RU2796129C1 - Method for removing stents without cystoscopy in children after reconstructive plastic surgery on the bladder and ureteral orifices - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: fringing suprapubic incision of the bladder mucosa around the refluxing orifice is performed, ureters are mobilized sharply, submucosal tunnels are formed in the transverse direction parallel to the inter-ureteral folds, anastomosis of the ureters with the bladder mucosa is performed. The ureters are stented and the bladder is drained with a Foley urethral catheter. After installing the stents in the ureters, the proximal ends of the Vicryl sutures are attached to the proximal ends of the stents, the distal ends of which are passed through the hole at the distal end of the Foley catheter to the drainage port and brought out, the Vicryl sutures are left with the Foley catheter for 7-8 days, after which the stents are removed, at the same time as the Foley catheter, by pulling out by the distal ends of the Vicryl sutures.

EFFECT: method allows to exclude cystoscopy for removal of stents from the ureters, reduces operational risks, anaesthetic risks and hospital expenses, and also reduces the risk of nosocomial infection, reduces the number of complications and repeated hospitalizations.

1 cl, 3 ex, 3 dwg

Description

The invention relates to medicine, in particular to surgery, namely to pediatric urology, and can be used to remove stents in children without cystoscopy after performing reconstructive plastic surgery on the bladder and ureteral orifices with vesicoureteral reflux, including double kidney.

Vesicoureteral reflux (VUR) is one of the most common urological anomalies. For the treatment of VUR in children, conservative therapy and surgical correction, including modern minimally invasive methods, can be used. Previously, the main treatment for high-grade VUR in children was open antireflux surgery. In recent decades, laparoscopic surgery has replaced open surgery for many urological diseases, including congenital anomalies of the urinary tract [Ansari, M. S., Yadav R., Arora S., et al. Bilateral Transvesicoscopic Cross-trigonal Ureteric Reimplantation in Children: Surgical Subtleties and a Prospective Summary // Urology. - 2017. - Vol.101. - P. 67-72.; Grimsby, G. M, Dwyer M. E., Jacobs M. A. et al. Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation //J. Urol. - 2015. - Vol.193(5 Suppl).-P. 1791-5.].

In the minimally invasive treatment of VUR, as in open surgery, two different approaches are known: extravesical (laparoscopic) and intravesical (vesicoscopic). For the first time, laparoscopic extravesical antireflux surgery was described by R. Ehrlich et al. in 1994, and vesicoscopic reimplantation of the ureter - K. Okamura et al. in 1995 [Herz, D., Fuchs M. Todd A., McLeod D., Smith J. Robotassisted laparoscopic extravesical ureteral reimplant: a critical look at surgical outcomes // J. Pediatr. Urol. - 2016. - Vol.12(6). - P. 402-el-402-e9.; Hong, C. H., Kim J. H., Jung H. J., et al. Singlesurgeon experience with transvesicoscopic ureteral reimplantation in children with vesicoureteral reflux // Urology. - 2011. - Vol.77(6). - P. 1465-9.]. Minimally invasive surgical procedures using laparoscopic and vesicoscopic approaches in older children are based on the same principles and techniques as their open counterparts. They have almost the same efficiency and at the same time can significantly reduce surgical trauma and improve the cosmetic result.

A known method of laparoscopic surgery according to the Lich-Gregoir principle (V.I. Dubrov, A.V. Strotsky. Comparison of the results of laparoscopic (Lich-Gregoir) and vesicoscopic (Cohen) operations in the treatment of vesicoureteral reflux in children. Original scientific publications, Medical journal, 3/2020, p. 70), according to which the peritoneum is opened above the posterolateral surface of the bladder distal to the vas deferens in boys or the round ligament of the uterus in girls, the posterolateral wall of the bladder and the distal ureter are exposed to the point of entry into the submucosal tunnel. The bladder is filled with 40-60 ml of saline and pulled up to the abdominal wall with the help of threads-holders to improve the visualization of the ureterovesical fistula zone. The detrusor is dissected to the bladder mucosa circularly around the ureterovesical anastomosis and in the proximal direction along the ureter. The length of the created submucosal tunnel is from 4 to 5 cm, depending on the diameter of the ureter, the volume-forming preparation is removed. After performing detrusorotomy, the ureter is placed on the mucous membrane of the bladder, and the detrusor is sutured over it. Additionally, the ureter is fixed to the detrusor at the entrance to the submucosal tunnel. The peritoneum above the bladder is sutured. The bladder is drained by a urethral catheter for 2 days.

