RU2795838C1 - Method of retroperitoneoscopic one-stage nephrectomy for pyonephrosis - Google Patents

Abstract

FIELD: medicine; video endoscopic urologic surgery.

SUBSTANCE: measure degree of kidney mobility using ultrasound, determine state of the pararenal fat body and vascular pedicle using MRI in the preoperative period, In the absence of significant infiltration and paranephritis perform retroperitoneoscopy in side-lying position, exposure of psoas muscle and renal fascia with mobilization of kidney posterior surface, then perform US-guided pyonephrosis puncture and evacuate purulent contents from herenal cavitary system with wound expanding with electric suction machine. Then expose, mobilize and cut the vascular pedicle, and gradually mobilize kidney with pararenal fat body with inclusion of renal fascia and ureter. During the evacuation of purulent contents at the initial stage kidney volume decreases and working volume expands, so, on the one hand, access to the vascular pedicle is technically simplified, on the other hand, stages of isolating the kidney with pararenal fat body are simplified, and decrease in the kidney volume allows to remove it through smaller incision.

EFFECT: method allows to perform nephrectomy in case of pyonephrosis in one stage and remove kidney with pararenal fat body and renal fascia by reducing the volume of the kidney and ensuring an adequate approach to the kidney vascular pedicle and technical simplifying the stages of kidney mobilization.

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Description

SUBSTANCE: invention relates to medicine, namely to video endoscopic operative urology, and can be used in the treatment of pyonephrosis.

Pyonephrosis is a fairly common complication of urolithiasis and other obstructive diseases of the upper urinary tract (Nguyen T.L., 1993; Lopatkin N.A., Shevtsov I.P., 1986). Often, patients are admitted in a serious condition due to intoxication against the background of a severe somatic status. This category of patients requires drainage of the kidneys and symptomatic therapy, since due to the serious condition, surgical treatment is fraught with formidable complications, even death.

On the other hand, in somatically intact patients, after preliminary drainage by the puncture method, delayed nephrectomy is performed. However, with percutaneous puncture drainage of the kidneys with pyonephrosis, most often the kidney is not sufficiently sanitized due to the many purulent cavities. In this regard, in the absence of paranephritis and other contraindications, performing a one-stage nephrectomy is the best way to rid the patient of the disease (Ribun V.V., 2017).

To date, nephrectomy remains the only treatment for pyonephrosis. Nephrectomy is most often associated with technical difficulties due to an increase in the size of the kidney, paranephritis, infiltration of perirenal tissue and vascular pedicle (Lopatkin N.A., Shevtsov I.P., 1986; Kuznetsov A.A., 2012; Kadyrov Z.A., 2017).

To successfully perform nephrectomy, it is necessary to choose the most optimal access, which depends on the side (right or left) and the extent of the proposed surgical intervention. One of the main stages of nephrectomy is access to the renal stalk and mobilization of the kidney from the surrounding tissues. When performing nephrectomy, surgeons most often use extraperitoneal lumbotomy access, since with laparotomy access the risk of contamination of infection from a purulent focus is high.

It should also be noted that preoperative diagnosis of the state of the kidney and its surrounding tissues is not always performed in full, which does not allow expanding the idea of the scope of the operation.

From the prior art, a method for removing a kidney by the traditional method is known: with a lumbar incision of about 25 cm, the incisions expose the kidney, extract it from the adhesions and bring it into the wound. The ureter is isolated, ligated and crossed at the border of its upper and middle thirds. The renal end of the ureter is pulled upwards and outwards, and the renal vessels are bluntly released from the surrounding tissues. With a Deschamps needle, a strong, thick catgut thread is circled around the vascular pedicle and tied away from the hilum of the kidney. After that, a S.P. clamp is applied to the leg above the ligature. Fedorov and the kidney are cut off. Under Clamp S.P. Fedorov bring the second piercing ligature. Drainage rubber tubes are brought to the renal bed and ureteral stump, after which the wound is sutured. In case of large hydronephrosis or pyonephrosis, to facilitate the nephrectomy technique, it is recommended to first puncture the bag shell and evacuate the contents with an electric suction. A purse-string suture is applied to the puncture site. In cases where the kidney is intimately fused with scarred surrounding tissues, with a short and unyielding renal pedicle, with infiltration in the region of the kidney hilum, it is recommended to perform subcapsular nephrectomy, described by S.P. Fedorov (Operative urology: // Guide / Edited by N.A. Lopatkin, I.P. Shevtsov. - L .: Medicine, 1986. - 780 p.). After the kidney is exposed, the fibrous capsule is dissected along the convex edge and bluntly separated from the parenchyma throughout. The fibrous capsule is dissected with a scalpel in the region of the kidney gate with a semicircular incision. A finger is inserted into this incision and the anterior surface of the ureter and vessels of the renal pedicle are released in a blunt way. In a similar way, the back surface of the leg is released. After that, the kidney becomes more mobile. The ureter is preliminarily ligated and crossed. A C.P. clamp is applied to the vascular pedicle. Fedorov and the kidney are cut off. The leg is stitched with a catgut ligature and bandaged. A drainage tube and a gauze graduate are brought to the renal bed, after which the wound is sutured (Operative urology: // Guide / Edited by N.A. Lopatkin, I.P. Shevtsov. - L .: Medicine, 1986. -780 p.) .

