RU2308893C2 - Surgical method for treating extended pelvic ureter segment strictures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves substituting ureter defect with vermiform appendix with neurovascular its mesentery structure being retained. The vermiform appendix is excised together with blind gut segment having diameter of 10-15 mm. Opening is made in urinary bladder wall at least 10 mm as large in diameter. The produced blind gut segment with vermiform appendix is end-to-side implanted into the opening. The ureter is transected 4 cm or more far from the stricture boundary. After excising the tip, end-to-end anastomosis is created between the distal vermiform appendix end and ureter.

EFFECT: reduced stenosis risk in anastomosis zone; improved antireflux action.

Description

The invention relates to medicine, more specifically to urology, and may find application in reconstructive surgery of damaged ureters.

The cause of defects (strictures) of the ureters are various lesions of the upper urinary tract: traumatic, including iatrogenic, associated with surgical interventions, as well as the aggressiveness of certain types of treatment (radiation therapy, etc.). According to various authors, the frequency of ureteral obstruction due to fibrosis ranges from 0.4% to 5.5%, and according to autopsy data of the dead with uremia, it reaches 35%. Ureter defects also occur as a result of injuries or a gunshot wound, lumbar sympathectomy, rupture with transurethral ureterolithoextraction, and injuries with ureteroscopy.

Reconstructive surgery for extended strictures of the pelvic ureter is a complex problem of reconstructive urology. It is associated with an increase in the number of patients with recurrent and complicated narrowing of the ureters and unsatisfactory results of plastic surgeries.

Most often, ureteroplasty is performed by the ileum. If the changes apply to both parts of the ureter or are bilateral in nature, then intestinal plasty or autologous kidney transplantation is used. With patchwork methods for repairing a ureter defect, a section is cut out from the bladder to replace it. If an indirect ureterocystastomosis is performed, then you always have to partially mobilize the bladder, and then cut a flap out of it. These manipulations lead to local denervation of the bladder, to deformation of its contours and a decrease in functional volume. This inevitably leads to anatomical and functional complications of the bladder.

In recent years, surgeons have shown interest in ureteroplasty with a vermiform appendix with its sufficient length. This operation is classified as rare. Single observations of various authors indicate the possibility of replacing the appendix with extensive narrowing of the ureter. For the first time, such an operation was performed abroad in 1905, and in Russia in 1975. At present, there are separate reports in the literature about the replacement by the vermiform appendix of the ureter, usually the right one, with damage of various genesis. Restrained attitude to this operation is due to far from the best near and distant results, limited technical capabilities in its implementation and almost always the availability of alternative methods of treatment.

At the same time, the possibility of ureteral plastic appendix due to the peculiarities of its structure. Anatomically, the appendix is a rudimentary continuation of the cecum and begins from its posteromedial or medial wall. The length of the process, according to literature and autopsy, in adults ranges from 2 to 24 cm and averages 9 cm. Its diameter is on average 8 mm. The appendix does not have a fixed position in relation to the cecum, is covered on all sides by the peritoneum and has a usually well-defined and mobile mesentery, in which the vessels and nerves pass. In adults, there is one appendicular artery, less often - two. They originate from the ileocecal artery or from one of its branches and pass in the free edge of the mesentery of the appendix. Here, several branches depart from the main artery. Sufficient length and diameter, mobility due to the long mesentery with the supply vessels suggest the possibility of using the vermiform appendix in reconstructive operations for extensive defects of the ureter.

Currently, no one in the world has sufficient clinical material to objectively judge the advantages and disadvantages of replacing the ureter with an appendix. Nevertheless, the progress of surgery achieved in recent years allows us to hope for the successful implementation of this complex organ-preserving operation in clinical practice.

Closest to the proposed method for the surgical treatment of extended strictures and defects of the pelvic ureter is the method described in the book Komyakova B.K., Guliev B.G. “Surgery of extended narrowing of the ureters”, St. Petersburg, 2005, p.146-153, which we took as a prototype.

The authors in their practice successfully used the vermiform process three times to replace defects of the ureter: in two patients for extended radiation strictures of the pelvic section and in one patient for plastic surgery of the proximal part of the right ureter damaged by a gunshot wound. We give a description of one of these cases.

The patient was admitted to the clinic in 1998 with a diagnosis of postradiation stricture of the lower third of the right ureter, hydroureteronephrosis, chronic pyelonephritis in the latent phase, and chronic cystitis. From the anamnesis it is known that in 1996 the patient underwent hysterectomy for cancer, and then radiation therapy was carried out.

