RU2768450C1 - Method for laparoscopic ureteroneocystoanastomosis using a single thread - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology, surgery, nephrology, transplantology. The ureter and bladder are mobilized, the ureter is ligated and transected, and the bladder detruser is incised. At the same time, the formation of ureteroneocystoanastomosis is carried out using a thread with a loop and a needle (V-lock type). To do this, two holding stitches are performed without puncturing the mucosa proximal to the spatulation zone. Then, the mucosa and muscle layer are punctured from the outside to the inside into the lateral angle of the bladder and ureter. After that, the posterior lip of the anastomosis is formed with a muscular-serous continuous suture from the lateral angle to the medial one, where a duplicate stitch is formed to prevent the suture from unraveling. An internal ureteral stent is placed. The anterior lip of the anastomosis is formed with a continuous muscular-serous suture from the medial to the lateral angle, where a duplicate stitch is also performed.

EFFECT: method allows to form a reliable hermetic anastomosis, reduce the operation time, reduce the traumatization of patients, which leads to a decrease in the frequency of intra- and postoperative complications, improves the final result of the operation, accelerates rehabilitation after surgery, reduces the length of the patient's stay in the hospital and reduces the economic costs of stage of the operation.

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Description

The field of technology to which the invention belongs

The invention relates to medicine, namely to urology, surgery, nephrology, transplantation, and can be used in the surgical treatment of patients with ureteral stricture, uretero-vaginal fistula and vesicoureteral reflux.

Hydroureteronephrosis is a disease that occurs as a result of obstruction of the ureter at any level and is characterized by the expansion of the ureter and pyelocaliceal system of the kidney. The lower the narrowing is, the longer the area of the dilated ureter involved in the obstructive process. Hydroureteronephrosis develops as a result of congenital or acquired obstruction of the ureter. The former include congenital strictures, neuromuscular dysplasia of the ureter and anomalies in its location. Acquired strictures, obliterations, and ureteral fistulas are the most common causes of hydroureteronephrosis. They can be divided into post-traumatic, post-operative, post-radiation, post-inflammatory, and those caused by external ureteral obstruction. Postoperative cicatricial narrowing prevails after endoscopic and open operations on the ureter, as well as as a result of its iatrogenic damage during gynecological and surgical interventions (Urology: textbook / B.K. Komyakov. - 2nd ed., Rev. and add. - M.: GEOTAR-Media, 2018. - 177-8 p.).

Violation of the adequate passage of urine along the upper urinary tract is often caused by trauma to the ureter of various origins. Although, according to the literature, trauma to the ureter accounts for only 1-5.7% of injuries to the genitourinary organs, it is this type of injury that is particularly difficult to diagnose and the greatest danger in the speed and frequency of development of serious complications for the health and life of the patient. The high frequency of traumatic injuries of the ureter during obstetric and gynecological interventions is due to the abundance of vascular formations in the pelvic area and the close anatomical relationships of the internal genital organs and urinary tract in women. A significant expansion of surgical activity and an increase in the list of complex interventions on the pelvic organs performed in recent years by laparoscopic access have led to an increase in the number of ureteral injuries. Moreover, the most traumatic are radical operations for malignant neoplasms of the female genital organs, when the complication rate reaches 30%. Unfortunately, in most cases (65-70%) ureter injury is diagnosed in the postoperative period. A frequent complication of ureter injury is the formation of a ureterovaginal fistula in the postoperative period. Uretero-vaginal fistulas are a complex and not fully resolved problem that brings deep physical and moral suffering to the patient. These complications are most relevant in young people. Patients counting on recovery sometimes face more formidable complications than the very reason for the gynecological operation. So, some types of damage to the ureter (pinpoint fistulas, slowly developing stenoses of the ureter) occur with poor symptoms. In the future, symptoms associated with obstructed outflow of urine from the kidney appear, when, even before urine is released from the vagina, the disease manifests itself as an acute inflammatory process in the kidney (obstructive pyelonephritis), or a pain symptom on the side of the lesion without signs of urinary infection. The more time urine has no outlet, the more extensive the urinary infiltrates. Over time, due to the cicatricial wrinkling process in the fistula zone, the outflow of urine from the kidney is disturbed, and the attached infection quickly destroys the renal parenchyma. Exacerbations of pyelonephritis occur with fever, chills and heavy sweat. In the case of such complications, patients need urgent restoration of urine outflow by performing a kidney puncture (percutaneous puncture nephrostomy) (Muslimova S.Z. Iatrogenic injury of the ureter in obstetric and gynecological practice // International Journal of Experimental Education. - 2016. - No. 12-3 . - pp. 340-349).

