RU2770740C1 - Method for endovideosurgical transvesical diverticulectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology. A puncture of the bladder is performed in the area of the dome under ultrasound control, and a trocar with a diameter of 12 mm is installed directly into the bladder cavity. The bladder is then sealed and the bladder cavity is insufflated with CO₂ under a pressure of 12 mm Hg. A videolaparoscope is then inserted into the bladder through the 12 mm trocar, trocars and ports for the working tools are placed in the bladder cavity. A circular layer-by-layer dissection of the bladder wall is performed at a distance of 0.5 cm from the diverticular neck up to the paravesical fat. Traction is then performed beyond the mobilised edge of the diverticular neck, blunt and sharp dissection of the tissues of the paravesical fat is performed along the diverticular wall until complete resection. The walls of the diverticulum bed and the edges of the bladder mucosa are approximated by applying sutures with a v-loc 3-0 thread with a 5/8 needle bend.

EFFECT: method provides a possibility of eliminating intraoperative damage to the internal structures of organs and abdominal tissues, formation of an adhesive process in the abdominal cavity, formation of pre-conditions for excessive surgical stress response, hemodynamic shifts, violations of the ventilation-perfusion ratio, contributing to the improvement in the results of treatment for the patient by reducing the trauma rate of surgical intervention.

2 cl, 6 tbl, 1 ex

Description

The invention relates to the field of medicine, namely to urology, can be used for the surgical treatment of bladder diverticula (DMP), concerns the use of endoscopic intervention techniques.

Patients with infravesical obstruction, often observed in prostatic hyperplasia, bladder neck stenosis and / or urethral strictures, as well as in neurogenic bladder, are at risk of developing false (acquired) diverticula. True (congenital) bladder diverticula are usually solitary, false - multiple [1]. Stones, tumors can be located in the diverticulum; in women, there is a focus of endometriosis [2]. Surgical treatment of bladder diverticulum is carried out in order to combat urinary stasis and infection that does not respond to drug therapy, as well as neoplasms developing in it.

Currently, the main treatment for bladder diverticula is open or laparoscopic diverticulectomy (DE). During these interventions, tissue alteration during access to the object of surgery in the abdominal cavity triggers a number of neuroendocrine, metabolic, and inflammatory reactions, the totality of which is called the surgical stress response (SSR) [3]. Excessive surgical stress response contributes to the development of disorders in the organs and systems of the body (coagulopathy, immunosuppression, cardiorespiratory and intestinal disorders, pain syndrome, etc.), which aggravate the patient's condition during surgery and complicate the course of the postoperative period. Laparoscopic interventions are much less invasive, however, and they involve surgical instrumentation in the abdominal cavity, as well as the obligatory creation of a carboxyperitoneum. The latter circumstance is associated with an increase in pressure in the abdominal cavity, which can cause thrombophlebitis of the veins of the lower extremities, respiratory complications due to a decrease in the excursion of the diaphragm, impaired ventilation of the lower lobes of the lungs, thromboembolic complications due to a decrease in blood flow velocity, violations of the mechanisms of regulation of the heart rhythm. In this case, there is a supersaturation with carbon dioxide and acidification of the deposited blood [4].

In addition to the above, during surgical interventions using open or laparoscopic access during instrument manipulation, it remains possible to injure a large vessel, the wall of a hollow abdominal organ (primarily the colon), which can lead to infectious complications both in the early and late postoperative period [5].

The objective of the invention was to create a DE method that excludes the possibility of developing negative consequences of carboxyperitoneum and surgical actions in the abdominal cavity, which will improve the results of patient treatment by reducing the trauma of surgical intervention, as well as reducing the risk of trauma to hollow organs. At the same time, it ensures the fullest possible effectiveness of treatment. Access through the cavity of the bladder almost completely eliminates the possibility of damage to the main vessels or organs of the abdominal cavity and small pelvis.

