UA53768C2 - Method for enterocystoplasty - Google Patents

Abstract

The invention relates to the medicine, in particular to the surgical treatment of bladder cancer. The method comprises the cyctectomy, the dissection of the small intestine, the recovery of the intestinal continuity, and the catheterization of the ureters. The artificial bladder is cut from the T-shaped loop made from the part of the ileum by sewing its mesenteric edge with the interrupted sero-serosal sutures. Then the openings in the non-vascular mesenteric area are generated between the sewed regions of the part of the ileum. The ureters with the catheters are passed through the openings and fixed to the intestine. The ileum is dissected throughout all the length of the T-shaped loop. The ureters are placed into the openings and the bowel is restored. The distal end of the intestine is placed onto the perinium within the canal between the anal sphincter and the separated anal mucosa.

Description

Description of the invention

The invention belongs to medicine, namely to the technique of forming a bladder from the small intestine during 2 surgical treatment of cancer.

Modern requirements for surgical treatment of bladder cancer in many cases include its complete removal. At the same time, immediately or after a certain period of time, the question of restoring the function of the bladder arises. Solving such a problem involves restoring the reservoir function of the bladder with the simultaneous restoration of the mechanism of urine removal and retention. In practice, in most cases, different sections of the small and large intestine are used to restore the capacity of the 70 bladder. To restore urinary retention, natural sphincters of the gastrointestinal tract are used - Bauginia valve, rectal sphincter.

Many surgeons restore the natural path of urinary excretion by forming an anastomosis between a segment of the intestine and the urethra. It is not always possible to achieve satisfactory results of intestinal plastic surgery. Until now, questions related to the prevention of the reflex of intestinal contents in the ureters/ the reliability of the ureteral-intestinal and urethral-intestinal anastomoses, the creation of a reliable mechanism of urine retention remain unsolved. In some cases, when the tumor is localized in the area of the urethral opening during the operation, part of the urethra has to be resected. In these cases, it is technically impossible to restore the natural way of urinary excretion.

There is a well-known method of small-intestinal plastic surgery of the urinary bladder according to Bricker (Shepylov V.Y. Cancer of the urinary bladder.-M.: Medicine. 1983.-192p. on p. 115) in which "a lower median laparotomy is performed.

The ileum is found and, retreating 30-40 cm from the point where it joins the cecum, a segment 25-30 cm long with a well-defined vascular pattern is cut out. The distal parts of the ureters are mobilized, and the left one is passed through the mesosigmoid, polyethylene tubes are inserted into them and implanted into the opening of the segment by one of the methods described above. The site of anastomoses is carefully peritonized with peritoneum. Segment c is placed transversely at the level of the promontorium to the posterior peritoneum and fixed with several sutures in such a way that (3 between them) the intestine could not be pinched. The end of the segment is brought out through an incision in the right or left iliac region 2 cm above the surface of the skin and fixed to the aponeurosis and skin. The intestinal-cutaneous anastomosis should be located in such a way that it is convenient to wear a fixing belt for the ureter. The defect in the mesentery is sutured and the integrity of the small intestine is restored with a "side-to-side" anastomosis.

The disadvantages of the known method are the small capacity of the newly formed bladder, the reflex of intestinal contents to the upper urinary tract and the resulting infection (chronic pyelonephritis, sepsis), which leads to the development of kidney failure, complications from the stoma (stenosis of the intestinal-cutaneous stoma, peristoma hernias). . in

However, the main disadvantage of this method is the presence of a stoma on the front abdominal wall, which causes severe physical and moral suffering to the patient. 3o The well-known method of small-intestinal plastic surgery of the urinary bladder according to A. Shilling with co-authors. (Shilling A., Friesen A., Fr

Grinvald V.A. A new method of surgical treatment of bladder cancer and its immediate results! //

