RU2724870C2 - Method for endovideosurgical modeling of ureter in pneumovesioxopic reimplantation in children with megahoureter - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely urology-andrology of childhood. Reimplantation of ureter is started from applying fixing ligature on ureteral orifice region with obstructive megoureter, ligature is tightened by clamp and coagulation hook to extract orifice by edging incision, ureter is gradually mobilized with consecutive coagulation of vessels throughout 7 cm and simulation of ureter is started, for this purpose in region of neck of bladder needle is introduced with bending at end, wherein ligature of monofilament material is left in the needle lumen and from the ligature, and an end of the separated ureter is placed into the created ligature loop, after which the ligature is pulled and the ureter is fixed along the entire length, then by continuous plication suture 4/0 of vicryl performing ureter modeling, reducing its diameter twice over 6 cm, and a maximum retracted from the paravesical space in the urinary bladder ureter is applied a fixing suture in the proximal segment, attaching it to the wall of the bladder within the incision, then forming submucous tunnel 5 cm long in the horizontal direction above the contralateral orifice, recovered ureter is performed in a submucosal tunnel and a ureteral orifice resection is performed by removing the contracted dysplastic tissues, after which the ureter is additionally fixed with an interrupted suture to the bladder wall in the formation of a new ureteral orifice, further ureter and bladder mucosa are connected by a continuous suture, and ureter and kidney are drained with external J stent, which is installed along string introduced into bladder through additional puncture in wall with puncture needle, bladder wound in the area of the separated orifice is closed with a suture, the bladder mucosa is closed with a continuous suture; the operation is completed by the installation of a urethral catheter and extraction of trocars.EFFECT: proposed method enabled ureter blockage to be ensured by point punctures in urinary bladder and to create more reliable antireflux mechanism in pancreatic ureter's layer and prevent the onset of vesicoureteral reflux as the most frequent complication of ureter reimplantation in children with obstructive megoureter.1 cl, 1 ex, 9 dwg

Description

The invention relates to medicine, namely to pediatric urology-andrology, and can be used to treat children with obstructive and reflux megaurethra.

Megaureter is considered an abnormal expansion of the ureter in length and width as a result of impaired patency in the prebubble section. Primary - congenital megaureter and secondary, arising from obstruction with calculus, are isolated. A megaureter can be obstructive and non-obstructive and non-refluxing. Deficiency is detected in 1: 10000. More common in boys. The ratio of boys to girls is 4.8: 1.0. The left ureter is affected more often 1.7-4.5: 1.0. Bilateral megaureter occurs in 10-20% of cases. The cause of the primary (congenital) obstructive megaureter is considered to be structural disorders in the muscle layer of the distal ureter segment, which are characterized by varying degrees of reduction or absence of longitudinal muscle fibrous fibers, hypertrophy or hyperplasia of circular fibro-muscle fibers or an increase in connective tissue fibers. These changes determine the pathology and can be expressed in various degrees from minimal manifestations to complete obstruction (S. Tekgul, HS Dogan, P. Hoebeke, JM Nijman, R. Kocvara, C. Redmayr, K. Stein. Upper urinary tract expansion (obstruction ureteropelvic segment or ureteral orifice. Recommendations for Pediatric Urology. European Association of Urology. 2016, 2 t, pp. 53-56).

Surgical methods for treating a megaureter are divided into endoscopic - dilatation of the ureter orifice, open (reimplantation of the ureter with dissection of the bladder) and minimally invasive endovideo surgery using laparoscopic and pneumovesicoscopic access.

A known method of surgical treatment of a megaureter according to the Cohen method, including dissection of the bladder, excretion of the ureter mouth with a bordering incision, is 5-7 cm. Resection of the dysplastic distal ureter (2-3 cm) and re-implantation of the ureter with the formation of a submucous tunnel in the horizontal direction, above the mouth of the opposite ureter (F. Khinman Operational urology. Atlas. Transtrigonal method of Cohen (Cohen) // Moscow, "Geotar-Med" 2001, S. 815-816). The operation is effective and is considered the standard treatment for megaureter in children.

However, the technique relates to open interventions with dissection of a large array of tissues, skin, subcutaneous fat, muscles of the anterior abdominal wall and muscles of the bladder. In the postoperative period, episodes of prolonged hematuria often occur, clots form in the lumen of the bladder, which interfere with the drainage of urine through the urethral catheter.

