RU2792787C1 - Method for augmentation ileocystoplasty using a marcius or marcius-simmonds flap in patients with radial vesicovaginal fistulas and microcystis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to operative urology. At the first - abdominal - stage, after reaching the exposure of the fistula, an incision is made in the bladder wall, bordering the fistula and in a sharp way, the walls of the bladder and vagina are separated for 1.5-2 cm. The anterior and lateral walls of the bladder are mobilized. The ureters are crossed at the level of the vagina. At the second - vaginal stage - one or two flaps of Marcius or Marcius-Simmonds are formed on the ventral or dorsal leg. After the creation of the paravaginal tunnel, the flap (or flaps) are moved into the pelvic cavity. At the third - abdominal - stage, the Marcius flap is fixed to the bladder and vagina, separating the suture lines of the vagina and bladder. If the Marcius-Simmonds flap is used, then the skin part of the flap along the entire circumference is sutured to the vaginal wall with separate interrupted sutures, and the muscle-fat part of the flap is fixed to the bladder and vagina. A segment of the ileum is formed, it is partially detubularized, leaving the cranial and caudal ends 3-4 cm long not detubularized, folded in a U-shape and sutured in the form of a duplication, lowered into the cavity of the small pelvis. Ileocystoanastomosis is performed with a continuous 2/0 absorbable suture. The distal ends of the ureters are spatulated and anastomosed with the non-detubularized ends of the ileum segment using the Wallece or Nesbit technique on external ureteral stents.

EFFECT: method allows to completely restore voluntary urination in patients with large radial vesicovaginal fistulas in combination with microcystis.

3 cl, 1 ex

Description

SUBSTANCE: invention relates to medicine, namely to urology, and can be used for surgical treatment of patients with radiation vesicovaginal fistulas in combination with microcystis.

In urology, several methods of ileocystoplasty are known in patients with radiation and recurrent vesicovaginal fistulas.

Thus, there is a known method (Mráz J.P., Sutorý M, 1994) of plasty of radial vesicovaginal cavities using a segment of the small intestine (4 cases are described). In 3 cases, the ileum was used and in 1 case, the jejunum. For plasty of vesicovaginal fistulas, the authors used a detubularized segment of the small intestine 8 cm long. The sizes of vesicovaginal fistulas in patients were from 2 to 3 cm. stopped with oxybutynin.

Also known from the prior art is a method (Matin Vaso et al., 2015) of vesico-vaginal fistula plasty with a detubularized segment of the ileum, based on the method of Mráz J.P., Sutorý., however, differing in that the segment of the small intestine was not used to augment the urinary bladder, and for fistula plasty with well-vascularized and non-irradiated tissue (the sizes of fistulas closed by the intestinal segment were 0.5 and 0.7 cm).

In addition, the prior art method (Hsu T.N. et al., 2002) of using a detubularized and U-shaped reconfigured segment of the small intestine 20 cm long for vesico-vaginal fistula repair and bladder augmentation. The orifices of the ureters were intact, the ureters were not reimplanted. The volume of the bladder in the patient before surgery was 83 ml, the size of the vesicovaginal fistula was 1 cm.

Also in 2004 Tabakov I.D. and Slavchev B.N. published data on the repair of 4 radial and recurrent vesicovaginal fistulas using a detubularized and U-shaped reconfigured segment of the small intestine, which the authors oriented in a horizontal direction. The ureters were also not reimplanted. The volume of the bladder in patients before surgery was from 40 to 90 ml, the size of vesico-vaginal fistulas was 1.5-3 cm. Using this technique, the authors achieved the effect in three patients out of four operated on.

However, all of the above methods have a number of significant drawbacks.

It should be noted that radial fistulas are usually located in the projection of the Lieuteau triangle and can reach large sizes (6-8 cm). With giant radial vesico-vaginal fistulas, there is often destruction of the proximal part of Lieutaut's triangle and intramural ureters, and the orifices of the ureters open at the edge of the vesico-vaginal fistula or lower into the vagina. Bladder capacity in such situations is usually reduced due to post-radiation fibrosis and is less than 100 ml. Often, vesicovaginal fistulas are combined with radial strictures of the pelvic ureters.

Fistuloplasty in such situations is impossible, since it is necessary not only to close the vesico-vaginal fistula, but also to reimplant the ureters into the bladder, to increase the capacity of the bladder. In the works described above, no intervention was performed with a fistula size of more than 3 cm, reimplantation of the ureters into the augmented bladder was not performed, which is the first drawback of these techniques.