Herald of surgery.-1994.- Mo 1 - 2. P. 82 - 90) in which a segment of the ileum 45 - 50 cm long is used to create an artificial bladder. Depending on the features of the anatomical structure of the mesenteric "vessels, the mobilized segment of the ileum forms an M- or MU-shaped bladder. Plastic casing is made according to the method described by Kosk using a continuous seam. For implantation of the ureters, the technique of Sateu and Ge Juis is used in the form of a so-called bifurcated sleeve. After the dome of the new bladder is formed, an anastomosis is placed between it and the funnel-shaped prostatic part of the urethra. At the same time, two semi-circular continuous seams with 1 ST1 Yuehop thread are applied at the level of 6 o'clock and carried out in different directions, forming a knot at the level of 12 o'clock. The dome of the new 49 bladder is sutured with a continuous suture. The opening of the anastomosis is drained with a silicone catheter Mo 22. The ureters are drained with two ureteral catheters, which are brought out to the front abdominal wall through a bladder stoma. Another co-urethral catheter Mo 20 is passed into the newly formed bladder for its constant irrigation and removal of the secretion of its mucous membrane. After 12 days, urinary catheters are removed and after 21 days - 7 bladder catheters.

Gee! 20 The disadvantage of the known method is the technical complexity of the operation, the reflux of intestinal contents into the upper urinary tract and the resulting infection (chronic pyelonephritis, sepsis). However, the main drawback of this known method is the impossibility of using it for primary plastic surgery of the bladder in patients with tumor localization in the area of the urethra opening, which makes it necessary to remove part of it for oncological reasons. In this situation, it is too difficult to anastomose between the intestine and the resected part of the urethra. 29 The use of this method is also not possible for secondary bladder plastic surgery after earlier

GF) performed cystectomy due to scar-sclerotic processes that develop in the stump of the urethra.

A well-known method of small-intestinal plastic surgery of the urinary bladder according to D.P. Chukhrienko. (Chuhrienko D.P., Lyulko A.V. about the Atlas of operations on the organs of the genitourinary system!. - M.: Medicine, 1972.-376 p.) in which, after removing the urinary bladder, the abdominal cavity is dissected and retreating 20 - ZOsm from the ileocecal angle, a 60 loop of the small intestine up to 25 cm long is resected. Intestinal patency is restored by side-to-side or end-to-end anastomosis. The loop of the resected intestine is brought out into the small pelvis. The edge of the peritoneum is sheathed around the mesenteric loop.

The abdominal cavity is closed tightly. The ends of the isolated loop are sewn. Both ureters are transplanted into the newly formed reservoir at a distance of 6-7 cm from each other. Then, along the outer edge between the ureters, the loop is cut and a drainage tube is inserted into the cut, which is removed through the urethra. because the edges of the formed bladder are fixed to the urethra and surrounding tissues with knotted sutures.

The disadvantage of the known method is the insufficient capacity of the newly formed bladder, the high risk of developing urointestinal anastomosis, the impossibility of using it for primary plastic surgery of the bladder in patients with tumor localization in the area of the urethral opening, which makes it necessary to remove part of it for oncological reasons. The use of this method is also not possible for secondary bladder plastic surgery after a previously performed cystectomy due to scar-sclerotic processes that develop in the urethral stump.

A well-known method of small-intestinal plastic surgery of the urinary bladder according to Sateu-e Otse (Managadze L.G., Chigogidze T.G.,

Rodionov I.A., Gotsadze D.T. Methods of supravesical diversion of urine and cystoplasty // Urology and nephrology.-1994.-Mo 3,-S. 45 - 49) is chosen as the prototype, in which 30 - 40 cm of the small intestine is isolated at a distance of 70 15 cm from the cecum, trying to isolate the segment so that its middle reaches the urethra freely without tension. The left ureter is anti-reflux anastomosed with the left "horn" of the intestinal segment. In the next stage, an intestinal-urethral anastomosis is performed, and then the right ureter is transplanted using the antireflux method into the top of the right "horn" of the intestinal segment.

The disadvantage of the known method is nocturnal urinary incontinence, which often develops and the causes of which are found "in 7/5 Significant peristaltic contractions of the tubular intestinal graft and in the weakening of the muscles of the pelvic floor" (Manadze L.G., Chigogidze T.G. Rodionov I. A., Gogadze D.T. Method of supravesical diversion of urine and cystoplasty // Urology and nephrology.- 1994.-Mo 3.-S.45 - 49), as well as, as in the above analogues, the impossibility of its use for primary bladder plastics in patients with tumor localization in the area of the urethral opening and the impossibility of using it for secondary, bladder plastics after a previously performed cystectomy due to scar-sclerotic processes that developed in the stump of the urethra.

