RU2763251C1 - Method for preventing intraoperative bleeding during endovidosurgical adenomeectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology. After the implementation of retropubic access to the prostate, carbon dioxide is insufflated into the retropubic space. Then, using a puncture needle, the anterior abdominal wall is punctured in the area of ​​the pubic articulation through all layers of tissue. After visualization of the needle tip in the operating space, the tissues are punctured in the region of the dorsal complex of the prostate gland to the right of the urethra and 2.5 ml of the prepared remestip solution is injected, namely, up to 10 ml of 0.9% saline solution is added to 0.4 mg of the remestip. Then another 2.5 ml of solution is injected symmetrically to the left of the urethra, then 2.5 ml of the solution is injected into the region of the neurovascular bundles of the prostate on the right and left, and the puncture needle is removed. After 3-5 minutes, a cross-section of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal to the puboprostatic ligaments, 5-7 cm long. A layer is isolated between the capsule and the adenomatous tissue of the right and left lobes of the prostate gland. Then, bluntly and using the THUNDERBEAT apparatus, the adenomatous nodes are cut off. The prostatic part of the urethra is cut off, then small vessels are coagulated by bipolar coagulation, the adenomatous nodes are immersed in a container, after removal of the adenomatous tissues, the posterior wall of the bladder with the urethra is fixed proximally by 1 cm of the vas deferens with a continuous V-Loc thread with a length of 15 cm with a 5/8 cm needle , produce "trigonization" of the posterior wall of the bladder, followed by puncture of the needle on the anterior surface of the upper leaf of the prostate capsule and suturing along the right semicircle of the capsule of the prostate gland with the capture of the wall of the urinary bladder along the lateral, with the transition to the anterior surface, suturing the tissues on the left side symmetrically; the tightness of the anastomosis is controled. Then the container is removed. A tubular drainage is installed in the retropubic space. Sutures are applied to the skin, iodine treatment and an aseptic bandage are applied.

EFFECT: method allows to reduce the volume of the patient's surgical blood loss associated with profuse bleeding from the prostate tissue as a result of dissection of the surgical capsule.

1 cl, 1 ex, 2 tbl

Description

The invention relates to medicine, in particular to urology, and can be used in urology.

Benign prostatic hyperplasia (BPH) is the most common disease among older men (after 60 years). Many large studies have proven the progressive nature of prostatic hyperplasia [1. Emberton M., Andriole GL, de la Rosette J., Djavan B., Hoefher K., Vela Navarrete R., Nordling J., Roehrborn C., Schulman C., Teillac P., Tubaro A., Nickel JC Benign prostatic hyperplasia: a progressive disease of aging men // Urology. - 2003. - T. 61, No 2. - C. 267-73; Emberton M., Cornel E.B., Bassi P.F., Fourcade R.O., Gomez J.M., Castro R. Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management // Int J Clin Pract. - 2008. - T. 62, No 7. - C. 1076-86; Prostate hyperplasia: Medico-social aspects, modern technologies of surgical treatment. / Apolikhin O.I., Kalininskaya A.A. - Moscow: Publishing House of the Academy of Natural Sciences, 2012. - 164 p.]. UN epidemiological studies [4. World Health Organization launches new initiative to address health needs of a rapidly aging population // Indian J Med Sci. - 2004. - T. 58, No 9. - C. 411-2. 5 United Nations. World Population Prospects: The 2015 Revision, Key Findings and Advance Tables // Department of Economic and Social Affairs, Population Division. - 2015.] indicate an increase in the proportion of older people in the population. There are more and more patients suffering from prostatic hyperplasia [Djavan B., Nickel J.C., de la Rosette J., Abrams P. The urologist view of BPH progression: results of an international survey // Eur Urol. - 2002. - T. 41, No 5. - C. 490-6.], and therefore it is very important to address the issue of effective treatment of this disease. To date, there are a significant number of different methods of surgical treatment of prostatic hyperplasia: (Transurethral Needle Ablation - transurethral needle ablation, Transurethral Microwave Therapy - transurethral microwave therapy, UroLift, laser and electric vaporization) [EAU Guidelines on Treatment of Non-neurogenic Male LUTS. EA Guidelines. / S. Gravas (Chair) J.N.C., M.J. Drake, M. Gacci, C. Gratzke, T.R.W. Herrmann, S. Madersbacher, C. Mamoulakis, K.A.O. Tikkinen, Guidelines Associates: M. Karavitakis I.K., S. Malde, V. Sakkalis, R. Umbach - Arnhem, The Netherlands: EAU Guidelines Office, 2018. EAU Guidelines.]. However, monopolar transurethral resection of the prostate (M-TUR) or bipolar transurethral resection of the prostate (B-TUR) and open adenomectomy are still the main methods for removing small and large adenomas [EAU Guidelines on Treatment of Non-neurogenic Male LUTS. EA Guidelines. / S. Gravas (Chair) J.N.C., M.J. Drake, M. Gacci, C. Gratzke, T.R.W. Herrmann, S. Madersbacher, C. Mamoulakis, K.A.O. Tikkinen, Guidelines Associates: M. Karavitakis I.K., S. Malde, V. Sakkalis, R. Umbach - Arnhem, The Netherlands: EAU Guidelines Office, 2018. EAU Guidelines. Today, endovidiosurgical adenomectomy is an alternative to open adenomectomy, as it is less invasive, but loses its advantage over endoscopic techniques in terms of blood loss.