When performing nephroureterectomy for pyonephrosis, an extraperitoneal lumbar incision is performed according to Bergman-Israel about 35 cm, exposing the retroperitoneal space. After the kidney is isolated from the surrounding tissues, the ureter is mobilized in a blunt way up to the bladder. At the bladder, the ureter is slightly stretched, bandaged and cut off. Sometimes the stump of the ureter is immersed with a purse-string suture into the wall of the bladder. The kidney is brought out into the wound, its vessels are tied up and cut off. A rubber tube is brought to the bed of the kidney, a rubber strip is brought to the stump of the ureter. The wound is sutured in the usual way (Operative urology: //Guide/ Edited by N.A. Lopatkin, I.P. Shevtsov. - L .: Medicine, 1986. -780 s).

However, traditional open surgeries are traumatic because require large incisions, which increase the trauma, and the perirenal tissue and fascia of Gerota are not completely removed, which can subsequently cause suppuration and prolonged wound infection.

A known method of nephrectomy with pio- and hydronephrosis, including exposure of the retroperitoneal space by retroperitoneal access, isolation of the kidney from fatty tissue, aspiration puncture of the kidney, isolation and ligation of the vascular renal pedicle (SPN) and ureter, their intersection and removal of the kidney from the wound, characterized in that retroperitoneal access is performed by a skin incision 2-3 cm long along the midaxillary line parallel to and below the 12th rib and blunt layer-by-layer intermuscular exposure of the retroperitoneal space, partial blunt exposure of the kidney is performed with a finger, after which a retroperitoneoscope (RPS) is inserted into the retroperitoneal space and its mirror is placed at posterior surface of the kidney, complete the isolation of the posterior surface of the kidney and expose the posterior surface of the SPN, move the mirror of the RPS to the anterior surface of the kidney, moving the parietal sheet of the peritoneum to the side, complete the isolation of the anterior surface of the kidney and expose the anterior surface of the SPN, perform aspiration puncture of the kidney, tighten the collapsed kidney into the surgical wound, ligate and cross the SPN, pull the kidney into the wound, isolate, ligate and cross the ureter, after which the kidney is removed (RF patent No. 2173963, dated 27.09.2001.).

However, this method is complicated and traumatic, as a result of which it is used by single urologists, most often with a wrinkled kidney with hydronephrosis and pyelonephritis, and rarely with pyonephrosis due to the fact that with a larger volume of the kidney, the working space is sharply limited, many stages of the operation are performed bluntly without vision control , which is fraught with complications in the form of bleeding and damage to the peritoneum and other surrounding tissues. With this technique, only the kidney is most often isolated, and the perinephric tissue and Gerota's fascia are not removed, which can be a source of infection and lead to postoperative complications. In addition, special tools are used here that require skills to use them, as well as elements of traditional access.

Closest to the claimed method is known surgical access to the kidney with pyonephrosis, through retroperitoneoscopic access, selected as a prototype (Ribun V.V. Retroperitoneoscopic operations for purulent-inflammatory diseases of the kidneys and retroperitoneal space. Diss. ... Candidate of Medical Sciences., M. - 2017. - 117 p.). The method allows to mobilize the kidney and its vessels. By creating a retropneumoperitoneum, the posterior surface of the kidney with perirenal tissue is mobilized and moved medially. Next, the renal pedicle (artery and vein) is mobilized, a clip is placed on them and crossed. After isolation and transection of the ureter, the kidney is removed with perirenal tissue in a single block from the mini-access.

However, this method has significant disadvantages. It is complex, traumatic and requires special skills, as a result of which it is rarely used by single urologists due to space limitations and lack of experience. The lack of preoperative diagnostics of the state of the kidneys and surrounding tissues does not provide an adequate approach to the kidney and vessels of the renal pedicle, does not always allow the operation to be completed successfully, and the risk of conversion is high.