In addition, when performing augmentation cystoplasty according to the methods described above, the wall of the intestinal segment is sutured with the wall of the bladder "edge to edge", which leads to a significant increase in the risk of recurrent vesicovaginal fistulas due to insufficient vascularization of the posterior wall of the bladder - the second main drawback. .

It is also known from the prior art to use the Marcius flap - a flap based on the adipose tissue of the labia and the superficial muscles of the urogenital diaphragm (bulb-spongy and ischiocavernosus muscle), as well as the Marcius-Simmonds flap - an axial islet skin-muscle-fat flap that differs from flap of Marcius by the presence of skin of the labia majora. The Marcius-Simmonds flap has one advantage: along with its other plastic functions, the flap, due to its skin portion, allows closing the defect in the vaginal wall in the form of a “patch”, which is of great importance in case of deficiency and rigidity of the vaginal wall (for example, with radial stenosis of the vagina ). Also, the absence of the need to bring the sutures together with the edge of the vaginal wall reduces ischemia in the surgical area.

Marcius and Marcius-Simmonds flaps are widely used in the repair of vesicovaginal radial fistulas by vaginal access, however, vaginal access itself limits the possibility of surgical manipulations to eliminate fistulas, which leads to the impossibility of complete clinical and functional recovery.

The closest to the proposed method (the closest analogue) is the method proposed by us in 2019 and includes the use of a partially detubularized segment of the ileum with non-detubularized cranial and caudal ends of 3-4 cm, folded in a U-shape and sewn in the form of a duplicate with an absorbable thread, which is lowered into the cavity of the small pelvis, ileocystoanastomosis is performed with an absorbable thread with a continuous suture, after which the distal ends of the ureters are spatulated for 2.5-3 cm and anastomosed with the non-detubularized ends of the ileum segment according to the Wallece method on the external ureteral stents with an absorbable thread.

However, this method also has disadvantages. Thus, making it possible to close large fistulas, reimplant the ureters, increase the capacity of the bladder, replace the section of the ureter with a stricture with a segment of the intestine, the method does not take into account the need to create conditions for tissue vascularization in the area of the fistula, the creation of additional conditions for feeding sutured tissues in order to reduce the time and improve their healing and the fastest, including functional rehabilitation.

The technical result of the proposed method is to restore voluntary urination in patients with radiation vesico-vaginal fistulas of large sizes in combination with microcystis.

To achieve the specified technical result, the method involves several stages of one surgical intervention, leading to the closure of the vesicovaginal fistula, an increase in the capacity of the bladder, the replacement of the ureter with a stricture with a segment of the intestine, which are supplemented by the use of a feeding flap. At the same time, not only the techniques used during the operation, but also their sequence and features of the operational access to perform each of the techniques, provide potentiation of the effect of each of the techniques with the achievement of a general result in the form of restoring a normal functional state.

The technical result and features of the effect potentiation will also be explained below.

At the first - abdominal stage - exposure of the vesicovaginal fistula is achieved, for which a longitudinal incision is made in the posterior wall of the bladder from the apex to the proximal edge of the fistula according to the O'Coner method. After reaching the exposure of the fistula, an incision is made in the bladder wall, fringing the fistula, and in a sharp way, the bladder wall and vagina are separated for 1.5-2 cm. bubble. After opening the parametria, the ureters are isolated to the level of the common iliac vessels, and they are crossed at the level of the vagina.

At the second stage, a Marcius or Marcius-Simmonds flap is formed from the labia majora on one or both sides by perineal access, and, proceeding from the third (abdominal) stage, the flap is moved into the pelvic cavity and fixed.

At the third stage, in addition to moving and fixing the flap after mobilization of the mesentery of the ileum segment, it is crossed in two places, a manual or mechanical ileoileoanastomosis is formed over the selected ileal segment. The segment of the ileum is partially detubularized, leaving the cranial and caudal ends 3-4 cm long not detubularized, folded in a U-shape and sutured with a 2/0 absorbable suture in the form of a duplication, lowered into the cavity of the small pelvis. Ileocystoanastomosis is performed with a continuous 2/0 absorbable suture. The distal ends of the ureters are spatulated for 2.5-3 cm and anastomosed with the non-detubularized ends of the ileum segment according to the Wallece or Nesbit method on external ureteral stents No. 8-10 Ch with a 4/0 absorbable suture. External ureteral stents are brought out contraperturally to the anterior abdominal wall.

The first stage allows you to gain access to the fistula area, prepare the surgical field for further intervention, including subsequent flaps.