06.06.98, the patient underwent lower middle laparotomy. In the small pelvis, pronounced retroperitoneal fibrosis with complete obliteration of the pelvic ureter was found. As a result of ureterolysis and resection of the ureter, a defect 10 cm long was formed. The pronounced cicatricial process in the area of the iliac vessels, deformation and reduction in the size of the bladder made it impossible to perform patchwork according to the Boari method. The presence and accessibility of a large (12 cm) vermiform appendix with a long mesentery and good blood supply made it possible to use it to replace a ureter defect. The appendix was cut off at the base. His mesentery was mobilized, the tip was cut off. The lumen is washed with saline. An end-to-end ureteroappendicoanastomosis isoperistically performed on a polyvinyl chloride tube. The distal end of the intubator is drawn through the appendix into the bladder and out through the urethra. Direct appendicocystanastomosis was performed intraperitoneally. The bladder is sutured tightly and drained transurethrally by a Foley catheter. The postoperative period was uneventful. The wound healed by primary intention. On the 13th day, the intubator was removed. On antegrade pyeloureterogram, patency of the upper urinary tract is good. After removal of nephrostomy drainage, the fistulous opening was closed. The patient was discharged for outpatient treatment. Within 5 years is observed in the clinic. There are no complaints, the analyzes are not changed, the kidney function is saved.

This clinical observation indicates that with careful and accurate mobilization of the appendix with preservation of the vascular-nervous structure of the mesentery, its isoperistaltic location in relation to the urinary tract, and mandatory resection of the apex of the appendix as an insufficiently supplied and poorly functioning site, the replacement of the ureter with the appendix is relatively simple and less traumatic in comparison with the methods used for extended defects of the ureter (intestinal plasty, autologous transplantation chki). The authors believe that, subject to the above provisions and a sufficient length of the appendix, it is possible to replace almost any part of the ureter. In our opinion, the advantages of the method include the fact that an autogenous organ of the diameter corresponding to the ureter with a similar wall structure is used. In addition, the appendix has a reduction directed towards its base, due to which, with an isoperistaltic arrangement, a good passage of urine is provided. Low resorption should be considered an advantage of appendicoureteroplasty, since the area of contact with urine is small, and it quickly passes through this section of the urinary tract created in this way.

However, such surgery is far from always feasible due to the anatomical and functional features of the patient. In addition, as noted by several authors, a frequent complication in the long term is a narrowing or obliteration in the area of the anastomosis between the appendix and the bladder. This is due to the fact that the lumen of the normal appendix is mainly 5-7 mm, and the anastomosis often leads to a further narrowing of the lumen. Under the conditions of ischemia present in the suture area, aseptic inflammation occurs, followed by scar formation. All this holds back doctors from performing such a surgical procedure.

The technical task of the present invention was to develop a method for replacing the affected ureter with a vermiform appendix, devoid of the above disadvantages, i.e. in improving the immediate and long-term results of such substitution.

This problem is solved in that the vermiform appendix is resected together with a segment of the cecum with a diameter of 10-15 mm with preservation of the neurovascular structure of the mesentery and resection of the apex of the appendix with subsequent suturing of the wound, a hole of at least 10 mm in diameter is made intraperitoneally in the bladder wall and the end-to-side type implanted implanted segment of the cecum with the vermiform appendix, and the distal end of the appendix is resected and anastomosed end-to-end with the ureter, previously excised within the new tissues at a distance of at least 4 cm from the border of the defect.

The resection of the appendix together with the segment of the cecum provides the formation of a wide anastomosis, which significantly reduces the risk of stenosis in the anastomosis zone.

This is due to the fact that in the cecum the intraorgan arterial network is developed quite powerfully and therefore each membrane of the vermiform appendix receives a very abundant vascular network. At the locations of solitary lymphatic follicles, which are found in large numbers in the submucosal layer of the cecum and appendix, the arterial network has the greatest density. In the same way as the intraorgan arterial network, the intraparietal venous and lymphatic systems of the appendix, which have extensive anastomoses with venous and lymphatic systems of the cecum, are arranged. It is known that intraparietal anastomoses can provide blood supply to the colon by an average of 3-5 cm. Given this, it can be confidently stated that the resected part of the cecum dome due to intraorgan anastomoses receives adequate blood supply. Hence, the use of a well-circulated worm-shaped appendix with a segment of the cecum with a diameter of 10-15 mm to replace the pelvic ureter and makes it possible to form a wide anastomosis between the appendix and the bladder in order to reduce stenosis in this zone.

The location in the resected segment of the cecum of the so-called “appendicular flap”, formed by a fold of the mucous membrane (which prevents leakage of intestinal contents from the lumen of the cecum into the appendix), provides an antireflux mechanism during anastomosis of the cecum segment with the bladder, which is a great advantage of the method.

Cutting off the damaged ureter in the area of healthy tissues, namely at a distance of at least 4 cm above the upper boundary of the damage (stricture), ensures normal peristalsis of the remaining part of the ureter, since it was established by intraoperative electromyography that the visual border of the non-repairing part of the ureter, on the basis of which it is selected as a rule, the level of resection is 15–20 mm lower than that determined by the intensity of the biopotentials of muscle contractions. The usually performed resection of the damaged ureter (2-3 cm proximal to its narrowing level) can lead to impaired peristalsis in the anastomotic region and insufficient passage of urine.

All of the above distinguishing features of the proposed method, as shown by us in the surgical treatment of extended ureteral strictures, significantly increase the safety of plastic surgery, as well as improve its immediate and long-term results.

The essence of the proposed method is illustrated by example.

