RU2791247C1 - Method for plastic surgery of a defect of the lower third of the left ureter by flatch transposition of the appendicular process - Google Patents

Abstract

FIELD: surgery; oncology and urology.

SUBSTANCE: operation is performed laparoscopically. The appendicular process is mobilized with the mesoappendix in the form of a triangular vascular flap. Then the appendicular process is cut off from the dome of the caecum. A patchwork transposition of the appendicular process on its mesentery in isoperistaltic position is performed into the formed window of the mesentery of the sigmoid colon to the left ureter. An ureteroappendicoanastomosis or appendicocystoanastomosis is formed according to the Demel method.

EFFECT: filling the ureter defect and avoiding graft necrosis by maintaining the blood supply of the latter, while ensuring proper passage of urine, maintaining the integrity of the gastrointestinal tract without developing corresponding complications, reduction of the risk of developing stricture and incompetence of the left ureter.

1 cl, 12 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery, oncology and urology, and can be used to repair a defect in the lower third of the left ureter by flap transposition of the appendicular process.

Modern treatment of ureteral defect is laparoscopic ureteroplasty.

One of the methods for restoring the passage of urine through a damaged ureter with a defect in its pelvic region is reimplantation of the latter to a healthy ureter “end-to-side” [1]. The obvious advantage of the method is the relative simplicity and minimal amount of plastic surgery.

However, this technique has a number of significant drawbacks and limitations. The length of the part of the left ureter preserved after resection is not always sufficient for transposition to the right side, which is observed with extensive damage to the pelvic ureter. Also, this technique involves the mobilization of both ureters, which can be difficult in patients who have received complex treatment for cancer, and increases the risk of damage to a healthy ureter. A contraindication for the formation of a transureteroureteroanastomosis is high-dose radiation therapy for cancer of the bladder or intestines, due to an increased risk of anastomosis failure. Relative contraindications include urolithiasis, since a stone can clog the common distal ureters. Tuberculous urinary tract infection and severe chronic pyelonephritis are also contraindications for end-to-side ureteral reimplantation [2].

Other methods of ureteral defect plasty are known. It is common to replace the affected segment of the ureter with a segment of the small or large intestine [3, 4, 5, 6]. The technique involves the delimitation of a segment of the intestine with a length of 5 to 7.5 cm, depending on the length of the ureteral defect [3]. If it is necessary to replenish an extended fragment, the segment of the intestine is divided into 2-3 sections with the preservation of the mesentery of each part, that is, with the preservation of the blood supply. Next, each intestinal segment is detubulated along the antimesenteric edge, the transverse edges of the segments are sutured together and retubularized, thereby obtaining a tubular graft from 12 to 18 cm, depending on the number of intestinal segments [3, 7]. The advantage of the method is the replacement of a sufficiently extended section of the ureter at any level from the proximal to the distal part.

A significant disadvantage of intestinal plastics is the forced intersection of the vessels of the intestinal wall during resection of a section of the intestine, which can later serve as a cause of failure of both the intestinal anastomosis and the ureteral graft. In addition, it is not always possible to assert a sufficiently long vascular flap of the intestine, due to its formation from the middle sections of the mesentery of the intestine. Also, damage to the neuromuscular system leads to a deterioration in the contractile function of the graft and the potential development of reflux [7]. In addition, in the case of using the small intestine, whose mucous layer has a developed absorption capacity, the risk of reabsorption of sodium chloride and urine into the bloodstream increases [8].

The disadvantage of this method: leads to a violation of the integrity of the gastrointestinal tract, reduces the contractility of the ureter, increases the risk of metabolic acidosis and does not allow the formation of a vascular flap of sufficient length, which can lead to ureter failure.

As the closest analogue, the method of plasty of the defect of the lower third of the left ureter, described by B.K. Komyakov in the article "Left-sided appendicoureteroplasty" in 2012 [9]. The authors describe three cases of successful left-sided plasty, which are the only ones of its kind in the Russian Federation. With this technique, the appendicular process is cut off together with a rounded platform from the dome of the caecum and mobilized to the maximum left side, 3 cm of the apex of the appendicular process is cut off. The defect of the caecum is sutured with a double row Vicryl suture. The fundamental element of the technique is the movement of the left ureter through the mesentery of the sigmoid colon to the appendicular process, after which an end-to-end ureteroappendicoanastomosis is performed. The distal end of the intubator is passed through the appendix into the bladder and out through the urethra along with the Foley catheter. At the final stage, a wide anastomosis is performed intraperitoneally between the formed "rosette" from the caecum and the bladder. The postoperative period was uneventful, but the proposed technique has a number of disadvantages.