A known method for endosurgical removal of prostate adenoma, including access to prostate adenoma and removal of adenoma (see RF patent RU 2647147 C1 according to IPC A61B 17/00 of 03/14/2018).

There is also known a method of extraperineoscopic adenomectomy of the prostate gland (see RF patent RU 2667612 C2 according to IPC A61B 17/00 dated 09/21/2018 - prototype).

The disadvantage of these methods is bleeding from the tissues of the prostate gland after dissection of its surgical capsule and during the period of separation of adenomatous nodes. Despite the simultaneous coagulation of small vessels, blood loss can be significant, affecting the duration of the operation and postoperative complications.

The technical problem to be solved is:

- a decrease in the volume of the patient's surgical blood loss associated with profuse bleeding from the prostate tissue as a result of dissection of its surgical capsule.

The solution of this problem is ensured by the fact that in the method for preventing intraoperative bleeding during endovidiosurgical adenomectomy, after retropubic access to the prostate, carbon dioxide is insufflated into the retropubic space, then, using a puncture needle, the anterior abdominal wall is punctured in the area of the pubic symphysis through all layers of tissues, after visualization of the needle tip in the operating space, tissues are punctured in the region of the dorsal complex of the prostate gland to the right of the urethra and 2.5 ml of the prepared solution of remestip is injected, (up to 10 ml of 0.9% saline is added to 0.4 mg of remestip), then another 2.5 ml of the solution symmetrically to the left of the urethra, then 2.5 ml of the solution is injected into the region of the neurovascular bundles of the prostate on the right and left, and the puncture needle is removed; after 3-5 minutes, a transverse incision of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate gland; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off, then small vessels are coagulated by bipolar coagulation, adenomatous nodes are immersed in a container, after removal of adenomatous tissues, the posterior wall of the bladder with the urethra is fixed proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long ., “trigonization” of the posterior wall of the bladder is performed, followed by needle puncture on the anterior surface of the upper sheet of the prostate capsule and suturing is performed along the right semicircle of the prostate capsule with the capture of the bladder wall along the side, with the transition to the anterior surface, the tissues are sutured symmetrically with left side; control the tightness of the anastomosis; then the container is removed; tubular drainage is installed in the retropubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.

