RU2218876C1 - Method for exposing and ligating dorsal venous complex - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves exposing deep dorsal vein of the penis via a separate incision done in the penis dorsum. The exposed blood vessels are ligated. Then, the dorsal venous complex is transected behind the pubic bones. EFFECT: improved hemostasis condition and operation field visualization quality.

Description

 The invention relates to medicine, namely to surgery, and can be used when performing surgical interventions: radical prostatectomy, posterior prostatectomy, cystrostatectomy in patients with prostate cancer, benign prostatic hyperplasia and bladder cancer.

 The known method of effective ligation of the dorsal vein, including the use of an original longitudinally expanding apparatus during the radical prostatectomy at the stage of ligation of the dorsal venous complex, which is carried out along the urethra into the bladder and, adhering from below to the dorsal venous complex, tightly compresses its lumen. After clamping in a limited area behind the pubic bones and anterior to the apex of the prostate gland of the dorsal vein, ligation and intersection of the dorsal venous complex is performed (US patent 48483b7). The disadvantage of this method is the use of a special device developed by American specialists, and the associated complicated procedure for conducting the operation.

 The closest to the claimed invention, the method of the same purpose for the totality of signs is a method of surgical modification of posadilon radical prostatectomy, in which the dorsal venous complex is isolated and ligated at a distance of 10-15 mm distally from the apex of the prostate gland, that is, slightly closer to the pubic bones than with the usual technique of surgery (J. Urol, 1998 Apr; 159 (4): 1281-5, adopted as a prototype).

 The reasons that impede the achievement of the following therapeutic effects are technical difficulties in ligation of the dorsal venous complex, which occur with large sizes of the prostate gland, as well as in the presence of an acute angle formed by the pubic bones, and a significant probability of damage to the sphincter of the urethra as a result of poor visualization of the urethra with its mobilization after crossing the venous complex.

 The claimed invention is aimed at solving the problem of performing organ-saving surgical intervention when performing radical prostatectomy, posterior prostatectomy, cystrostatectomy, in particular, the restoration of voluntary self-urination.

Use in clinical practice of the claimed invention allows to achieve the following therapeutic results:
- ensuring thorough hemostasis and good visualization of the surgical field,
- the implementation of adequate access during surgery to the urethra and the apex of the prostate gland,
- the ability to accurately isolate the urethra and maintain the external urethral sphincter.

 The indicated therapeutic results are achieved due to the fact that, as in the known method, the dorsal venous complex is isolated and ligated. A feature of the claimed invention is that they carry out preliminary isolation of the deep dorsal arteries and dorsal veins of the penis through a separate incision in the back of the penis, clamping them by applying a turnstile and subsequent ligation and intersection of the venous complex behind the pubic bones.

 The invention consists in the following.

 In operations associated with complete (post-lobar radical prostatectomy and cystoprostate vesiculectomy) or partial (posadilon adenomectomy) removal of the prostate gland, one of the most common and serious intraoperative complications is bleeding from the veins of the dorsal venous complex (Santorini plexus). The main venous collector, which forms the dorsal venous plexus, are the veins of the penis. To ensure adequate access during surgery to the urethra and the apex of the prostate gland, ligation of the dorsal venous complex and its intersection immediately behind the pubic joint are necessary.

 Often during the operation, pronounced venous bleeding develops, which is associated with a significant thickness of the complex, the depth of the surgical wound and the relatively narrow angle that the pubic bones form. With the development of bleeding from the dorsal veins, the sphincter apparatus of the urethra can easily be damaged, which leads to postoperative urinary incontinence and is more likely to perform non-radical surgery (residual tumor along the urethral resection line).

 The inventive method of ligation of the dorsal complex includes the preliminary allocation of deep veins through a separate incision in the back of the penis and their temporary clamping. This technique allows you to drastically limit blood flow to the dorsal complex, to ligate and cross it under conditions of careful hemostasis. At the same time, good visualization of the urethra and the apex of the prostate gland is also achieved, which allows to increase radicalism and improve the functional results of the operation. Thorough hemostasis and good visualization of the surgical field during ligation and intersection of the venous complex allow the urethra to be accurately identified and the external urethral sphincter to be maintained, which in turn allows us to solve the problem of restoring voluntary self-urination. At the same time, the absence of venous bleeding and good visibility allow observing the radicalism of surgical intervention and removing the tumor within healthy tissues.

