RU2775881C2 - Method for kidney resection in situ in child under conditions of cold perfusion in nephroblastoma - Google Patents

Abstract

FIELD: medicine; pediatric urology; oncology.

SUBSTANCE: kidney is isolated, renal artery and vein, and abdominal aorta in the projection of the mouth of the renal artery are mobilized. At the same time, renal vessels are hung out on turnstiles, a pouch suture is applied to the aorta. Puncture catheterization with 16G port is performed in the center of the pouch suture with subsequent passage of a catheter to the renal artery. A vascular clamp is applied to a distal part of the renal vein. The renal vein is cut by 3 mm laterally to the applied vascular clamp. The kidney is covered with sterile ice. A cooled Custodiol solution is injected to the kidney through the catheter, kidney perfusion is carried out during 10 minutes, and then, a kidney resection stage is carried out. Through access to the pelvis, a ureteral stent is installed, the kidney parenchyma is sutured, and the hemostasis is performed. Ice is extracted, the vein is sutured in a transverse direction Prolen 6.0. The vascular clamp is taken off the retinal vein, the turnstile applied to the retinal artery is extracted. Blood flow is resumed, after which the catheter is extracted from the aorta, a cannula hole in the aorta is sutured with a pouch suture, and the wound is sutured layer by layer.

EFFECT: proposed method allows for provision of required conditions of cold perfusion in the surgical removal of tumor of left or right kidney with the minimal risk of development of postoperative complications, as well as for achievement of good direct and indirect results of the surgical treatment.

1 cl, 13 dwg, 1 ex

Description

SUBSTANCE: invention relates to medicine, in particular to pediatric urology and oncology, and can be used for anti-ischemic protection during organ-preserving treatment of the left or right kidney when it is temporarily switched off from the bloodstream during its resection.

A known method of anti-ischemic protection of the kidney when it is temporarily turned off from the bloodstream during surgical treatment. Cold protection of the kidneys consists in perfusion of solutions cooled to +4°C through the renal artery and placing ice over the kidney (Matveev V.B., Perlin D.V., Figurin K.M., Volkova M.I. Organ-preserving treatment of kidney cancer. Practical Oncology, 2005, No. 3, pp. 162-166).

However, the method is laborious and the whole body is cooled, and not just the kidneys.

A known method of anti-ischemic protection of the kidney using perftoran or other blood-substituting solutions (Mager V.O. Improvement of organ-preserving surgical treatment of kidney cancer with the use of perftoran for anti-ischemic protection: abstract of dissertation of Candidate of Medical Sciences / Ufa., 2008. - p. thirty).

However, this method used chilled perftoran up to +4°C, which constantly enters the general circulation, which limits the time for surgical intervention and increases the risk of volemic complications. In addition, perfusion is carried out through the opened lumen in the renal artery, which creates the risk of stenosis of the latter after suturing the defect.

A known method of extracorporeal resection of the kidney with its subsequent autotransplantation (Matveev B.P. Clinical oncourology. - M., 2011). The kidney is cut off from the vessels, it is perfused with a cardioplegic solution outside the body, and then transplanted to the external iliac vessels.

This method is laborious, and its main disadvantage is damage to the renal vessels and, as a result, a high risk of their thrombosis during autotransplantation.

A known method of anti-ischemic protection of the kidney during its temporary shutdown from the bloodstream during the surgical treatment of kidney diseases (Komyakov B.K., Shlomin V.V., Guliyev B.G., Zamyatnin S.A., Tovstukha D.V., Nechaev I. .I. Kidney resection for cancer in conditions of its prolonged cold ischemia // Medical Bulletin of Bashkortostan. - 2013. - V. 8, No. 2. - P. 302-304). Isolated perfusion of the kidney with a cardioplegic solution is performed.

However, when performing this method, a high risk of damage to the renal artery and vein is created due to the opening of their lumen and the need for subsequent suturing of vascular defects.

A known method of kidney resection under conditions of perfusion with a cooled solution "Eurocollins". The renal artery is clamped, its lumen is opened, and the kidney is perfused with a cooled Eurocollins solution (Sukonko O.G., Pilotovich B.C., Kushnirenko P.S., Rolevich A.I., Zhegalik A.G., Yushko D.E. Resection single kidney with isolated perfusion with a chilled Eurocollins solution // Oncourology, No. 1, 2006, pp. 57-60).

However, there is a high risk of damage to the renal artery due to the opening of its lumen, and the perfusion of the kidney isolated from other organs is not performed, since the outflow of the solution is carried out into the common venous bed.

