RU2271159C1 - Method for ureterocystoneoanastomosis in case of urinary bladder's cancer - Google Patents

Abstract

FIELD: medicine, oncourology.

SUBSTANCE: the present innovation deals with treating malignant neoplasms of urinary bladder at invasion in ureter's mouth. For this purpose, one should perform cystotomy, apply about 5-6 ligatures leaving some space against affected wall of urinary bladder. Moreover, it is necessary to circle the tumor with ligature ring. Then comes electroresection of urinary bladder's wall till the appearance of ureter, the latter should be isolated intravesically followed by applying the holders upon it. Then ureter should be dissected leaving 3 cm against the tumor and intubated with a tube; ureter should be applied towards the upper angle of urinary bladder's wound followed by applying a neoanastomosis; then it is necessary to suture in the defect of urinary bladder's wall and install an urethral catheter. Then comes vesicoplexia followed by suturing in the wound up to drainages. The innovation suggested enables to exclude the strictures in anastomosis area.

EFFECT: higher efficiency.

10 dwg, 1 ex

Description

The invention relates to medicine, namely to oncourology, and can be used in the treatment of malignant neoplasms of the bladder with invasion in the mouth of the ureter of various degrees of malignancy.

A known method of re-implantation of the ureter is Boari operation (see D.P. Chukhrienko, A.V. Lyulko, M .: Medicine, 1972, p. 113) with deep invasion by the tumor process of the bladder wall in the area of the mouth. The method consists in replacing 6-7 cm of the ureter.

However, this method has disadvantages: neuromuscular dysfunction of the bladder wall in the anastomotic zone and persistent vesicoureteral reflux.

The well-known "Method of re-implantation of the ureter into the bladder" (see Pollitano-Lidbetter D.P. Chukhrienko A.V. Lyulko, M .: Medicine, 1972, p. 112), according to which the ureter is carried out for 1-2 cm under the mucous membrane a layer of the bladder and only after that they are brought to the surface of the wall of the bladder and fixed.

However, this method has disadvantages: obstruction of the ureter as a result of edema or contraction of the thickened wall of the bladder against a background of spasm. Persistent ureteral obstruction is a progressive expansion of the upper urinary tract.

The well-known “Method of plastic surgery of the urinary ureteral anastomoses” (see Gill's surgery, p. 110 D.P. Chukhrienko, A.V. Lyulko M .: Medicine, 1972), which we selected as a prototype.

It is known that transplantation of the ureters into the bladder (ureterocystoneostomy) is performed for violations of the patency of the pelvic ureter, or for damage to the mouth of the ureter with a tumor. After neostomy of the ureter, strictures or vesicoureteral refluxes are often observed. In order to avoid these complications, the author conducts neostomy with the formation of a “papilla” from the distal ureter, protruding into the cavity of the bladder by 0.5-1.0 cm, and the formation of an ureteral-urinary bubble angle of 35 °. However, the technique of Gill's operation involves excision of the adventitia and the muscle layer of the ureter, as a result of which trophic disturbances occur. The most common complication in the early and late stages after plastic surgery of the vesicoureteral ureteral anastomoses is stricture in the anastomotic region and, as a rule, hydronephrotic transformation of the kidney, often recurring pyelonephritis, formation of kidney stones, nephrogenic hypertension, nephrosclerosis and death of the kidney.

The aim of the invention in the formation of ureterocystone anastomosis is the exclusion of stricture in the anastomosis, the provision of a double mechanism of antireflux protection and the restoration of normal passage of urine in a patient.

This goal is achieved by the fact that after cystotomy and assessment of the condition of the bladder wall affected by the tumor process in the area of the ureter mouth and, retreating from the tumor by 2.5-3.0 cm, impose 5-6 nylon threads, take these threads on the clamp, slightly they are tightened, thereby the tumor is limited by the filament ring, then the bladder wall is electrically resected around the filament ring until the adiposebubular fat and ureter appear, the latter is isolated sharply and bluntly, continuing to carry out traction by the holding thread, stepping back from the tumor by 3 cm, the ureter is cut off, having previously taken it to the holder, the ureter is intubated by 15-20 cm with a polyvinyl chloride tube and fix it to it with a catgut; then an intubated ureter is brought into the upper corner of the wound of the resected bladder wall and a neoanastomosis is performed, with 5-6 vicryl sutures being applied, two independent mechanisms of antireflux protection are achieved, after removal of the endotracheal drainage for 14-16 days, an antireflux cuff is formed and the ureter forms a bladder angle of approximately 35 °, the remaining defect in the resected bladder wall is sutured with a 2/0 single-row vicryl suture continuously to a new mouth, the operation is completed with cystos omiey, with breeding intubation with cystostomy drainage installation and the urinary catheter, anterior bladder wall sutured one thread vicryl two rows to continuously drains, while fulfilling the same vezikopeksiyu thread vicryl to the rectus abdominis muscle.