 The method is as follows.

 A separate longitudinal section of a length of about 0.5-1.0 cm cut through the skin and superficial fascia in the back of the penis directly at its root. Deep dorsal arteries and veins of the penis are isolated and separated over 1.0-1.5 cm from the cavernous bodies. Turnstiles (from a thin latex strip) are placed on the vessels and tightened until their gleam is completely clamped. Behind the pubic bones, the surface branch of the dorsal vein of the penis is ligated and crossed, after which the inner pelvic fascia is cut to the right and left of the prostate gland, the prostate gland is bluntly mobilized along the lateral surfaces. The pubic-prostatic ligaments cross the right and left. The dorsal venous complex is flashed immediately behind the pubic bones with atraumatic non-absorbable sutures (Etibond 3.0). After flashing the venous complex, the turnstile is removed from the deep veins of the penis in front of the pubic bones, after which hemostasis is re-evaluated. If necessary, the dorsal venous complex is stitched and bandaged additionally. A wound in the area of the root of the penis is sutured. Next, surgery is continued according to standard methods.

 Clinical examples.

 1. Patient G., 63 years old, was admitted to the Department of Oncourology of the Moscow P.A. Herzen 12.03.00 with a diagnosis of prostate cancer of the II stage, T2NXM0. Morphology: small-acinar adenocarcinoma, 6 points according to Gleason. PSA-18.7 ng / ml. Prostate volume according to TRUS - 70.0 cc

 The patient underwent surgery: radical prostatectomy.

 During the operation, the patient was allocated dorsal vessels of the penis anterior to the pubis and the turnstile was applied to them. After this, the dorsal venous complex was stitched and ligated behind the pubic bones. Blood loss at the stage of ligation and intersection of the dorsal venous complex was 100.0 ml. In conditions of adequate hemostasis, a precise allocation of the urethra was made, which allowed to maintain the maximum functional length of the urethra (external urethral sphincter). Blood loss over the entire duration of the operation was 850.0 ml. The postoperative period was uneventful, the wound healed by first intention, the urinary catheter was removed on day 19. 1 month after surgery, the patient recovered independent voluntary urination, there is no residual urine.

 2. Patient G., 49 years old, was under examination and treatment at the oncourology department of the Moscow Scientific Research Institute for Surgery. P.A. Herzen. Clinical diagnosis: bladder cancer, II stage, T2bN0M0. Morphology: poorly differentiated transitional cell carcinoma. The patient underwent surgery: cystrostatic vesiculectomy with orthotopic plastic of the bladder in the small intestine. During the operation, during the mobilization of the prostate gland before ligation of the dorsal venous complex, deep dorsal arteries and penile veins were isolated through a separate incision and a turnstile was placed on them with compression of the lumen. After this, the dorsal venous complex was stitched behind the pubic bones, its intersection and mobilization of the urethra. Bleeding at this stage was not observed. After ligation of the venous complex, the turnstile was removed from the penile vessels, blood flow was restored, after which stable hemostasis was noted. The total blood loss during the operation was 1050 ml. The postoperative period was uneventful, the wound healed by first intention. Foley's urethral catheter was removed on day 19. 14 days after removal of the urinary catheter, the patient recovered voluntary urination.

 Thus, from the foregoing, it follows that the claimed method of isolation and ligation of the dorsal venous complex meets the criteria of patentability and has significant advantages compared with known methods of the same purpose.

Claims (1)

The method of isolation and ligation of the dorsal venous complex, characterized in that preliminary isolation of the deep dorsal vein of the penis and dorsal artery of the penis is carried out through a separate incision in the back of the penis, their compression by applying a turnstile and subsequent ligation and intersection of the venous complex behind the pubic bones.