RU2415649C1 - Method of ureter transplantation - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to urology, and is intended for surgical treatment of violation of urine passage in ureter as result of obstructive process, or insufficiency of vesicourethral fistula, as well as in case of kidney transplantation. Tunnel is formed. Ureter is placed into said tunnel. Distal part of ureter is fixed to urinary bladder. Preliminarily, on mid-line in suprapubic part performed is trocar puncture cystostomy under ultrasound control and introduction into urinary bladder cavity of drainage tube-intubator with perforation on spiral on its distal end. Operation access to ureter is performed more laterally than usual suprapubic access in inguinal region. Ureter is cut off from urinary bladder, perforated part of tube is removed out of formed in it orifice. Tunnel between layers of urinary bladder walls is formed. Ureter is dissected at acute angle, preferably 45 degrees, tube is introduced in it for 2/3 of its length. Narrowed ureter is passed through intubated with tube tunnel. Ureter is fixed to urinary bladder wall. Transplantation is performed with apex of cut toward urethra, ureter mucosa is sewn near base of acute cut with two sutures. The remaining part of ureter cut is placed into urinary bladder lumen, fixed in stretched position like petals in three different directions by means of ""-shaped "anchor" sutures, applied from urinary bladder lumen outward, through all layers of urinary bladder walls with further drawing of ureter inside urinary bladder. ^ EFFECT: method makes it possible to reduce length of operation access, reduce its trauma, as rectus muscles of abdomen are not cut off, white line, where post-operational hernias are formed, is not dissected, urinary bladder wall is not opened and access to its lumen is provided on small section, blood circulation and innervation of urinary bladder are not disturbed. ^ 3 dwg, 1 ex

Description

The invention relates to medicine, namely to urology, and is intended for the surgical treatment of disorders of the passage of urine through the ureter as a result of the obstructive process or insufficiency of the vesicoureteral fistula, as well as during a kidney transplant.

A known method of transplantation of the ureter with vesicoureteral reflux in children and adult patients. If the degree of reflux is high and there is an unfavorable general background, then surgical treatment is proposed - antireflux surgery. The essence of any antireflux operation is the creation of an intramural ureter, whose length is 4-5 times its width (Vozianov O.F., Lyulko O.V. Atlas-Guide to Urology: 3 vol. - 2nd ed., Revised) . and add. - Dnepropetrovsk: RVA "Dnepro-VAL", 2001. - 692 p.).

The extravesical ureter transplantation technique is known, in which the ureter is fixed to the base of the bladder, and the muscle of the bladder is stitched around the ureter - the Lich-Gregoir method or detrusorrafia. A lower middle or transverse incision is made above the pubis. Dissect the transverse fascia over the bladder, move it upward with a finger, exposing the obliterated umbilical arteries. The ureter is isolated, it is taken on rubber holders. Bandage several perforating vessels behind the ureter, preserving the vessels in the adventitious ureter, if possible. Mobilize the ureter towards the bladder. Raise it on a holder. With a curved clamp, the intramural part is separated from the muscle membrane of the bladder to the level of the mucous membrane. The muscular membrane of the bladder is cut with a scalpel to the submucosa, forming a trench 3 cm long, located almost in the vertical direction. They put the bladder in place to make sure that the direction of the incision coincides with the natural course of the ureter. Separate the edges of the muscular membrane of the bladder from the submucosa, so that they can be stitched over the ureter. The ureter is placed in the formed gutter. The edges of the detrusor are not tightly sutured over the ureter with interrupted sutures with synthetic absorbable suture. The swelling of the mucous membrane is eliminated by screwing inward into the cavity of the bladder. Check if the ureter is squeezed at the site of entry into the bladder. They put the bladder in place, drain the operation area with a rubber graduate, suture the wound in layers (F. Khinman. Operational urology: Atlas: Transl. From English. - M.: GEOTAR-MED, 2003, p. 817-818).

