RU2794864C1 - Method for simultaneous treatment of bladder diverticula by transvesical method with formation of ureterocystone anastomosis - Google Patents

Abstract

FIELD: medicine; urogic surgery.

SUBSTANCE: perform US-guided puncture of bladder in the dome area when the patient is lying on the surgery table on his back after insertion of urethral catheter and filling the bladder with solution of 0.9% sodium chloride and the subsequent insertion of trocar with 12 mm diameter for video laparoscope directly into the bladder. Then empty the bladder with urethral catheter and block the latter. Insufflate bladder with CO₂ at a pressure of 12 mm Hg. Then insert laparoscope into the bladder through 12 mm trocar, place trocars and ports for operating instruments in the bladder: one port with a diameter of 5 mm is inserted with scalpel through skin puncture 3 cm to the right of the main access guided with iliac bones position. The second port of 11 mm diameter is placed 3 cm to the left of the main access, guided with iliac bones position. Then perform circular lamellar dissection of the bladder, departing from diverticulum neck 0.5 cm up to paravesical tissue. Then perform traction by the mobilized edge of diverticulum neck, carry out blunt and sharp dissection of paravesical tissue along the diverticulum wall until it is completely cut off. Then form ureterocystoneoanastomosis by suturing with a v-loc 3-0 thread with 5/8 needle bend. After that examine paravesical tissue and perform hemostasis. Remove excised tissue of the diverticulum in a single block in a container through 11 mm port, remove instruments and trocars, apply sutures by layers and aseptic dressing to the skin. EFFECT: method allows to exclude possibility of negative consequences of carboxyperitoneum developing and surgical actions in the abdominal cavity, which will improve results of patient treatment by reducing trauma of surgical intervention, as well as reducing risk of trauma to hollow organs and restoring urine passage through the ureter, and almost completely eliminate the possibility of damage to the main vessels or abdominal and pelvic organs.

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Description

The invention relates to the field of medicine, namely to urology, can be used for the surgical treatment of bladder diverticula (DMP) in cases where the ureter flows into the diverticulum area and, for the use of endoscopic, namely transvesical technique, without laparoscopy.

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, complications from the respiratory organs due to a decrease in diaphragmatic excursion, impaired ventilation of the lower lobes of the lungs, thromboembolic complications due to a decrease in blood flow velocity, violations of the mechanisms of heart rhythm regulation. 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 the manipulation of instruments, 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.

The solution of this problem is ensured by the fact that in the method of simultaneous treatment of bladder diverticula by the transvesical method with the formation of ureterocystone anastomosis 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 V3-control, a puncture of the urinary bladder is performed. bladder in the area of the dome and subsequent installation directly into the cavity of the 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 CO2 under a pressure of 12 mm Hg; then a 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 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 the paravesical tissue along the wall of the diverticulum is carried out until it is completely cut off; when visualizing the orifice of the ureter, its stenting is performed, then a ureterocystone anastomosis is formed by suturing with a v-loc 3-0 thread with a 5/8 needle bend; then they inspect the cavity of the paravesical tissue and carry out hemostasis; the excised tissue of the diverticulum is removed as a single block in a container through an 11 mm port, instruments, trocars are removed, sutures and an aseptic dressing are applied in layers on the skin.

The method provides the full maximum efficiency 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. This method allows performing surgical treatment of diverticula having such aggravating factors as the ureter falling into the diverticulum area with further violation of urodynamics along the upper urinary tract. The uniqueness of this method lies in the fact that both the removal of the diverticulum and the formation of the ureterocystoneoanastomosis are performed transvesically during one surgical intervention.

The method is carried out as follows: At the first stage, under endotracheal anesthesia with 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 bladder cavity of 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 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 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 paravesical tissue tissues along the wall of the diverticulum is carried out up to its complete cutting off, it was not possible to visualize the orifice of the left ureter. Excision of the mucosa of the diverticulum of the bladder was performed, when the mucosa was cut off, the orifice of the left ureter was revealed, stenting of the left ureter with a ureteral catheter - stent No. 5 was performed, the mucosa was separated, careful hemostasis, the diverticulum was sutured, the entrance gate of the diverticulum was tightened with the formation of a ureterocystone anastomosis on the left, the separated mucosa was removed under visual control from the bladder and sent for histological examination, a 3-way profiled urethral Foley catheter No. 18 was installed in the bladder. The balloon is inflated to 10 ml. Hemostasis control, dry. Desufflation. Stitches on the skin. Iodine. Aseptic bandage. Macropreparation: the resected mucosal diverticulum of the bladder was sent for histological examination.

