific process in the kidney, as well as the accession of a secondary non-specific infection. As a result, the kidney dies due to pyonephrosis or hydronephrotic transformation. (Bellendir E.N., 1985; Strukov A.I., Solovieva I.P., 1986; Komyakov B.K., Guliev B.G., 2005; Ariel B.M., Bellendir E.N., 2006 ; Nersesyan A.A., 2007; Chijioke A., 2001).

The involvement of the underlying parts of the urinary tract in case of kidney tuberculosis with the formation of its cicatricial narrowing and deformities occurs in 54.0-84.7% of cases (Nersesyan A.A., 2007; Bogorodskaya E.M. et al. 2011), and the frequency of multiple and extended ureteral narrowing due to tuberculous lesion is 16.7% (Shin KY et al. 2002; McAllen SJ et al. 2007; Muravyov AH, Zuban OH, 2012). Hydroureteronephrosis developing in this case is an inevitable and formidable pathological condition that is steadily causing compression of the kidney parenchyma, secondary pyelonephritis and organ death (Komyakov B.K., Guliev B.G., 2005). In these cases, the usually surgical method of choice is to replace the ureter with flaps of the bladder or intestines. Often with this disease, it is necessary to perform lifelong drainage of the urinary tract or nephrectomy (Komyakov B.K., Guliev B.G., 2005; Trapeznikova M.F. et al., 2014; Zuban O.N., Skornyakov S.N. and et al., 2014; Komyakov B.K., 2015, 2017; Schott F. et al., 2017; Kim A., 2018).

et al. 2016;

et al. 2017).The use of urinary tract tissue in patients with extended strictures or ureteral obliteration when performing ureterocystoanastomoses in various modifications inevitably causes injury to the detrusor and significantly reduces the capacity of the bladder (Laurent O.B., 2014; Martov A.G., 2015; Nesterov S.N. ., 2017; Zhong W., et al., 2017; Andrade C. et al., 2016;

et al. 2016;

et al. 2017).

The use of various intestinal segments as autografts for replacement ureters of the ureters is quite an effective method, but it has a significant number of early and distant postoperative complications, including electrolyte ones, it has significant intraoperative trauma and requires high surgical technique (O. Zuban et al. , 2012; Komyakov, B.K. et al., 2015, 2018; Schott F. et al., 2017).

Against this background, it is relevant to search for other methods for the restoration of VMP. The principle of these operations should remain the same as with any other reconstruction - the creation of a urine-impermeable, extensible and well-vascularized anastomosis (Arvind P., Ganpule et al., 2018).

Ureter replacement plastic meets a buccal autograft, which needs further development (Naude JH, 1999; Trapeznikova MF et al., 2014; Bazaev V. et al., 2014; Uryaev Yu.M., Sheludko S.V.) ., 2016; Katibov M.I. et al., 2018; Kroepfl D. et al., 2010; Arvind P., Ganpule et al., 2018).

A method of surgical treatment of extended ureteral strictures is known from the existing level of technology (RF Patent No. 2625782, 07/18/2017), including a longitudinal section of its stenotic part with an extension of the incision into healthy tissues by at least 0.5 cm in each direction and replacement of the resulting ureter defect a patch formed from an autograft of the mucosa of the cheek, characterized in that the patch formed from an autograft of the mucosa of the cheek is sutured to the ventral surface of the lumbar muscle, followed by stitching ureter dissected wall edges to the edges of the said patches and carry nephropexy.

The disadvantage of this technical solution is that the cicatricial, and often the infiltrated tissue of the ureter is not completely removed, which leaves the possibility for relapse in those diseases where purulent-destructive damage to the urethral wall occurs.

A method has been developed for the surgical treatment of extended urethral strictures and obliterations (RF patent No. 2 657939, 06/18/2018), including resection of the urethra, excision of scar tissue, replacement of a urethral defect with a graft, characterized in that the transplant of the oral mucosa is fixed on a previously de-epithelized scapular flap where the flap should be 3-4 cm wide, 2-3 cm longer than the urethral defect, form a tubularized neourethra so that the transplant of the oral mucosa it became the inner surface of the tubular neourethra, which is immersed in place of the native urethra, perform a proximal urethro-urethroanastomosis between the neourethra and the preserved portion of the prostatic urethra or the neck of the bladder, and the distal anastomosis between the neourethra and its own anterior urethra is performed after 3 months.

