RU2749869C2 - Method for forming an anastomosis on urethra ventral surface without crossing spongy body in case of strictures of bulbous urethra. - Google Patents

Abstract

FIELD: medicine; urology.SUBSTANCE: invention relates to urology. Access to the spongy body in the bulbous urethra is carried out only on the ventral surface, without performing full mobilization of the bulbous urethra. For this the urethra is dissected on the ventral surface from the distal to the proximal border of the affected area. Provisional suturing of the right and left edges of the dissected urethra and installation of "bulldog" hemostatic clamps on the spongy body distal and proximal of the stricture zone are performed. The cicatricially changed mucosa is excised with complete preservation of the posterior semicircle of the urethra spongy body. Then part of the ventral spongy body with spongiofibrosis is excised. An anastomosis is formed on the urethral catheter between the formed distal and proximal parts of the urethra, the defect of the spongy body is sutured.EFFECT: method makes it possible to prevent the development of sexual dysfunctions and to minimize the risk of recurrence of urethral stricture due to the maximum preservation of blood supply and tissue innervation in the area of the surgery, as well as to provide the possibility of radical excision of the spongiofibrosis zone.1 cl, 4 dwg, 1 ex

Description

Technology area

The invention relates to medicine, namely to urology, and can be used to improve the surgical technique in surgical interventions for strictures of the bulbose urethra in men.

State of the art

For short strictures (no more than 3 cm) of the bulbous urethra, end-to-end anastomotic urethroplasty is considered the most preferable method, which ensures treatment success in more than 90% of cases. However, this technique involves transection of the spongy body, which is accompanied by the transection of the urethral artery and nerve fibers along the urethra. As a result, there is a deterioration in the blood supply to the distal urethra and a violation of the sensitivity of the head and distal part of the body of the penis, which can lead to various sexual dysfunctions.

In order to reduce the risk of these side effects of end-to-end anastomotic urethroplasty, anastomotic urethroplasty without transection of the spongy body was proposed, which allows to preserve antegrade blood flow and innervation in the spongy body in the affected part of the urethra to the maximum extent (Andrich DE, Mundy AR Non-transecting anastomoticplasty: urethra a preliminary report. BJU Int. 2012; 109 (7): 1090-4. doi: 10.1111 / j.l464-410X.2011.10508.x), based on the original idea of GH Jordan et al. (Jordan G.H., Eltahawy E.A., Virasoro R. The technique of vessel sparing excision and primary anastomosis for proximal bulbous urethral reconstruction. J Urol. 2007; 177 (5): 1799-802). It is this technique that is the closest to the proposed invention in terms of the technical essence and the achieved result, therefore, it can be considered as a prototype of the operation technique developed by us. The prototype of our operation technique consists in circular mobilization of the entire bulbose urethra, dissection of the bulbose urethra along the dorsal surface in the projection of the stricture, circular excision of scar tissue of the urethral mucosa on the dorsal surface, and performing anastomosis between the healthy ends of the urethra.

This operation technique has a number of significant disadvantages:

- Complete mobilization of the bulbous urethra and unfolding of the urethra to expose the dorsal surface is accompanied by the risk of damage to arterial vessels along the urethra and bleeding during surgery.

- Full-fledged isolation of the dorsal surface is not ensured due to the impossibility of complete reversal of the urethra in this area due to the anatomical and topographic structure of this zone.

These factors lead to increased bleeding during surgery and the formation of a narrow and deep zone on the dorsal surface of the bulbous urethra, limiting the view of the operating field and manipulation actions. As a result, the possibilities of radical excision of the affected part of the urethral mucosa and the implementation of a full connection of the healthy ends of the urethra are reduced, which leads to a rather high risk of intra- and postoperative complications, as well as recurrence of urethral stricture.

Disclosure of invention

The objective of the invention is to create a method of surgery for stricture of the bulbose urethra with high efficiency and low risk of complications.

The technical result consists in improving the conditions for viewing the operation area, complete excision of the affected tissues and connection of the healthy ends of the urethra.