Thus, the stricture of the lower third of the ureter and ureterovaginal fistula are serious complications leading to kidney block, obstructive pyelonephritis, urosepsis, which require emergency surgery in the form of drainage of the upper urinary tract.

After emergency drainage of the upper urinary tract, all patients are shown to perform a surgical operation - ureteroneocystoanastomosis to restore the normal passage of urine through the urinary tract and get rid of drainage.

The essence of the operation is to isolate the ureter within healthy tissues, expose the bladder wall and perform an anastomosis between the ureter and bladder with stenting.

The result of a successful operation is the restoration of the outflow of urine from the kidney through the ureter to the bladder, which allows the patient to save the patient from previously installed nephrostomy drains, prevent progressive death of the renal parenchyma, chronic infection and, as a consequence, the development of renal failure.

The most important stage of the applied surgical intervention, as follows directly from the name of the operation (ureteroneocystoanastomosis), is the stage of ureteroneocystoanastomosis. For this stage and preparation for it, many modifications have been proposed, but the main point is to stitch the distal end of the ureter to the bladder wall and stent.

The probability of developing complications directly depends on the correctness of the stage of ureteroneocystoanastomosis. In this case, all complications can be divided into three groups: intraoperative, early and late. Let's analyze each of them in detail.

Intraoperative complications are complications that occur directly during the operation. These include bleeding, damage to surrounding vessels and organs, damage to the ureter and bladder wall that occur when they are captured by instruments and as a result of a suture.

Early postoperative complications are complications that occur while the patient is in the hospital. They include bleeding, anastomotic failure with the development of urinary leakage, infection of the wound with purulent complications, urinary fistulas.

Late postoperative complications are complications that occur from the moment the patient is discharged from the hospital. The most formidable complication in this period is the occurrence of stricture in the anastomosis zone, leading to relapse of hydronephrosis, the need for emergency drainage and reoperation.

In case of development of complications, ineffectiveness of the first operation, a relapse of the disease occurs. Reoperation is aggravated by the fact that due to the increasing scarring of tissues, each subsequent operation in a particular area has a worse prognosis for a favorable outcome, gradually fading away after several failures. In some cases, this leads to the forced removal of a normally functioning kidney and the patient's disability.

Considering that, due to the iatrogenic origin of the disease, a significant part of patients belong to the category of young women of the reproductive period, the need for repeated operations, in addition to traumatization, also causes significant cosmetic defects.

At the same time, the likelihood of complications and the risk of stricture recurrence due to ineffective surgery depend directly on the correctness of ureteroneocystoanastomosis suture. Therefore, the seam technique must strictly meet certain requirements. We will analyze each of the requirements separately.

1. The seam must be airtight. This is one of the key conditions that eliminates the risk of urinary leakage. The tightness of the seam implies the absence of through defects between two sewn walls.

2. The seam must be performed without excessive tension of the sewn fabrics throughout. Such tension, as a rule, occurs with an initial large diastasis between the suturing surfaces. With a high tension of the seam sections, it is possible to cut through the wall of the stitched tissues and form through defects, which are subsequently difficult to eliminate.

3. The minimum amount of suture should be used. Despite the use of modern suture materials with various antimicrobial components, the thread that remains in the body is a foreign body, a source of inflammation. And given that patients initially suffer from hydronephrosis and urine is infected, the less suture material remains in the suture line, the less risk of scarring and recurrence of stricture.

4. In the process of applying the seam should not unravel. That is, the thread must have a mechanism that holds the tissue after closing in the desired position. Such properties are possessed by modern threads of the V-lock type.

5. There should not be excessive tightening of the suture, and in the case of a continuous suture, there was no “stranglehold” effect, a situation where, when tightened, the anastomotic opening narrows, which inevitably leads to recurrence of the stricture.

6. The completed anastomosis must be passable and at the same time have anti-reflux protection.

7. Minimal use of suture units to reduce the economic cost of the operation.

8. The stage of ureteroneocystoanastomosis should be performed in a minimally invasive laparoscopic version. With the laparoscopic method, the most favorable conditions for reparative processes are created. The advantages of laparoscopic techniques are low invasiveness, reduction in the duration and severity of hematuria in the postoperative period, early activation of the patient, less need for analgesia, and shortening of inpatient treatment.