The known method - the Lich-Gregoir method (Lich-Gregoir) or detrusorography - has several significant drawbacks.

The method is carried out by means of a sufficiently traumatic approach, leaving behind a noticeable postoperative scar - a lower middle laparotomy or transverse suprapubic access. In addition, such access has worse healing conditions, as it passes through the suprapubic “fat pad”, limits the possibilities of revision, mobilization and dressing of the ureter on the affected side (usually to the left). The possibility of removing drainage tubes and cystostomy through separate punctures, outside the area of postoperative sutures on the bladder and skin, is reduced. Two or more drainage tubes are used (for intubation of the ureter and drainage of the bladder). The bladder is widely mobilized, opened by two incisions, which injures its wall, is accompanied by hematuria in the postoperative period, lengthens the healing time of the wound, requires drainage of paravesical fiber for the prevention of urinary flow.

A known method of kidney transplantation, including the processing of a donor kidney, the formation of anastomoses of the vessels of the donor kidney with the vessels of the recipient, where the avascular zone of the apex of the bladder is distinguished, two defects of the muscle layer are formed in this zone, they are connected together by a tunnel in the mucosal layer, and the ureter is passed through the tunnel with withdrawal to the above muscle layer with the subsequent application of neoureterocystoanastomosis, immersion in the axillary layer, after the ureter is removed into the above muscle layer through it a stent is carried out that exceeds the length of the ureter by 4-7 cm, one end is placed in the renal pelvis through a section of the ureter, the other end is immersed into the bladder, the ureter is dilated in the area of the neoureterocystoanastomosis, then the ureteral mucosa is sewn from the bladder mucosa on the stent RF patent No. 2226367, IPC А61В 17/00, published on April 10, 2004).

The disadvantages of this method

1. In this case, a ureteral transplant is possible only for a donor kidney, and in the case of congenital or acquired pathology (megaureter, PMR, cicatricial stenosis), the method is of little use, since an opening in place of the removed ureter is not used.

2. The disadvantage is that for the introduction of the stent, it is necessary to additionally dissect the ureter "over 7 mm", which increases the possibility of failure of the sutures, stenosis.

3. For drainage of the bladder in the postoperative period, the installation of an additional catheter in the bladder is required.

4. If there is a stent in the bladder cavity, it is impossible to fully control the passage and the quality of urine from the operated kidney, to perform postoperative ureterocystography.

5. The mucosa of the ureter and bladder sewn edge to edge in the area of the anastomosis, which increases the risk of eruption and failure of the sutures, stenosis of the anastomosis.

6. To remove the stent, additional medical manipulation is required - cystoscopy, a month after surgery. Wide operative access and mobilization of the bladder increases the invasiveness of the operation.

Closest to the proposed method is extravesical submucosal ureterocystoanastomosis (RF patent No. 2297801, IPC АВВ 17/11, published on April 27, 2007), intended for anastomosis of the ureter with the bladder or intestinal reservoir after cystectomy. In the specified method of ureterocystoanastoanastomosis, including laying and fixing the ureter, immersing the distal end of the ureter in a cystotomy incision, the length of which corresponds to half the circumference of the ureter, first open the outer case of the bladder, consisting of adventitia and muscle wall, for four diameters of the ureter away from the incision, and the ureter is laid in the formed tunnel, the proximal ureter at the entrance to the tunnel is fixed to the outer case, then the outer case begins to be sutured with the outer wall of the ureter approaching, a cystotomy incision is made on the inner case and the ureter is immersed in the urinary reservoir so that 1 cm of the ureter remains in the lumen, after which the outer case is closed.

This method has several significant disadvantages. The method does not provide for drainage and intubation of the transplanted ureter, which can cause a violation of its patency in the near postoperative period and require emergency nephrostomy, it does not allow to fully control kidney function on the affected side. A significant number of sutures imposed on the ureter and bladder, an extended incision of the bladder wall pose a threat of eruption, insufficiency of sutures, the formation of urinary leakage, "anastomositis" and stenosis of the anastomosis.