The invention is based on the task of improving the method of enterocystoplasty by plasticizing the small intestine with the creation of a new reservoir and a new urethra, as well as using the anal sphincter as a retaining mechanism, to ensure reliable restoration of the reservoir function of the newly formed bladder and the mechanism of urine retention during bladder removal, for example, due to cancer and with SC localization mainly in the area of the opening of the urethra.

The task is solved by the fact that during the formation of an artificial bladder, i)

A T-shaped loop made from the ileum of the small intestine by suturing its mesenteric edge with knotted gray-serous sutures, then holes are formed between the sewn sections of the ileum of the small intestine in the avascular zone of the mesentery, ureters are passed through this hole together with catheters arranged in them, fixing so z each of them, after which the small intestine is dissected along the entire T-shaped loop, the ureters are arranged in the opening of the intestine and form a small-intestinal reservoir with the ureters arranged in it, then on the perineum X, the distal end of the small intestine is brought, and the last one under the erection time is contained in the channel between the sphincter M of the rectum and the separated mucous membrane of the anal canal.

What is new in the declared decision is that during the formation of the artificial bladder, Fr

A T-shaped loop of the intestine, the ureters are conducted between the sutured walls of the small intestine, the small intestine is reduced to the perineum, and the latter during reduction is contained in the channel between the sphincter and the separated mucous membrane of the anal canal. The use of a T-shaped loop makes it possible to obtain a sufficient capacity of the bladder with a minimum number of sutures. Conducting the ureters between the sutured sections of the small intestine makes it possible to obtain a rather larger area of surfaces that grow together, and to avoid the need to use complex technical techniques for the formation of a ureteral-intestinal anastomosis. Bringing the small intestine to the perineum in the tunnel between the separated mucous membrane of the anal canal and the sphincter allows, on the one hand, to preserve its retaining function, and on the other hand, to separate the intestinal contents of the rectum from urine. with The method is carried out as follows.

After removal of the bladder and catheterization of the ureters, the small intestine is transected with the mesentery using the UO-40 device, preserving the (supplying) small intestinal vessels, in ZOsm and 8Osm from the Bauginia c valve. Intestinal continuity is restored by end-to-end small-small-bowel anastomosis. Restore the integrity of the mesentery of the small intestine. The section of the small intestine on the mesenteric peduncle is turned so that the distal end descends into the small pelvis. At the same time, if the length of the mesentery is not enough for free placement of the graft in the pelvis, dissection of avascular areas of the mesentery is performed. The proximal end of the intestine, sewn with a hardware suture, is immersed in the pouch suture. A T-shaped loop is formed by the iliac section of the small intestine

Me, by suturing its mesenteric edge with nodular gray-serous kapron sutures. Near the base of the T-shaped loop, between the sutured sections of the small intestine, holes are made with a clamp in the avascular zone of the mesentery. The ureters together with the urethral catheters are passed through these holes and each of them is fixed with 3-knot sutures placed between the serous membrane of the ureter. The small intestine is dissected along the entire T-shaped loop. ov Ureters together with catheters into the opening of the intestine. A continuous catgut suture is placed on the back lip of the interintestinal anastomosis and on the front lip, using a Connell suture. Nodal kapron (F, gray-serous sutures) are applied, thus completing the formation of the small-intestinal reservoir with the ureters arranged in it. A tunnel is formed from the front from the rectum to the muscles of the pelvic floor and the proximal end of the small intestine is placed in it. on the side of the perineum, dissection of the mucous membrane of the anal canal is performed on the border with the perianal skin along the front semicircle for 1/3 of its length. The mucous membrane of the anal canal is peeled back to the level of the internal sphincter. The incision at the level of the internal sphincter cuts through the muscular and adventitial membranes of the intestine, thus penetrating into the pelvic cavity. The proximal end of the small intestine is grasped and reduced to the perineum in the channel between the rectal sphincter and the separated mucosa of the anal canal. Sutures are applied between the small intestine and the perianal skin along the anterior semicircle of Her 65 and the separated mucosa of the anal canal along its posterior semicircle. sides of the abdominal cavity perform its drainage and suturing of the abdominal wall.