A known method of anti-ischemic protection of the kidney when it is temporarily turned off from the bloodstream during the surgical treatment of its diseases. Perform lumbar laparotomy. The right kidney is gradually isolated, the renal artery and vein are mobilized. The renal artery is clamped at the base, that is, at the place where it originates from the aorta. Then the lumen of the renal artery is opened and the first cannula is inserted into it. According to the installed cannula, the right kidney is perfused with saline cooled to +4°C through the cannulated renal artery. Then open the lumen of the renal vein, cannulate it. Subsequent isolated perfusion of the organ is carried out with a cardioplegic solution, while the outflow of the solution is carried out through the cannula from the renal vein [Komyakov B.K., Shlomin V.V., Guliyev B.G., Zamyatnin S.A., Tovstukha D.V., Nechaev I.I. Kidney resection for cancer in conditions of its prolonged cold ischemia // Medical Bulletin of Bashkortostan. - 2013. - V. 8, No. 2. - S. 302-304].

However, when opening the lumen of the renal artery, there is a risk of its narrowing and obliteration after suturing the defect and, as a result, the risk of loss of organ function, and when opening the lumen of the renal vein, there is a risk of its narrowing and obliteration after suturing the defect. Cannulation of the renal vein also increases the risk of rupture.

The closest (prototype) to the claimed invention is a method of anti-ischemic protection of the left kidney during its temporary shutdown from the bloodstream during surgery (EN 2595060 C1). Allocate the left kidney. The left renal artery and vein are mobilized, as well as the testicular/ovarian vein and the abdominal aorta in the projection of the mouth of the left renal artery. Marginal pressing of the aorta is performed at the place where the left renal artery originates from it, the aortic lumen is opened, and the left renal artery is cannulated through it. The left kidney is perfused until it is completely washed away from the blood with a cardioplegic solution into the left renal artery cannulated through the aorta. Then, the left renal vein is clamped and the left testicular/ovarian vein extending from it is cannulated. After that, isolated perfusion of the left kidney is carried out through the cannulated left renal artery with a cardioplegic solution. EFFECT: method makes it possible to provide the possibility of long-term intracorporeal disconnection of the left kidney from the main blood flow during surgical interventions on it.

However, in the known method, access to the aorta is carried out using marginal pressing at the place where the left renal artery departs from it and was used in an adult patient of 59 years old, therefore this method cannot be used in children, due to the small diameter of the aorta, since the diameter of the abdominal aorta in children is about 1 cm, and the diameter of the abdominal aorta in adults is about 3 cm. In addition, when accessing the aorta during its squeezing, the aorta is dissected, which in turn increases the risk of uncontrolled bleeding. When access is made using aortic dissection in case of atherosclerotic lesions, the risk of damage to the intima in the region of the renal artery mouth also increases. And this method is limited to use only for tumors of the left kidney, and in some cases the tumor develops in the right kidney, or is located in a single kidney, in connection with this, the use of the nearest prototype is impossible in children.

The objective of the proposed technical solution is to reduce the risk of postoperative complications in children after removal of a tumor of the left or right kidney, as well as with a tumor of the only kidney that develops with prolonged disconnection from the blood flow of the left or right kidney from the main blood flow.

This problem is solved by the fact that in the same way as in the known method allocate the kidney, mobilize the renal artery and vein and the abdominal aorta in the projection of the mouth of the renal artery.

A feature of the proposed method is that the renal vessels are hung on tourniquets, a purse-string suture is applied to the aorta, puncture catheterization with a 16G port is performed in the center of the purse-string suture, followed by passing the catheter into the renal artery, a vascular clamp is applied to the distal part of the renal vein, lateral to the superimposed vascular clamp a 3 mm renal vein incision is made, the kidney is covered with sterile ice, a cooled Custodiol solution is injected into the kidney through the catheter, the kidney is perfused for 10 minutes, and then the kidney resection step is performed: a ureteral stent is installed through the access in the pelvis, the kidney parenchyma is sutured, and hemostasis, ice is removed, the vein is sutured in the transverse direction with Prolen 6.0, the vascular clamp is removed from the renal vein, the tourniquet applied to the renal artery is removed, blood flow is resumed, after which the catheter is removed from the aorta, the cannulated opening in the aorta is sutured with a purse-string suture, and the next step is performed. suturing the wound.

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

Fig. 1 - Schematic location of the tumor: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 5 - tumor, 6 - renal vein.