When creating an extravesical submucosal anastomosis, “open the outer (adventitious-muscular) bladder case over four diameters of the ureter and bluntly prepare the cases away from the incision”, which requires wide operative access, extended isolation and preparation of the bladder and ureter wall. “The distal end of the ureter is immersed in the urinary reservoir, so that 1 cm remains in the lumen”, while the end of the ureter protruding into the lumen of the bladder remains unfixed, with unpredictable possibilities of cicatricial deformity, which complicates catheterization and promotes stenosis. The disadvantage of this method of transplantation is also the possibility of bleeding from a section of the ureter, because he simply plunges into the bladder, which can lead to tamponade of the bladder and require additional surgical intervention; accompanied by hematuria in the postoperative period.

The purpose of the invention is to reduce the morbidity of surgery - transplantation of the ureter - to reduce the likelihood of developing postoperative complications,

The present invention is based on the task of creating a method for extravesical transplantation of the ureter, which would reduce the disadvantages of the known methods by increasing the efficiency of drainage of the ureter and pyelocaliceal system of the kidney and eliminating stress in the urinary system, eliminating incisions in the bladder wall, torsion and stenosis of the ureter when primary surgery.

The technical result of the invention is the ability to drain the pyelocaliceal system of the kidney, eliminate the likelihood of stricture of the ureter, its excessive length, avoid the development of urinary leakage, maintain the antireflux technique for the formation of the bladder anastomosis, and prevent the possibility of additional surgery on the urinary tract.

The technical result in the implementation of the invention is achieved by the fact that in the method of extravesical transplantation of the ureter (ureterocystoanastomosis), including the formation of the tunnel, laying the ureter in it and fixing its distal section to the bladder, first a midline puncture cystostomy is performed along the midline in the suprapubic section with ultrasound monitoring the introduction of a drainage tube-intubator into the bladder cavity, with perforation at its distal end up to 2/3 of its length, surgical access to the ureter is performed laterally bony suprapubic lateral access in the inguinal region, then the ureter is cut off from the bladder, and the perforated part of the tube is removed from the mouth formed in it, a tunnel is formed between the muscular and submucous layers of the bladder wall from the mouth side, the ureter is excised at an acute angle, preferably 45 degrees, a tube is inserted into it to a depth of 2/3 of the length so that the drainage side holes are located in the lumen of the transplanted ureter, and the last two holes are located in the lumen of the urine of the bladder, it is passed through a tube intubated with a narrowed ureter, after which the ureter is fixed to the wall of the bladder, and the ureter is transplanted with the tip of the urethra and the mucosa of the ureter is sutured at the base of the oblique section with two sutures, the rest of the ureter section is placed the bladder and is fixed in the stretched position like the petals in three different directions with special "anchor" U-shaped sutures imposed from the lumen of the bladder outward, through all ou bladder wall. Perforation in the tube-intubator is preferably made in a spiral.

In the proposed method, the length of operative access is reduced, its trauma is reduced, because the rectus abdominis are not cut off, the white line is not cut, where postoperative hernias are most often formed. The wall of the bladder does not open, and access to its lumen is provided in a small area at the site of the ureter, that is, at the place of the natural opening, while the blood supply and innervation of the bladder are not disturbed.

Prompt access over the distal segment of the ureter allows for its full rectification, dressing and resection, which is difficult for suprapubic incision. The absence of an incision in the bladder provides a quick restoration of its function and reduces the duration of postoperative hematuria.

The use of a drainage tube with a spiral-shaped course of the lateral drainage holes improves the outflow of urine from the ureter, since at any position of the tube part of the holes that are not in contact with the ureter wall remain free.

Installing a drainage tube-intubator so that the last two holes of the distal part remain in the lumen of the bladder, provides a complete outflow of urine both from the ureter and from the cavity of the bladder through a single drainage system.