EXAMPLE 1. By-L., 41 years old, on January 25, 2005 was urgently admitted to the clinic with a diagnosis of iatrogenic damage (ligation) of both ureters, postrenal anuria, posthemorrhagic anemia. From the anamnesis, it is known that on January 23, 2005, in one of the gynecological departments of St. Petersburg, the uterus was extirpated with the removal of both ovaries due to uterine fibroids. The operation was carried out with significant technical difficulties and was accompanied by massive bleeding. Over the next two days, the patient's condition was extremely serious. The patient is dynamic, inhibited, diuresis was absent, blood creatinine 308 μmol / l and anemia up to 56 g / l. An ultrasound revealed an expansion of the cavity system of the kidneys. According to vital indications, the patient was transferred to the urology department. On January 25, 2005, percutaneous nephrostomy was performed on the right, and on January 31, 2005, on the left. Intensive therapy was carried out aimed at replenishing blood loss, normalizing water-electrolyte and acid-base balance, improving cardiovascular activity, as well as detoxification and anti-inflammatory therapy. Gradually, the patient's condition improved, kidney function recovered, and on February 15, 2005, the patient was discharged for outpatient treatment.

For reconstructive surgery, the patient was hospitalized on March 14, 2005, as planned, repeatedly. When examining blood creatinine - 83 μmol / l, urea - 4.5 mmol / l, hemoglobin - 108 g / l, hematocrit - 33.1%. With intravenous urography and computed tomography of the kidneys, defects in the pelvic sections of both ureters were revealed.

March 23, 2005, the patient was taken for reconstructive surgery. An indirect ureterocystanastomosis according to Boari was performed on the left with the antireflux technique. On the right, after the ureter was excreted, its defect was found to be 8 cm long. Given the presence of a large (11 cm) vermiform appendix with a long mesentery, it was decided to use it to replace a defect in the right ureter. They mobilized the appendix and its mesentery. A circular incision around the mouth of the appendix excised a rounded area with a diameter of 15 mm. The wound of the cecum was sutured with a double-row vicryl suture. 3 cm were cut off from the distal end of the appendix, its patency was checked, and washed with saline.

The ureter was bandaged and cut off from its defect at a distance of 4 cm above its border. Then, an end-to-end ureteroappendicanastomosis was performed isoperistically on a polyvinyl chloride tube. A hole with a diameter of 10 mm was made intraperitoneally in the wall of the bladder through which the distal end of the intubator was passed through the appendix into the bladder and brought out along the urethra with the Foley catheter. After that, a wide anastomosis was performed between the bladder and the resulting "outlet" from the cecum.

The postoperative period was uneventful. The wound healed by primary intention. On the 12th day, the ureteral intubator was removed on the left, on the 13th - on the right. Independent urination recovered, and the patient was discharged for outpatient treatment.

During the follow-up examination 5 months after the operation, the patient's condition is satisfactory, with the ultrasound examination, the cavity system of the kidneys is not expanded, in the urograms the kidney function is timely, the urinary tract on both sides is well passable. The ureter site, replaced by the appendix, contrasts in the form of a narrow strip that does not differ from the cystoid of the normal ureter. No changes in blood and urine tests were noted. With cystoscopy, the volume of the bladder is sufficient, the mucosa is not changed, the zone of anastomosis of the rounded area of the cecum with the bladder is well visualized. The opening of the appendix opening into the lumen of the bladder is similar in size and configuration to the mouth of the ureter.

Currently, the patient is fully adapted and in the social aspect, returned to her previous work.

To date, the proposed method has undergone surgical treatment of 3 patients with extended strictures of the pelvic ureter, and one of them had a defect in the left ureter, but with a sufficiently large length of the mesentery and appendix (about 12 cm), we were able to successfully replace the damaged ureter with it . All patients are currently alive, in satisfactory condition and working.

The proposed method in comparison with the known has several significant advantages.

1. Unlike the prototype, it significantly reduces the risk of stenosis in the anastomosis zone, and also provides an antireflux mechanism, which improves the immediate and long-term results of treatment.

2. Since absorption is practically absent in the appendix, its inclusion in the urinary tract has less effect on electrolyte metabolism and the acid-base state of the blood.

3. The method significantly violates the anatomical relationship in the abdominal cavity.

4. Appendicoplasty is less traumatic, because does not require bowel resection.

The method was developed in the Department of Urology of the city multidisciplinary hospital N 2 of St. Petersburg and underwent clinical testing in 3 patients with a positive result.

Claims (1)

A method of surgical treatment of extended strictures of the pelvic ureter by replacing the defect with the appendix with preservation of the neurovascular structure of the mesentery and resection of the apex of the appendix, characterized in that the appendix is resected together with a segment of the cecum with a diameter of 10-15 mm followed by suturing of the wound in the urine wall the bubble intraperitoneally make a hole of at least 10 mm in diameter and the end segment of the cecum with the vermiform appendix is implanted end-to-side by type, and the distal The end of the process is resected and anastomosed end-to-end with the ureter, previously cut off at a distance of at least 4 cm from the stricture border.