The disadvantage of this method: leads to a violation of the integrity of the gastrointestinal tract in the form of resection of the site from the caecum, which can contribute to the development of obstruction in the area of the ileocecal junction, increases the risk of stricture and failure of the left ureter when it directly passes through the mesentery of the sigmoid colon, which can lead to ureterohydronephrosis with impaired renal function.

The technical result of the invention is the use for plastics of a defect in the lower third of the left ureter of the appendicular process, which has anatomical characteristics similar to the ureter: comparable diameter, tubular structure; physiological characteristics: peristaltic activity, low absorption capacity of the mucous layer; the invention also makes it possible to avoid graft necrosis by maintaining its blood supply when moving to the left side, to maintain the integrity of the gastrointestinal tract without the development of appropriate complications, to reduce the risk of developing stricture and incompetence of the left ureter due to the transposition of the appendicular process to the ureter, and not vice versa.

The specified technical result is achieved in the method of plasty of the lower third of the left ureter, including the mobilization of the appendicular process on the mesentery while maintaining the neurovascular structure of the mesentery, the formation of a window in the mesentery of the sigmoid colon by perforation, resection of the affected area of the ureter within unchanged tissues, characterized in that the operation is performed laparoscopically, the appendicular process is mobilized with a mesoappendix in the form of a triangular vascular flap, after which the appendicular process is cut off from the dome of the caecum, then a flap transposition of the appendicular process on its mesentery in the isoperistaltic position is performed into the formed window of the mesentery of the sigmoid colon to the left ureter, ureteroappendicostomy is formed Demel's method.

.It is advisable in the case of extended diastasis between the ends of the left ureter and / or the absence of the distal end of the ureter to additionally form appendicocystoanastomosis according to the Demel method.

The key points of the operation are the use of the appendicular process for plasty, its movement in an isoperistaltic position to the left side to the left ureter while maintaining blood supply due to the maximum mobilization of the appendicular process with the mesoappendix in the ileocecal angle with the formation of a triangular vascular flap from the mesoappendix of sufficient length and the creation of a window in the mesentery sigmoid colon.

The essence of the invention is illustrated in Fig. 1-12, where:

In FIG. 1 - mobilization of the ileocecal angle and appendicular process with mesoappendix, where 1 - appendicular process; 2 - dome of the caecum; 3 - mesoappendix.

In FIG. 2 - cutting off the appendicular process with a hardware suture from the dome of the caecum, where: 1 - appendicular process; 2 - dome of the caecum; 3 - mesoappendix.

In FIG. 3 - formation of a triangular vascular flap of the mesoappendix, where: 1 - appendicular process; 3 - mesoappendix.

In FIG. 4 - formation of a window in the mesentery of the sigmoid colon, where: 1 - appendicular process; 4 - window in the mesentery of the sigmoid colon; 5 - mesentery of the sigmoid colon.

In FIG. 5 - movement of the appendicular process to the left side in isoperistaltic position, where: 1 - appendicular process; 4 - window in the mesentery of the sigmoid colon; 5 - mesentery of the sigmoid colon; 6 - sigmoid colon.

In FIG. 6 - stenting of the appendicular process, where: both the proximal and distal ends of the ureter; 1 - appendicular process; 6 - sigmoid colon; 7 - ureteral stent (7 Fr).

In FIG. 7 - stenting of the appendicular process and the proximal and distal ends of the ureter, where: 1 - appendicular process; 8 - proximal end of the left ureter; 9 - distal end of the left ureter.

In FIG. 8 - formation of proximal and distal anastomoses with interrupted sutures, where: 1 - appendicular process; 10 - proximal ureteroappendicoanastomosis; 11 - distal ureteroappendicoanastomosis.

In FIG. 9 - urography from 02/17/21: stricture of the lower third of the left ureter, where: 12 - nephrostomy on the left; 13 - left pyelocaliceal system; 14 - stricture of the lower third of the left ureter (example 1).

In FIG. 10, 11 - urography data from 06/03/2021: ureterovaginal fistula on the left, stricture of the left ureter 15 (example 2).