However, this method was used only for strictures of the urethra, and not the ureter, and is directly related to the use of scrotal skin.

There is also a known method of urethral plasty with its extended defects, which includes replacing the defect with a prefabricated, tubular beam graft on microvascular anastomoses (RF patent No. 2664166, 08/15/2018), characterized in that the cheek mucosa is used for prefabrication, namely: from the cheek with the transition to a rectangular flap of the mucous membrane is cut out on the lip and then on the other cheek, the defect is sutured, the flap is cleaned of adipose tissue and glandular elements, the upper dermis is removed on the inner surface of the forearm in accordance with the area the flap, the flap is adapted to the radiation site and fixed to the skin, after 1.5 months the affected area of the urethra is removed, the urethral diastasis is replaced by the formed prefabricated tubular radiation flap with the formation of an arterial and venous anastomosis.

The disadvantages of this method is the high invasiveness, multi-stage nature of the operation and the technical complexity of its implementation. Also, this method was used only for the surgical treatment of urethral strictures, and not the ureter.

A known method of endovascular surgical treatment of strictures of the pyelourethral segment (RF Patent No. 2677051, 01/15/2019), including a longitudinal section of its stenotic part with an extension of the incision into healthy tissues by at least 0.5 cm in each direction, replacing the resulting ureter defect with a patch formed from an autograft of the mucous membrane of the cheek, and wrapping a large omentum around the site of implantation of the transplant, characterized in that the patch formed from the autograft of the mucosa of the cheek and the hemmed area is large autoplasma enriched with platelets is administered at the rate of 0.5 ml per 1.0 cm of patch length.

However, it is known that the use of adipose tissue is not the best choice for vascularization of the flap of the cheek mucosa - the omentum wrapping around the implantation site can cause the development of circular stenosis due to scarring of the omentum. In this case, repeated surgery on the ureter (in the case of relapse) will be extremely technically difficult due to the numerous scar adhesions of the ureter with the omentum; the affected tissue of the pyelourethral segment must be completely removed, otherwise the risk of stricture recurrence is high.

The results of surgical treatment are described in 48 patients aged 35 to 69 (51.0 ± 0.6) years with extended or multiple strictures of the ureters of specific and non-specific origin (Zuban ON, Chotchaev PM, Skornyakov SN, Arkanov L.V., Novikov B.I. // Intestinoureteroplasty for tuberculosis and other diseases of the ureter. - Tuberculosis and socially significant diseases. - No. 1. - 2015. - P 44-50). Patients underwent ureteroplasty using intestinal auto-grafts (intrastinal plastic of the ureters). In 45 patients, the ileum was used, in three - the appendix. In 26 (54.2%) patients, only the ureter was replaced; in 22 (45.8%), the ureter and bladder were replaced. Substitution with a segment of the intestine of one ureter was performed in 43, both in five patients. It was established that these operations can save patients from lifelong external drainage of the kidneys in most cases, thereby significantly improving the quality of life.

However, intestinal ureteral repair is a highly traumatic surgical procedure with a large number of early and late complications. In weakened and gerontological patients, intestinal reconstruction of the urinary tract is associated with a greater risk of failure of anastomoses and electrolyte disorders.

Closest to the proposed technical solution is a method of surgical treatment of extended strictures and ureteral obliteration (RF Patent No. 2407463, 12/27/2010), including excision of the scar-stenotic part with the subsequent connection of the proximal and distal ends of the ureter, characterized in that after excision the proximal and distal ends the ureter is sewn along their posterior surface in the form of a semicircle, then the front walls of the ends of the ureter are dissected in the longitudinal direction, and lice are formed into the defect formed There is a patch from the autograft of the mucosa of the cheek with separate sutures atraumatic suture material. The invention can be used in the operative correction of strictures and obliterations of the ureter, up to 5 cm long.

This method is accepted by us as a prototype.

The disadvantages of this technical solution are:

1. Limitation of the maximum length of replacement plastics to 5 centimeters, which is often not enough for specific inflammatory, post-inflammatory and recurrent processes in the ureter.

2. The possibility of involvement of the pyeloureteral segment is not taken into account, which almost always accompanies stricture of the upper third of the ureter.

3. The insufficient degree of neovascularization of the flap with this method.

4. The use of individual seams reduces the tightness of the anastomosis. These disadvantages of the prototype are eliminated in the claimed technical solution.