The essence of the invention is as follows.

- Access to the cancellous body in the bulbous urethra is carried out only along the ventral surface.

- Complete mobilization of the bulbous urethra is not performed.

- The urethra is dissected on the ventral surface from the distal to the proximal border of the affected area of the urethra.

- Provisional suturing of the right and left edges of the dissected urethra is performed and hemostatic clamps "bulldog" are installed on the spongy body distal and proximal to the stricture zone in order to prevent bleeding during the operation.

- Excision of the cicatricial mucosa is performed with complete preservation of the posterior semicircle of the spongy body of the urethra.

- At the next stage, a part of the ventral spongy body with hemostatic sutures superimposed on it is released, and in the presence of spongiofibrosis, this area of the spongy body is excised.

- The resulting two independent urethral stamps (distal and proximal) are sutured on a urethral catheter using the classic anastomotic technique.

- The defect of the spongy body is sutured transversely or longitudinally.

Brief Description of Drawings

FIG. 1 shows a general view of the stricture of the bulbose urethra. FIG. 2 shows a view of the bulbose urethra after excision of the scar-altered mucosa with complete preservation of the posterior semicircle of the spongy body of the urethra. FIG. 3 shows two independent urethral stamps (distal and proximal) formed as a result of the operation before performing their subsequent anastomosis. FIG. 4 shows the technique of suturing a spongy body defect.

Implementation of the invention

An example of implementation of the invention.

Patient M., 43 years old.

A pronounced weakening of the urine stream began about 9 years ago after contact ureterolithotripsy (contact crushing of a stone in the ureter) in Yaroslavl. One year after the operation, acute urinary retention developed, trocar cystostomy was performed. Then optical urethrotomy in Rostov-on-Don. Improvement within 6 months, then - again worsening urination with periodic urinary retention, repeated bougienage of the urethra. Urethrogram 2019 - a stricture up to 1.5 cm in length is determined in the bulbous section of the urethra, then the contrast freely enters the bladder. An operation was performed at the urology clinic - plasty of the stricture of the bulbose urethra without complete mobilization and intersection of the dorsal semicircle of the spongy body of the urethra. 3 months after the operation, the patient notes a significant improvement in urination, corresponding to the norm. Maximum uroflow rate of urination ... 15.5 ml / sec, average uroflow rate of urination ... 6.9 ml / sec, with a volume of urination of 142 ml. Maximum uroflow rate of urination ... 15.5 ml / sec, average uroflow rate of urination ... 6.9 ml / sec, with a volume of urination of 142 ml. There is no erectile dysfunction, the patient is regularly sexually active.

Thus, the proposed method made it possible to save the patient from urethral stricture and achieve normal urination rates without impairing sexual function.

The proposed method for performing urethroplasty was used in 15 patients, which made it possible to ensure 100% success of treatment (no recurrence of urethral stricture) without deterioration of sexual function with a postoperative follow-up period of 3 to 36 months.

Formation of anastomosis on the ventral surface of the urethra without complete mobilization and intersection of the dorsal semicircle of the spongy body of the urethra prevents the development of sexual dysfunctions and minimizes the risk of recurrence of urethral stricture by maximizing blood supply and innervation of tissues in the surgical area, as well as providing the possibility of radical excision of the spongiofibrosis zone.

Claims (1)

A method of forming an anastomosis with strictures of the bulbose urethra, characterized by the fact that access to the spongy body in the bulbose urethra is carried out only along the ventral surface, without completely mobilizing the bulbose urethra, for which the urethra is dissected on the ventral surface from the distal to the proximal border of the affected area, perform provisional suturing of the right and left edges of the dissected urethra and the installation of hemostatic clamps "bulldog" on the spongy body distal and proximal to the stricture zone, excision of the cicatricial mucosa with complete preservation of the posterior semicircle of the spongy body of the urethra, then excision of a part of the ventral coexisting spongy body of the anastomosis on the urethral catheter between the formed distal and proximal parts of the urethra, the defect of the spongy body is sutured.

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