RU2777237C1 - Method for treatment of urethrorectal fistula - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely proctology. Under endoscopic control, a probe with holes along the perimeter is inserted, on which a layer of porous material is fixed, so as to place the latter in the cavity of the defect while ensuring their tight contact. After that, the probe is connected to an aspiration unit and continuous vacuum drainage is carried out at negative pressure with regular replacement of the probe with a porous material with a gradual reduction in the size of the latter. At the same time, at the preparation stage, a urethral catheter is installed in a patient with a previously diagnosed urethrorectal fistula. Epicystostomy and the imposition of a double-barrel sigmostoma are performed. After that, a rectoromanoscopy is performed with an assessment of the localization, diameter and extent of the urethrorectal fistula. A polyvinyl chloride probe with an internal diameter of 3.3 mm is inserted into the defect cavity, the end of which is centrally immersed in a porous material, as which polyurethane foam is used to fill wounds. The probe with a thread is fixed to the skin of the perianal area, connected to the aspiration unit and continuous vacuum drainage at a negative pressure of 20-40 mm Hg is carried out when replacing the probe with polyurethane foam to fill wounds every 5 days.

EFFECT: method makes it possible during treatment to divert the patient’s biological fluids to exclude their interaction with the edges of the fistula, accelerate the healing of the defect, evaluate the defect parameters and perform endoscopic control, prevent the dislocation of the probe, perform synchronously with the treatment the assessment of its effectiveness in dynamics and gradually reduce the size of the porous material.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, in particular to urology, and can be used to treat urethrorectal fistula.

A known method for the treatment of urethrorectal fistulas, including perineal and intrarectal accesses, dissection of the urethrorectal anastomosis, excision of fistulas of the urethra and rectum, restoration of the integrity of the urethra, characterized in that a skin flap is cut out from the middle of the lower part of the scrotum on a leg from the scrotum septum, it is carried out into the lumen of the rectum intestines through the subcutaneous tunnel, the surgical wound on the perineum and the wound of the rectum are sutured intrarectally to the edges of the wound of the rectal mucosa and sutured on the leg of the flap and the wall of the rectum from the side of the perineal wound (see RF patent No. 2003289, IPC A61B 17/00, date publications 11/30/1993).

Since the known solution involves surgical intervention, the significant disadvantages of such treatment are its high invasiveness, the need for deep anesthesia, the presence of surgical trauma and, as a result, pain.

As the closest analogue, a method for treating defects of the gastrointestinal tract was adopted, including patient preparation, after which, under endoscopic control, a probe with holes around the perimeter is inserted, on which a layer of porous material is fixed, so as to place the latter in the defect cavity while ensuring their tight contact. , after which the probe is connected to the suction unit and continuous vacuum drainage is carried out at negative pressure with regular replacement of the probe with porous material with a gradual decrease in the size of the latter (see https://cyberleninka.ru/article/n/blizhayshie-rezultaty-lecheniya-bolnyh -s-pronikayuschimi-defektami-stenki-pischevoda-method-endoskopicheskogo-vacuumnogo/viewer).

However, the closest analogue is intended only for the treatment of patients with penetrating defects in the esophageal wall.

The task to be solved by the claimed invention is the development of an effective and minimally invasive method for the treatment of urethrorectal fistula.

The technical result, which manifests itself in solving the problem, is expressed in the possibility of treating urethrorectal fistula while ensuring high efficiency.

The problem is solved by the fact that a method for treating a urethrorectal fistula, including patient preparation, after which, under endoscopic control, a probe with holes around the perimeter is inserted, on which a layer of porous material is fixed, so as to place the latter in the defect cavity while ensuring their tight contact, after whereby the probe is connected to an aspiration unit and continuous vacuum drainage is carried out at negative pressure with regular replacement of the probe with a porous material with a gradual decrease in the size of the latter, it differs in that at the preparation stage, a urethral catheter is installed for a patient with a previously diagnosed urethrorectal fistula, an epicystostomy is performed and a double-barreled sigmostoma is applied, after that, sigmoidoscopy is performed with an assessment of the localization, diameter and extent of the urethrorectal fistula, a polyvinyl chloride probe with an inner diameter of 3.3 mm is inserted into the defect cavity, the end of which is centrally immersed in the porous th material, which is used as polyurethane foam for filling wounds, fix the probe with a thread to the skin of the perianal area, connect it to the suction unit and carry out continuous vacuum drainage at a negative pressure of 20-40 mm Hg. Art. when replacing the probe with polyurethane foam for filling wounds every 5 days.

Comparative analysis of the features of the proposed solution with the features of the prototype and analogues indicates the compliance of the proposed solution with the criterion of "novelty".

At the same time, the distinctive features of the formula provide the solution of the following functional tasks.

Signs “at the stage of preparation, a urethral catheter is installed in a patient with a previously diagnosed urethrorectal fistula, an epicystostomy and a double-barreled sigmostoma are performed” allow the patient’s biological fluids to be removed to exclude their interaction with the edges of the fistulous tract.

Signs "carry out sigmoidoscopy with an assessment of the location, diameter and length of the urethrorectal fistula" allow you to evaluate the parameters of the defect and carry out endoscopic control.