The invention “A method for ureterocystone osteoastritis in case of bladder cancer” is new, since it is unknown from the level of medicine in oncourology in the treatment of malignant neoplasms of the bladder located in the area of the mouth of the ureters.

The novelty of the invention lies in the fact that when electroresection of the bladder wall occurs when the ureter appears, the resection is stopped, the ureter is intrapubularly isolated with a blunt and sharp pathway, the ureter is applied and 3 cm away from the tumor. The ureter is intubated by a 15–20 cm PVC tube and fixed to her with vikril 4/0. Then they proceed to the plastic stage - ureterocystone anastomosis with double antireflux protection. An intubated ureter is brought into the upper corner of the wound of the resected bladder wall and neoanastomosis is performed - 5-6 vicryl sutures are applied, achieving 2 independent mechanisms of antireflux protection. The first - after removal of the intubation drainage on the 14th, 16th day, an inversion of the transplanted ureter mucosa is formed - an antireflux cuff, the second - an ureteropelvic angle is formed, which also prevents the formation of active and passive refluxes. The remaining defect of the resected bladder wall is sutured continuously with a single-row vikril seam, which is the prevention of the formation of ligature stones.

The invention "The method of ureterocystone anastomosis in bladder cancer" is industrially applicable, as it can be used in health care institutions, research oncological institutes, cancer clinics and other medical institutions involved in the treatment of bladder cancer with invasion of the wall in the area of the mouth of the ureter of varying degrees of malignancy without damage to regional lymph nodes and distant metastases.

"The method of ureterocystone anastomosis in bladder cancer" is as follows.

The position of the patient on the back with an elevated pelvis. Previously, after the evacuation of urine, gas (oxygen) is injected into the bladder. Tissues (skin, subcutaneous tissue, rectus and pyramidal muscles) are dissected layer by layer with the middle supral or arched transverse (according to Pfanenstil) access. Hemostasis along the wound. Dissect the prevesical tissue. The front wall, the apex and the lateral wall of the bladder are mobilized with a topper as much as possible (the lateral wall mobilization is determined by the location of the tumor). When the bladder is mobile and hemostasis is performed, two holders are placed on the front wall of the bladder. The holders slightly tighten and between them open the wall of the bladder with a section of 7-8 cm. Next, examine the cavity of the bladder, assess the condition of the mouths, neck of the bladder, the nature and location of the tumor.

With pronounced infiltrative growth of the tumor (Figure 1-1, a tumor affecting the mouth of the ureter), which does not allow the mouth of the ureter to be detected, the following is performed: departing from the tumor by 2.5-3 cm, several (5-6 pcs.) Nylon holders are applied ( Figure 2-2, the dashed line indicates the line of ligatures surrounding the tumor), taking these threads on the clamp, pull them slightly, thereby the tumor is located in the (filament) ring, then the bladder wall is electrically resected, continuing light traction by the holding threads. Immediately after the appearance of the ureter, electroresection is stopped. The ureter is isolated dull and sharp (one of the main stages of our technique) by the intravesical route, fixation holders are placed on it and it is cut off by 3 cm from the tumor (Fig. 3-1 wound of the bladder wall after resection). The ureter is intubated by 15-20 cm with a polyvinyl chloride tube and fixed to it with a 4/0 catgut thread. Then they proceed to the plastic phase of the operation, perform ureterocystone anastomosis with antireflux protection. An intubated ureter is brought into the upper corner of the wound of the resected bladder wall and neoanastomosis is performed (5-6 vicryl sutures are applied), achieving the formation of a cuff-roller (Fig. 4-1 mouth of the transplanted ureter). Thus, after removal on the 14-16th day after the operation of the endotracheal drainage, an eversion of the transplanted ureter mucosa is formed - an antireflux cuff (Figure 5-1), and an ureteral-urinary bubble angle of 35 ° is formed (Figure 5-3), which also prevents the formation of active and passive refluxes. The remaining defect in the bladder wall is sutured with vicryl continuously in a single row, which is the prevention of the formation of ligature stones (Figs. 4-2 and Figs. 5-5 line of a continuous vikril seam of the resected bladder wall). Figures 5-2 and 5-4 of the intamural and juxtasical sections of the transplanted ureter. The operation is completed by the installation of a balloon urethral catheter, a cystostomy with the endotracheal drainage removed together, the cystotomy wound of the bladder is sutured continuously with one vicryl thread in two rows to the bladder drainage with vesicopexy.