The task to which the claimed invention is directed is to develop a more effective method for reconstruction of the upper third of the ureter and pyelourethral segment in patients with urinary tuberculosis, post-tuberculosis lesions of the upper urinary tract and recurrent strictures / obliterations after previously unsuccessful reconstruction of the ureters.

This problem is solved by the fact that in the method of surgical treatment of extended strictures and obliterations of the ureter and pelvis-ureteric segment with its tuberculous (post-tuberculosis or recurrent) lesion, the affected part of the ureter with surrounding tissue and resection of the pelvis-ureteric segment is completely removed. A buccal-labial flap 2.0 cm wide is taken from the oral cavity, which allows you to replace up to 12 cm of the ureter. The flap is tubularized, fixed with the labial end to the tissue of the pelvis, then fixed with one wall (back) of internal single monocrylic 4/0 sutures to the lumbar muscle by 1/3 of its diameter, an internal drainage stent No. 6 is installed, the flap is sutured over the stent with a continuous external monocrylic 4 / 0 seam. With single monocrylic sutures 4/0, the flap is fixed to the invariable distal end of the ureter. Nephrofixation to the lumbar muscle is performed.

The technical result provided by the given set of signs is to reduce the invasiveness of the intervention and reduce the number of postoperative relapses in patients with tuberculosis of the urinary system, post-tuberculosis lesions of the upper urinary tract, and recurrent strictures after previously unsuccessful reconstruction of the ureters.

This result is achieved due to the radical removal of the affected tissues: part of the pelvis, pyeloureteral segment, the affected segment of the ureter and all adjacent fiber are removed. The opportunity was obtained to replace sections of the upper third of the ureter up to 10-12 cm with simultaneous replacement of the pyelourethral segment and part of the renal pelvis due to the complete replacement of the ureter defect with the use of the oral mucosa. At the same time, the flap taken from the oral cavity can be increased with the additional use of the mucous membrane of the lip, which is used for simultaneous replacement of the ureteropelvic segment and part of the pelvis (the mucous lip is thinner), additional flap vascularization can be carried out by fixing the neoureter by 1/3 diameter to the lumbar muscle, which provides improved vascularization of the neoureter due to muscle tissue, the integrity of the anastomosis is ensured by the use of a continuous suture.

The justification for the complete removal of the affected ureter and surrounding tissue with resection of the pyelourethral segment and part of the pelvis is that specific or prolonged nonspecific inflammation, repeated surgical interventions in this area, post-tuberculous scarring causes massive sclerosis of the ureter wall against the background of replacement of necrotic areas (B. Komyakov ., 2015). Non-radical removal of scar-inflammatory tissues dramatically increases the risk of relapse. This is especially relevant for the tuberculosis process in the ureter, since in this case the entire wall of the organ is totally affected and resection techniques do not make sense.

The use of a tubularized buccal-labial flap to replace the completely removed part of the ureter and the resected pelvis is due to the fact that, as a rule, the zone of the pelvic-ureteric segment is almost always involved in the scar-inflammatory process of the upper third, which dictates the need to remove this area, which is replaced by a labial part of the flap.

Fixation of the posterior wall of the tubularized flap by 1/3 of the diameter with internal sutures to the lumbar muscle significantly improves its vascularization, in contrast to the omentum tissue used in most cases (Belomyttsev S.V., 2012; Paronnikov M.V. et al., 2017) .

Installation of the internal drainage stent No. 6 and suturing of the flap (tubularization) over the stent with a continuous external monocrylic suture 4/0, which ensures complete tightness of the anastomosis.

A detailed description of the method and examples of its clinical implementation

The method is as follows.

The operation is performed under endotracheal anesthesia. Surgical access to the upper ureter is performed. The LMS zone, the extrarenal part of the enlarged pelvis and the affected area of the ureter are distinguished. The ureter is cut off distally within healthy tissues, minimally mobilized, the pelvis is resected by a transverse incision, the drug is removed together with the adjacent scar-modified fiber. The length of the removed ureter is measured. The transplant of the oral mucosa is carried out according to the generally accepted method. Its width is at least 2.0 cm, the length is determined by the length of the defect, the incision begins along the mucous membrane of the cheek with the transition to the lower lip. The flap is cleaned of muscle tissue, the buccal end is fixed to the ureter, previously dissected 1 cm along the front surface, with a continuous monocryl seam 4/0.

