RU2723462C1 - Method of surgical management of patients with neurogenic dysfunction of lower urinary tract and other bladder diseases - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, specifically to urology. Appendix is cut off with a circular incision with blind-wall wall capture and turned through 180° with an apex to the skin opening. Appendicostomy is placed inside the abdominal cavity. Visceral peritoneum is exposed above a right lateral wall of a bladder. Base of the appendix is anastomosed with a bladder or an intestinal reservoir through a submucosal tunnel on its right upper side wall to form a fistula from a segment of the blind gut on an appendix. Then together with mesentery it is placed into tunnel. Base of the appendix is fixed outside to the bladder or intestinal vessel wall. Bladder or intestinal reservoir is fixed to anterior abdominal wall around stoma. Appendix top is obliquely cut at angle 45°. It is delivered through an opening in the peritoneum and anastomosed with umbilical bluetongue by interrupted sutures.EFFECT: method provides the reliable formation of a catheterised appendicocystostomy or appendicoreservoirostomy, as well as prevention of dental implantation, which reduces the number of recurrences and improves the quality of life in these patients.1 cl, 2 dwg, 2 ex

Description

The invention relates to medicine, namely to urology, and may be applicable for the surgical treatment of patients with neurogenic dysfunction of the lower urinary tract, including those arising from tuberculous spondylitis and other diseases of the bladder.

Currently, the rehabilitation of patients with tuberculous spondylitis complicated by myelopathy is a serious medical and social problem. The resulting neurological disorders, leading to plague and paralysis in almost one in ten patients, are accompanied by pelvic organ dysfunction, which is clinically manifested by disorders of urination and defecation (Burlakov S.V. et al. 2011), which, in turn, may be complicated by a urinary infection ways and hydronephrotic transformation (Lebedev A.A. et al. 2012). In some patients, urine is evacuated using a Foley catheter transurethrally inserted into the bladder, in some, urination is uncontrolled (Muravyov A.N. et al. 2015). In the future, as a rule, prolonged drainage of the lower urinary tract is used in the form of cystostomy drainage, which leads to the inevitable loss of bladder elasticity and constant urinary tract infection with the inevitable development of severe complications up to sepsis and death.

In these patients it is possible to use periodic catheterization - a method that is quite safe and affordable, but in some cases impossible or difficult due to inaccessibility of the urethra due to severe skeletal deformities, obesity, inadequate patient mobility and lack of skills, its dependence on a wheelchair, urethral obstruction or maintaining its normal sensitivity, and therefore, its soreness (Stizer O. et al., 1997).

Some patients using periodic transurethral catheterization indicate a decrease in quality of life, discomfort, and even aversion to the method.

Phe V., et al. (2017), based on a systematic review of the literature, concluded that continental (urine-holding) catheterizable stomas are an effective treatment for patients with neurogenic dysfunction who cannot or do not want to perform periodic self-catheterization.

In 1980, Mitrofanoff R. proposed an alternative method for periodic catheterization of the bladder, which consisted in creating a continental (retaining urine) canal from the appendix, implanted into the bladder and brought out as a stoma on the anterior abdominal wall. In 1986, Duckett J.W., Snyder H.M. popularized this method in the USA under the name of the Mitrofanov principle.

The main components of the Mitrofanov principle are: a catheterizable canal, which is connected to the bladder (intestinal reservoir) and brought to the abdominal wall; a retention mechanism that prevents urinary incontinence (involuntary discharge) through the stoma; hidden skin stoma. To achieve the success of the operation as a whole, it is necessary to create or have an adequate cervical-urethral closure mechanism and a urinary reservoir with good extensibility, high capacity and low pressure. According to the original description, the appendix was separated from the cecum while maintaining mesenteric blood supply from the terminal branches of a. Ileocolica, was implanted in a pre-created submucosal tunnel of the bladder and displayed as a stoma on the anterior abdominal wall (Mitrofanoff P. Cystostomie continente transappendiculairedans le traitement deserveies neuroiogiques / P. Mitrofanoff // Chir. Pediatr. - 1980. Vol.21, N 1 . - P. 297-305.).

Mitrofanov’s principle in the vast majority of cases is based on the use of a leaf valve mechanism. The increase in pressure inside the tank when it is filled is transmitted to a channel of small diameter located under the mucous membrane, compressing its lumen, which ensures retention of urine (continent).

Another continental mechanism that is part of this method is the nipple valve mechanism. In this case, the catheterized canal is invaginated into the urinary reservoir in the form of a nipple. The pressure in the lumen of the channel will be equal to the pressure in the tank and prevent the leakage of urine.