The disadvantage of the known method of laparoscopic surgery according to the principle of Lich-Gregoir, for the category of sick children with vesicoureteral reflux, is the lower efficiency, the difficulty of creating a sufficient length of the submucosal tunnel in children of a younger age group.

There is also known a method of vesicoscopic surgery according to the Cohen principle (V.I. Dubrov, A.V. Strotsky. Comparison of the results of laparoscopic (Lich-Gregoir) and vesicoscopic (Cohen) operations in the treatment of vesicoureteral reflux in children, Original scientific publications, Medical Journal , 3/2020, p. 71), which is the closest to the claimed method. In the known method, in the position of the patient on the back, cystoscopy is performed, after which CO ₂ is insufflated into the bladder until tight filling. Under cystoscopic control, the bladder is fixed with ligatures to the anterior abdominal wall. Around the refluxing orifice, a fringing incision of the bladder mucosa is performed, and the ureter is mobilized in a sharp way for 4-5 cm, depending on its diameter, the volume-forming preparation is removed. In the transverse direction, parallel to the interureteral fold, a submucosal tunnel 4-5 cm long is formed, through which the ureter is passed, an anastomosis of the ureter with the bladder mucosa is performed with interrupted sutures, the mucous membrane is sutured in place of the old mouth, the bladder is drained by a urethral catheter for 5 days.

The main disadvantage of the Cohen vesicoscopic operation is the transverse orientation of the submucosal tunnel, which subsequently, due to insufficient bladder volume, significantly complicates ureteral catheterization, ureterocystoanastomosis, and ureteral stenting in children under 3 years of age.

Ureteral stenting has become an integral part of many urological surgical interventions in the treatment of patients with obstructive diseases of the upper urinary tract. Despite advances in the development of stents, problems associated with their use, such as the formation of bacterial biofilms, encrustation, occlusion, migration and destruction, still remain relevant in urological practice. To remove long-standing stone-encrusted ureteral stents, various surgical interventions are used, often requiring different accesses. Forgetfulness of parents, leading to similar complications in children, is a problem that unites the community of urologists in the search for ways to solve it [Baibikov R.S., Akhunzyanov A.A., Takhautdinov Sh.K. https://ecuro.ru/article/zabytyi-mochetoclmikovyi-stent-u-rebenka-mladshego-vozrasta].

Stenting reduces the risk of ureteral obstruction in the postoperative period, ensures the passage of calculus fragments. In addition, stents promote healing of the damaged area of the ureteral mucosa caused at the time of the operation [Nabi G, Cook J, N'Dow J, McClinton S. Outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta-analysis. BMJ 2007 Mar 17;334(7593):572. doi: 10.1136/bmj.39119.595081.55.; Pengfei S, Yutao L, Jie Y, Wuran W, Yi D, Hao Z, Jia W. et al. The results of ureteral stenting afterureteroscopic lithotripsy for ureteral calculi: a systematic review and meta-Analysis. J Urol 2011; 186(5): 1904-1909. doi: 10.1016/j.juro.2011.06.066.; Romanova Ju. M., Gincburg A. L. Bacterial biofilms as a natural form of the existence of bacteria in the environment and in the host organism. Zhurnal mikrobiologii, epidemiologii i immunobiologii. Zhurnal mikrobiologii, epidemiologii i immunobiologii. 2011;(3):99-109. (In Russian)].