Also known is the common method of surgical treatment of a megaureter, which has become popular with the development of minimally invasive technologies, the method of endoscopic dilatation of the narrowed ureter orifice with a buzi and the installation of a ureteral stent.

However, the known method is very minimally invasive, but the main disadvantage of this method is the low efficiency of treatment with a megaureter (no more than 60%), in addition, in some cases in young children it is not possible to install a conductor in the ureter due to the small diameter of the narrowed mouth. The method has limited application (M. Lima, D. Manzoni. Pediatric urology. Modern surgical techniques from the prenatal period to the development of puberty. Obstruction of the ureterovesical segment //. Moscow, Geotar-Media 2018, pp. 131-142)

Since re-implantation of the ureter remains the most effective way of treating obstructive megaureter, the use of endovascular surgical approaches for this operation has been developing in recent years.

As the closest analogue, we have adopted the method of laparoscopic reimplantation of the ureter Lich-Greguoir (Lich-Gregior). The method consists in the fact that to eliminate narrowing in the distal ureter, laparoscopic access to the abdominal cavity is performed. Install 3 trocars one 5 mm in the navel area for the camera and two 3 mm trocars in the right and left iliac region along the midclavicular line. The peritoneum is cut in the region of the distal ureter for 7-10 cm. The distal ureter is mobilized for 10 cm, cut off from the bladder. The ureter stump is ligated. The bladder is taken on a holder, fixed to the anterior abdominal wall by ligature. The coagulator dissects the muscles of the bladder to the mucosa. Carefully isolate the edges of the wound, creating a bed for the ureter 5 cm long. The ureter, if it is significantly expanded, is brought out through the opening of the trocar and modeled, reducing its width with a continuous seam of 4,0 Vicryl for 5-6 cm. An anastomosis of the ureter with a continuous bladder is formed seam 5 \ 0 vikril. The ureter is drained by a JJ stent. The ureter is placed in a previously formed bed in the wall of the bladder and the edges of the dissected detrusor are sutured with a continuous 4,0 Vicril interrupted suture (F. Khinman Operational Urology. Atlas. Laparoscopic method of ureterocystoneostomy. Lich-Gregoire extravasive technique // Moscow, Geotar-Med "2001, S. 822-823).

The disadvantage of this method is the operation in the abdominal cavity, the risk of damage to the great vessels, spermatic cord in boys, uterine ligaments in girls. The difficulty of modeling the ureter with its output through the opening of the trocar.

The technical result of the proposed solution is the creation of an effective minimally invasive method for surgical treatment of ureteral malformations, which allows traumatic reimplantation of the ureter with excision of the dysplastic segment and intravesical modeling of the enlarged ureter using a new endoscopic surgical pneumo-vesoscope without traumatic dissection of the anterior abdominal wall and bladder as an access. reduce the number of complications in the postoperative period, such as prolonged hematuria, bladder tamponade, exacerbation of pyelonephritis and ureteral stenosis.

These technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, re-implantation of the ureter is carried out, the ureter is mobilized in the distal section and re-implanted into the bladder with preliminary modeling for 6 cm.

A feature of the claimed method lies in the fact that the re-implantation of the ureter begins with the application of a fixative ligature to the area of the ureter orifice with an obstructive megaureter, the ligature is pulled with a clamp and a coagulation hook, the mouth is secured with a bordering incision, the ureter is gradually mobilized with sequential coagulation of the vessels for 7 cm and this, a needle with a bend at the end is inserted into the neck of the bladder, and in the lumen of the needle and outside, a ligature of monofilament material is left and the end of the selected ureter is laid in the created loop from the ligature, after which the ligature is pulled and the ureter is fixed along the entire length, then with a continuous pleating suture 4 \ 0 Vicryl perform modeling of the ureter, reducing its diameter by half over 5 cm and, on the ureter, maximally removed from the paravesical space in the bladder, fix the suture in the proximal region, linking it to the bladder in the dissection area, then form a submucosal tunnel 5 cm long in the horizontal direction above the contralateral mouth, the selected ureter is carried out in the submucosal tunnel and the ureteral mouth is resected, removing dysplastic tissues of the narrowed segment, after which the ureter is additionally fixed with a suture to the bladder wall in the area of the formation of a new ureter orifice, then the ureter and bladder mucosa are connected with a continuous suture, and the ureter and kidney are drained with an external J stent, which is placed along the string inserted into the bladder through an additional puncture in the wall with a puncture needle, a bladder wound in the area of the allocated mouth sutured with a nodal suture, the bladder mucosa is sutured with a continuous suture, the operation is completed with the installation of an urethral catheter and trocar extraction.