The signs “a polyvinyl chloride probe with an inner diameter of 3.3 mm is inserted into the defect cavity, the end of which is centrally immersed in a porous material, which is used as polyurethane foam for filling wounds” describe the characteristics of the probe and porous material.

Signs "fix the probe with a thread to the skin of the perianal region" prevent dislocation of the probe.

Signs “connect [the probe] to an aspiration unit and carry out continuous vacuum drainage at a negative pressure of 20-40 mm Hg. Art. " allow to accelerate the healing of the defect by preventing the contact of biological fluids with the walls of the fistulous tract.

Signs "when replacing the probe with polyurethane foam for filling wounds every 5 days" allow synchronously with the treatment to evaluate its effectiveness in dynamics and gradually reduce the size of the porous material.

Figures 1-6 show the cavity of the urethrorectal fistula without a probe with a porous material from a clinical example during treatment:

Fig.1 - photo from 06/15/2020;

Fig.2 - photo from 06/23/2020;

Fig.3 - photo from 06/26/2020;

Fig.4 - photo from 06/30/2020;

Fig.5 - photo from 07/21/2020.

Fig.6 - photo from 05/18/2021.

Figure 7 shows the stage of fixing the porous material on the probe.

Figure 8 shows the probe with a porous material fixed on it.

The drawings show a probe 1 and polyurethane foam 2 for filling wounds.

The inventive method is carried out on standard equipment.

A patient with a previously diagnosed urethrorectal fistula is placed with a urethral catheter, an epicystostomy and a double-barreled sigmostoma are performed according to the standard technique.

The dimensions (length and width) of the porous material are determined, which is used as polyurethane foam 2 for filling wounds (for example, Suprasorb CNP), depending on the diameter of the urethrorectal fistula, and taking into account ensuring their tight contact, a fragment is cut out along them.

The end of a sterile probe 1 made of polyvinyl chloride with an inner diameter of 3.3 mm, for example 14 Ch, is centrally immersed in a fragment of polyurethane foam 2 to fill wounds about half the length of the latter, stitch them and tie polyurethane foam 2 around the probe 1 with sterile suture material, for example, non-absorbable thread 3/0 (see Fig.8).

Under intravenous sedation on spontaneous breathing, with the patient lying on the left side with knees bent at 45°, sigmoidoscopy is performed using a video colonoscope, during which the fistulous tract is visualized, the localization, diameter and length of the urethrorectal fistula are assessed.

Under endoscopic control, the proximal end of the probe 1 with polyurethane foam 2 attached to it is inserted into the cavity of the urethrorectal fistula to fill the wounds.

The probe 1 is fixed with a thread to the interrupted suture on the skin of the perianal region, the probe 1 is connected to the suction unit and continuous vacuum drainage is performed at a negative pressure of 20-40 mm Hg. Art. when replacing the probe with polyurethane foam for filling wounds every 5 days until the urethrorectal fistula is completely closed.

Clinical example

A 66-year-old man was hospitalized at the Center for Surgery of the FEFU Medical Center from 06/04/2020 to 07/24/2020 with a diagnosis of prostate cancer T2cNoMo stage II.

Preoperative parameters: total blood PSA 14.8 ng/ml, MRI OMT with contrast enhancement - gland volume 72.2 cm3, structural heterogeneity of the peripheral zone of the prostate (not classified according to Pirads2v), transrectal puncture biopsy of the prostate - in 6 samples areas of acinar adenocarcinoma , Gleason 6 points, with low proliferative activity (IHC confirmed).

From the moment of morphological verification to surgery 2 months. No associated somatic pathology was identified. The patient has a history of gastric resection due to peptic ulcer in 1998.

On 06/05/2020, surgery was performed in the scope of laparoscopic retroperitoneoscopic radical prostatectomy, drainage of the abdominal cavity. Damage to the rectal wall up to 0.5 cm was diagnosed intraoperatively, laparoscopic suturing was performed with interrupted sutures with Vicril 3/0 thread. The postoperative period proceeded smoothly, the drainage from the abdominal cavity was removed on 06/09/2020 and 06/10/2020 due to the absence of discharge.

On June 11, 2020, intestinal discharge appeared along the urethral catheter. Objectively: urination through the urethral catheter, light yellow urine with a moderate amount of brown suspension, gas in the urinal, diuresis 1300 ml over the past day. The gases are leaving. The chair on the eve of unformed, once. The dressings are dry, in places where the drains were removed, they were moderately soaked with serous discharge. The scrotum and perineum are moderately edematous, compacted. The urethral catheter was washed with NaCl solution 0.9%, leakage of the washing liquid from the rectum is noted. Given the clinical picture of the urethrorectal fistula, an emergency surgical intervention was performed in the amount of suprapubic cystostomy, drainage of the retroperitoneal space on the right, sigmostomy by extraperitoneal access. Intraoperatively, sigmoidoscopy was performed: along the anterior wall of the rectum, a 5 cm defect up to 2 cm in diameter, through which a defect in the posterior wall of the urethra of the same size is determined, a urethral catheter is visualized, an aspiration probe made of polyvinyl chloride with polyurethane foam is brought to the formed defect to fill the wounds, a system of permanent active aspiration has been established. The postoperative period proceeded smoothly. Replacement of the probe with polyurethane foam for filling wounds was carried out 1 time in 3-7 days.