Removal of the ureteral stent in children is performed under general anesthesia and with the help of a cystoscope. In some cases, the stent is removed under X-ray control: the guidewire is inserted as deep as possible, the tube is straightened, the outer end is grasped and the stent is pulled out [Shuaibu S.I., Gidado S., Oseni-Momodu E. Endoscopic retrograde JJ-stenting of the ureter without fluoroscopy guidance -an appraisal of outcome. Niger J. Med. 2013;22(4):348-350.]

The exclusion of cystoscopy to remove the ureteral stent is also relevant for pediatric urology. A. Kajbafzadeh et al. presented the results of 523 pyeloplasty performed in children by laparoscopic access with the installation of a jj-stent, the proximal end of which was fixed to the 3Ch tube, brought out through a pyelotomy incision on the skin. Transdermal stent removal was performed 3-4 weeks after surgery on an outpatient basis. In older children, the advantage of this approach, the authors attribute the absence of the need for postoperative bladder catheterization and cystoscopy to remove stents, as well as a reduction in the length of stay and the frequency of postoperative complications [Kajbafzadeh A.M., Zeinoddini A., Ebadi M., et al. External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non- cystoscopic removal. Int. Urol. Nephrol. 2014;46(4):671-676].

The technical task of the claimed method for removing stents without cystoscopy in children after reconstructive plastic surgery on the bladder and ureteral orifices is to create a non-invasive method that improves the effectiveness of the treatment of vesicoureteral reflux.

The technical result of the claimed invention is to increase the effectiveness of the treatment of vesicoureteral reflux due to the simultaneous removal of stents with a Foley catheter in children after reconstructive plastic surgery on the bladder and ureteral orifices, eliminates the need for cystoscopy to remove stents from the ureters, reduces surgical risks , anesthetic risks and hospital costs, and also reduces the risk of nosocomial infection, reduce the number of complications and readmissions.

The technical result is achieved by the fact that in a method for removing stents without cystoscopy in children after reconstructive plastic surgery on the bladder and ureter orifices, including performing a fringing suprapubic incision of the bladder mucosa around the refluxing orifice, mobilizing the ureters in a sharp and blunt way, forming submucosal tunnels in in the transverse direction parallel to the interureteral folds, performing anastomosis of the ureters with the mucous membrane of the bladder and installing stents in the ureters, draining the bladder with a Foley urethral catheter, according to the invention, after installing the stents in the ureters, the proximal ends of the Vicryl sutures are attached to the proximal ends of the stents, the distal ends of which passed through the hole at the distal end of the Foley catheter to the drainage port and brought out, the vicryl sutures are left with the Foley catheter for a period of 7-8 days, after which the stents are removed simultaneously with the Foley catheter by pulling them out by the distal ends of the vicryl filaments.

The inventive method, unlike known analogues, allows simultaneously with the Foley catheter to remove stents from the ureters without requiring re-anesthesia, significantly reduce the time spent in the hospital and the costs associated with performing cystoscopy.

The claimed method is safe and viable, which can be successfully used in pediatric urology.

The invention is illustrated by the following graphics,

Where:

in fig. 1 - a urethral two-way Foley catheter is shown with Vicryl threads passed through its drainage port;

in fig. 2 - a urethral two-way Foley catheter is shown with Vicryl threads passed through its drainage port, the proximal ends of which are extended to the ureters;

in fig. 3 - a urethral two-way Foley catheter is shown with Vicryl sutures passed through its drainage port, the proximal ends of which are fixed on the distal part of the stents.

The designations in Fig. 1-fig. 3: 1 - hole at the distal end of the Foley catheter; 2- inflatable balloon of the Foley catheter; 3 - tube of the Foley catheter; 4-connector of the drainage port of the Foley catheter; 5 - port through which balloon 2 is inflated and deflated; 6 - proximal ends of Vicryl threads; 7 - distal ends of the krill threads; 8 - proximal ends of the stents.

The method is carried out as follows.

