RU2716458C1 - Method for forming ileourocutaneostomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to urology. Terminal portion of the ileum is separated in length of 20–25 cm. Isolated ends of the segment are connected with ureters and urine is drained through a reservoir brought to the anterior abdominal wall. Urinary V-shaped reservoir is formed from the existing segment. In the proximal and distal portions of the reservoir, the ureters are anastomosed to form a double-barrelled ileourocutaneostomy.

EFFECT: method enables distinguishing urine outflow from left and right kidneys, performing postoperative control in case of an inconsistency of one of the anastomoses, possibly stenting or draining by placing a nephrostome on one side.

1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, namely to urology and can be used in the treatment of patients with urethrocutaneostomy (short length of the ureters) that were imposed for invasive cancer of the bladder, as well as in the treatment of other diseases of the genitourinary tract, the result of which is surgical treatment in volume of cystectomy, or pelvic exenteration.

After surgical treatment to remove the bladder, the question often arises about methods of derivation of urine. The choice of urine derivation method solely depends on the severity of the patient.

A known method of forming an ileourocutaneostomy (RU 2655950 C1 from 2018 MKI A61B 17/00). This method is intended for the treatment of patients with urethrocutaneostomy that were imposed for bladder cancer or in patients with postradiation, ischemic or postinflammatory fibrotic changes in the ureters.

The disadvantages of this method are:

- the large extent of the intestinal segment used;

- the formation of two intestinal segments and the presence of an excess anastomosis, increases the volume of surgical intervention and the risk of postoperative complications.

The closest analogue is Bricher’s operation, which is the most frequently used and technically simplest way to form an ileourethrocutaneostomy (Bricker EM Bladdersubstitutionafterpelvicevisceration / EMBricker // SurgClinNorthAm - ... 1950. - V. 30. - P. 1511-1521).

This method is as follows. They produce a median laparotomy, mobilize the ileum, retreating 15-20 cm from the place where it enters the cecum, and cut a 40-50 cm long segment with a well-defined vascular pattern. Intestinal tract continuity is restored by applying an end-to-end or side-by-side anastomosis. Ureters are implanted to a selected segment or a single site. The distal end of the intestinal segment is brought to the anterior abdominal wall, the stoma is formed in the mesogastric region in a section convenient for wearing the urinal. In the abdominal cavity, the intestinal segment is laid transversely at the level of the promontorium and fixed to the posterior peritoneum with several sutures.

The disadvantages of this method are:

- as a result of the lack of separation of the outflow of urine, in the presence of purulent pyelonephritis, on the one hand, contamination of a healthy kidney can occur;

- in the case of insufficient length of one of the ureters, the problem of the formation of the anastomosis and its failure in the future may arise, and in the later stages after the operation - cicatricial stenosis of the ureostomy, stricture or obliteration of the ureteral-intestinal anastomoses and the need for repeated reconstructive operations.

The objective of the invention is to provide a new method for the formation of ileourocutaneostomy, providing dissociation of the flow of urine and eliminating the problems of insolvency of anastomoses and their consequences.

The specified result is achieved as follows: at 20-25 cm from the ileocyclic angle, the ileum segment is taken up to 20-25 cm in length (ileoconditis). Intestinal integrity is restored by end-to-end anastomosis. The proximal end of the ileum segment is divided into the adducting and abducting knees of the right and left ureter, respectively, according to the “double-barreled” type. The ureter of the left ureter, taken along the mesentery of the sigmoid colon, is anastomosed in the adducting knee. In the abducting knee, the right ureter. Ileoconditis is displayed on the anterior abdominal wall through an additional incision. With this technique of ileocystoplasty, the outflow of urine from the left and right kidneys is differentiated. And in the postoperative period, it is possible to control urethroconduit anastomoses, that is, if one of the anastomoses fails, stenting or drainage is possible by installing a nephrostomy on one side.

The technical result of the invention is achieved due to the possibility of urine diversion in patients with a deficiency of the length of the ureters, thereby eliminating the problem of the formation of anastomosis and its failure. As well as the presence of separation of the outflow of urine.

The invention is illustrated in the drawing, where in FIG. 1 shows the final stage of the formation of ileourocutaneostomy 1. The proximal end of the ileum segment, divided into the leading and abducting knee 2.

The method is as follows.

The lower middle laparotomy (or laparoscopy) is performed, the ureters are excreted, and if there are necrotic and scar tissues, to the well-supplied distal end of the ureter. After the stage of cystrostatectomy with pelvic lymphadenectomy, in the case of a one-stage operation. 20-25 cm from the ileocyclic angle, a section of the terminal ileum is isolated and it is taken up to 20-25 cm in length (ileoconditis). Intestinal integrity is restored by applying an end-to-end or side-to-side anastomosis. The urinary “V-shaped” reservoir is formed from the existing segment. The ureters are anastmosed to the proximal and distal portions of the reservoir and the reservoir is discharged to the anterior abdominal wall in a typical location, similar to a double-barreled ileourocutaneostomy _with

Defects of the mesentery are sutured, the abdominal cavity is sanitized and drained.

Clinical example.

Patient D., 67 years old, was admitted to the department of oncourology "MSC Neftyanik", Tyumen. Complaints upon receipt of difficulty urinating, discomfort in the lower abdomen, an admixture of blood in the urine periodically.

From the anamnesis: these complaints worry about 6 months. An examination at the place of residence suspected a neoplasm of the bladder. Directed for further examination at the "Multidisciplinary Clinical Medical Center" in Tyumen. A cystoscopy with a biopsy was performed, the diagnosis was confirmed.

Morphological picture of moderately differentiated papillary urothelial carcinoma G2.

According to the results of cystoscopy, a villous tumor up to 5 cm occupies almost the entire front wall. There are several similar tumors of smaller diameter along the side walls of the bladder walls.

CT OBP, OMT: the bladder is quite full, formation with tuberous contours, size 43-30 mm, with spreading to the mouth of the right ureter is determined along the back wall of the bladder. Paravesical space without features. Urethrohydronephrosis on the right with a block at the level of the mouth of the ureter.

Diagnosis: bladder cancer, T2NxM0, stage II, clinical group II.

The patient underwent radical cytotomy with expanded lymphadenectomy and simultaneous derivation of urine according to the proposed method.

After the operation, the patient received antibacterial, symptomatic therapy. The postoperative period without features, the ureostomy is functioning, the urinal is selected. Discharged 16 after surgical treatment under outpatient observation. Examined 3 months after the operation, data for relapse and metastases were not found, according to the results of excretory urography and ultrasound of OBP iOMT, a satisfactory function of the kidneys was noted, there were no enlargement of the heart and ureters.

Claims (1)

The method of forming an ileourocutaneostomy, including the allocation of the terminal ileum of 20-25 cm in length, connecting the selected ends of the segment with the ureters and urinating through a reservoir brought to the front abdominal wall, characterized in that a urinary "V-shaped" reservoir is formed from the existing segment, in the proximal and distal parts of the reservoir, the ureters anastomose with the formation of a double-barreled ileourocutaneostomy.

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