Dynamics of the endoscopic picture (time count from the moment the drainage system was installed):

06/15/2020 (see figure 1): a cavity up to 20 mm was visualized, covered with granulation tissue and fibrin, which communicates with the bladder cavity and mesorectal tissue, a probe with polyurethane foam was installed in the lumen of the latter to fill the wounds. The polyurethane foam wound filling probe is removed.

06/23/2020 (see figure 2): a cavity up to 20 mm was visualized, made with a contact-vulnerable granulation tissue, the cavity was cleared, communication with the mesorectal space was closed, communication with the bladder cavity was maintained.

06/26/2020 (see figure 3): a cavity up to 10 mm was visualized, made with a contact-vulnerable granulation tissue, the cavity was cleared, communication with the bladder cavity is preserved.

06/30/2020 (see figure 4): a fistulous opening is determined, made with a contact-vulnerable granulation tissue, up to 10 x 7 mm in size, then a cavity with a diameter of up to 15 mm at the border with the bladder wall. In the lumen of the urethrorectal fistula, a polyurethane foam was installed for filling wounds, mounted up to 8 mm in diameter, up to 15 mm long.

07/03/2020: a fistula opening made with a contact-vulnerable granulation tissue, up to 7 mm in size, then a cavity up to 10 mm in size at the border with the bladder wall, where the urethral catheter is determined, is determined. In the lumen of the fistula opening, polyurethane foam was installed for filling wounds, mounted up to 8 mm in diameter, up to 10 mm long.

07/07/2020: there is a positive trend in the form of a reduction in the size of the fistula cavity to 7 mm. Under the control of colonoscopy, the urethral catheter was changed.

07/14/2020: there is a positive trend in the form of a reduction in the size of the fistulous cavity to 2 mm, the defect is not clearly visualized, it is made with contact-bleeding granulation tissue.

07/21/2020 (see Fig. 5): a probe was installed in the lumen of the lower ampulla of the rectum, the porous material of which was made with granulations, the probe with the porous material was removed. At the site of a pre-existing defect, a granulating wound surface with signs of epithelialization is determined, no defects are determined. The dynamics is positive in the form of separation of the fistulous cavity.

07/21/2020: under IV sedation, diagnostic cystoscopy was performed - at 6 o'clock of the conditional dial, at a distance of 0.3 cm from the neck, a depression up to 1.5 cm in diameter, made by a rich pink mucosa (urethrorectal fistula in the epithelialization stage). Additional formations, cavities, wall defects were not revealed.

On July 22, 2020, the urethral catheter was removed. When the cystostomy drainage is blocked, restoration of independent adequate urination is noted. It is recommended to block the drainage on your own daily for 3 hours in the morning.

On July 24, 2020, the patient was discharged in a satisfactory condition. Histological examination data from 06/15/2020 - acinar adenocarcinoma, Gleason 6 b, G1, surgical margin is negative. After discharge, he was observed on an outpatient basis by a surgeon, a urologist. 3 weeks after discharge, the cystostomy drain was removed.

After 2 months from the completion of treatment, a control colonoscopy was performed: a scar of the anal canal (a history of urethrorectal fistula). Endoscopic picture of the disconnected intestine.

The patient came to the study after 6 months. Conclusion - in the rectum, 2 cm from the anus, a white scar. After 10 days from the control colonoscopy, surgery was performed: upper median laparotomy, reconstructive and restorative surgery to close the colostomy, drainage of the abdominal cavity.

The postoperative period was uneventful, discharged in a satisfactory condition. At the moment, the patient has independent urination and stool. On the part of the underlying disease, clinical and biochemical remission is observed (total blood PSA <0.008 ng/ml).

Claims (1)

A method for treating a urethrorectal fistula, which includes patient preparation, after which, under endoscopic control, a probe with holes around the perimeter is inserted, on which a layer of porous material is fixed, so as to place the latter in the defect cavity while ensuring their tight contact, after which the probe is connected to an aspiration unit and carry out continuous vacuum drainage at negative pressure with regular replacement of the probe with a porous material with a gradual decrease in the size of the latter, characterized in that at the preparation stage, a urethral catheter is installed for a patient with a previously diagnosed urethrorectal fistula, an epicystostomy is performed and a double-barreled sigmostoma is applied, after which sigmoidoscopy is performed with assessing the localization, diameter and extent of the urethrorectal fistula, a polyvinyl chloride probe with an inner diameter of 3.3 mm is inserted into the defect cavity, the end of which is centrally immersed in a porous material, which is polyurethane foam is used to fill the wounds, the probe is fixed with a thread to the skin of the perianal area, connected to the suction unit, and continuous vacuum drainage is performed at a negative pressure of 20-40 mm Hg. Art. when replacing the probe with polyurethane foam for filling wounds every 5 days.

Images