With the patient in the supine position, a fringing suprapubic incision is made to expose the anterior wall of the bladder. The bladder is vertically opened throughout (without injuring the neck of the bladder) - thus providing good access to the bladder triangle. The state of the mouths of the ureters is assessed (their size, shape, location). The ureter (or both) is intubated with a Nelaton catheter and fixed with a Vicryl suture behind the posterior wall of the ureteral orifice - this avoids trauma to the intramural ureter. A circular incision around the mouth opens the mucous membrane of the bladder. The incision should not be at least 2 mm from the hole. Gradually carving, the lower part of the ureter is pulled into the cavity of the bladder. Next, the Valdeira muscle is visualized and isolated, closely adjacent to the ureter and forming around the ureter, up to the middle third, a sheath in the avascular zone, which is dissected. Further, the formation of a submucosal tunnel in order to continue its length by 1.5-2.0 cm, 3.5-4.0 cm of the ureter is released, i.e. the ureter should be longer than the formed tunnel. The tunnel is laid along the interureteral fold to the opposite side, and the ureter is anastomosed with the bladder mucosa with interrupted PDS 6/0 sutures. With bilateral vesicoureteral reflux, the operation is performed simultaneously on both sides. As a rule, the formation of the anastomosis is carried out on a thin elastic tube-tire. After that, stents are installed in the ureters and the bladder is drained using a Foley urethral catheter, to fix which 2.5-3 ml of physiological saline is injected through port 5 into balloon 2.

Next, to the proximal ends of the stents 8 installed in the ureters, the proximal ends of the Vicryl filaments 6 are attached, the distal ends of which are passed through the hole at the distal end of the tube 1 of the Foley catheter into the drainage port 4 and brought out, the distal ends of the Vicryl filaments 7 are left with the Foley catheter. The bladder is sewn up tightly.

On the 7th-8th day in the postoperative period, the installed stents are removed simultaneously with the Foley catheter. To do this, the physiological solution introduced during the installation of the catheter is first evacuated from the balloon 2 of the Foley catheter with a syringe, after which the Foley catheter itself is removed, holding and carefully pulling the distal ends of the 7 vicryl filaments, the stents are pulled out.

Thus, given the tenderness of the structure of the mucous membrane of the urethra and the structure of the ureters, especially the vesicoureteral segment, the proposed method allows you to remove stents in children without cystoscopy after reconstructive plastic surgery on the bladder and ureteral orifices.

Results are confirmed by clinical examples

Example 1. Patient E., 1 year 9 months.

Clinical diagnosis: Bilateral vesicoureteral reflux IV-V degree. Right-sided cryptorchidism, inguinal retention. Condition after surgery: Endoscopic plasty of the pyeloureteral segment of the ureter of the right kidney, nephrostomy from 11/27/2020. Endoscopic correction of the orifice of the left and the orifice of the right ureter with Urodex 0.5 ml from 03/05/2021.

Concomitant diagnosis: Apical ventricular septal defect 4 mm. Open oval window. Atrioventricular blockade 1 degree. Funnel chest deformity.

Main postoperative diagnosis: ICD-10 code: Q62.7 Congenital vesicouretero-renal reflux.

Concomitant postoperative diagnosis: ICD10 code: Q21.0 Ventricular septal defect.

Child from first birth. Childbirth - Apgar score 8/9 points, body length at birth 56 cm, body weight at birth 4360 gr. The degree of maturity at birth full-term. Physical development up to a year - moderate weight gain. Psychomotor development up to a year crawls, sits on its own, stands with support, walks with support. Children's infections - did not hurt. For the first time, the disease congenital malformation, infravesical obstruction, was detected by ultrasound prenatally at 37 4/7 weeks of polyhydramnios. Megacystis.

After birth, he urinated on his own. Bilateral vesicoureteral pelvic reflux. He underwent an episode of pyelonephritis on 11/16/2020, remission. On November 27, 2020, surgical treatment was performed: Endoscopic plasty of the pyeloureteral segment of the ureter of the right kidney, nephrostomy. The postoperative period is smooth. Was discharged with a nephrostomy and urinary catheter.