The invention is illustrated by a detailed description, clinical examples and illustrations, which depict:

FIG. 1 is a diagram of the installation of trocars.

FIG. 2 - trocar location scheme: along the midline, in the center between the navel and pubic bones - a trocar for optics 5 mm; on the right and left in the iliac region - two 3 mm working trocars.

FIG. 3 is a diagram of the installation of a trocar under the visual control of a cystoscope, between two ligatures that fix the bubble to the anterior abdominal wall.

FIG. 4 is a diagram of the fixation of a mobilized dilated ureter with a loop using a Tahuoka needle inserted near the neck of the bladder.

FIG. 5 - scheme of fixation to the wall of the bladder: the expanded ureter is narrowed (modeled) by a continuous suture.

FIG. 6 is a diagram of transtrigonal mobilization of the bladder mucosa in the horizontal direction above the mouth of the contralateral ureter.

FIG. 7 - operation diagram: the ureter is guided into the created submucosal tunnel (Cohen's operation) and is fiscated to the muscles of the bladder in the area of the old location of the mouth and in the area of the newly formed mouth.

FIG. 8 - operation diagram: the mouth is formed by a continuous seam 5 \ 0 vikril; the kidney is drained by an external stent, held along the string to the pelvis and fixed to the skin from the outside.

FIG. 9 - examination of patient U. before surgery: a) radiograph obstructive megaureter on the left; b) static nephroscintigraphy, a 40% decrease in left kidney function; Specific contribution 28% on the left, 72% on the right

The method is as follows.

Surgical intervention is performed in all children under endotracheal anesthesia, the child is standing on his back with a roller under the buttocks.

The operation begins with a tight filling of the bladder with saline. A cystoscope is inserted into the bladder, ligatures are fixed under visual control to fix the bladder to the anterior abdominal wall. The first two are in the middle of the distance between the navel and the pubic joint. Use ligatures 1 or 0 vikril on a large round needle. A 5 mm trocar (for optics) is inserted between two ligatures and I fix the trocar to the ligatures to prevent displacement and exit of the trocar from the bladder during manipulations, insertion and extraction of optics. Two other ligatures are applied in the iliac regions, 3 mm instrument trocars are placed there (Fig. 1, Fig. 2, Fig. 3). Saline is removed from the bladder and carbon dioxide is introduced. The cystoscope is removed. Ureter reimplantation begins with the application of a fixative ligature to the area of the ureter orifice with an obstructive megaureter. Use Vikoil 4 \ 0. The ligature is pulled up with a clamp and the coagulation hook secures the mouth with a bordering incision. The ureter is gradually mobilized with sequential coagulation of the vessels for 7 cm. Next, modeling (dressing of the ureter) begins in case of significant, more than 25 mm expansion. To stabilize (fix) the ureter in the neck of the bladder, a needle is inserted with a bend at the end (for example, Tahuoki), a ligature of monofilament material (for example, Prolene 3 \ 0) is left in the lumen of the needle and outside, and the end of the selected ligature is laid ureter (Fig. 4 and 5). The ligature is tightened and the ureter is fixed throughout. Next, continuous ilirovshimi (narrowing) suture 4 \ 0 vikril perform modeling of the ureter, reducing its diameter by half over 6 cm (Fig. 5). The ureter is placed on the maximally removed from the paravesical space into the bladder fixative suture in the proximal section and connected with the wall of the bladder in the area of its dissection, to prevent the return of the ureter to the vesical space. A submucosal tunnel 5 cm long is formed in the horizontal direction above the contralateral mouth (Fig. 6). An isolated ureter is carried out in the submucosal tunnel (Fig. 7). Resection of the mouth of the ureter is performed, removing dysplastic tissues of the narrowed segment. The ureter is additionally fixed with a nodal suture (Vicryl 4 \ 0) to the wall of the bladder in the area of formation of a new mouth of the ureter. The mucosa of the ureter and bladder are connected by a continuous suture (5/0 vicryl) (Fig. 8). The ureter and kidney are drained by an external J stent, which is installed along a string inserted into the bladder through an additional puncture in the wall with a puncture needle. The wound of the bladder in the area of the mouth is sutured with a nodal suture 4,0 Vicryl. A continuous seam of Vicryl 5/10 sutures the mucosa of the bladder. The operation is completed by the installation of a urethral catheter and the extraction of trocars. Impose a pressure bandage on the bladder and tightening adhesive bandages on the incision area. The urethral catheter is removed on 4-5 days.