The method is carried out as follows: under endotracheal anesthesia in the position of the patient lying on the operating table on his back, after installing the urethral catheter and filling the bladder with a solution of 0.9% sodium chloride, under ultrasound control, the bladder is punctured in the area of the dome and subsequent installation directly into the cavity of the urinary bladder trocar with a diameter of 12 mm for a video laparoscope, then the bladder is emptied through a urethral catheter, the latter is blocked; produce insufflation of the bladder cavity with CO2 at a pressure of 12 mm Hg; then a video laparoscope is inserted into the bladder through a 12 mm trocar, trocars and ports for working instruments are placed in the bladder cavity: one port with a diameter of 5 mm is installed through a skin puncture with a scalpel 3 cm to the right of the main access, focusing on the iliac spine ; the second port with a diameter of 11 mm or 5 mm is placed 3 cm to the left of the main access, focusing on the iliac spine; then a circular layer-by-layer dissection of the bladder wall is performed, departing from the neck of the diverticulum 0.5 cm up to the paravesical tissue; then traction is performed for the mobilized edge of the neck of the diverticulum, blunt and sharp dissection of the tissues of paravesical tissue along the wall of the diverticulum is carried out until it is completely cut off; then they inspect the cavity of the paravesical tissue and carry out hemostasis; the walls of the diverticulum bed and the edges of the bladder mucosa are brought together by suturing with a v-loc 3-0 thread with a 5/8 needle bend; the excised tissue of the diverticulum is removed as a single block in a container through an 11 or 12 mm port, instruments, trocars are removed, sutures are applied in layers and an aseptic bandage is applied to the skin.

The advantages of the proposed method of surgical treatment of bladder diverticula are the absence of risks of possible intra- and postoperative complications of manipulations in the abdominal cavity, small pelvis during open and laparoscopic surgical interventions. At the same time, the described operational manual provides the full maximum effectiveness of the treatment of bladder diverticula.

Currently, the proposed method has no analogues.

Clinical example 1.

Patient B., aged 57, was treated in the urology department of the GBUZ KB named after V.I. Saint Luke from 11/16/2020 to 11/23/20.

Clinical diagnosis: Benign prostatic hyperplasia of the second stage. Condition after transurethral resection of benign prostatic hyperplasia from March 2020

Complications: Chronic urinary retention. Bladder diverticulum.

Concomitant diseases: Ischemic heart disease. Atherosclerotic cardiosclerosis. Hypertensive disease of the III degree, arterial hypertension of the 2nd degree, the risk of cardiovascular complications - 4. Chronic heart failure of the 2nd functional class. Diabetes mellitus type 2, compensated.

Upon admission, he complained of a feeling of incomplete emptying of the bladder. Anamnesis data: Transurethral resection of prostate adenoma dated 03.2020 for prostatic hyperplasia, chronic urinary retention (residual urine volume 350 ml.). Further examined. The volume of the bladder diverticulum is 150 ml when the bladder is filled to a significant urge to urinate 200 ml. The volume of residual urine is 150 ml, mainly due to the diverticulum of the bladder.

The results of the preoperative examination.

I. Clinical blood test (from 11/19/2020)

II. Biochemical blood test (from 11/19/2020)

III. Coagulogram (from 11/19/2020)

IV. General urine analysis

V. Results of instrumental studies

VI. Expert advice

On November 19, 2020, a surgical intervention was performed: endovideosurgical transvesical diverticulectomy. The course of the operation is described above.

Postoperative period: no features. The urethral catheter was removed on the third day. There is a complete preservation of the continent.

Conservative treatment: symptomatic and anti-inflammatory therapy, alpha-blockers, preoperative antibiotic prophylaxis (NaCl 0.9% - 200.0 ml and ceftriaxone - 2.0 intravenous drip once). Compression hosiery of the lower extremities.

Discharged in a satisfactory condition with improvement. Recommended: 1) supervision of a urologist, therapist, neurologist, endocrinologist of a polyclinic at the place of residence; 2) kanefron, 2 tab. 3 times a day for three months; 3) urological collection, 3 times a day for three months.

The method of endovideosurgical transvesical diverticulectomy was applied by us in 12 cases of treatment of bladder diverticula. In each of these cases, no additional instruments or ports were used, all interventions were completed without conversion to traditional open techniques or the standard laparoscopic option, the median duration of the intervention was 88 min (76-108 min), the median volume of blood loss was 65 ml (40- 120 ml), there were no intraoperative complications and no need for blood transfusion. The early postoperative period was uneventful, the duration of drainage of the bladder through a urethral catheter averaged 4 days, the length of stay in the hospital did not exceed 5 days.

Thus, the application of the proposed method in persons with appropriate indications allows to obtain the following technical results:

1) full implementation of all stages of endovideosurgical transvesical diverticulectomy;

2) the maximum safety of the technique implemented by the proposed method to date, compared with the level of safety in open and laparoscopic interventions due to the maximum reduction in surgical trauma and the time of surgical intervention.