At the outpatient stage, the nephrostomy migrated. Observed by specialists at the place of residence.

03/05/2021 - endoscopic correction of bilateral vesicoureteral reflux was performed. At the outpatient stage, there was no exacerbation of the urinary tract infection.

According to the control ultrasound dated 10/16/2021. The maximum size of the pelvis is up to 22.7 mm on the right.

Cystography. 11/02/2021. With passive filling of the bladder (100 ml Omnipaque 240), vesicoureteral reflux IV-V st. at both sides. The contours of the bladder are clear, even, its shape is correct rounded.

At the moment of micturition, the urethra is contrasted throughout, without local constrictions. When reducing the bladder with an uneven contour. Ultrasound of the kidneys and bladder. 11/02/2021. The right kidney is 77 × 32 mm, the anteroposterior pelvis size is 18.6 mm, the anteroposterior cup size of the upper group is up to 16.7 mm, the lower group is up to 9 mm, the ureter in the upper third is expanded to 8.6 mm, the lower third of the ureter is expanded to 12, 2 mm. The left kidney is 71×30 mm, the anteroposterior cup size of the upper group is up to 13.0 mm, the middle group is up to 4.7 mm, the lower group is up to 7.0 mm, the upper third of the ureter is expanded to 7.7 mm, the lower third of the ureter is expanded to 8 .3 mm. The patient is prepared for reconstructive plastic surgery. On November 3, 2021, surgical treatment was performed: Ureterocystoanastomosis for recurrent forms of ureterohydronephrosis. The operation was performed according to the claimed method on both sides with stenting of the ureters and installation of a 10Fr Foley catheter. Bringing down the right testicle according to Petrivalsky.

In the postoperative period received: Antibiotic (ampisid), painkillers, antihistamines, antispasmodics, infusion therapy.

The postoperative period proceeded smoothly. Foley catheter 10Fr together with stents from the bladder was removed on the 7th postoperative day according to the claimed method. After removal of the catheter, the child's urination is free, painless and without macroimpurities. Postoperative wound healing by primary intention, intradermal absorbable sutures. At the time of examination before discharge, the general condition of the child is assessed as satisfactory. Body temperature 36.6C. There are no complaints from the mother. Appetite is good, nutrition assimilates.

The skin, visible mucous membranes are clean, pink. On palpation, the peripheral lymph nodes were not enlarged.

Vesicular breathing is auscultated above the lungs, rales are not auscultated. CHD-24dv. in min.

Percussion borders of the heart are not expanded. On auscultation, the heart sounds are clear and rhythmic. Heart rate - 110 beats. in min.

On palpation, the abdomen is soft, not swollen, symmetrical, sensitive in the wound area.

According to the mother, the chair is decorated.

He urinates on his own, diuresis is adequate, there is no gross hematuria.

Locally: clean in the seams, no discharge. Processing: 1% brilliant green.

The testicles are palpated in the cavity of the scrotum, there is no edema of the right half of the scrotum. Given the recovery of the postoperative period, the child was discharged home in a satisfactory condition in a satisfactory condition.

Example 2. Patient M., 7 months old.

Clinical diagnosis - Main: Bilateral vesicoureteral reflux IV-V degree. Condition after: Cystoskipy with modeling of the orifices of the ureters from 12/10/2021.

The main diagnosis at discharge: ICD-10 code: Q62.7 Congenital vesicouretero-renal reflux.

She was born from the 1st pregnancy, against the background of toxicosis (inpatient treatment), the first urgent delivery with a body weight of 3580 grams and a length of 53 cm. She was discharged on the 6th day (intrauterine hypoxia, antibiotic therapy against the background of leukocytosis). The child is only on artificial feeding + complementary foods. BCG vaccination in the maternity hospital, V2 hep B, V2 Pentaxim, then examination and observation by a nephrologist. The vesicoureteral reflux is observed by the nephrologist. Infection of the urinary system. (Cystoscopy with modeling of mouths). Seen by an orthopedist. Torticollis. Receives massage and physiotherapy treatment. Allergy anamnesis was not revealed. Contact with infectious patients denies. A smear for coronavirus was negative on 03/12/22 in a child and mother.