The disadvantage of this method is the increased risk of relapse of incontinence (urinary incontinence), due to the unreliable attachment of the appendix, as a catheterized channel, by the apex to the bladder mucosa, which can lead to leakage of urine from the stoma opening.

The following procedure is considered standard for this operation (Averin V.I. Surgical treatment of urinary incontinence in children // Military Medicine. - 2006. - No. 1. - P.22-23), taken by us as a prototype. After performing the lower middle laparotomy and revision of the ileocecal angle, the bladder is mobilized to the neck, its lumen is opened and the ureters are catheterized. The neck of the bladder is sutured. After this, an appendectomy is performed with the preservation of the mesentery of the appendix. The cecum is sutured with double-row interrupted sutures. The top of the appendix is cut off, the lumen is washed with a solution of furatsilina and pass through it with a probe. After that, an antireflux submucosal tunnel 3-4 cm long is formed in the bladder on a stretched detrusor. Through it, an appendix is introduced into the bladder and its tip is fixed with interrupted sutures to the mucous membrane. The base of the appendix, while maintaining straightness, is withdrawn extraperitoneally along the midline to the navel (Fig. 1).

The disadvantage of this method is the increased risk of relapse of incontinence (urinary incontinence), due to the location of the appendix with the tip of the bladder mucosa, which can lead to leakage of urine from the stoma opening.

The specified disadvantage of the prototype is eliminated in the claimed technical solution.

The invention is illustrated in FIG. 1-2. In FIG. 1 shows a diagram of the operation of the prototype method. In FIG. 2 shows a diagram of the operation of the claimed method.

The problem to which the invention is directed, is the development of an alternative effective method for the prevention of stomal incontinence in the surgical treatment of patients with neurogenic dysfunction of the lower urinary tract and other diseases of the bladder.

The problem is solved in that the mesentery of the appendix is mobilized from the mesentery of the cecum, the appendix is cut off with a circular incision from the cecum to capture its wall, the apex of the appendix is obliquely cut at an angle of 45 degrees for sufficient patency of the 14 Ch catheter, which subsequently allows self-catheterization, after which the appendix is rotated 180 ° apex to the skin opening, the visceral peritoneum is opened over the right upper lateral wall of the bladder, the base of the appendix is anastomosed with the bladder or with the intestinal reservoir through the submucous tunnel on its right upper side wall, with the formation of an anastomosis from the area located on the appendix additionally fix the base of the appendix from the outside to the wall of the bladder or intestinal reservoir, fix the bladder or intestinal reservoir to the anterior abdominal wall around the stoma, remove the tip of the appendix through a small hole in the peritoneum and anastomose with a contraceptive swarm of navel skin with interrupted sutures.

The technical result obtained by using the essential features of the proposed method is that the reliability of the formation of a catheterizable canal of the appendicocystostomy or appendicoreservarostomy in patients with neurogenic dysfunction of the lower urinary tract, including that occurring against tuberculous spondylitis, as well as other diseases of the bladder, provides prevention of stomal incontinence, which reduces the number of relapses and improves the quality of life in these patients.

This technical result is achieved due to the formation of an original reliable mechanism of urine retention - appendix implantation is strictly isoperistaltic in relation to the bladder or intestinal reservoir - the apex to the anterior abdominal wall, and the base to the bladder or intestinal reservoir, which allows creating an additional mechanism due to its contractions retention, since different layers of the appendix muscle are contracted tonic and periodically. And in this case, taking into account the location of the appendix, the reduction of its layers will occur from the top to the base, thereby enhancing the effect of the continent. Oblique clipping of the apex of the appendix at an angle of 45 degrees provides an increase in the area of the outlet of the catheterized canal and prevents the development of its stenosis. Fixing the base of the appendix to the wall of the bladder (or intestinal reservoir) significantly increases the reliability of the catheterized canal, which prevents leakage of urine from the bladder. The intestinal reservoir is formed from various parts of the gastrointestinal tract in case of removal of the bladder with its tumor lesion or with the tuberculous process leading to its wrinkling.

The intraperitoneal location of the appendicostomy provides the most direct passage of the canal and prevents infringement of the mesentery of the appendix. Fixation of the bladder or intestinal reservoir to the anterior abdominal wall around the stoma, as well as in addition at several points, prevents subsequent appendix twisting.

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

The method is as follows.