Fig. 2 - scheme of applying a purse-string suture to the aorta: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 5 - tumor, 6 - renal vein, 7 - purse-string suture on the aorta.

Fig. 3 - aortic catheterization scheme, with catheter insertion into the renal artery: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 5 - tumor, 6 - renal vein, 7 - purse-string suture on the aorta, 8 - holder, 9 - catheter.

Fig. 4 - scheme: application of a vascular clamp to the renal vein; section of the renal vein: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 5 - tumor, 6 - renal vein, 7 - purse-string suture on the aorta, 8 - holder, 9 - catheter, 10 vascular clamp , 11 – section on the renal vein.

Fig. 5 - kidney perfusion scheme: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 5 - tumor, 6 - renal vein, 7 - purse-string suture on the aorta, 8 - holder, 9 - catheter, 10 vascular clamp, 11 - incision on the renal vein, 12 - aspirator for fluid evacuation (the arrow indicates the direction of fluid flow), 13 - ice.

Fig. 6 - scheme of the resection stage; removal of a kidney tumor: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 5 - tumor, 6 - renal vein, 7 - purse-string suture on the aorta, 8 - holder, 9 - catheter, 10 vascular clamp , 11 - incision on the renal vein, 12 - aspirator for fluid evacuation (arrow indicates the direction of fluid flow), 13 - ice, 14 - post-resection surface.

Fig. 7 - scheme for suturing the defect of the kidney, vein, aorta: 1 - inferior vena cava, 2 - aorta, 3 - renal artery, 4 - kidney, 6 - renal vein, 7 - purse-string suture on the aorta (sutured), 11 - incision on the renal vein (sutured), 14 - post-resection surface (sutured), 15 - suture material.

Fig. 8 - Computed tomography: a) tumor of the upper pole of the left kidney; b) tumor of the lower pole of the left kidney.

Fig. 9 - Preparatory stage for resection of the left kidney; cannulation of the left renal artery: the region of the tumor of the upper pole of the kidney is highlighted in purple; the region of the lower pole of the kidney is highlighted in yellow.

Fig. 10 - Preparatory stage for resection of the left kidney; the kidney is covered with ice (the area is highlighted in blue). The introduction of a cooled solution of Custadiol through the catheter.

Fig. 11 - Resection stage: removal of the tumor of the upper pole of the left kidney (the area is highlighted in purple).

Fig. 12 - Resection stage: removal of the tumor of the lower pole of the left kidney (the area is highlighted in yellow).

Fig. 13 - The resection stage is completed; the final view of the resected left kidney (the area is highlighted in green).

The method of kidney resection in situ in a child under conditions of cold perfusion in nephroblastoma (Fig. 1) is performed as follows.

Perform median relaparotomy, mobilize the left half of the transverse colon, mobilize the kidney.

The renal vessels are hung on tourniquets, a purse-string suture is applied to the aorta (Fig. 2). In the center of the purse-string suture, puncture catheterization is performed with a 16G port, followed by a catheter (cannula) into the renal artery (Fig. 3).

A vascular clamp is applied to the distal part of the renal vein. Lateral to the superimposed vascular clamp, a 3 mm renal vein incision is performed (Figure 4).

The kidney is covered with sterile ice. A cooled Custodiol solution is injected into the kidney through a catheter. The kidney is perfused for 10 minutes. Simultaneously perform aspiration of fluid from the operating field (Figure 5).

After the perfusion is completed, the tumor is removed within healthy tissue (Fig. 6). The kidney parenchyma is sutured, hemostasis is performed, ice is removed, the vein is sutured in the transverse direction. The vascular clamp is removed from the renal vein. The imposed tourniquet on the renal artery is removed, blood flow is resumed. The catheter is removed from the aorta, after which the cannulated opening in the aorta is sutured with a purse-string suture (Fig. 7).