At a medical examination at 1.5 months (09/28/2021) - bilateral pyelectasis (12-13 mm), in the analysis of urine on 09/30/2021 - leukocyturia 12-15 in the field of view, on 10/11/2021 - leukocytes 20-25 in the field of view, received course of amoxicillin. 11/09/2021 was examined in the consultative and diagnostic department, children's treatment and rehabilitation complex: ultrasound of the kidneys and bladder: right kidney - anteroposterior pelvis size 9.5 mm, upper groups of the bowl 5.6 mm, ureter in the lower third 7.5 mm, left kidney - anteroposterior pelvis size 12.3 mm, upper groups of the cup 4.5 mm, ureter in the lower third 9.2 mm.

Last hospitalization in December 2021, cystoscopy with modeling of the orifices of the ureters dated 12/10/21. examined: according to ultrasound, there are no signs of kidney obstruction.

Urinalysis at the time of admission without pathology.

03/15/2022. Cystography. Introduced 50 ml of iohexol + chlorhexidine (1:1)

With passive retrograde filling of the bladder and at the time of micturition, reflux into the renal cavitary systems to the cups (III degree) is determined. The bladder is irregularly ovoid in shape, with an uneven contour. Contrasting of the urethra at the time of micturition is uneven. 03/15/2022. Duplex scanning of the renal artery. Inspection against the background of a hungry pause.

Blood flow in the abdominal aorta of the main type, AT was within the normal range, signs of diastolic depletion of blood flow were not detected. The main renal arteries - on the left 40-9-0.78, on the right - 47-10-0.79

Renal blood flow of the main type, norm-resistive.

The venous outflow is preserved.

Conclusion: In the main renal arteries on the right and left, the blood flow is main, norm-resistive.

03/15/2022. Inspection 60 minutes after eating.

Blood flow in the abdominal aorta of the main type, AT was within the normal range, signs of diastolic depletion of blood flow were not detected. The main renal arteries - on the left - 53-12-0.78, on the right - 46-10-0.78

Renal blood flow of the main type, norm-resistive.

The venous outflow is preserved.

Conclusion. In the main renal arteries on the right and left, the blood flow is main, norm-resistive.

03/15/2022. Inspection against the background of a hungry pause.

Echo signs of bilateral pyelocalic ectasia with thickening (on the right), hardening of the walls of the pyelocaliceal system on both sides, moderate dilatation of the ureters in the upper third on the right, upper and middle third on the left.

With ultrasonography, in the projection of the mouths of the right and left ureters, hyperechoic inclusions (collagen) with a diameter of up to 6.3 mm are visualized, on the left - up to 5.9 mm.

On ultrasonography, the wall of the bladder of weak filling is uneven, somewhat thickened up to 3.6 mm.

03/15/2022. Inspection 60 minutes after eating.

Echo signs of bilateral pyelocalic ectasia with thickening (on the right), hardening of the walls of the pyelocaliceal system on both sides, moderate dilatation of the ureters in the upper third on the right, upper and middle third on the left.

On ultrasonography in the projection of the mouths of the right and left ureters, hyperechoic inclusions with a diameter of up to 6.3 mm are visualized, on the left up to 5.9 mm.

Ultrasonography: the wall of the bladder of weak filling is uneven, somewhat thickened up to 3.6 mm.

Furagin 50 mg ¼ tab. 2 - times a day.

Based on the results of the examination, the final diagnosis was verified:

Bilateral vesicoureteral reflux IV-V degree.

The patient is prepared to perform reconstructive plastic surgery.

The operation was performed: 03/18/2022. Ureterocystoanastomosis in recurrent forms of ureterohydronephrosis. Cohen's operation in children. The operation was performed on 2 sides according to the claimed method with stenting of the ureters and placement of an 8Fr Foley catheter into the bladder cavity

In the postoperative period received: Infusion therapy, antibiotic therapy (ampisid 150 mg/kg) and painkillers.