Clinical trials were conducted in the children's uroandrological department of the Research Institute of Urology and Interventional Radiology. ON THE. Lopatkina.

The proposed method operated on 23 children aged 11 months. up to 10 years. Long-term results were tracked in a period of 6 months. up to 5 years. No complications of ureteral stricture were observed. The formation of vesicoureteral reflux was observed in one child. The cause of the complication was neurogenic dysfunction in the bladder. An endoscopic correction of PMR was carried out by introducing a volume-forming substance into the mouth area. All patients achieved a good functional and cosmetic result. According to ultrasound, a decrease in the size of the pelvis, calyx and ureter was noted. A decrease in urine flow according to uroflowmetry was not detected.

Clinical trials have shown that the proposed method for the treatment of obstructive megaureter can reliably eliminate the narrowing of the distal ureter and reimplant the ureter with its width modeling with the creation of an antireflux mechanism. It was possible to reduce the number of complications such as prolonged hematuria in the postoperative period, ureteral stenosis, exacerbation of pyelonephritis. Good functional and cosmetic results allow us to recommend this minimally invasive method of surgery for the treatment of obstructive megaureter in children.

Clinical example

Patient U., 1 year old, was admitted to the hospital with a diagnosis of obstructive megaureter on the left. Expansion of the pelvis up to 48 × 38 mm, calyx up to 18-23 mm, the ureter expanded to 23 mm throughout. But according to the radiography of statics, a decrease in the function of the left kidney by 40% (Fig. 9 a, b).

06/26/2018 an operation was performed according to the proposed method, under intubation anesthesia in the position of the patient on his back with a roller under the buttocks.

The operation began with the installation of a urethral catheter. Tight filling of the bladder with warm saline. A catheter was removed and a cystoscope was inserted. Under the control of the cystoscope, in the middle of the distance between the pubic bones and the navel, two parallel sutures (Vicryl 1) were placed to fix the bladder to the anterior abdominal wall. Similar paired sutures were placed in the iliac regions on the right and left. Then, trocars were introduced between the seams through the puncture. At first, the workers (3 mm) were in the iliac regions and fixed the trocars to the skin and previously applied ligatures with interrupted sutures. Then between the ligatures a 5 mm trocar for optics was installed, the latter was fixed to the previously applied sutures. The bladder was emptied and filled with carbon dioxide (pressure 10 atm). One nodal unstretched suture was used on the area of the narrowed mouth of the obstructive megaureter, which was used as a ligature holder (4/0 vikril). A coagulator (in the form of a hook) was used to isolate the mouth of the narrowed ureter with a fringing incision, sequentially mobilizing and drawing the ureter into the bladder for 7 cm. To isolate the ureter, a coagulation hook was used throughout which the adhesions were dissected, with preliminary hemostasis of the tissues. To perform ureteral dressing, a Tahuoka needle (with a curved end) was inserted into the lumen of the bladder in the neck region in which a ligature was performed (4/0 prolene). The needle and the adjacent ligature created a loop into which the end of the mobilized ureter was laid. Pulling out the Tahuoka needle and ligature, the loop was tightened, and the ureter inside the bladder stretched along its entire length. On the expanded ureter in the area of its exit from the bladder, its maximally proximal part, a ureter was curved (tiling - creating a longitudinal fold) along the width of the nodal suture (Vicryl 4/0), then further continuous dressing continued for 6 cm to the distal ureter. Further, in the maximally inward position, the ureter was fixed with a nodal suture to the wall of the bladder (Vicryl 4/10), which made it possible to prevent the ureter from sliding into the cystic space. Then a submucosal tunnel was formed in a horizontal position above the mouth of the contralateral ureter, for this purpose, the Mosquito clip and 3 mm scissors exfoliated the mucous membrane of the bladder from the muscle layer for 5 cm. Then, an incision was made over the mouth of the opposite ureter and, on the other hand, the created submucous tunnel was expanded, into which the isolated ureter was laid. Further, the distal ureter was fixed to the wall of the bladder in a new place. Then, the ureteral orifice was resected within the healthy tissue, excising the narrowed dysplastic wall of the vicious ureter (biopsy). The mouth was formed by a continuous suture (Vicryl 5/0), comparing the mucous membrane of the ureter and the bladder. The ureter was drained by an external stent, which was inserted into the ureter to the pelvis through a conductor inserted into the bladder using a puncture needle. The stent channel was previously expanded with a dilator. The stent was fixed externally to the skin with a nodal suture 4,0 Vicryl. A defect in the muscles of the bladder was sutured with a nodal suture 4,0 Vicryl, the mucosa was sutured with a continuous suture 5,0 Vicryl. The operation was completed by the installation of a urethral catheter. The trocars were removed and a pressure bandage was applied to the anterior abdominal wall. The holes on the skin were pulled together with plaster seams.