In addition, the kidney is not emptied intraoperatively. Most often, only the kidney is isolated, and Gerota's fascia is not excised or removed, and perirenal tissue is not always removed, which can be a source of infection and cause postoperative complications.

The objective of the claimed invention is to increase the efficiency of nephrectomy in pyonephrosis, reduce the risk of complications and conversion.

The problem is solved by the method of retroperitoneoscopic single-stage nephrectomy for pyonephrosis, which includes retroperitoneoscopy, mobilization of the posterior surface of the kidney with perinephric tissue, exposure and mobilization of the vessels of the renal pedicle and removal of the kidney with perinephric tissue, after the patient's kidney condition is assessed at the preoperative stage and surrounding tissues according to ultrasound and MRI data, the absence of pronounced infiltration and paranephritis is established, after which retroperitoneoscopy is performed, then, under combined endoscopic and ultrasound control, pyonephrosis is punctured and the puncture site is expanded to 1 cm with an electric knife, then purulent contents are evacuated from the cavitary cavity with a 10 mm electric pump. the kidney system, which, with the retroperitoneal space, is washed with an antiseptic solution to clean water; the lumbar muscle is exposed, the vascular pedicle of the kidney is isolated along its course, which is clipped and crossed; produce a phased mobilization of the kidney with perirenal tissue within the fascia of Gerota and the ureter; the affected kidney with retroperitoneal perirenal tissue and Gerota's fascia is removed as a single block with a ligated and transected ureter; after control for hemostasis, the kidney bed is drained, the median wound is sutured.

As a result of the method we developed for retroperitoneoscopic one-stage nephrectomy for pyonephrosis, it became possible to perform nephrectomy in one stage due to the preoperative assessment of the state of the kidney and surrounding tissues, reducing the volume of the kidney during surgery and ensuring an adequate approach to the vascular pedicle of the kidney, which technically simplifies the stages of kidney mobilization. This greatly simplifies the operation, expands the circle of urologists who are able to master it. At the same time, the invasiveness of the operation, the number of complications and relapses are reduced.

This technical result is achieved due to the fact that the proposed method is applicable for one-stage nephrectomy with pyonephrosis in patients. The presence of this pathology determines further tactics during surgical access, namely, after a preoperative assessment of the condition of the kidney and surrounding tissues - in the position of the patient on the side, a retropneumoperitoneum is created, the posterior surface of the kidney is mobilized without opening the fascia of Gerota, under combined endoscopic and ultrasound control, a puncture and evacuation are performed purulent contents from the kidney, then the lumbar muscle is mobilized and along the course of the lumbar muscle they reach the vascular pedicle and expose them with subsequent processing.

A significant advantage of the proposed method is that during the evacuation of purulent contents at the initial stage, the volume of the kidney decreases and the working space expands, which, on the one hand, technically simplifies access to the vascular pedicle, on the other hand, the steps for isolating the kidney from the perinephric tissue are also simplified, and the volume is reduced. kidney allows you to remove it through an incision of a smaller diameter.

Thus, the main features of the claimed operational access are:

1. Preoperative evaluation by ultrasound and MRI of the condition of the kidney and surrounding tissues in order to identify the degree of infiltration of perirenal tissue and exclude paranephritis.

2. Surgical intervention begins with the patient in the lateral position with the introduction of the laparoscope retroperitoneally along the posterior axillary line, then the creation of a working space by CO2 insufflation, the introduction of 2 additional 5 and 10 mm trocars along the anterior and middle axillary lines, and the mobilization of the posterior surface of the kidney without opening the Gerota fascia.

3. Pyonephrosis puncture under combined endoscopic and ultrasound control and expansion of the puncture site up to 1 cm with an electric knife, then purulent contents are evacuated from the kidney cavity system with a 10 mm electric pump.

4. After the purulent contents are evacuated from the cavitary system of the kidney, it and the retroperitoneal space are washed with an antiseptic solution to clean water.

5. Isolation of the vascular pedicle of the kidney, along the exposed psoas muscle, which is clipped and transected. Produce a phased mobilization of the kidney with pararenal tissue within the fascia of Gerota and the ureter.

6. The kidney with perirenal tissue within Gerota's fascia with the ureter is removed from the mini-access.

7. All stages of the operation are carried out under optical control, which minimizes the risk of bleeding and other complications.