Carrying out a training tube through the tunnel with intubation of the ureter, followed by the application of a neuroretrocystoanastomosis of the type of petals with special "anchor sutures" allows you to reliably form the mouth of the transplanted ureter, making it easily accessible for visual monitoring and catheterization during cystoscopy.

Figure 1. The scheme of the first stage of the operation is a drainage tube in the bladder, a ureter resection.

Figure 2. The scheme of the second stage of the operation is the removal of the drainage tube from the bladder and intubation of the ureter.

Figure 3. The scheme of the third stage of the operation is the formation of the mouth of the ureter.

The method is as follows.

Surgery begins with the installation of a silicone drainage tube (3) in the bladder with a diameter of at least 10 Fr on the Charriere scale, with multiple side openings, over 10-15 cm, for subsequent drainage of the lumen of the ureter. The drainage tube (3) is prepared from a soft silicone tube 50-60 cm long, the drainage side holes are laid in a spiral along the distal part of the tube. The drainage tube-intubator (3) is carried out in the bladder by means of a trocar puncture cystostomy under the control of ultrasound (figure 1). To do this, under general anesthesia, before the start of the surgical incision, the bladder is filled until the walls are completely straightened, and the puncture point is indicated under ultrasound control. The skin is pierced with a pointed scalpel along the midline in the suprapubic area, the anterior abdominal wall and the wall of the bladder are punctured with a trocar, after which the trocar stylet is removed, a drainage tube of 15-20 cm length is inserted into the bladder, ultrasound monitoring of its standing in the bladder , the sleeve of the trocar is removed and the bladder is washed to "clean water" with sterile saline. Re-treat the surgical field in the incision area and perform a skin incision in the projection of the inguinal canal, on the side of the affected ureter (2). Open the front wall of the inguinal canal, secrete the ureter throughout the distal third, take it to the holder. After clipping, resection, and dressing of the ureter, a clamp with long branches is inserted into the lumen of the bladder through the hole at the ureteral mouth, the drainage tube-ureter of the ureter is removed, after cutting and resection of the ureter, an endotracheal tube is passed through it, one end of it is placed in the renal pelvis through the renal pelvis ureteral section. A tunnel is formed between the submucosal and muscle layer of the bladder 2.5-3 cm long, exfoliating them in a blunt way, and a narrowed ureter is passed through the tunnel with an intubated tube (figure 2), after which the ureter is fixed to the bladder wall with synthetic absorbable sutures, using "Anchor sutures", the ureter before implantation is cut obliquely, at an angle of 45 °, with the transplantation carried out by the tip of the cut towards the urethra, the ureteral mucosa is sutured at the base of the oblique cut with two sutures, the rest of the cut is urine regular enrollment is placed into the lumen of the bladder and is fixed in a stretched position, the type petals, in three different directions, special "anchor" U-shaped seams imposed from the lumen of the bladder to the outside, through all layers of the bladder wall (3).

When applying “anchor” sutures to the ureter section, the following technique is used: the edge of the cut ureter is sutured from the muscular membrane with an atraumatic absorbable suture with two stitch needles, parallel to the ureter edge, after which both thread needles are loaded into the needle holder, parallel to each other, and then simultaneously with two needles at once, pierce the wall of the bladder through the opening of the excised ureter, introducing them into the lumen of the bladder and poking it on the outer surface of the wall, after which the suture is tied. Thus, each of the three walls of the cut of the ureter is fixed in the expanded form, which models the mouth of the ureter and provides valve function. The distance between the needles parallel to the needle holder is 0.4-0.5 cm. In this case, the intubator tube passes through the lumen of the bladder and exits through the puncture of the abdominal wall in the form of a puncture cystostomy, while two drainage holes are located in the lumen of the bladder . The bladder wall defect is sutured at the site of the excised ureter, the ureter is fixed to the walls of the bladder at the exit of the submucosal tunnel with interrupted sutures. A postoperative wound is sutured in layers. The bladder is not additionally drained, the drainage tube is washed with physiological saline and fixed to the skin with ligatures. In girls, when an ureter is transplanted, an endotracheal tube can be passed through the urethra, without applying a puncture cystostomy.