The postoperative period proceeded smoothly, healing: primary intention, intradermal absorbable sutures.

The 8Fr Foley catheter with stents was removed according to the claimed method on the 7th postoperative day. Urination independent, free and painless. Urine is clear.

03/25/2022 Complete blood count: C-reactive protein - 7.00 mg/l, leukocytes - 8.5, hemoglobin - 108.0 g/l. Urine microscopy: leukocytes 80-100 per field of view, erythrocytes - 80-100 per field of view, bacteria - 1+.

The general condition of the child at the time of discharge is assessed as satisfactory. Not feverish. Enteral nutrition absorbs. Doesn't burp. Conscious. He reacts negatively to the examination.

The skin is clean, pale pink, normal humidity. Visible mucous membranes are moist, pink, clean.

On auscultation, puerile breathing is carried out in all parts of the lungs, there are no wheezing. Respiration rate - 24 movements per minute. Auscultatory heart sounds are clear, rhythmic. The heart rate is 100 beats per minute. On palpation, the abdomen is soft and painless. The chair was not examined. Urination is independent.

He was discharged home in a satisfactory condition with recommendations.

Example 3. Patient A., 2 years 4 months

Clinical diagnosis: Obstructive magureter on the right. Condition after surgery: Resection-reimplantation of the right ureter from 06/18/2020. Laparoscopic plasty of the pyelourethral segment on the right from 07/15/2020. Postoperative vesicoureteral reflux on the right IV degree. Main diagnosis at discharge: ICD10 code: N13.7 Uropathy due to vesicoureteral reflux. Date of diagnosis: 04/12/2022

Entered the Department of Pediatric Surgery malformation in a planned manner for the purpose of examination and choice of tactics of surgical treatment.

A child from 1 pregnancy, which proceeded against the background of toxicosis, in the third trimester of pregnancy, ultrasound of the fetus revealed pyelectasis on the right, 1 urgent delivery. Apgar score: 7/8 points; body length at birth: 51 cm; body weight at birth: 3250 gr. Physical development: up to a year: corresponds to age. Mass-growth increases are adequate. Psychomotor development: up to a year holds the head: from 2, turns from back to stomach: from 4.5 months, turns from stomach to back: from 4.5 months, active. Postponed conditions: March 2020 acute respiratory viral infection with catarrhal syndrome. Urinary tract infection due to Klebsiella pneumoniae in June 2020 (antibacterial therapy: fosfomycin), further furagin. She did not have childhood infections. Preventive vaccinations honey tap. Allergological anamnesis: according to the words, without features. Heredity: the father has a congenital absence of a kidney.

Congenital malformation of the urinary system was first detected in the 3rd trimester of pregnancy. From 05/16/20 to 06/15/20, she was examined at the Department of Pediatric Surgery for Developmental Malformations, and congenital hydronephrosis was finally diagnosed. Megaureter on the right. Endoscopic bougienage, stenting of the right ureter to the level of the pyelourethral segment from 06/16/2021. Stent migration and the stent was removed on 06/16/2021. Resection-reimplantation of the right ureter from 06/18/2021. 07/15/2021. Laparoscopic plasty of the pyelourethral segment on the right. Ultrasound of the kidneys and bladder 04/08/2022. Expansion of the pyelocaliceal system up to 3 mm and the bowl up to 6-8 mm, on the left without change. Renal blood flow of the main type, highly resistive. Additional renal artery on the left. Venous outflow is preserved on the right and left.

Cystography 30.03.2022. 100 ml (Iohexol + physiological saline) was injected into the bladder.

On cystograms with tight filling of the bladder and at the time of micturition, right-sided reflux is determined. When micturating, the cast reaches the pelvicalyceal system of the right kidney.

Excretory urography 03/31/2022. Introduced intravenously as a bolus of 24 ml of iohexol + 16 ml of saline.