An example of a specific application of the "Method of ureterocystoneoanastomosis in bladder cancer" on a patient. Patient N., 55 years old. Medical history No. 8505/632.

I was hospitalized in 2-level. Dep. OB-2 of Rostov-on-Don from 06/03/03 to 06/26/03. Complaints: an admixture of blood in the urine periodically, for a month, frequent urination with cuts.

Objectively: The area of the kidneys is painless on palpation, with Pasternatsky negative on both sides, palpation above the bosom is painless, OAM: lake - 50-60, er - 20-25, white - 0.33, epithelium - 2-5, reaction - acidic, density - 1015, urea - 5.7; creatinine - 0.100, total protein - 84.0 g / l, PSA - 0.89 ng / ml.

Ultrasound: kidneys without features, CLS is not expanded, no calculi. Parenchyma homogeneous 20-22 mm. The bladder is ovoid in shape, its capacity is 350 ml, on the left side wall in the projection of the mouth of the left ureter, a formation of 5.0 × 4.5 cm in diameter is located. Residual urine - 20 ml. (Fig. No. 6).

CT of the pelvic organs (Fig. 9, 10), the bladder is of normal size, on the left wall is a formation with a tuberous contour, the infiltrating wall of the bladder is 30 × 40 × 50 mm. No enlarged lymph nodes were found in the retroperitoneal space and in the pelvic area.

Urinary tract X-RAY No. 5078-81. In the overview image (Fig. No. 6) without shadows suspicious of calculi. After the introduction of a contrast medium (76% urographin), the function of the right kidney is from 7 minutes (Fig. No. 7), the pyelocaliceal system is not changed. The function of the left kidney in the form of a nephrogram is determined from 15 minutes, the pyelocaliceal system and ureter are not contrasted. The bladder is round in shape, on the left side wall a filling defect of irregular shape (Fig. No. 8).

01/28/02. Electroresection of the bladder wall with urterocystone anastomosis. Blood loss - 200 ml. In the early postoperative period, he received planned analgesia, infusion and antibacterial therapy, and daily dressings. The postoperative period is smooth. Stitches removed on time. Postoperative wound healing by primary intention. The urethral catheter was removed on the 6th day, the endotracheal drainage on the 14th day, the cystostomy drainage was removed after the restoration of self-urination. Bed day was 23 fps. Histological conclusion No. 14583-90: Moderately differentiated papillary urothelial cancer with invasion of the muscle layer. After discharge from the hospital, the patient was sent to the RNII for further treatment.

The technical and economic effectiveness of the “Method of ureterocystone anastomosis for bladder cancer” consists in the following advantages of the method: when excreting the ureter, paravesical tissues and large vessels are less likely to be mechanically affected, which significantly reduces the risk of bleeding. The principle of antireflux (in our example, double antireflux) protection is preserved, the ureter-urinary bladder angle is formed, and the antireflux oyster is formed. The principle of ablasticity is maintained. Reliable tightness of the bladder wall wound. When suturing the front wall of the bladder, one thread is used. The operation is organ-preserving and radical. Reduction of the patient’s hospital stay due to better healing of the postoperative wound. Restoring normal passage of urine in a patient.

Claims (1)

The method of ureterocystone osteoanastomosis in case of bladder cancer with a lesion of the ureter orifice, including cystotomy, characterized in that, departing from the tumor wall of the bladder by 2.5-3 cm, 5-6 nylon threads are applied, they are clamped, they are slightly tightened, Surrounding the tumor with a filament ring, then the bladder wall is electrically resected until the ureter and adipose-adipose tissue appear in the field of vision, then the ureter is separated with a blunt and sharp path, the holders and compartment are placed on it the ureter is retreated by 3 cm from the tumor, the ureter is intubated by 20-25 cm with a polyvinyl chloride tube and fixed to it with a 4-0 catgut, then the ureter is brought into the upper corner of the wound of the resected bladder wall and neoanastomosis is performed, the rest of the bladder wall defect is sutured in one row with a vikril suture continuously, the operation is completed by the installation of a urethral catheter, epicystostomy with the removal of intubation drainage along with a cystostomy, the defect of the anterior wall of the bladder is sutured with one vikril thread in two rows discontinuously with simultaneous vesicopexy to drainage, the wound is sutured in layers to drainage.

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