The essence of the method is explained by the drawings, where Figures 1 - 9 show:

Figure 1. 1 - Baugin valve; 2 - small intestine;

C - directions of dissection of the small intestine and its mesentery; 4 - small intestine mesentery; 5 - mesentery vessels of the small intestine; 6 - the direction of rotation of the small intestine. 70 Figure 2. 7 - hardware seam; 8 - mesenteric edge of the small intestine; 9 - gray-serous seams; - purse stitch.

Figure 3. It is the openings between the sutured sections of the small intestine.

Figure 4. 12 - ureters; 13 - urethral catheters; 14 - sutures that fix the ureters to the intestine.

Figure 5. 15 - the direction of dissection of the wall of the small intestine.

Figure 6. 12 - ureters; 13 - urethral catheters; ch 16 - the direction of movement of the ureters into the opening of the small intestine; 17 - opening of the small intestine. and)

Figure 7. 18 - continuous catgut seam.

Figure 8. so z 12 - ureters; 19 - gray-serous seams; ise) 20 - formed small intestinal reservoir. M

Figure 9. 21 - rectum; i) 22 - the reduced distal end of the small intestine; u 23 - sphincter of the rectum.

The method is carried out as follows. A lower median laparotomy is performed. After the cystectomy, catheterization of the ureters is carried out according to the usual method. Then cross section (Fig. 1, item 3) of the small intestine (Fig. 1, Item 2) with the mesentery (Fig. 1, Item 4) using the UO - 40 apparatus, preserving the (supplying) small intestinal "bodies" (fig. 1, p. 5, in 30 cm and 40 cm from the Bauginian valve (fig. 1, p. 1). Intestinal continuity is restored pl) with end-to-end small intestinal anastomosis. Restore the integrity of the mesentery of the small intestine. The section is thin. the intestines on the mesenteric leg are turned (Fig. 1, p.b) in such a way that the distal end descends into the small pelvis. a At the same time, if the length of the mesentery is not sufficient for free placement of the graft in the pelvis, dissection of the avascular areas of the mesentery is performed. The proximal end of the intestine, sewn with a hardware suture (Fig. 2,

P. 7), dip into the pouch seam (fig. 2, p. 10). A T-shaped loop is formed from part of the ileum by suturing its mesenteric edge (Fig. 2, item 8) with nodular gray-serous kapron sutures (Fig. 2, item 9). At the base

A T-shaped loop, between the stitched sections of the small intestine, holes are made with a clamp (Fig. 3, item 11) in the avascular zone of the mesentery. The ureters (Fig. 4, item 12) are passed through these holes together with the urethral catheters (Fig. 4, Item 13) and each of them is fixed with - 4 knotted sutures (Fig. 4, Item 14), placed between the serous membrane of the intestine and the adventitial membrane of the ureter. They dissect (fig. 5, p. 15) the small intestine along the entire T-shaped loop.

Me, Ureters (fig.b, item 12) together with catheters (fig.b, item 13) are arranged (fig.b, item 16b) in the opening of the intestine (fig.b, item 17). A continuous catgut suture (Fig. 7, p. 18) is placed on the back lip of the interintestinal anastomosis and on the front, using a Connell suture. Continuous or knotted kapron "gray-serous sutures" are applied (Fig. 8, p. 19), thus completing the formation of the small-intestinal reservoir (Fig. 8, p. 20) with ovoid ducts arranged in it (fig. 8, p. .12). A tunnel is formed from the front of the rectum to the muscles of the pelvic floor and contains the distal end of the small intestine. From the side of the perineum, dissection of the mucous membrane of the anal canal is performed on the border with

F) perianal skin along the front semicircle for 1/3 of its length. The mucous membrane of the anal canal is peeled off to the level above the internal sphincter. Above the level of the internal sphincter, the muscular and adventitial membranes of the intestine are crossed, thus penetrating the pelvic cavity. The distal end of the small intestine in the channel between the sphincter of the rectum and the separated mucous membrane of the anal canal is captured and brought to the perineum. Sutures are applied between the small intestine and the perianal skin along its anterior semicircle and the separated mucous membrane of the anal canal along its posterior semicircle. From the side of the abdominal cavity, its drainage and suturing of the wound of the abdominal wall are carried out.