Then the graft is fixed on 1/3 of its width with monocryl 4/0 by separate seams with the epithelium outward to the ventral surface of the lumbar muscle starting from the buccal edge of the flap and not reaching 2 cm to the end of the labial edge. A stent of internal drainage No. 6 is installed, the flap is sutured (tubularized) over the stent by a continuous external monocrylic suture 4/0, not reaching 1 cm to the end of the labial edge. Then a suture is made with monocryl thread 4/0, stitching from the top inward the top of the V-shaped flap of the pelvis, then from the inside out the corner of the end of the tubularization section of the flap. The second seam is imposed at a distance of 0.2 cm from the first. Both seams are tied with 5 knots, one end of each thread is cut. A continuous seam of the back line of the anastomosis of one of the threads is continued to the top of the neoureter, with an overlap on each 4-5th stitch. Similarly, the anastomotic anterior line is sutured. Both threads are tied at the top of the neoureter, one of them is cut off, and the remaining kidney pelvis defect is sutured with the other.

Nephrofixation is performed by fixing the middle segment of the kidney to the lumbar aponeurosis with absorbable suture material 2/0, avoiding both excessive tension and excessive kidney mobility. Insurance drainage is brought to the place of operation. Uterine stenting is performed for 3 months. Insurance drainage is removed after cessation of wound discharge of less than 30 ml.

The performance of the proposed method is confirmed by the following clinical examples.

Example 1

Patient C-see, 29 years old, operated on 07/19/2016. The patient has been suffering from tuberculosis of the urinary system for 5 years, transferred to an inactive group. The performed study made it possible to establish the following diagnosis.

Diagnosis: Long-term post-tuberculosis obliteration of the upper third of the right ureter. Nephrostoma on the right.

The patient performed the operation of the claimed method. Under general anesthesia, retroperitoneal access was made to the pelvis of the right kidney and to the obliterated upper part of the right ureter.

In the retroperitoneal tissue, a scar-inflammatory conglomerate is determined. One block removed a part of the pelvis (direct cut), pyelourethral segment, obliterated segment of the ureter 7 cm long and all adjacent fiber. It should be noted that it was not possible to separate the affected fiber from the ureter wall.

Then a flap was taken from the oral cavity. After treatment of the oral cavity, its mucous membrane was hydrotreated, a transplant of 2.0 × 8.0 cm was taken within the submucosal layer according to generally accepted rules. Starting from the mucosa of the right cheek (4.5 cm) with the transition to the mucosa of the lower lip. The flap is processed - the elements of the submucosal and muscle layers are removed. Hemostasis of the wound of the oral cavity, the defect is sutured with a continuous seam of Vicryl 3/0.

With its buccal end, the flap is fixed to the ureter, previously dissected by its front surface by 1 cm, with a continuous seam of monocryl 4/0.

Retreating distally by 1 cm, the graft is fixed on 1/3 of its width with monocryl 4/0 with separate sutures by the epithelium outward to the ventral surface of the lumbar muscle, not reaching the end of the 2 cm flap.

An internal drainage stent No. 6 was installed. The flap was tubularized above the stent with a continuous external 4/0 monocrylic suture, not reaching 1 cm to the end of the labial edge. Two seams of monocryl 4/0 were applied, stitching from top to bottom the top of the V-shaped flap of the pelvis, then from the inside out the corner of the end of the tubularization section of the flap. Both seams are tied with 5 knots. A continuous seam of the back line of the anastomosis was laid up to the top of the neoureter with 4/0 monocryl overlap on each 4-5th stitch. The anastomosis front line is also sutured. Both threads at the top of the neoureter are tied, one of them is cut off, the remaining defect of the renal pelvis is sutured with the second thread.

The kidney was fixed through its capsule to the lumbar muscle with 2 nodal sutures with Vicryl 2/0. An insurance drainage has been brought to the site of the operation, which has been removed through contraperture in the lumbar region. The wound is sutured in layers tightly.

The stent was removed after 3 months. With a control ultrasound of the kidney after 1, 3, 6 weeks - no increase in hydronephrosis was detected. On the control computed tomography of the kidneys with contrast after 6 months, we pass the right ureter. The patient is under observation for 32 months, no increase in hydronephrosis is observed, on the control excretory urography - moderate dilatation of the ureter in the area of the replaced site.

Example 2

Patient K., 63 years old, operated on 12/15/2018.