In FIG. 12 - data of repeated urography from 06/18/2021: data for the insolvency of the appendicular process, urinary leakage was not received, where: 1 - appendicular process; 7 - ureteral stent (7 Fr); 13 - left pyelocaliceal system; 16 - Demel's technique; 17 - bladder with a contrast agent (example 2).

The method is based on a study including patients with a ureteral defect on the left: in 7 cases (29.2%), due to external beam radiation therapy, in 16 cases (66.6%) - after iatrogenic injury and 1 (4.2%) case ureterovaginal fistula. The average length of the defect of the ureter on the left was 5.3±1.4 cm. The average length of the mesentery of the mobilized appendicular process was 9±2.2 cm. Replacement of the ureter with the appendicular process and additionally with a flap of the bladder using the Demel method was performed in 5 cases (20.8%) , in other cases, ureteroappendicoanastomoses and appendicoureteroanastomoses "end-to-end" were formed - 19 (79.1%). Median removal of the 7 Fr ureteral stent was 21±3.74 days. Early complications (<30 days) included 4 cases of catarrhal appendicitis (Clavien-Dindo II), 3 cases of reflux pyelonephritis (Clavien-Dindo III), 1 case of partial leakage of one of the anastomoses of the left ureter on the 29th day after undergoing Sars-Cov -2 infections. All complications resolved conservatively and did not require reoperation. Dynamic nephroscintigraphy was performed in 70.8% of patients, the average isotope accumulation time was 4.18±0.22 minutes, the half-life was 11.36±0.45 minutes.

The method is carried out, for example, as follows.

At the first stage, a wide mobilization of the ileocecal angle and appendicular process 1 with mesoappendix 3 is performed. After a preliminary assessment of the length and local blood supply, appendicular process 1 is cut off from the dome of the caecum 2 with a 45 mm Endogia hardware suture.

At the second stage, a window 4 is formed in the mesentery 5 of the sigmoid colon 6 to move the appendicular process 1, while the mesentery 5 of the intestine 6 is sequentially perforated from both sides - from the appendicular process 1 and from the left ureter 8-9 until the optimal width of the mesentery window 5 is reached.

In the third stage, the appendicular process 1 is moved isoperistaltically under the mesentery 5 of the sigmoid colon 6 to the left side after the preliminary maximum mobilization of the mesoappendix 3 in the form of a "triangle".

The fourth step is resection of the affected area of the left ureter 8-9 within the unchanged tissue.

The final step is to form the proximal 10 and distal 11 anastomoses between the isoperistaltically located appendicular process 1 and the ends of the left ureter (8 - proximal end, 9 - distal end) on a pre-installed stent 7 (7 Fr).

If it is necessary to form directly appendicocystoanastomosis with an extended diastasis of the left ureter, the described method of plasty is supplemented with the Demel method.

The achievement of the technical result is confirmed by the following clinical examples:

Example 1. Patient T., 57 years old. BMI 22.77 (Fig. 9).

Clinical diagnosis: non-Hodgkin's lymphoma, anaplastic large cell stage IVB, ALK+. Diagnostic laparoscopy, biopsy of retroperitoneal lymph nodes from 06/15/2020 6 SNOEP from 07/2020 to 10/2020 Complete answer.

Treatment complication: Stricture of the lower third of the left ureter. Ureterohydronephrosis stage 2 Nephrostomy on the left from 06.2020

According to the urography data of February 17, 2021, there was a contrasting of the PCL on the left and the left ureter up to its lower third. The flow of the contrast agent outside the organ was not detected. The entry of KB into the bladder was not determined (Fig. 9).

Treated according to the claimed method of ureteroplasty: performed a wide mobilization of the ileocecal angle and appendicular process with mesoappendix. The mesoappendix is formed in the form of a triangular flap. The appendicular process was cut off from the dome of the cecum with a 45 mm Endogia hardware suture. A window was formed in the mesentery of the sigmoid colon, after which the appendicular process was moved isoperistaltically under the mesentery of the sigmoid colon to the left side. Performed resection of the affected area of the ureter within the unchanged tissue. Proximal and distal anastomoses were formed between the isoperistaltically located appendicular process and the ends of the left ureter on a pre-installed 7 Fr stent.

Intraoperatively, a cicatricial deformed lower third of the left ureter was detected for 4 cm - from the intersection with the iliac vessels to the juxtavesical section.

In the postoperative period, the wound healed by primary intention, without complications.

