RU2801605C1 - Method of surgical treatment of extended strictures of upper urinary tract - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: ileograft is obtained by resection of a segment of the ileum. It is used to replace an extended defect, to give a funnel-shaped form, a necessary section of the ileograft is resected on the protivomesenteric side. Moreover, the length of the segment corresponds to the length of the affected area of the upper urinary tract. And after resection, the integrity of the ileograft is restored in the distal direction until its distal end matches the diameter of the ureter, then the stricture of the upper urinary tract is replaced with the formed ileograft, then the defects of the ileum are sutured and the wound is drained.

EFFECT: method makes it possible to eliminate the risks of corrugation and bending of the formed ileograft, to give the ileograft an anatomically identical shape to the upper urinary tract, to form a functionally reliable, well-perfused and accessible for adequate drainage of the upper urinary tract uretero-intestinal anastomosis stent.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, in particular to urology, namely to the surgical treatment of extended strictures of the upper urinary tract affecting the pyeloureteral segment and the ureter, carried out when it is impossible to replace the defect with unchanged urinary tract tissues.

The stricture of the pyeloureteral segment is the result of a number of reasons, which for a long time may not have symptoms due to clinically insignificant narrowing of the lumen, but ultimately lead to a violation of the outflow of urine and the appearance of corresponding patient complaints, as well as to a decrease in the function of the obstructed kidney. The choice of treatment depends on a number of factors, among which the type of pelvis (intra- or extrarenal), the presence of aberrant vessels, and the extent of the stricture should be distinguished. It is the latter fact that makes it difficult to restore patency with the help of unchanged parts of the upper urinary tract. In such cases, in practice, the methods of using various segments of the gastrointestinal tract have justified themselves, in which a segment on the mesentery with a feeding blood vessel is isolated and the affected part of the upper urinary tract is replaced by it. Depending on the method, the segment is either anastomosed immediately or after reconfiguration, mainly by cutting the segment along the anti-mesenteric margin and shaping it.

A known method of surgical treatment of extended strictures of the upper urinary tract (1), where W.H. Yang proposed to convert the short segment of intestine into a long, narrower intestinal tube by dissecting at the anti-mesenteric margin, reconfiguring, turning 90°, and re-tubularizing transversely on an intubator. The idea was tested experimentally and introduced into clinical practice by P.R. Monti et al. (2).

Closest to the claimed is a method of surgical treatment of extended strictures of the ureter - modification B. Ali-el-Dein and M. Ghoneim ileoureteroplasty according to the method of W.H. Yang (3). The method consists in replacing an extended ureteral defect with two reconfigured segments of the ileum of the same length, which are then detubularized by dissection along the antimesenteric edge, followed by a 90° turn and tubularization on an intubator in the longitudinal direction. The result of this reconfiguration is a tube-like ileograft, the diameter of which approximately corresponds to the diameter of the ureter.

This method has several disadvantages:

1. Narrowing of the ileograft at any site of suturing can lead to failure of the uretero-intestinal anastomosis with the development of urinary leakage, retroperitoneal phlegmon, and obstructive uropathy.

2. After rotation of the segments of the ileum in the area of their connection, there is an excess of intestinal tissue (corrugation), and short mesentery creates tension and does not allow straightening the resulting long intestinal strip. In this case, during tubularization in the area of the anastomosis, a kink of the ileograft occurs, which is a common cause of its obstruction.

3. The constancy of the diameter does not allow the use of this technique for the treatment of extended strictures of the upper urinary tract, in which the pyeloureteral anastomosis is affected.

The objective of the invention is the need to develop a highly effective method for the surgical treatment of extended strictures of the upper urinary tract, devoid of the above disadvantages.

The technical result of the invention consists in eliminating the risks of corrugation and bending of the formed ileograft, in giving the ileograft an anatomically identical funnel-shaped portion of the upper urinary tract, and in creating a functionally reliable, well-perfused and accessible for adequate drainage of the upper urinary tract with a uretero-intestinal anastomosis stent.

The specified technical result is achieved in a method for the surgical treatment of extended strictures of the upper urinary tract using an ileograft to replace an extended defect, characterized in that in order to give a funnel shape, a section of the ileograft is resected on the antimesenteric side, and the length of the ileograft corresponds to the length of the stricture of the upper urinary tract, the integrity of the ileograft is restored in the distal direction until its distal end corresponds to the diameter of the ureter, then the stricture of the upper urinary tract is replaced with the formed ileograft.

Within the framework of the proposed method, during the formation of the graft, its axis does not rotate, which eliminates its kink and corrugation. Due to the absence of the need for a 90° rotation of the ileograft, as well as resection of the site on the antimesenteric side, the architectonics of the mesentery is not disturbed, which ensures the integrity of the supply vessels without disturbing the blood supply.

Making the ileograft anatomically identical to the portion of the upper urinary tract in a funnel-shaped form is ensured by resection of the ileograft section on the antimesenteric side with further restoration of integrity by applying a continuous suture in order to gradually reduce the diameter of the resulting ileograft in the distal direction and to match the diameter of its distal end with the diameter of the ureter.