Thus, the stage of direct implementation of ureteroneocystoanastomosis must strictly meet certain requirements. Therefore, the use of an effective technique of ureteroneocystoanastomosis, and, in particular, the suture, will speed up the operation, reduce the likelihood of complications and significantly improve the results of the operation.

State of the art

Cohen's operation from intravesical access is known, including the introduction of a catheter into the mouth of the ureter, its fixation with one interrupted suture to the mucous membrane of the bladder. A platform with a diameter of 15-20 mm is cut out around the mouth and the intramural part of the ureter is mobilized (up to 30-50 mm). Parallel to the interureteral fold, a submucosal canal is created bluntly in the transverse direction, through which the mobilized ureter is passed. 6-8 interrupted sutures are applied (catgut, vicryl rapid 5/0-6/0) between the previously isolated bladder mucosa together with the orifice and the mucosa of the newly created orifice located above the contralateral one. The area of the old mouth is sutured. The defect of the muscular and mucous membranes is sutured. The main principle of the operation: the creation of a passive valve due to a long narrow intravesical submucosal canal in the bladder.

This method is applicable for mild dilatation of the ureter, since with significant dilatation, using only intravesical access, it is not possible to model the ureter to the proper length (N.A. Lopatkin, A.G. Pugachev // Vesicoureteral reflux // M. Medicine , 1990, pp. 124-127; N.A. Lopatkin, A.G. Pugachev // Children's urology. Manual // M. Medicine, 1986, pp. 204-205).

The disadvantage of the method: the submucosal canal, in which the mobilized ureter is located, has a length of about 30 mm, and the ureter is fixed in the bladder only between the mouth of the ureter and the mucous membrane of the bladder. The mucous membrane of the bladder is mobile and shifts, there is also a physiological tone and tension of the ureter, and when the bladder is filled, the bladder wall also shifts, the length of the ureter located in the submucosal canal decreases and the formed mouth retracts. The number of fixing sutures 6-8 between the mouth of the ureter and the mucous membrane of the bladder impairs blood microcirculation at the site of the anastomosis. Therefore, a recurrence of vesicoureteral reflux or stenosis of the vesicoureteral anastomosis is possible.

A known method for extravesical reimplantation of the ureter, including the formation of a tunnel, laying the ureter in it and fixing its distal section to the bladder (RF Patent No. 2415649, IPC A61B 17/00, publ. 10.04.2011).

This method is carried out as follows - first, along the midline in the suprapubic part, a trocar puncture cystostomy is performed under ultrasound control with the introduction of a drainage tube-intubator into the cavity of the bladder, the surgical access to the ureter is performed lateral to the usual suprapubic transverse access in the inguinal region, then the ureter is cut off from the urinary bladder, and a perforated part of the tube is removed from the mouth formed in it, a tunnel is formed between the muscular and submucosal layers of the bladder wall from the side of the mouth, a tube is inserted into the ureter so that the drainage side holes are located in the lumen of the transplanted ureter, and the last two holes are located in lumen of the bladder. The narrowed ureter is passed through the tunnel, after which the ureter is fixed to the wall of the bladder, and the mucosa of the ureter is sutured at the base of the oblique cut with two sutures, the rest of the cut of the ureter is placed in the lumen of the bladder and fixed in a stretched position like petals in three different directions.

The disadvantages of this method: 1. There is no possibility of mobilization of the ureter in the proximal direction. 2. The method is performed through an incision in the inguinal region, which is traumatic and lengthens the period of hospitalization. 3. The need for long-term drainage of the bladder and ureter using a drainage tube, cystostomy and urethral catheter creates prerequisites for the development of infectious complications.

A known method of forming extravesical submucosal ureterocystoanastomosis (RF Patent No. 2297801, IPC A61B 17/11, publ. 02.11.2005).