Example 2. Patient X., 46 years old. BMI 30.85 (Fig. 10-12).

Diagnosis: Ca colli uteri pT1a1N0M0 (ad\ca). Condition after surgical treatment from 26.02.2021 in the scope: Laparoscopy. Operation Wertheim. 03/04/2021 Laparoscopy. Revision of the abdominal cavity. Sanitation and drainage of the abdominal cavity.

Complication of treatment: Suppuration of the cyst of the right iliac region. Ureterovaginal fistula on the left.

According to CT scan of the OBP, OMT (urography) dated 06/03/2021: stricture of the lower third of the left ureter, ureterovaginal fistula on the left (Fig. 10, 11).

Surgical treatment was performed in the amount of laparoscopic separation of the ureterovaginal fistula on the left, as well as resection of the left ureter with one-stage appendoplasty according to the claimed method.

Intraoperatively, involvement of the lower third of the wall of the left ureter in the suture of the vaginal stump was found. Scarring of the ureter was traced for 7 cm.

In this case, when forming the appendicocystoanastomosis, the Demel technique was performed.

Data of repeated urography from 06/18/2021: CV is traced in the bladder, then in the left ureter, PLS of the left kidney. Data for the presence of leakage of KB outside the bladder is not received (Fig. 12).

On July 13, 2021, the ureteral stent was removed.

During the period from November 2019 to May 2021, 24 operations were performed for intracorporeal replacement of the lower third of the ureteral defect on the left by flap transposition of the appendicular process on the vascular pedicle. All patients were female. The age of the patients varied from 43 to 70 years (mean 56.3±0.3 years). In all cases, a positive result was achieved.

The inventive method makes it possible to fill the defect of the ureter and avoid necrosis of the transplant by maintaining the blood supply to the latter, while ensuring the proper passage of urine; reduces the risk of developing stricture and incompetence of the left ureter.

Information sources:

1. Higgins C. Transuretero-ureteral anastomosis. Report of a clinical case. J Urol. 1935. 34:349.

2. Udall DA, Hodges CV, Pearse HM, Burns AB. Transureteroureterostomy: a neglected procedure. J Urol. May 1973; 109(5):817-20. doi: 10.1016/s0022-5347(17)60550-0. PMID: 4699675

3. Ali-el-Dein B, Ghoneim MA. Bridging long ureteral defects using the Yang-Monti principle. J Urol 2003; 169:1074-7.

4. Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: An evidence-based analysis. BJU Int 2004; 94:277-89

5. Obaidah A, Mane SB, Dhende NP, Acharya H, Goel N, Thakur AA, et al. Our experience of ureteral substitution in pediatric age group. Urology 2010; 75:1476-80.

6. Boxer RJ, Fritzsche P, Skinner DG, Kaufman JJ, Belt E, Smith RB, Goodwin WE. Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. Trans Am Assoc Genitourin Surg. 1978; 70:99-102. PMID: 753030.

7. Ureteroplasty according to Yang-Monti, B.K. Komyakov, B.A. Ochelenko, A.X. Gaziev, X.M. Mhanna, Urological Gazette Volume V No. 1 2015.

8. Deyl RT, Averbeck MA, Almeida GL, Pioner GT, Souto CA. Appendix interposition for total left ureteral reconstruction. J Pediatric Urol. 2009 Jun; 5(3):237-9. doi: 10.1016/j.jpurol.2008.11.010. Epub 2008 Dec 23. PMID: 19109072.

9. Komyakov B.K., Ochelenko V.A., Mizyakin A.G., Nikolaev N.M. Left-sided appendicoureteroplasty. Preventive and clinical medicine. - 2012. - No. 4 (45). - S. 12-18.

Claims (1)

Method for plasty of the lower third of the left ureter, including mobilization of the appendicular process on the mesentery with preservation of the neurovascular structure of the mesentery, formation of a window in the mesentery of the sigmoid colon by perforation, resection of the affected area of the ureter within unchanged tissues, characterized in that the operation is performed laparoscopically, the appendicular process is mobilized with a mesoappendix in the form of a triangular vascular flap, after which the appendicular process is cut off from the dome of the caecum, then a flap transposition of the appendicular process on its mesentery in an isoperistaltic position is performed into the formed window of the mesentery of the sigmoid colon to the left ureter, a ureteroappendicoanastomosis or appendicocystoanastomosis is formed according to the Demel method.

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