The method is illustrated in Fig. 1-4 where:

In FIG. 1 - resection of the scar-modified section of the upper urinary tract;

In FIG. 2 - selection of a segment of the ileum;

In FIG. 3 - giving funnel-shaped ileograft and creating pyeloileoanastomosis;

In FIG. 4 - creation of ileoureteroanastomosis.

The method is carried out as follows.

Surgical treatment of extended stricture 1 of the upper urinary tract is performed laparoscopically by transperitoneal access. Three ports are located, the kidney and ureter are mobilized. Produce resection of the extended stricture of the upper urinary tract (Fig. 1). Allocate a segment of the ileum 2 of the appropriate length (Fig. 2). The patency of the ileum is restored with a hardware suture. The resulting ileograft 3 to replace the affected pyeloureteral segment with an extended ureteral defect is formed from the ileum of the desired length, which corresponds to the length of the lesion of the upper urinary tract. To give a funnel-shaped form, resection of the required area of the ileograft 3 on the anti-mesenteric side is performed (Fig. 3). After resection, the integrity of the ileograft 3 is restored with a continuous suture using 3/0 Vicryl in the distal direction. (Fig. 4).

The extended stricture of the upper urinary tract is replaced with a formed ileograft 3. Pyeloileo- and ileoureteroanastomoses 4 are performed on the ureteral stent (Fig. 4). Mesenteric defects are sutured, the wound is drained.

The method is confirmed by a clinical example.

Patient K., 61 years old, on September 24, 2018, was hospitalized in a urological clinic in a planned manner with complaints about the presence of a nephrostomy on the right side, periodic pain in the right side. Diagnosis at admission: Recurrent stricture of the upper third of the right ureter. hydronephrosis on the right. Nephrostomy on the right. Chronic pyelonephritis, latent phase. From the anamnesis, it is known that in 2017, a stricture of the pelvic-ureteral segment on the right was diagnosed. hydronephrosis on the right. 05/20/18. performed laparoscopic plasty of the ureteropelvic segment on the right. After 1 month, the ureteral stent was removed, after the removal of the stent, after 1 week, the patient developed acute pain in the right side and an increase in body temperature up to 39°C. An ultrasound examination of the patient revealed a pronounced expansion of the pyelocaliceal system on the right (cups - 23 mm, pelvis - 36 mm, the upper third of the ureter is not visualized), on an emergency basis, the patient underwent percutaneous nephrostomy on the right, antibiotic therapy was prescribed. After stabilization of the condition, she was discharged for outpatient treatment. During examination, on antegrade pyelography, the contrast agent does not pass into the ureter, and when performing simultaneous ante- and retrograde ureteropyelography, obliteration of the upper third of the right ureter was revealed for 4-5 cm.

Taking into account the extent of obliteration, the surgery, a decision was made to perform laparoscopic small bowel plasty. Under endotracheal anesthesia in the position on the left side. During laparoscopy, pronounced cicatricial changes in the region of the right kidney are determined, with technical difficulties, the pelvis of the right kidney and the upper third of the right ureter are isolated. A resection of an extended defect of the right ureter was performed. Then a segment of the ileum of appropriate length was isolated. The patency of the ileum was restored with a hardware suture. The resulting ileograft to replace the affected pyeloureteral segment with an extended ureteral defect was formed from a portion of the ileum of arbitrary length, which corresponds to the length of the lesion of the upper urinary tract. To give a funnel-shaped form, resection of the necessary area of the ileograft was performed on the protivomesenteric side. After resection, the integrity of the ileograft was restored with a continuous suture using 3/0 Vicryl in the distal direction. The operation ended with the placement of a Ch6 ureteral stent. The duration of the operation is 255 minutes. The volume of blood loss is 100 ml. The patient was extubated in the operating room and transferred to the recovery room.

There were no early postoperative complications. On the 7th day the patient was discharged for outpatient treatment. On November 16, 2018, the patient's ureteral stent was removed and a diagnostic ureteroscopy was performed on the right, where good patency of the entire ureter, including the intestinal graft, is determined, the anastomoses are consistent and have good patency. After the removal of the stent, the nephrostomy was blocked; on the control ultrasound examination of the kidneys, there was no expansion of the pelvicalyceal system on the right. On day 2, the nephrostomy drain was removed. Control ultrasound also without expansion of the pelvicalyceal system. The patient had no complaints for 4 years. The above technique was applied in the treatment of extended stricture of the upper urinary tract in 5 patients.

Information sources:

1. Yang W.H. Yang needle tuning technique in creating antireflux and continent mechanisms. J. Urol. 1993; 150: 1993.

2. Monti P.R., Lara R.C., Dutra M.A., de Carvalho J.R. New techniques for construction of efferent conduits based on the Mitrofanoff principle. J. Urol. 1997; 49(1):112.

3. Ali-el-Dein V., Ghoneim M.A. Brilging long ureteral defects using the Yang-Monty principle. J. Urol. 2003; 169(3): 1074-1077.

Claims (1)

A method for surgical treatment of extended strictures of the upper urinary tract using an ileograft to replace an extended defect, characterized in that, in order to give a funnel-shaped shape, a section of the ileograft is resected on the antimesenteric side, and the length of the ileograft corresponds to the length of the stricture of the upper urinary tract, the integrity of the ileograft is restored in the distal direction to match its distal end to the diameter of the ureter, then the stricture of the upper urinary tract is replaced with the formed ileograft.