An example of a specific implementation of the method. 65 Patient V., 48 years old, medical history No. 107082, was hospitalized in the urology department of the Donetsk Regional Antitumor Center on December 6, 1999. with the diagnosis: bladder cancer T3z3MoMo. After further examination and pre-operative preparation, it was decided to perform a cystectomy with a primary plastic small intestine according to the developed technique, which was carried out. A middle-lower-middle laparotomy was performed. After the intraoperative assessment of the spread of the tumor process, it was decided to perform the intended operation. Cystectomy was performed according to the usual technique. The ureters were isolated and their catheterization was performed. The small intestine was sutured with a UO-40 suturing device and crossed twice at a distance of 40 and 80 cm from the Baugii valve. The mesentery of the small intestine was transected while preserving the (supplying) vessels. Intestinal continuity was restored by end-to-end small-small-bowel anastomosis. The integrity of the mesentery of the small intestine was restored. The area of the small intestine on the mesenteric leg is turned so that the distal end is lowered into the small pelvis. The proximal end of the intestine, sewn with a hardware suture, was immersed in the pouch suture. A T-shaped loop was formed from part of the ileum by suturing its mesenteric edge with nodular gray-serous nylon sutures. Near the base of the T-shaped loop, between the sutured sections of the intestine, holes were made in the avascular zone of the mesentery. The ureters together with the urethral catheters were passed through these holes and each of them was fixed with 3-4 knotted sutures placed between the serous membrane of the intestine and the adventitial membrane of the ureter. The intestine was dissected along the entire T-shaped loop. Ureters together /5 Catheters were placed in the opening of the intestines. A continuous catgut suture was applied to the posterior and anterior lips of the interintestinal anastomosis using a Connell suture. Knotted kapron gray-serous sutures were applied, thus completing the formation of the thin-pelvic reservoir with the ureters arranged in it.

A tunnel was formed from the front of the rectum to the muscles of the pelvic floor and the distal end of the small intestine was inserted into it with ureteric catheters inserted into it. From the side of the perineum, the mucous membrane of the anal canal was separated at the border with the perianal skin along the front semicircle for 1/3 of its length. The mucous membrane of the anal canal above the internal sphincter was peeled off. Above the level of the internal sphincter, the muscular and adventitial membranes of the intestines were cut, thereby penetrating the pelvic cavity. The distal end of the small intestine was lowered into the perineum in the channel between the sphincter of the rectum and the separated mucous membrane of the anal canal. Sutures were applied between the small intestine and the perianal skin along its anterior semicircle of the skin and separated mucous membrane of the anal canal along its posterior semicircle and separated mucous membrane of the anal canal along its posterior semicircle. From the side of the abdominal cavity, it was drained and the wound of the abdominal i) wall was sutured.

All patients would be operated on. All patients had a smooth postoperative period. Life expectancy was 38.5 months. All patients were examined 3, 6, 9, 12, 24 months after surgery. The capacity of the newly formed bladder was on average 300 - 35 Oml, all patients retained urine. There were no signs of ascending urinary tract infection. ise)

Thus, the advantage of the method is the reliable restoration of the reservoir function of the urinary bladder and the mechanism M of urine retention. co

Zo

Claims (1)

The formula of the invention is a method of enterocystoplasty, which includes cystectomy, transection of the small intestine, restoration of intestinal continuity, catheterization of the ureters, which is distinguished by the fact that during the formation of an artificial urinary bladder, a T-shaped loop is used, made from part of the ileum by suturing its mesenteric edge with with nodular gray-serous sutures, then holes are formed in the avascular zone of the mesentery between the sewn sections of the ileum, ureters are passed into these holes along with the catheters placed in them, fixing each of them to the intestine, after which the ileum is dissected along of the entire T-shaped loop, the ureters are placed in the opening of the intestine and form a small intestinal reservoir, then the distal end of the intestine is brought down to the perineum, and the latter is placed in the channel between the sphincter of the rectum and the separated mucous membrane of the anal canal during contraction. (95) -I b 50 IR e) F) name) 60 b5