This method is carried out as follows - open the outer case of the bladder, consisting of adventitia and muscle wall, for four diameters of the ureter. Bluntly dissect the case away from the incision. The distal end of the ureter is placed in the formed tunnel. The proximal ureter is fixed to the outer case. Then begin to take in the outer case with the capture of the outer wall of the ureter. A cystotomy incision is made on the inner case for a length corresponding to half the circumference of the ureter. Immerse the ureter into the urinary reservoir so that 1 cm of the ureter remains in the lumen. Finish suturing the outer case. EFFECT: method provides anti-reflux protection of ureterocysto- or uretero-reservoir anastomosis, allows to apply it without wide opening of the urinary reservoir, prevent stenosis of the anastomosis, preserve tissue hemodynamics.

The above method has a number of disadvantages: 1. It is carried out by performing a highly traumatic access, leaving behind a noticeable postoperative scar - lower median laparotomy or transverse suprapubic access. 2. Has the worst healing conditions, because it passes through the suprapubic "fat pad". 3. Limits the possibility of revision, mobilization and narrowing of the ureter throughout its entire length.

A known method is the laparoscopic formation of ureterocystoanastomosis in the transverse direction (Patent RU 2730923 C1, IPC A61B 17/00, publication date 26.08.2020).

A method for laparoscopic formation of ureterocystoanastomosis in the transverse direction, including mobilization of the distal pathological ureter transperitoneally from the level of the iliac vessels to the bladder, ligation of the ureter and cutting it off from the bladder, dissection in the region of the posterior wall of the bladder of the detrusor in the transverse direction at two points throughout to the mucosa membranes with the expansion of the formed holes, the formation of a submucosal tunnel in the transverse direction from one to the other formed holes, moving the ureter into the tunnel, creating a hole on the opposite side of the mucous membrane, installing a stent and applying an anastomosis between the ureter and the mucous membrane of the bladder, suturing the detrusor over the ureter in the place of the formed neostia and fixation of the ureter at the point of entry into the tunnel to the detrusor.

The disadvantages of this method: 1. Detrusor damage in two areas at once. 2. Violation of contractility and damage to the neurovascular bundles passing into the posterior wall of the bladder is possible. 3. High risk of perforation of the bladder mucosa when creating a tunnel. 4. Rigidity of the tunnel due to cicatricial changes in the detrusor after its dissection, which reduces the effectiveness of antireflux protection.

The closest analogue is the method of laparoscopic transverse extravesical reimplantation of the ureter with complete doubling of the upper urinary tract (Patent RU 2710924 C1, IPC A61B 17/92, publ. 14.01.2020).

A method for laparoscopic transverse extravesical reimplantation of the ureter into the bladder with complete duplication of the upper urinary tract, consisting in the fact that the pathological ureter is mobilized in the distal section, followed by the formation of an antireflux tunnel in the transverse direction, for this, the detrusor is cut in the transverse direction to the bladder mucosa , the edges of the detrusor are diluted with a grasper, before reimplantation, an internal drainage stent is installed in the ureter, a hole is created in the place of the supposed fistula in the mucous membrane, into which the distal “curl” of the stent is moved and a ureterocystoanastomosis is formed with separate muco-muscular sutures, after which the ureter is placed in the formed bed and the detrusor is sutured over it with separate interrupted sutures, at the entrance to the tunnel the ureter is fixed to the detrusor with sutures in order to prevent its extravesicalization.

The disadvantages of this method: 1. Damage to the detrusor over a large area (2.5-4 cm) 2. Violation of contractility. 3. Damage to the neurovascular bundles passing into the posterior wall of the bladder, which can lead to neurogenic dysfunction of the bladder. 4. High risk of perforation of the bladder mucosa when creating a bed. 5. Rigidity of the tunnel due to cicatricial changes in the detrusor after its dissection, which reduces the effectiveness of antireflux protection.

The technical problem to be solved is the creation of a method for laparoscopic ureteroneocystoanastomosis using a single thread, devoid of the disadvantages of analogues.

Disclosure of the essence of the claimed invention

The technical results achieved by implementing the created method are:

- performing a reliable hermetic anastomosis,

- reduction of operation time,

- reduction of traumatization of patients,

which generally leads to a decrease in the frequency of intra- and postoperative complications, accelerates rehabilitation after surgery.