Clinical example

Patient R., 2 years old. Clinical diagnosis: Bilateral nephroblastoma, metanephric adenoma of the left kidney, localized form. Clinical stage V. Therapy according to the SIOP UMBRELLA 2016 protocol for preoperative PCT (2 lines), surgery (dated 03/16/2020 - median laparotomy, resection of the right kidney R1, biopsy of the paracaval lymph nodes. Right: local stage 1, low-risk histological group. Condition after trukat -biopsy of the left kidney dated 04/01/2020 Condition after implantation of the venous port system and 10 courses of chemotherapy Condition after median relaparotomy Resection of the left kidney against the background of pharmaco-cold ischemia, paraortal lymphadenectomy dated 02/18/2021

The patient's medical history is from September 2019, when, according to CT data, a solid multilocular tumor of both kidneys was diagnosed - nephroblastoma of considerable size with a pronounced mass effect, a small volume of residual renal parenchyma, and a decrease in kidney function. On September 19, 2019, PCT was started - 5 weeks of AV were performed according to the UMBRELLA SIOP 2016 protocol. According to CT data from 10/23/2019. There is a negative CT dynamics from 09/18/19. by increasing the total volume of tumor formations in both kidneys; positive dynamics due to a decrease in the tumor formation of the upper pole of the right kidney. Further PCT was performed according to scheme 2 of the Etoposide/Carboplatin line according to the SIOP 2016 protocol, 5 courses were conducted. A partial effect has been achieved.

According to the control CT examination in the projection of the renal parenchyma, two solid tumor neoplasms with dimensions of 29×30 mm and 25×21 mm remain (Fig. 8).

The patient underwent removal of tumor nodes of the left kidney against the background of pharmaco-cold ischemia.

A median relaparotomy was performed. In the left lateral canal, a tumor-altered left kidney was determined. The left lateral canal was opened and the splenic angle of the colon was mobilized. The left kidney with tumor nodes was sharply isolated from the surrounding tissues. A detailed revision of the left kidney revealed 2 tumor nodes: the 1st in the projection of the upper pole along the lateral surface up to 3 cm along the length of the oval shape with predominantly extrarenal growth; The 2nd node totally replaces the lower sections of the left kidney with intraparenchymal spread to the middle segment. The renal vein and artery were identified and traced. Performed paraaortic lymphadenectomy l / y. The aorta was isolated and traced from the bifurcation to the level of the renal arteries, and a decision was made to perform a resection of the left kidney against the background of pharmaco-cold ischemia. A purse-string suture was placed on the aorta at the level of the origin of the renal arteries, followed by cannulation of the left renal artery. Next, a 16G catheter was inserted into the left renal artery. A vascular clamp was applied to the left renal vein (Fig. 9).

A 3 mm incision was made in the left renal vein distal to the vascular clamp. The kidney is covered with sterile ice. Chilled Custodiol was introduced into the kidney through the catheter (Fig. 10). Within healthy tissues, the tumor of the upper pole of the left kidney was removed (Fig. 11) and the tumor of the lower pole of the left kidney was removed (Fig. 12).

There was an opening of the PCS in the area of the middle segment. A ureteral stent was placed. Closure of the CHLS. Hemostasis. In the region of the upper and lower poles, a "Lip" was formed with a U-shaped suture with Vicryl 3.0 thread (Fig. 13). The catheter was removed from the renal artery and the defect of the left renal vein was sutured with Polyglycolide 6.0 thread. The aortic defect is sutured. Restored blood flow in the left kidney. Performed hemostasis by coagulation and stitching. The left lateral canal was drained with a plastic tube brought out through the counter-opening. The operation was completed by layer-by-layer suturing of the wound.

The patient was routinely discharged in a satisfactory condition on the 10th day after the operation.

The proposed method allows to provide the necessary conditions for cold perfusion during surgical removal of a tumor of the left or right kidney with a minimal risk of postoperative complications, as well as to achieve good immediate and long-term results of surgical treatment.

Claims (1)

A method for resection of the left kidney in situ in a child under conditions of cold perfusion in nephroblastoma, including the isolation of the kidney, the mobilization of the renal artery and vein and the abdominal aorta in the projection of the mouth of the renal artery, characterized in that the renal vessels are hung on tourniquets, a purse-string suture is applied to the aorta, in the center of the purse-string suture, a puncture catheterization is performed with a 16G port, followed by passing the catheter into the renal artery, a vascular clamp is applied to the distal part of the renal vein, a 3 mm incision of the renal vein is performed lateral to the applied vascular clamp, the kidney is covered with sterile ice, a cooled solution is injected into the kidney through the catheter Custodiol, the kidney is perfused for 10 minutes, and then the kidney resection is performed: a ureteral stent is installed through the access in the pelvis, the kidney parenchyma is sutured, hemostasis is performed, the ice is removed, the vein is sutured in the transverse direction with Prolen 6.0, the vascular clamp is removed from the renal vein , on the the tourniquet placed on the renal artery is removed, blood flow is resumed, after which the catheter is removed from the aorta, the cannulated opening in the aorta is sutured with a purse-string suture, and the wound is sutured in layers.

Images