The advantages of the proposed method for the surgical treatment of bladder diverticula are the absence of risks for the development of possible intra- and postoperative complications of manipulations in the abdominal cavity, small pelvis during open and laparoscopic surgical interventions. This method of surgical treatment allows you to effectively and safely eliminate the diverticulum of the bladder and preserve the possibility of separating urine through the ureter by forming a ureterocystone anastomosis by the transvesical method.

At present, the proposed method is innovative and unique.

Clinical example 1.

Patient A., 46 years old, was treated in the urology department of the St. Petersburg State Healthcare Institution of St.

Clinical diagnosis: Bladder diverticulum.

Complications: Acute urinary retention (kupirovna). Epicystostomy from 08/08/2020.

Concomitant diseases: Hypertensive disease of the I stage, arterial hypertension of the 1st degree, risk of cardiovascular complications 2. Chronic gastritis without exacerbation. BPH stage 2. Transurethral enucleation of BPH with a bipolar (TUEB). Secondarily wrinkled left kidney.

Upon receipt complained of the presence of cystostomy, periodic aching pain in the left lumbar region. Anamnesis data: for a long time there was a deterioration in the parameters of urination in the form of frequent painless urination, a decrease in the pressure of urination, episodes of urinary retention were observed. On 08/08/2020, trocar epicystostomy was performed for acute urinary retention, and on 04/29/2021, transurethral enucleation of BPH with a bipolar (TUEB) was performed. Sent by the urologist of the polyclinic at the place of residence in St. Petersburg State Budgetary Institution of Health Clinical Hospital of St. Luke for surgical treatment.

An investigation was carried out.

The results of the preoperative examination.

On August 24, 2021, a surgical intervention was performed: endovideosurgical transvesical diverticulectomy with the formation of a ureterocystone anastomosis on the left. Stenting of the right ureter. The course of the operation is described above.

Postoperative period: no features. Removal of the urethral catheter was made on the second day, cystostomy drainage was removed on the third day. There is a complete preservation of the continent.

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

The results of the postoperative examination.

Discharged in a satisfactory condition with improvement. Recommended: 1) supervision of a urologist, a general practitioner at a polyclinic at the place of residence. 2) restriction of physical activity, saunas and alcohol for 1 month, sexual rest for 1 month 3) Tamsulosin 0.4 mg 1 r / d - 1 month 4) Kanefron 2 tablets 3 times a day for three months; 5) Rowatinex 2 tablets 3 times a day for one month urological collection, 3 times a day for three months; 6) Appearance at the St. Luke Clinical Hospital in St. Petersburg at the Department of Urology No. 2 to remove the ureteral stent in 4-5 weeks.

The method of endovideosurgical transvesical diverticulectomy with the formation of ureterocystone anastomosis was applied by us in 2 cases of treatment of bladder diverticula with the location of the mouth of the ureter in the region of the bladder diverticulum. 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 duration of interventions was 270 minutes and 240 minutes, the volume of blood loss was 65 and 50 ml, respectively, intraoperative complications and the need there were no blood transfusions. The early postoperative period was uneventful, the duration of drainage of the bladder through a urethral catheter averaged 3 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) in the presence of a diverticulum involving the orifice of the ureter, it is possible to simultaneously perform both ureterocystone anastomosis and transvesical diverticulectomy;

3) the current maximum safety of the technique carried out by the proposed method, 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 hyperplasia 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 and perfusion ratio and other undesirable consequences of carboxyperitoneum.

In general, in the surgical treatment of bladder diverticula involving the orifice of the ureter, the use of the proposed method allows maintaining the patency of the ureter, reducing the likelihood and number of complications, and improving the quality of life in the early and late postoperative period.

Conclusion: Simultaneous endovideosurgical transvesical diverticulectomy with the formation of ureterocystone anastomosis 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.rii/leaming/articles/o_negativnykh_effetoneuma/.

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

Claims (1)

A method for the simultaneous treatment of bladder diverticula in the event that the ureter flows into the diverticulum area by the transvesical method with the formation of a ureterocystone anastomosis, 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 bladder cavity of 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 CO ₂ under a pressure of 12 mm Hg; then a 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 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 the paravesical tissue along the wall of the diverticulum is carried out until it is completely cut off; then produce the formation of ureterocystone anastomosis by suturing thread v-loc 3-0 with a bend of the needle 5/8; then, paravesical tissue is examined and hemostasis is carried out; the excised tissue of the diverticulum is removed as a single block in a container through an 11 mm port, instruments, trocars are removed, sutures and an aseptic dressing are applied in layers on the skin.