During the evacuation of purulent contents at the initial stage, the volume of the kidney decreases and the working space expands, which, on the one hand, technically simplifies access to the vascular pedicle, on the other hand, the stages of isolating the kidney from the perirenal tissue are simplified, and reducing the volume of the kidney allows it to be removed through an incision of a smaller diameter .

EFFECT: method makes it possible to remove a kidney with perirenal tissue within Gerota's fascia in case of pyonephrosis in one stage and to sanitize the purulent focus as much as possible, which allows minimizing postoperative wound complications. All this is achieved through a preoperative assessment of the state of the kidney and surrounding tissues, a decrease in the volume of the kidney during surgery and an adequate approach to the vascular pedicle of the kidney and technical simplification of the stages of mobilization of the kidney with perinephric tissue.

Detailed description of the method and examples of its clinical application

The method is carried out with pyonephrosis in patients as follows. In the preoperative period, the degree of mobility of the kidneys is measured for the patient by ultrasound, according to MRI, the state of the perinephric tissue and the vascular pedicle is determined. Thus, before the operation, the state of the kidney with the surrounding tissues is assessed in order to identify the degree of infiltration of the perinephric tissue and exclude paranephritis.

If, during the preoperative assessment of the state of the kidney and surrounding tissues according to ultrasound and MRI, there is no pronounced infiltration and paranephritis proceed to surgery under endotracheal anesthesia. Surgical intervention is started in the position of the patient on the side with the introduction of a laparoscope (laparoscopic rack "Karl Storz", Germany) retroperitoneally along the posterior axillary line, then a working space is created by CO2 insufflation, the introduction of 2 additional 5 and 10 mm trocars along the anterior and middle axillary lines. After revision of the retroperitoneal space, the posterior surface of the kidney is mobilized without opening the fascia of Gerota.

Under combined endoscopic and ultrasound control, puncture of pyonephrosis is performed and the puncture site is expanded to 1 cm with an electric knife, then purulent contents are evacuated from the cavitary system of the kidney with a 10 mm electric suction. The cavitary system of the kidney and the retroperitoneal space are washed with an antiseptic solution to clean water.

Then the lumbar muscle is exposed and along it the vascular pedicle of the kidney is isolated, clipped and transected. The next step is to produce a phased mobilization of the kidney with perirenal tissue within the fascia of Gerota and the ureter.

All stages of the operation are carried out under optical control, which minimizes the risk of bleeding and other complications. The affected kidney with retroperitoneal pararenal tissue and Gerota's fascia is removed as a single block with the ligated and transected ureter. After monitoring for hemostasis, the kidney bed is drained. The median wound is sutured.

This operation meets the requirements of purulent surgery and allows one-stage nephrectomy for pyonephrosis.

The proposed method of retroperitoneoscopic one-stage nephrectomy for pyonephrosis, can be performed for pyonephrosis without signs of purulent paranephritis and extensive infiltration of perinephric tissue, improves the quality of the treatment process, reduces the time of hospitalization and return to normal life.

The performance of the claimed method is confirmed by the following examples from clinical practice.

Example 1

Patient B-s, 66 years old, was admitted to the urological department. During the examination, according to ultrasound and MRI, it was diagnosed: Urolithiasis. A stone in / from the ureter is about 2 cm. Pyonephrosis.

Taking into account the somatic status and the absence of signs of severe intoxication, as well as purulent paranephritis, a retroperitoneoscopic single-stage nephrectomy with pyonephrosis was performed under endotracheal anesthesia according to the claimed method.

Surgical intervention begins with the patient in the lateral position with the introduction of the laparoscope retroperitoneally along the posterior axillary line, then the creation of a working space by CO2 insufflation, the introduction of 2 additional 5 and 10 mm trocars along the anterior and middle axillary lines, and the mobilization of the posterior surface of the kidney without opening the Gerota fascia. During the operation, pyonephrosis was confirmed, minimal infiltration of perirenal tissue. Under combined endoscopic and ultrasound control, a pyonephrosis puncture was performed and the puncture site was expanded to 1 cm with an electric knife, then purulent contents were evacuated from the renal cavitary system with a 10 mm electric pump: about 200 ml of purulent contents were evacuated from the kidney cavitary system. The cavitary system of the kidney and the retroperitoneal space are washed with an antiseptic solution to clean water. The lumbar muscle is exposed and along it the vascular pedicle of the kidney is isolated, they are clipped and transected. Produce a phased mobilization of the kidney with pararenal tissue within the fascia of Gerota and the ureter.

