RU2734510C2 - Method for surgical treatment of extended strictures or obliteration of pelvic ureter - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to urology. Under the endotracheal narcosis, pneumoperitoneum is created and 4-5 trocars are installed. Parietal peritoneum is opened above the ureter. Stricture or obliteration zone and a healthy part of the ureter are separated by 1–2 cm above the stricture or obliteration; a ureter crosswise is transected, a bladder is mobilized, and flap 2–4 cm wide and 10–12 cm long is cut out from its anteriolateral wall. Flap is sutured into the tube with interrupted sutures of vicryl 3.0, ends of ureter and formed tube connect "end-to-end" on inner stent using antireflux protection. If the width of the ureter is more than 2 cm, a complete papilla is created; if the width of the ureter is less than 2 cm, then half-papilla is created as in fig. 3.

EFFECT: method enables effective and safe treatment of long strictures or obliteration of pelvic ureter with using laparoscopic technique, in which it is impossible to perform ureterocystoanastomosis due to the presence of a large defect between the bladder and ureter, and reduces the length of recovery of operability and reduced medical and economic costs of treatment.

1 cl, 1 ex, 5 dwg

Description

The invention relates to medicine, in particular to urology, namely to the surgical treatment of extended strictures / obliterations of the pelvic ureter, in which it is impossible to perform ureterocystoanastomosis due to the presence of a large defect between the ureter and the bladder.

At present, with extended strictures / obliterations of the pelvic ureter, in which it is impossible to perform ureterocystoanastomosis, the standard of treatment is pulling the bladder to the psoas muscle, and if ineffective, performing Boari operation (reconstruction of the ureter with a bladder flap). A relative contraindication to Boari surgery is a small bladder volume, especially in neurogenic dysfunction. There are other alternative treatments for these types of strictures. We are talking about bringing down the kidney, kidney autotransplantation, as well as various options for intestinal ureteral plastic surgery using the appendix, cecum, etc. However, these methods are not widely used in practice, since they are difficult to perform and are associated with a large number of postoperative complications.

Reconstruction of the ureter with a bladder flap was first performed in ureteral-vaginal fistulas, it was performed by N.F. Ockerbladt (1936) and G. Caughlan (1942). In 1953 A.P. Frumkin successfully applied this operation for bilateral ureteral-vaginal fistulas. Before them, only G. Nystom in 1918 used this method to restore the passage of urine, disturbed by a tumor of the female genitals. Boari's operation was little known, although the ingenious idea to create a "bridge" between the ureter and the bladder belongs to W. Van Hook (1893) and A. Boari (1894). By the decision of the International Terminology Commission, it was named after the Italian surgeon A. Boari.

This operation entered clinical practice only at the beginning of the second half of the 20th century. First, the bladder is mobilized and a flap is cut out of its anterolateral wall. The apex width of the flap should be 2 cm or 3 times the diameter of the ureter to avoid compression of the ureter in the tube formed from the flap. The width of the flap at the base is not less than 4 cm. The ratio of the width and length of the flap should be 2: 3. The flap is placed transversely; if it is necessary to compensate for a significant length of the ureter, an oblique or S-shaped incision is made in the bladder wall. Then the flap is sutured into the tube with interrupted sutures. After that, the ends of the ureter and the formed tube are connected end-to-end or by invagination (antireflux protection) on the internal stent.

For the formation of a submucosal tunnel of sufficient length, it is necessary that the bladder flap and the ureter lie on top of each other at least 3 cm.If this is not achieved, the ureter is additionally mobilized, preserving its adventitia, in which the blood vessels from the renal pelvis pass. If the length of the ureter is insufficient, the tunnel is not formed and the end of the ureter is sutured to the edge of the bladder flap. If the length of the ureter is not enough for this, the kidney is mobilized inside Gerota's fascia and moved 4-5 cm down. In all cases, tension on the ureter should be avoided. As a rule, the results of this operation are quite satisfactory, however, open surgery lengthens the rehabilitation period and increases the cost of treating such patients.

With the development of laparoscopic surgery, the direction of laparoscopic operations to restore the integrity of the ureter is developing. The history of laparoscopic access in performing this operation began in 2001, when Fugita O.E. presented the first experience of three operations. Castillo O.A. and colleagues published in 2005 in The Journal of Urology, a report on eight performed operations. In 2007, Rassweiler J.J. with colleagues published in European Urology a report on 4 operated patients.

However, the main disadvantage of the laparoscopic technique in Boari surgery is the difficulty in performing antireflux protection. Therefore, most often, surgeons impose an end-to-end anastomosis between the ureter and the bladder, which directly impairs the clinical efficacy of surgery due to clinically significant reflux (pain in the lumbar region during urination), which can result in decreased renal function.

The technical result of the proposed invention is the development of an effective and safe method for the treatment of extended strictures (obliterations) of the pelvic ureter using laparoscopic techniques, in which it is impossible to perform ureterocystoanastomosis due to the presence of a large defect between the ureter and the bladder, which will shorten the recovery time and reduce medical -economic costs of treatment.

The indicated technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, the reconstruction of the ureter with a bladder flap is performed (Boari's operation).

A feature of the proposed method is that pneumoperitoneum is created under endotracheal anesthesia and 4-5 trocars are installed, the parietal peritoneum is opened over the ureter, the area of stricture (obliteration) and the healthy part of the ureter is isolated 1-2 cm above the stricture, the ureter is transversely crossed, the bladder is mobilized and a flap 2-4 cm wide and 10-12 cm long is cut out from its anterolateral wall, the flap is sutured into a tube with interrupted sutures vicryl 3.0, the ends of the ureter and the formed tube are connected “end-to-end” on the internal stent using antireflux protection , if the width of the ureter is more than 2 cm, then create a full papilla, if the width of the ureter is less than 2 cm, then create a half-papilla.