According to the proposed method, 6 patients were operated on. In the postoperative period, there were no complications associated with insufficiency of sutures, there were no urinary streaks.

The invention is illustrated by the following example.

The patient B-s Nikita Igorevich, 1 year 9 months, was in the department of pediatric surgery KKTSOMD from 11/15/06. Clinical diagnosis: CMD MVS: stenosing ureterohydronephrosis on the left 3 degrees. Secondary chronic pyelonephritis, latent course. Concomitant diagnosis: Allergic bronchitis, remission period. Acute adenoviral conjunctivitis. Communicating dropsy of the shells of the left testicle.

Upon receipt: no active complaints. Medical history: in the neonatal period - interstitial nephritis. There were no further changes in the analysis of urine. In September 2006, he was treated in a hospital at the place of residence for bronchitis, an abdominal ultrasound scan was performed, and hydronephrosis was detected on the left. Consulted by a urologist, performed ultrasound, the diagnosis is confirmed. He entered the examination and treatment as planned.

Objectively: General condition is stable, satisfactory. The kidney area is not visually changed. The kidneys are not palpable. The symptom of striking is negative on both sides. Testicles in the scrotum. The left half of the scrotum is enlarged due to the accumulation of fluid.

Clinical and laboratory examination.

Ultrasound of the kidneys and bladder from 10.25.06: The ureter is dilated all the way up to 1.5 cm. ECHO are signs of hydroureteronephrosis on the left.

Duplex examination of the bladder from 11.21.06: a good stream of the stream from the mouth of the right ureter was obtained. The stream of the stream from the mouth of the left ureter is reduced. An enlarged left ureter is determined throughout. RI (resistance index) of the right renal artery 0.6; RI of the left renal artery 0.72.

Ultrasound of the abdominal cavity from 12/01/06: left kidney with dimensions of 8.8 × 3.8 × 3.5. The thickness of the parenchyma is 1.0 cm. On the left, the cups are expanded to t1.9-2.0 cm, the pelvis to 5.8 cm; the upper third of the left ureter is expanded to 2.4 cm, the lower third of the ureter is up to 1.8 cm. The mouth of the ureter is up to 1 mm. Hydronephrosis of the left kidney. Megaureter on the left.

Survey urography from 11/20/06 - the ureter on the left is expanded to 17 mm, elongated, S-shaped. Excretion on the left is slowed down. Hydronephrosis on the left. Megaureter on the left.

General urine analysis

date of color Ud.weight District Prose protein sugar Lei. in 1 ml Er. in 1 ml 11/16 s / f 1012 her full 0,033 neg 80-100 all the time 6-8 3000

3. Biochemical en. blood (Cobas Mira)

date of Total protein Ast Alt Bilirubin (pr + nepr) glucose amylase creature urea 12/14 64.8 40 eleven 7.5 (3.3-4.2) 5.3 122 59 4.1

Urinalysis according to Zimnitsky from 11/17/06: specific gravity 1.006-1.014. Nocturnal diuresis 260.0, daytime 319.0.

The treatment was carried out:

11/23/06 - operation under general anesthesia - "percutaneous puncture nephrostomy on the left."

12/8/06 - operation under general anesthesia - "Cystostomy, Ureterocystoneomy with non-bubble access on the left, Ross operation on the left."