A patient with neurogenic dysfunction of the lower urinary tract and other diseases of the bladder, including those arising against the background of tuberculous spondylitis, in combination with the inability to restore self-urination carry out anesthesiological allowance. Access - lower median laparotomy. The cecum and terminal ileum are mobilized along with the mesentery for further free movement of the appendix. At the base of the appendix, the sutures of the holder are imposed, cut off with a circular incision to capture the wall of the cecum, the mesentery of the appendix is separated from the mesentery of the cecum without disturbing its blood supply. The cecal defect is sutured with a double-row suture. With a short appendix or in patients with obesity, the appendix is lengthened due to the cecum by forming a tube of the required length from it. Turn the appendix 180 ° (Fig. 2). The visceral peritoneum is opened over the right upper lateral wall of the bladder, the base of the appendix is anastomosed with the bladder or with the created intestinal reservoir through the submucous tunnel. The intestinal reservoir is formed from various parts of the gastrointestinal tract in case of removal of the bladder with its tumor lesion or with the tuberculous process leading to its wrinkling.

The appendix along with the mesentery is laid in the tunnel. The wall of the bladder (intestinal reservoir) is sutured. The appendix body is additionally fixed outside to the wall of the bladder (intestinal reservoir) with single sutures.

The apex of the appendix is obliquely cut at an angle of 45 degrees for sufficient patency for a 14 Ch catheter and anastomose with a contra -perture of the umbilical skin with interrupted sutures. The bladder or intestinal reservoir is fixed to the anterior abdominal wall around the stoma, as well as additionally at several points to prevent appendix twisting.

The abdominal cavity is drained, the wound is sutured in layers.

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

Example 1

Patient Kev, 62 years old, pulmonary tuberculosis was detected in 1986, initial infiltrative tuberculosis of the upper lobe of the left lung. The course of the process is recurrent - against the background of treatment, tuberculomas of the upper lobe of the left lung have formed. In February 2014, a resection of S1-2 of the left lung was performed due to its multiple tuberculosis. In April 2014, T2aNxM0 bladder cancer was detected, 04/01/14 performed cystoscopy, installation of a stent for internal drainage of the right ureter, transurethral resection of the bladder wall with a tumor. The postoperative period was uneventful. Histological examination - urothelial (transitional cell) carcinoma of a moderate degree of malignancy with a section suspicious of invasion to the muscle layer. On 02/02/2015, in connection with a relapse of the disease, a cystoprostat vesiculectomy with ileocystoplasty (formation of the intestinal reservoir) was performed according to Studer, with pathomorphological revealed multiple foci of highly differentiated transitional bladder cancer without signs of invasion in areas of previously resected foci of transitional cell carcinoma.

The patient's condition worsened 04/12/16, when ureterohydronephrosis was detected on both sides, laboratory tests showed an increase in blood urea and creatinine, leukocyturia, bacteriuria, septic changes (the growth of pathogenic microorganisms from blood and urine with total drug resistance). 04/21/16 performed an autopsy of the abscess of the left perinephral region, the patient was superimposed nephrostomy on both sides. 07/26/16, an audit of the left kidney was performed regarding apostematous pyelonephritis, its decapsulation, and renephrostomy. Renephrostomy has been repeatedly performed for the patient due to nephrost dislocation, including due to inaccurate patient behavior.

In the future, the patient was hospitalized 03/27/17 for a routine examination. In connection with the presence of bilateral obstruction of the ureters, in order to restore the passage of urine through the urinary tract and improve the quality of life of the patient, it was decided to perform surgical treatment in the amount of bilateral urethral resuscitation of the ureters with an intestinal reservoir and the formation of a catheterized canal using the appendix.

The patient performed the operation of the claimed method. An anesthetic allowance has been made. The lower middle laparotomy was performed on the old scar. Hemostasis by coagulation. The intestinal reservoir together with the adducing tubular ileum is isolated from adhesions and adhesions by the acute route. An audit of the ureters revealed that their distal parts are obliterated. The ureters are mobilized, obliquely cut off. Their anastomosis was carried out with the tubular ileum leading to neocystis according to the Wallace method on ureteric stents No. 7 Ch. The appendix with a length of 10 cm together with the dome of the cecum is turned off from the continuous intestine, left on the vascular pedicle. The cecal defect is sutured with two rows of 2/0 vicryl stitches. The resected dome of the cecum is partially tubularized, thereby extending the appendix by 2.0 cm. The appendix is rotated 180 °. The top of the appendix is obliquely cut at an angle of 45 degrees for sufficient patency of the 14 Ch catheter. The base of the appendix is anastomosed with the tubular ileum leading to the intestinal reservoir on the Foley catheter No. 14, then the appendix is anastomosed with the counter-puncture of the umbilical skin with interrupted sutures. The abdominal cavity is drained by two silicone drains, sutured in layers. The wound is sutured in layers tightly.