The advantages of endovideosurgical transvesical diverticulectomy in relation to the open or laparoscopic technique are associated with the peculiarities of the direct surgical intervention, namely, it provides a normoergic course of inflammatory and immune reactions that have arisen in response to surgical tissue damage, thereby preventing the development of postoperative purulent-septic complications, delayed hyperalgesia and formation of chronic pain syndrome; accelerates the postoperative recovery of the motor function of the gastrointestinal tract, which contributes to an earlier start of enteral nutrition.

The advantage of using a minimally invasive intravesical approach, in addition to minimizing the volume of dissected tissues, is also the absence of carboxyperitoneum and manipulations in the abdominal cavity. Constant intra-abdominal pressure and an intact abdominal cavity exclude intraoperative damage to the internal structures of organs and tissues of the abdominal cavity, the formation of an adhesive process in the abdominal cavity, the formation of prerequisites for an excessive surgical stress response, hemodynamic shifts in the form of changes in peripheral vascular resistance, blood pressure, CVP and MOS, violations of ventilation perfusion ratio and other undesirable consequences of carboxyperitoneum.

In general, in the surgical treatment of bladder diverticula, the use of the proposed method can reduce the likelihood and number of complications, improve the quality of life in the early and late postoperative period.

Conclusion: endovideosurgical transvesical diverticulectomy makes it possible to treat patients with the corresponding pathology of the urinary system with high efficiency and safety.

Information sources

1. Alyaev Yu.G., Glybochko P.V., Pushkar D.Yu. Urology. Russian clinical guidelines. M.: GEOTARMEDIA, 2016 - 496 p.

2. Vlasov P.V., Kotlyarov P.M., Zhuk Yu.N. X-ray diagnostics in urology. Tutorial. M: Vidar-M, 2010 - 95 p.

3. Strashnov V.I., Zabrodin O.N., Mamedov A.D., Strashnov A.V., Koryachkin V.A. Prevention of the consequences of intraoperative stress. - St. Petersburg: ELBI-SPb, 2015 - 160 s: ill.

4. Golubev A.A., Eremeev A.G., Artemov V.V., Artemov V.V., Sitkin S.I., Kononova A.G., Baranova V.A. On the negative effects of carboxyperitoneum //2017. - Access mode: https://efamedica.ru/learning/articles/o_negativnykh_effektakh_karboksiperitoneuma/.

5. Mauro Pacella, Guglielmo Mantica, Massimo Maffezzini, Matteo Justich. Large bladder diverticula: a comparison between laparoscopic excision and endoscopic fulguration. 2018. Scandinavian Journal of Urology 52(2):1-5.

Claims (2)

1. The method of endovideosurgical transvesical diverticulectomy, characterized in that in the position of the patient lying on the operating table on his back, after installing the urethral catheter and filling the bladder with a solution of 0.9% sodium chloride, under ultrasound control, the bladder is punctured in the area of the dome and the subsequent installation directly into the cavity of the bladder a trocar with a diameter of 12 mm for a video laparoscope, then the bladder is emptied through a urethral catheter, the latter is blocked; produce insufflation of the bladder cavity with CO ₂ under a pressure of 12 mm Hg; then a video laparoscope is inserted into the bladder through a 12 mm trocar, trocars and ports for working instruments are placed in the bladder cavity: one port with a diameter of 5 mm is installed through a skin puncture with a scalpel 3 cm to the right of the main access, focusing on the iliac spine; the second port with a diameter of 11 mm or 5 mm is placed 3 cm to the left of the main access, focusing on the iliac spines; then a circular layer-by-layer dissection of the bladder wall is performed, departing from the neck of the diverticulum 0.5 cm up to the paravesical tissue; then traction is performed for the mobilized edge of the neck of the diverticulum, blunt and sharp dissection of the tissues of paravesical tissue along the wall of the diverticulum is carried out until it is completely cut off; then inspect the cavity of the paravesical tissue and carry out hemostasis; the walls of the diverticulum bed and the edges of the bladder mucosa are brought together by suturing with a v-loc 3-0 thread with a 5/8 needle bend; the excised tissue of the diverticulum is removed as a single block in a container through an 11 or 12 mm port, instruments, trocars are removed, sutures are applied in layers and an aseptic bandage is applied to the skin. 2. The method according to p. 1, characterized in that the traction is performed using monopolar or combined ultrasonic energy.