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

FIG. 1 - a) scheme of trocar placement; b) installed trocars.

FIG. 2 is a diagram of cutting out a flap from the bladder.

FIG. 3 - a) scheme of complete and b) incomplete papilla.

FIG. 4 - computed tomography of the kidneys with intravenous contrast before surgery: a) hydroureteronephrosis on the right (enlarged pelvis); b) hydroureteronephrosis on the right (dilated ureter).

FIG. 5 - computed tomography of the kidneys with intravenous contrast enhancement 9 months after the operation: a) the ureter in the middle third on the right; b) the pelvis and the upper third of the right ureter.

The method is carried out as follows.

With extended strictures (obliterations) of the pelvic ureter, in which it is impossible to perform ureterocystoanastomosis due to the presence of a large defect between the ureter and the bladder, pneumoperitoneum is created under endotracheal anesthesia, 4-5 trocars are installed (Fig. 1). The parietal peritoneum is opened above the ureter, the stricture (obliteration) zone and the healthy part of the ureter are isolated 1-2 cm above the stricture. The ureter is transversely transected. The bladder is mobilized and a flap (2-4 cm wide and 10-12 cm long) is cut out of its anterolateral wall (Fig. 2). The flap is sutured into a tube with interrupted sutures (vicryl 3.0), the ends of the ureter and the formed tube are connected end-to-end on the internal stent using antireflux protection, if the width of the ureter is more than 2 cm, then a full papilla is created if the width of the ureter is less 2 cm, then create a half-papilla (Fig. 3). After 6 weeks, the inner stent is removed.

Clinical example of the proposed method.

Patient F., 29 years old, with a diagnosis of Extended stricture of the pelvic section of the right ureter. Chronic pyelonephritis, remission.

It is known from the anamnesis that in 2017 a panhysterectomy was performed at the place of residence for cervical cancer. In the postoperative period, the patient developed pain in the right lumbar region, hyperthermia up to 37.5 C. With ultrasound of the kidneys - ureterohydronephrosis, which required puncture nephrostomy on the right. Later, an internal stent was installed in a patient with technical difficulties. After removal of the stent (after 1 month), an adequate passage of urine from the right kidney did not recover, which was the reason for the preparation of the patient for surgery.

When examining:

- according to CT of the abdominal cavity and kidneys with excretory urography - the stricture of the pelvic ureter on the right is 2 cm above the common iliac artery on the right, ureterohydronephrosis on the right (pelvis up to 3.8 cm, ureter up to 1 cm) (Fig. 4 a, b) ;

- according to dynamic nephroscintigraphy, the secretory function of the left kidney is satisfactory. There is no purification deficit. The secretory function of the right kidney is reduced. Cleansing deficit 32%;

- according to the data of the cystogram - the bladder of physiological capacity is 250-300 ml.

- according to CT of the abdominal cavity, CT of the lungs, there is no evidence of a relapse of the underlying disease.

The patient was admitted to the Institute of Urology and Interventional Radiology. ON. Lopatkina. The patient underwent a laparoscopic Boari operation on the right with the formation of antireflux protection using a semi-papilla. Under endotracheal anesthesia, a pneumoperitoneum was created and 5 trocars were installed, the parietal peritoneum was opened above the ureter, the stricture (obliteration) zone and the healthy part of the ureter were isolated 2 cm above the stricture, the ureter was transversely crossed, the urinary bladder was mobilized and the anterolateral wall was cut out from its anterolateral wall 3 12 cm long, the flap was sutured into a tube with interrupted sutures vicryl 3.0. The ends of the ureter and the formed tube were connected end-to-end on an internal stent using antireflux protection, the width of the ureter was less than 2 cm, so a half-papilla was created. After 6 weeks, the inner stent was removed.

The insurance drain was removed 3 days after the operation. The patient was discharged on the 5th day. The inner stent was removed 6 weeks after surgery. 9 months after the operation, the patient had no complaints, according to the computed tomography of the kidneys with contrast, the patency of the right ureter was restored (Fig. 5), no stricture, insignificant clinically insignificant pyeloureterectasia on the right was determined. According to dynamic nephroscintigraphy, the secretory function of the left kidney is satisfactory. There is no purification deficit. The secretory function of the left kidney is reduced. Cleansing deficit 29%.

The use of the proposed method in clinical practice made it possible to achieve the following clinical and economic results:

- no stricture 9 months after surgery;

- the terms of rehabilitation have been reduced;

- medical and economic costs have been reduced.

Claims (1)

A method of surgical treatment of extended strictures or obliterations of the pelvic ureter, characterized in that under endotracheal anesthesia, a pneumoperitoneum is created and 4-5 trocars are installed, the parietal peritoneum is opened over the ureter, the stricture zone and the healthy part of the ureter are isolated 1-2 cm above the stricture or obliteration, the ureter is transversely crossed, the bladder is mobilized and a flap 2-4 cm wide and 10-12 cm long is cut out of its anterolateral wall, the flap is sutured into a tube with interrupted sutures vicryl 3.0, the ends of the ureter and the formed tube are connected end-to-end on the internal stent using antireflux protection, if the width of the ureter is more than 2 cm, then create a full papilla, if the width of the ureter is less than 2 cm, then create a half-papilla, as in Fig. 3.

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