All stages of the operation are carried out under optical control, which minimizes the risk of bleeding and other complications.

The affected kidney with perirenal tissue and Gerota's fascia is removed as a single block with a bandaged and transected ureter from a mini-access. After monitoring for hemostasis, the kidney bed is drained. The median wound is sutured.

The postoperative period is smooth. Discharged on the 7th day.

Postoperative diagnosis: Urolithiasis. Pyonephrosis. Sclerotic changes in the renal structures and perirenal tissue.

Example 2

Patient K-eva, aged 42, was admitted to the urological department. During the examination, according to ultrasound and MRI, it was diagnosed: Urolithiasis. Stricture of the ureteropelvic segment. Pyonephrosis. According to the study, there were no signs of paranephritis with an adhesive-cicatricial process in the paranephria. Given the somatic status and the absence of signs of severe intoxication, retroperitoneoscopy was performed under endotracheal anesthesia, nephrectomy with pyonephrosis according to the specified method.

Surgical intervention begins with the patient in the lateral position with the introduction of a laparoscope retroperitoneally along the posterior axillary line, then the creation of a working space by CO2 insufflation, the introduction of 2 additional 5 and 10 mm trocars along the anterior and middle axillary lines, and the mobilization of the posterior surface of the kidney without opening the Gerota fascia.

During the operation, pyonephrosis was confirmed, infiltration of perinephric tissue without signs of a purulent process. Under combined endoscopic and ultrasound control, a pyonephrosis puncture was performed and the puncture site was expanded to 1 cm with an electric knife, then purulent contents were evacuated from the renal cavitary system with a 10 mm electric pump: about 350 ml of purulent contents were evacuated from the kidney cavitary system. The cavitary system of the kidney and the retroperitoneal space are washed with an antiseptic solution to clean water. The lumbar muscle is exposed and along it the vascular pedicle of the kidney is isolated, they are clipped and transected. Produce a phased mobilization of the kidney with pararenal tissue within the fascia of Gerota and the ureter.

The affected kidney with perirenal tissue and Gerota's fascia is removed as a single block with a bandaged and transected ureter from a mini-access. After monitoring for hemostasis, the kidney bed is drained. The median wound is sutured.

All stages of the operation are carried out under optical control, which minimizes the risk of bleeding and other complications. The postoperative period is smooth. Discharged on the 8th day.

Postoperative diagnosis: LMS stricture. Pyonephrosis. Infiltrative changes in renal structures and perirenal tissue.

The inventive method has been tested in the clinic and proved to be effective in the treatment of pyonephrosis in 18 somatically healthy patients.

During clinical testing, the following advantages of the proposed method were revealed:

When applying the claimed method, due to the preoperative assessment of the condition of the kidney and surrounding tissues, reducing the volume of the kidney during manipulation, adequate access to the kidney and blood vessels is created, the risk of complications - bleeding, blood loss, conversion is minimized, and surgical intervention is simplified. This greatly simplifies the operation, expands the circle of urologists who are able to master it. At the same time, the invasiveness of the operation, the number of complications and relapses are reduced.

The method of retroperitoneoscopic one-stage nephrectomy in pyonephrosis was tested on a significant amount of clinical material, showed its effectiveness, reproducibility and achievement of the claimed technical result. This allows us to recommend it for widespread use in specialized surgical hospitals.

Claims (1)

A method for retroperitoneoscopic one-stage nephrectomy for pyonephrosis, including retroperitoneoscopy, mobilization of the posterior surface of the kidney with perinephric tissue, exposure and mobilization of the vessels of the renal pedicle, and removal of the kidney with perinephric tissue, characterized in that at the preoperative stage, the condition of the kidneys and surrounding tissues is assessed in the patient according to ultrasound data and MRI, establish the absence of pronounced infiltration and paranephritis, after which retroperitoneoscopy is performed, then, under combined endoscopic and ultrasound control, a pyonephrosis puncture is performed and the puncture site is expanded to 1 cm with an electric knife, then purulent contents are evacuated from the cavitary system of the kidney with a 10 mm electric suction, which with the retroperitoneal space is washed with an antiseptic solution to clean water; the lumbar muscle is exposed, the vascular pedicle of the kidney is isolated along its course, which is clipped and crossed; produce a phased mobilization of the kidney with perirenal tissue within the fascia of Gerota and the ureter; the affected kidney with retroperitoneal perirenal tissue and Gerota's fascia is removed as a single block with a ligated and transected ureter; after control for hemostasis, the kidney bed is drained, the median wound is sutured.