On a series of urograms, the kidneys are located at the usual level, their shape is bean-shaped, the contours are even, the contrasting of the abdominal systems is timely. On the right, the arches of the cups are smoothed, the cups are moderately dilated (from 7 to 16 mm), the pelvis (measured at 45 minutes) has a transverse size of up to 14 mm, the pyeloureteral segment is rounded; the ureter is not dilated. On the left, the vaults of the bowls are preserved, the cavitary system and the ureter are not dilated.

The contrast in the bladder is visible from 10 minutes.

According to the analysis without features.

The diagnosis was verified and reconstructive plastic surgery was performed.

Operation: 04/05/2022. Ureterocystoanastomosis in recurrent forms of ureterohydronephrosis. Cohen's operation in children. The operation was performed on 2 sides with stenting of the ureters and installation of a 12Fr Foley catheter into the bladder cavity according to the claimed method.

The postoperative period proceeded smoothly. Healing is primary. Intradermal absorbable sutures, removal required. Foley catheter №12Fr was removed from the bladder cavity on the 8th postoperative day. Received Ampisid 500 mg × 3 times a day. Anesthesia: Analgin 50% 0.3 ml + No-shpa 0.3 ml every 6 hours. Dicynon 12.5% - 1.5 ml × 3 times. Paracetamol 120 mg 2 times a day. Glucose 10% 50 ml/hour. Sterofundin 15 ml/hour. After the abolition of the antibiotic, she was transferred to uroseptics Furagin 50 mg 1/2 tab 3 times a day.

At discharge, the general condition of the child is assessed as satisfactory. Body temperature is 36.7 C. The skin is clean, pale pink, normal humidity. Subcutaneous fat is well developed. On palpation, the peripheral lymph nodes were not enlarged. There are no edema. Vesicular breathing is auscultated over the lungs, no wheezing. ChDD-22dv. in min.

On auscultation, the heart sounds are clear and rhythmic. Heart rate - 110 beats. in min.

On palpation, the abdomen is soft, painless, not swollen. The liver and spleen are not enlarged. The bladder is not palpable. According to the mother, the chair is decorated. Urination is free, diuresis is adequate. The child was discharged home in a satisfactory condition.

The results of simultaneous removal of stents with a Foley catheter in children without cystoscopy after reconstructive plastic surgery on the bladder and ureteral orifices were assessed as: satisfactory, relatively satisfactory and unsatisfactory. 3-6 months after the operation, the patients were examined using ultrasound, Dopplerography with duplex scanning of the vessels of the kidneys and bladder, X-ray methods of investigation (excretory urography, voiding cystography), laboratory tests. All children had satisfactory long-term results. When ascertaining a satisfactory result, children within one year, once every 6 months, ultrasound, dopplerography of the ureterovesical ejection of urine, voiding cystoureterography and laboratory tests were performed with positive conclusions.

Thus, the proposed method allows to exclude the performance of cystoscopy to remove stents from the ureters, reduces operational risks, anesthetic risks and hospital costs, and also reduces the risk of nosocomial infection, reduces the number of complications and repeated hospitalizations.

Claims (1)

A method for removing stents without cystoscopy in children after reconstructive plastic surgery on the bladder and ureter orifices, including performing a fringing suprapubic incision of the bladder mucosa around the refluxing orifice, sharply mobilizing the ureters, forming submucosal tunnels in the transverse direction parallel to the interureteral folds, performing anastomosis of the ureters with the mucous membrane of the bladder, stenting of the ureters and drainage of the bladder with a urethral Foley catheter, characterized in that after the installation of stents in the ureters, the proximal ends of the vicryl threads are attached to the proximal ends of the stents, the distal ends of which are passed through the hole at the distal end of the Foley catheter into the drainage port and taken outside, the vicryl sutures are left with the Foley catheter for a period of 7-8 days, after which, simultaneously with the Foley catheter, the stents are removed by pulling them by the distal ends of the vicryl sutures.

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