The postoperative period was uneventful. The urethral catheter was removed 4 days after surgery, the child was discharged home with an external urethral stent. The latter was removed 1 month after surgery. On the control ultrasound, 2 months after surgery, there was a positive trend, the size of the pelvis, calyx and ureter decreased, urine tests were normal, with prolonged therapy using uroseptics (furagin 1 \ 3 t × 3 times). With the control ultrasound after 1 year, the pelvis of the left kidney is 29 × 21 mm, the calyx is 14-18 mm, the ureter is up to 8 mm. Positive dynamics and reduction in the size of the pyelocaliceal system and ureter are noted. The result of the operation is recognized as good.

A good result is achieved due to the fact that in the proposed method, mobilization of the ureter and fixing it inside the bladder with a ligature allowed the ureter to be narrowed and create a more reliable antireflux mechanism in the submucosal layer of the ureter using modern minimally invasive high-tech pneumo-vesicoscopic access through urinary punctures in the urinary bladder. This method of modeling the ureter throughout the bladder helps prevent the occurrence of vesicoureteral reflux, as the most common complication of ureteral reimplantation in children with obstructive megaureter.

Using the invention allows to obtain the following technical and therapeutic result:

- a wide ureter with a megaureter that requires dressing during reimplantation with pneumovesicoscopic access is not removed from the bladder to perform modeling (dressing);

- modeling is performed on a ureter mobilized (elongated in length), the ureter is mobilized without flashing it, only by pulling the loop inserted into the bubble on the Tahuoka needle;

- narrowing, modeling of the ureter inside the bladder, allows to reduce its width and thereby create a submucous tunnel of sufficient length to provide a reliable antireflux mechanism;

- the use of pneumo-vesicoscopic (intravesical) access for reimplantation of the ureter can reduce the risk of postoperative bleeding, reduce surgical trauma, since the operation is carried out through pin punctures, instead of a wide section of the bladder wall, minimally invasive access reduces the stay in the clinic and provides an excellent functional and cosmetic result.

Claims (1)

A method for endovideosurgical modeling of the ureter during pneumo-vesioxic reimplantation in children with a megaureter, which includes minimally invasive access through punctures in the bladder, intravesical mobilization of the ureter for 6 cm and its reimplantation into the bladder with preliminary modeling, characterized in that they re-establish the implantation the ureteral region with an obstructive megaureter, tighten the ligature with a clamp and coagulate with a coagulation hook, secrete the ureter with sequential coagulation of the vessels for 7 cm and begin modeling the ureter, for this, a needle with a bend at the end is inserted into the bladder neck, and the lumen of the needle and the outside leave a ligature of monofilament material and the end of the selected ureter is laid in the created loop of the ligature, after which the ligature is pulled up and the ureter is fixed throughout, further ureter modeling is performed using a rivulent 4/0 vicryl suture, reducing its diameter by half over 6 cm, and the ureter is inserted into the proximal section as far as possible from the paravesical space into the bladder, connecting it with the wall of the bladder in the dissection area, then a submucosal tunnel 5 cm long is formed in a horizontal direction above the contralateral orifice, the extracted ureter is carried out in the submucosal tunnel and the ureter mouth is resected, removing dysplastic tissues of the narrowed segment, after which the ureter is additionally fixed with a nodular suture to the bladder wall in the area of formation of the new ureter orifice, Further, the mucous membrane of the ureter and bladder is connected with a continuous suture, and the ureter and kidney are drained with an external J stent, which is inserted along the string inserted into the bladder through an additional puncture in the wall with a puncture needle, a bladder wound in the area of the allocated ear orifice they are sutured with a nodal suture, the bladder mucosa is sutured with a continuous suture, the operation is completed by the installation of an urethral catheter and trocar extraction.

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