Carrying out the second and third stages reduces the risk of fistula recurrence by “bringing” a vascularized flap to the site of intervention, which takes on the function of additional nutrition of the operating area, additional dissociation of organs, closure of the bladder wall defect in the fistula area, and also allows increasing its capacity. The peculiarity of using these flaps in this technique is that the described flaps were previously used only for fistuloplasty by vaginal access, and the technique for using these flaps, passing them into the abdominal cavity and methods of their fixation to the vagina using abdominal access in combination with augmentation cystoplasty are described for the first time .

The method is carried out as follows:

Perform surgical access (usually lower median laparotomy). In the presence of internal female genital organs, a hysterectomy with appendages is performed. After the intersection and ligation of the round ligaments of the uterus and the funnel-pelvic ligaments of the ovaries on both sides, the vesicouterine fold of the peritoneum is crossed and the bladder is separated from the cervix in an acute way. At this stage, the bladder cavity is opened in the region of the proximal edge of the vesicovaginal fistula. After the intersection and ligation of the uterine vessels at the level of the internal os, the intersection and ligation of the elements of the sacrouterine-cardinal complex on both sides of the uterus, the uterus is cut off from the vagina at the level of the vaginal vaults. For better exposure of the vesicovaginal fistula, a longitudinal incision is made in the posterior wall of the bladder from the apex to the proximal edge of the fistula using the O'Coner technique. After reaching the exposure of the fistula, an incision is made in the bladder wall, bordering the fistula and in a sharp way, the bladder wall and vagina are separated for 1.5-2 cm. Next, the median umbilical fold and peritoneum are crossed along the medial cystic folds, the anterior and lateral walls of the bladder are mobilized . After opening the parametria, the ureters are isolated to the level of the common iliac vessels, and they are crossed at the level of the vagina. Next, go to the vaginal stage of the operation. After a skin incision is made along one or both labia majora, one or two Marcius or Marcius-Simmonds flaps are formed, respectively, on the ventral or dorsal pedicle. After the creation of the paravaginal tunnel, the flap (or flaps) is moved into the pelvic cavity. The wound of the labia is sutured in layers, drained with active drainage according to the Redon method. Next, they re-pass to the abdominal stage. If a Marcius flap is used, the vagina is sutured with a continuous suture with absorbable suture, and the Marcius flap is fixed to the bladder and vagina, separating the suture lines of the vagina and bladder. If a Marcius-Simmonds flap is used, then the skin of the flap is sutured along the entire circumference to the vaginal wall with separate interrupted sutures with absorbable suture material, using the skin of the flap as a patch. Next, the musculoskeletal part of the flap is fixed to the bladder and vagina, separating them from the suture lines of the vagina and bladder. At a distance of 15 cm from the ileocecal junction, a loop of the ileum 20-25 cm long is marked, which is supplied with blood by 2-3 arteries. After mobilization of the mesentery of the ileum segment, it is transected in two places. A manual or mechanical ileoileoanastomosis is formed over the selected segment of the ileum. The segment of the ileum is partially detubularized, leaving the cranial and caudal ends 3-4 cm long not detubularized, folded in a U-shape and sutured with a 2/0 absorbable suture in the form of a duplication, lowered into the cavity of the small pelvis. Ileocystoanastomosis is performed with a continuous 2/0 absorbable suture. The distal ends of the ureters are spatulated for 2.5-3 cm and anastomosed with the non-detubularized ends of the ileum segment according to the Wallece or Nesbit method on external ureteral stents No. 8-10 Ch with a 4/0 absorbable suture. External ureteral stents are brought out contraperturally to the anterior abdominal wall. The bladder was drained with a Foly urethral catheter No. 18-20 Ch and a cystostomy drain No. 18-20 Ch. Drainage is installed contraperturally into the cavity of the small pelvis. The surgical wound is sutured in layers, tightly.

An example of the implementation of the method:

Patient G., 47 years old.