The postoperative period was uneventful. The patient performs self-catheterization through appendicoreservarostomy. No leakage of urine. Monitoring of the patient continues.

Example 2

Patient A-yang, 49 years old, was admitted to the department on 09/04/18. Considers herself a patient since the beginning of January 2018, when, after using drugs, sharp pains appeared in the thoracic spine during exercise. She was treated at home on her own. Subsequently, general weakness and numbness appeared in the lower extremities, difficulty urinating, a periodic increase in body temperature to 39.0 ° was noted. She was treated on an outpatient basis by a general practitioner with a diagnosis of community-acquired pneumonia? Fever of unknown origin. Upon further examination, the patient was diagnosed with "chronic spondylitis Th10-Th11 of vertebrae of unspecified etiology (tuberculous?), Complicated by paravertebral sore abscesses, spinal stenosis at this level, lower spastic paraparesis, pathological compression fracture of the vertebral body L1". Hospitalized in a specialized hospital. In August 2018, urination gradually disappeared; against the background of urinary retention, the patient was transferred to intermittent catheterization of the bladder. Then the patient underwent a two-stage radical reconstructive surgery - left-sided thoracolumbofrenotomy, Th10 vertebral corporectomy, Th11 vertebral resection, L1 vertebral corporectomy, spinal cord decompression, separate 2-level ventral support spinal fusion with autocynthesia vascular autopsynthesis and multivascular synthesis. The second stage performed transpedicular spinal fusion of Th7-L4 (10/16/2018).

However, the patient's independent urination within six months did not recover. It was decided to perform a patient operation of the claimed method.

After anesthetics, the lower median laparotomy was performed. The cecum and terminal ileum were mobilized along with the mesentery, the sutures were held at the base of the appendix, it was cut off by a circular incision with the capture of the wall of the cecum. The cecal defect is sutured with a double-row suture. The appendix is rotated 180 °. The visceral peritoneum is opened over the right upper lateral wall of the bladder and the base of the appendix is anastomosed with the bladder through the submucous tunnel on the right upper lateral wall of the bladder. The appendix along with the mesentery is laid in the tunnel. The wall of the bladder is sutured, the appendix is additionally fixed externally to the wall of the bladder.

The apex of the appendix is obliquely cut at an angle of 45 degrees for sufficient patency by a 14 Ch catheter and is anastomosed with a counter -perture of the umbilical skin with interrupted sutures. The bladder is fixed to the anterior abdominal wall around the stoma, and also in addition to the muscles. The abdominal cavity is drained by two tubular drains, the wound is sutured in layers tightly.

The postoperative period in the patient proceeded without features. It independently performs self-catheterization through appendicocystostomy. Leakage of urine is not observed. It is under the supervision of a urologist.

Thus, the claimed method allows to improve the quality of life of patients by reducing the likelihood of leakage of urine from appendicocystostomy or appendicoreservarostomy, to improve the treatment results of patients with neurogenic lower urinary tract dysfunction and other diseases of the bladder.

A method for the surgical treatment of patients with neurogenic lower urinary tract dysfunction and other diseases of the bladder was tested in a clinic in 28 patients with neurogenic lower urinary tract dysfunction, with tuberculosis of various locations, malignant tumors, and showed the reliability of the formation of a catheterized canal of the appendecystostomy or appendecortic reservuarcostomy, incontinence, which allowed to reduce the number of relapses and improve the quality of life in these patients.

A method of surgical treatment of patients with neurogenic dysfunction of the lower urinary tract and other diseases of the bladder can be recommended for widespread use in specialized hospitals.

Claims (1)

A method for surgical treatment of patients with neurogenic dysfunction of the lower urinary tract, including the introduction of the appendix into the bladder and fixing it with one end to the mucous membrane of the bladder and the other to the abdominal wall, characterized in that the appendix is cut off with a circular incision with the capture of the wall of the cecum and deployed on 180 ° apex to the skin hole, have an appendix in the abdominal cavity, open the visceral peritoneum over the right upper lateral wall of the bladder, the base of the appendix is anastomosed with the bladder or intestinal reservoir through the submucous tunnel on its right upper lateral wall with the formation of the anastomosis from the site of the anterior appendix then, together with the mesentery, they are laid in a tunnel, an appendix base is additionally fixed outside the bladder wall or intestinal reservoir, a bladder or intestinal reservoir is fixed to the anterior abdominal wall around the stoma, the tip of the appendix is obliquely cut They are bent at an angle of 45 °, they are brought out through an opening in the peritoneum and anastomosed with contrapertures of the navel skin with interrupted sutures.

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