Under general anesthesia, before the start of the surgical incision, the bladder is filled until its walls are completely flattened, and a puncture point is identified under ultrasound control. After processing the surgical field, under the control of ultrasound, through a puncture of the anterior abdominal wall with a trocar, a silicone drainage tube with a diameter of 10 Fr, 50 cm long, with multiple side openings imposed in a spiral, over 10 cm, 15-20 cm long was drawn into the bladder. , for subsequent drainage of the lumen of the ureter. Conducted ultrasound monitoring of her standing in the bladder, removed the sleeve of the trocar and washed the bladder to “clean water” with sterile fiz.r-rum. Re-treated the surgical field in the projection of the incision, in the projection of the inguinal canal, parallel to and above the inguinal fold, on the side of the affected ureter. The anterior wall of the inguinal canal was opened, the obliterated umbilical artery was crossed, the ureter was isolated over the distal third. After excision, resection, and dressing of the ureter, a clamp was held with long branches in the lumen of the bladder through an opening at the mouth of the excised ureter, an endotracheal tube was removed, a blunt way formed a tunnel between the submucous and muscle layer of the bladder 2.5-3 cm long and passed through it with an intubated tube, a narrowed ureter, after which the mouth of the ureter with the wall of the bladder was fixed using "anchor sutures". A postoperative wound was sutured in layers. The drainage tube was fixed to the skin with ligatures.

In the postoperative period, the child received antibiotic therapy, electrical stimulation on the area of the left ureter No. 4; symptomatic therapy (enterosorbents, analgesia, antispasmodics). HBO course number 8.

The drainage tube was removed 12 days after surgery. No prolonged hematuria was noted. Pain is not pronounced. Patency of the ureter on the left restored. In satisfactory condition he was discharged at the place of residence for outpatient treatment. Examined after two years - no relapse.

The technical result of the use of ureterocystoanastomosis according to Yu.A. Kravtsov is:

- to improve the blood supply to the body due to the rejection of long sections of the wall of the bladder;

- to reduce operating injury by reducing the length of the skin incision by using a separate puncture of the bladder wall;

- in reducing the number of drains, since the proposed tube-intubator drains both the ureter and the bladder.

The proposed method for extravesical transplantation of the ureter is effective, reliable and low-traumatic. The method is easily reproducible in a hospital in the department of urology, pediatric surgery. Thus, the claimed invention meets the criterion of "industrial applicability".

Please call the proposed method of neocystostomy a method of extravesical transplantation of the ureter according to Yu.A. Kravtsov.

Information sources

1. Vozianov O.F., Lyulko O.V. Atlas-guide to urology: in 3 vols. - 2nd ed., Revised. and add. - Dnepropetrovsk: RVA "Dnepro-VAL", 2001. - 692 p.

2. Hinman F. Operative urology: Atlas: Transl. From English. - M.: GEOTAR-MED, 2003, - p. 817-8184.

3. RF patent No. 2226367, IPC АВВ 17/00, publ. 04/10/2004

4. RF patent No. 2297801, IPC АВВ 17/11, publ. 04/27/2007,

Claims (1)

A method for transplanting the ureter, including forming a tunnel, laying the ureter in it and fixing its distal section to the bladder, characterized in that preliminary a midline puncture cystostomy is performed along the midline in the suprapubic section under ultrasound control with the introduction of a drainage tube - an intubator into the bladder cavity perforation in a spiral at its distal end, surgical access to the ureter is performed lateral to the usual suprapubic transverse access in the inguinal region, then the ureter is cut off from the bladder, from the mouth formed in it, the perforated part of the tube is removed, a tunnel is formed between the layers of the wall of the bladder, the ureter is excised at an acute angle, preferably 45 °, the tube is inserted into it to a depth of 2/3 of its length, then it is passed through a tunnel intubated a tube, a narrowed ureter, after which the ureter is fixed to the wall of the bladder, and the transplant is performed with the top of the slice towards the urethra, the ureteral mucosa is sutured at the base of the oblique slice with two sutures, and the rest of the slice is urinated nick is placed in the lumen of the bladder and is fixed in a stretched position by type lobe in three different directions U-shaped "anchor" seams imposed from outside the lumen of the bladder, through the bladder wall layers, followed by drawing the ureter bladder inward.

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