On December 27, 2013, an operation was performed for cervical cancer - extended extirpation of the uterus with appendages, pelvic lymphadenectomy. Histological conclusion: keratinizing squamous cell carcinoma of the cervix with a depth of invasion to the entire thickness of the cervix (2 cm), continued growth in the lower segment of the uterine body, invasion of the myometrium by 1 cm; endometrium, ovaries, tubes, vaginal stump, parametrial lymph nodes without tumor growth. Stage IIB (T2bN0M0) was established. From 07/09/2014 to 08/08/2014, a course of remote radiation therapy (SOD 40 Gy) was carried out. From August 18, 2014 to September 4, 2014, a course of intracavitary radiation therapy (SOD 21 Gy) was performed. After the end of radiation therapy, 4 courses of polychemotherapy were performed according to the scheme "carboplatin + paclitaxel". Subsequently, she was regularly observed by an oncologist. PET-CT dated February 4, 2019: no data for recurrence. Ultrasound of the small pelvis from 03.2020: no pathology was detected. She was consulted by an oncologist on 08/05/2020, no evidence of recurrence was found. Subsequently, she was not examined due to the COVID-19 epidemic. Since October 2019, she began to notice urinary incontinence. Examined on an outpatient basis. Ultrasound of the kidneys and bladder from October 30, 2019: U3-picture of bilateral ureterohydronephrosis, chronic urinary retention (pelvis on the left 3 cm, pelvis on the right 4 cm, residual urine 700 ml). She was treated by a urologist at the place of residence for neurogenic dysfunction of the bladder with a positive effect, urination was restored. Ultrasound of the kidneys from 11/14/2019: no structural changes (regression of ureterohydronephrosis). Ultrasound of the kidneys and bladder from 12/11/2019: the pyelocaliceal system of the kidneys is not dilated, there is no residual urine. Since September 2020, she began to notice a decrease in the urge to urinate, urinary incontinence. Addressed to the urologist at the place of residence. Ultrasound of the kidneys and bladder from February 16, 2021: the pyelocaliceal system of the kidneys is not dilated, there is no residual urine. In April 2021, a vesicovaginal fistula was diagnosed. Subsequently, she was further examined at the Clinical Hospital of the UDP RF. On May 19, 2021, cystoscopy and bladder biopsy were performed. Cystoscopic conclusion: vesicovaginal fistula (fistula 1 cm above the mouth of the left ureter), chronic radiation cystitis. Histological conclusion: a fragment of the bladder wall, covered with urothelium with reactive hyperplasia, the lining is partially absent, lymphocytic infiltration and fibrosis are determined in the stroma. Cystovaginography from May 20, 2021: vesico-vaginal fistula, microcystis (the capacity of the bladder and vaginal stump is 130 ml). Excretory urography from 07/16/2021: there are no violations of the excretory function of the kidneys. On July 27, 2021, in the gynecological department of the Federal State Budgetary Institution Clinical Hospital of the UDP RF, an operation was performed as planned - lower median laparotomy, adhesiolysis, fistuloplasty using the Marcius flap, augmentation ileocystoplasty, cystostomy, drainage of the abdominal cavity, hernioplasty using a synthetic mesh prosthesis, abdominoplasty, drainage of the subcutaneous fatty tissue of the anterior abdominal wall and left labia according to Redon. No fistula recurrence was noted in the early and late postoperative period.

In 2019, 4 patients were operated on using augmentation ileocystoplasty. Recurrent vesicovaginal fistula occurred in 3 out of 4 operated patients. Subsequently, all 3 patients underwent repeated fistuloplasty by vaginal access using the Marcius or Marcius-Simmonds flap according to the proposed method. 3 patients with radial vesicovaginal fistulas and microcystis were operated on with a positive effect, no recurrences of fistulas were noted.

Claims (3)

1. A method for augmentation ileocystoplasty in patients with radiation vesico-vaginal fistulas and microcystis, including the use of a partially detubularized segment of the ileum with non-detubularized cranial and caudal ends of 3-4 cm, folded in a U-shape and sewn in the form of a duplicate with an absorbable thread, which is brought down into pelvic cavity, ileocystoanastomosis is performed with an absorbable thread with a continuous suture, after which the distal ends of the ureters are spatulated for 2.5-3 cm and anastomosed with non-detubularized ends of the ileum segment on the external ureteral stents with an absorbable thread, characterized in that before the formation and use of the ileal segment intestines to achieve exposure of the vesicovaginal fistula, a longitudinal incision is made in the posterior wall of the bladder from the apex to the proximal edge of the fistula according to the O'Coner method, an incision is made in the bladder wall, bordering the fistula, 1.5-2 cm bladder and vaginal veins, mobilize the anterior and lateral walls of the bladder, isolate the ureters to the level of the common iliac vessels, cross them at the level of the vagina, proceed to the vaginal stage of the operation, forming one or two Marcius or Marcius flaps - Simmonds on the ventral or dorsal leg, then create a paravaginal tunnel, through which the formed flaps are moved into the pelvic cavity; re-pass to the abdominal stage, fixing the flaps so as to separate the suture lines of the vagina and the bladder, after which they proceed to the formation of a partially detubularized segment of the ileum. 2. The method according to p. 1, characterized in that when using the Marcius flap, it is fixed to the bladder and vagina. 3. The method according to claim 1, characterized in that when using the Marcius-Simmonds flap, its skin part along the entire circumference is sutured to the vaginal wall with separate interrupted sutures with absorbable suture material, and the muscle-fat part is fixed to the bladder and vagina.