The technical result is achieved due to the following set of essential features:

- perform mobilization of the ureter and bladder;

- ligate and cross the ureter;

- dissect the bladder detruser;

- using a thread with a loop and a needle, type V-lock, two holding stitches are applied without puncture of the mucosa proximal to the spatulation zone; for this, an injection is made into the wall of the bladder and ureter, stitching only the muscle layer, then the injection is carried out, forming the first stitch, then the needle with the thread is inserted into the loop on the thread, forming the second holding stitch;

- carry out a puncture of the mucosa and muscle layer from the outside-in to the lateral angle of the bladder and ureter;

- a muscular-serous continuous suture is used to form the posterior lip of the anastomosis from the lateral to the medial angle, where a duplicate stitch is formed to prevent the suture from unraveling;

- install an internal ureteral stent;

- the anterior lip of the anastomosis is formed with a continuous muscular-serous suture from the medial to the lateral angle, where a duplicate stitch is also performed.

Brief description of the drawings

The method of laparoscopic ureteroneocystoanastomosis using a single thread is illustrated by drawings, where:

Fig. 1 is a diagram of the preparatory stage before making a seam. Fig. 2 is a diagram of the first holding stitch. Fig. 3 is a diagram of the second holding stitch. Fig. 4 - diagram of the formation of the posterior lip of the anastomosis. Fig. 5 is a diagram of the completed posterior lip and duplicate stitch at the anastomosis angle, with an internal ureteral stent placed. Fig. 6 - diagram of the formation of the anterior lip of the anastomosis. Fig. 7 is a diagram of the completed anastomosis.

Implementation of the invention

The method of laparoscopic ureteroneocystoanastomosis using a single thread is carried out as follows:

The preparatory stage of the operation is underway. The patient is on the operating table in the supine position with the lowering of the head end of the table under general combined anesthesia with tracheal intubation. The operating field is processed. A pneumoperitoneum is created with a Veress puncture needle, an optical trocar is installed. Under the control of the image on the monitor, three additional 5 mm trocars are inserted.

Next, the bladder 1 is isolated, the ureter 2 is isolated within healthy tissues, and the ligature is applied 3. After that, the ureter 2 is crossed and its distal end is spatulated 4 - dissected longitudinally. In the bladder detruser 1, an opening 5 is created in the transverse direction (Fig. 1).

With the help of thread with a loop and a needle 6 of the V-lock type, the first holding stitch is sewn. To do this, the injection is carried out in the wall of the bladder and ureter proximal to the spatulation zone 4. Moreover, only the muscle layer is stitched without puncturing the mucosa (Fig. 2).

After the needle with the thread is punctured, it is passed into the loop 7 on the thread 6 and a second holding stitch, similar to the first one, is formed (Fig. 3).

Further, the retaining stitches are tightened, an injection is made from the outside-in into the lateral angle 8 in the bladder 1 and ureter 2 with a puncture of the muscular wall and mucous membrane. Further, the posterior lip 9 is formed with a muscular-serous continuous suture from the lateral angle 8 to the medial angle 10 (Fig. 4).

When passing through the medial angle 10, a duplicate stitch 11 is formed to prevent the seam from unraveling, after which the internal ureteral stent 12 is installed (Fig. 5).

Next comes the formation of the anterior lip 13 of the anastomosis with a continuous muscular-serous suture from the medial angle 10 to the lateral angle 8 (Fig. 6).

After completion of the anterior lip 13 of the anastomosis, a duplicate stitch 14 is performed in the lateral corner 8, the thread 6 is cut off - the anastomosis is completed (Fig. 7).

The proposed method of laparoscopic ureteroneocystoanastomosis using a single thread has the following advantages:

- use of one thread with a loop: 1) Significantly speeds up the operation, so there is no need to introduce additional threads with needles and tie knots. 2) Minimizes the amount of remaining suture material in the wound, which promotes better healing and reduces the risk of stricture recurrence;

- formation of two retaining stitches: 1) Allows to reduce the load on the sutures of the anterior and posterior lip of the anastomosis, which prevents the eruption of the sutures and the development of urinary leakage. 2) Facilitate the work of the surgeon when manipulating tissues, thereby increasing atraumaticity and speeding up the operation;

- the use of duplicate stitches in the medial and lateral corner, coupled with the retaining mechanism of the thread itself (notches): 1) prevents the thread from unraveling with the appearance of suture defects during suturing, and especially stenting, which prevents the development of urinary leakage; 2) allows you to perform a uniform tension of the seam, which prevents excessive tissue compression and ischemia with subsequent scarring;

- the use of a duplicate stitch in the medial angle prevents the “noose” effect when the anastomotic opening narrows, which inevitably leads to a recurrence of the stricture;

- the use of a duplicate stitch in the lateral corner allows you not to tie the thread, which reduces the amount of suture material left and speeds up the operation.