Diagnosis: Recurrent stricture of the LMS on the right. Calculi of the right kidney. Nephrostoma on the right. Plastic LMS in 2010, 2015

The patient performed the operation of the claimed method. Under general anesthesia with significant technical difficulties, the LMS zone was identified on the right, which is located in the scar-modified fiber.

One block removed a part of the pelvis, pyelourethral segment, obliterated segment of the ureter 4 cm long and all adjacent fiber. The calculi were removed from the pelvis. A flap was taken from the oral cavity - after processing, the mucosa was hydrotreated, a transplant of 2.0 × 5.0 cm was taken within the submucosal layer according to generally accepted rules, starting from the mucosa of the right cheek (4.0 cm) with the transition to the mucosa of the lower lip. The flap is processed - the elements of the submucosal layer are removed. Performed hemostasis of the wound of the oral cavity, the mucosal defect is sutured with a continuous seam of vicryl 3/0. The buccal end of the flap is fixed to the ureter, which is pre-saturated by 1 cm on the front surface with a continuous seam 4/0 monocryl. Then, retreating proximally 1 cm from the edge of the anastomosis, the graft is fixed 1/3 of its width with monocryl 4/0 with separate epithelial sutures outward to the ventral surface of the lumbar muscle, not reaching the end of the 2 cm flap.

A stent of internal drainage No. 6 was installed. The flap is tubularized over the stent with a continuous external monocrylic suture 4/0, not reaching 1 cm to the end of the labial edge.

The pelvis was simulated with continuous atraumatic monocrylic sutures No. 4/0. Fixation of the kidney to the lumbar muscle. The insurance drainage was brought to the place of operation; it was removed through contraperturbation in the lumbar region. The wound is sutured in layers tightly. The stent was removed after 3 months. During the control ultrasound of the kidney 1, 3, 6 weeks after stent removal - no increase in hydronephrosis was detected.

The patient continues to be observed. A control CT scan of the kidneys with contrast is planned.

The proposed method is an alternative to intestinal plasty of extended ureteral strictures, since it is less traumatic and reduces the number of postoperative relapses.

The claimed method operated on 15 patients: 5 - tuberculous stricture or obliteration of the ureter, 6 - post-tuberculous stricture / obliteration of the ureter, 3 - recurrent stricture / obliteration after previously unsuccessful reconstruction of the ureter, 1 - iatrogenic obliteration of the ureter against urolithiasis. The follow-up period for patients ranged from 3 to 30 months. Relapse of the disease to date has not been observed.

Thus, the proposed method for the surgical treatment of extended tuberculosis, post-tuberculosis and recurrent after previously unsuccessful reconstruction of ureter strictures and ureteral obliterations in combination with resection of the ureteropelvic segment provides a lasting effect for more than 2.5 years (observation period). The proposed method is reproducible in a hospital environment and when it is used, the indicated technical result is achieved.

Using the proposed method makes it possible to simultaneously replace the pyelourethral segment and the upper third of the ureter for a considerable period, reduces the possibility of recurrence due to the complete removal of the affected tissue, tubularization of the flap and improvement of its vascularization. The operation compared with intestinal derivation of urine is less traumatic, has no significant postoperative immediate and distant complications.

The inventive method is tested on sufficient clinical material, has shown its effectiveness and applicability and can be recommended for use in specialized hospitals.

Claims (1)

A method for the surgical treatment of extended strictures and obliterations of the ureter and ureteropelvic segment with its tuberculous lesion, including excision of the scar-stenotic part and plastic from the autograft of the cheek mucosa, characterized in that the affected part of the ureter is completely removed with the surrounding tissue and resection of the pelvis-ureter, make buccal-labial flap cutting out from the oral cavity 2.0 cm wide, the flap is fixed to the ureter with the buccal end, flaxly dissected along its front surface by 1 cm, with a continuous seam of 4/0 monocryl, the graft is fixed with internal single monocrylic 4/0 sutures by the epithelium outward onto the ventral surface of the lumbar muscle by 1/3 of its diameter, starting from the buccal edge of the flap and not reaching 2 cm before the end of the labial edge, set the internal drainage stent No. 6, the flap is sutured over the stent with a continuous external monocrylic suture 4/0, not reaching 1 cm to the end of the labial edge, the flap is fixed with the labial end of continuous monocryl bubbled 4/0 sutures for tissue pelvis and to operate nefrofiksatsiyu psoas muscle.