The proposed method is illustrated by a clinical example.

Patient O., aged 34, was admitted to the hospital with a diagnosis of stricture of the lower third of the right ureter. The patient has a history of gynecological surgery complicated by iatrogenic injury of the ureter, hydronephrosis on the right, obstructive pyelonephritis, emergency percutaneous puncture nephrostomy. Upon receipt of a complaint about the presence of nephrostomy drainage, periodic episodes of a rise in body temperature up to 37.3C.

The patient underwent laparoscopic ureteroneocystoanastomosis using a single thread. The patient was on the operating table in the supine position with a slight lowering of the head end of the table under general combined anesthesia with tracheal intubation. Processed operating field. A pneumoperitoneum was created with a Veress puncture needle, an optical trocar was installed, three additional 5 mm trocars were introduced under the control of the image on the monitor. Next, the bladder and right ureter were isolated within healthy tissues, ligatures were applied above the level of the stricture. After that, the ureter is crossed and its distal end is spatulated (dissected longitudinally). A hole is created in the bladder detruser in the transverse direction. Using a thread with a V-lock needle, the first holding stitch was made by injecting into the wall of the bladder and ureter proximal to the spatulation zone with flashing only the muscle layer without puncturing the mucosa. After the needle with the thread was punctured, it was passed into the loop at the end of the thread and a second holding stitch, similar to the first one, was formed. Further, the retaining stitches are tightened, an injection is made from the outside-in into the lateral angle in the bladder and ureter with a puncture of the muscular wall and mucous membrane. After that, a muscular-serous continuous suture formed the posterior lip from the lateral angle to the medial angle. During the passage of the medial angle, a duplicate stitch was formed to prevent the suture from unraveling, after which an internal ureteral stent was installed. Further, the anterior lip of the anastomosis was formed with a continuous muscular-serous suture from the medial angle to the lateral angle. After completing the front lip, a duplicate stitch is made in the lateral corner, and the thread is cut. The trocars were removed and skin sutures were performed. Operation completed.

The operation time was 95 minutes, blood loss was 50 ml, intraoperative complications were not detected. The postoperative course was smooth, the wound healed by primary intention, the patient was activated on the 1st day after the operation, and was discharged on the 4th day in a satisfactory condition under the supervision of a urologist at the place of residence. The internal ureteral stent was removed 30 days after surgery. The follow-up examination revealed no recurrence of stricture.

A total of 18 laparoscopic ureteroneocystoanastomoses were performed using a single thread. The duration of operations was 102.2±10.5 minutes. There were no intraoperative complications and no reoperations were required. Postoperative bed-day is 4±2.1 days. No complications were noted in the early postoperative period. At control examinations, all patients showed a good long-term result.

Experimental clinical studies of the proposed method of laparoscopic ureteroneocystoanastomosis using a single thread showed its high efficiency. The proposed method, when used, ensured the implementation of a reliable hermetic anastomosis, reduced the operation time, reduced the traumatization of patients, which reduced the frequency of intra- and postoperative complications, improved the final result of the operation, accelerated rehabilitation after surgery, led to a reduction in the length of the patient's stay in the hospital and reduced economic costs. costs during the operation.

Claims (1)

A method for laparoscopic ureteroneocystoanastomosis using a single thread, including mobilization of the ureter and bladder, ligation and transection of the ureter, dissection of the bladder detruser, stenting, formation of a ureteroneocystoanastomosis, characterized in that when forming an ureteroneocystoanastomosis, a thread with a loop and a needle is used, while two holding stitches are applied proximal spatulation zones, for this, an injection is made into the wall of the bladder and ureter, stitching only the muscle layer, then the injection is carried out, forming the first stitch, then the needle with the thread is inserted into the loop on the thread, forming the second holding stitch; then the mucosa and muscle layer are punctured from the outside-in to the lateral angle of the bladder and ureter, after which the posterior lip of the anastomosis is formed from the lateral to the medial angle with a muscular-serous continuous suture, a duplicate stitch is formed, an internal ureteral stent is installed, the anterior lip of the anastomosis is formed with a continuous muscular - with a serous suture from the medial to the lateral angle, and a duplicate stitch is performed.

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