The achieved technical result is to reduce the volume of the patient's operative blood loss associated with heavy bleeding from the prostate tissue as a result of dissection of the surgical capsule, due to the use of a solution of remestip by intraoperative injection of it into the region of the dorsal complex and the neurovascular bundles of the prostate gland, which allows for higher efficiency. in the prevention of intraoperative bleeding.

The method is carried out as follows:

After the retropubic access to the prostate has been made by introducing an optical trocar and two working trocars into the retropubic space, carbon dioxide is insufflated into the retropubic space. With the help of a puncture needle, the anterior abdominal wall is punctured in the area of the pubic symphysis through all layers of tissues. After visualizing the tip of the needle in the operating space, tissue is punctured in the area of the dorsal complex of the prostate to the right of the urethra and 2.5 ml of remestip solution is injected (up to 10 ml of 0.9% saline is added to 0.4 mg of remestip), then another 2 5 ml of solution symmetrically to the left of the urethra. Then 2.5 ml of the solution is injected into the region of the neurovascular bundles of the prostate on the right and left. The puncture needle is removed. After 3-5 minutes, a transverse incision of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate gland; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off. Small vessels are coagulated by bipolar coagulation. Adenomatous nodes are immersed in a container. After the removal of adenomatous tissues, the posterior wall of the bladder is fixed with the urethra proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long, the posterior wall of the bladder is “trigonized”, followed by the removal of the needle on the anterior surface of the upper leaf capsule of the prostate gland and suturing is performed along the right semicircle of the capsule of the prostate gland with the capture of the wall of the bladder along the side, with the transition to the front surface, suturing the tissues on the left side is symmetrically performed; control the tightness of the anastomosis; this allows the taper of the bladder neck and eliminates the formation of the so-called "prebladder"; then the container is removed; tubular drainage is installed in the back of the pubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.

The method is highly effective, as it not only reduces the amount of blood loss, but is also safe to use.

The use of a solution of remestip, by intraoperative injection of it into the region of the dorsal complex and the neurovascular bundles of the prostate gland, allows for a higher efficiency in preventing intraoperative bleeding.

Currently, the proposed method has no analogues.

The authors carried out a comparative analysis of the results of treatment of patients with BPH, who underwent endovidiosurgical adenomectomy with and without intraoperative administration of remestip solution, on the basis of the Saint Luke Clinical Hospital. The following indicators were assessed: the patient's age, prostate volume, duration of surgery, blood loss, hemoglobin and hematocrit levels before and on the 1st day after surgery, the mass of the removed tissue, presented in Table No. 1 below.

The safety of the method was assessed, the data are presented in table No. 2

Comparison of the results of the two groups indicates that the proposed method has a clear advantage in terms of reducing blood loss, reducing the duration of surgery and complications in the postoperative period. This method is safer, radical and effective.

The possibility of performing endovideosurgical removal of prostate adenoma according to the proposed method is confirmed by a clinical example of performing such an operation in patient V., 67 years old. Date of admission to the clinic - 04/13/2020. Diagnosis: prostate adenoma of the 3rd degree.

According to the results of ultrasound: the volume of prostate adenoma is 132 cm3, the volume of residual urine is 150 ml. PSA - 3.3 ng/µl. On April 16, 2020, endovidiosurgical adenomectomy was performed.

The position of the patient on the back under general combined anesthesia with tracheal intubation. A Foley catheter No. 18 is placed in the bladder; further along the midline of the abdomen, lateral to the umbilical ring, an incision 2 cm long is made, access is made in layers to the pre-cystic space; then, with the help of the index finger, a primary cavity is formed, into which a balloon trocar dissector is inserted and a working space is formed; then, through this trocar, a laparoscope is inserted to assess the formed cavity; if the space is formed correctly, then the laparoscope and the balloon trocar dissector are removed and the first trocar with a diameter of 10 mm is installed. through which the laparoscope is inserted into the working cavity; carry out insufflation of CO ₂ to 12 mm Hg; extraperitoneally and laterally and downwards on both sides under visual control, two ports are placed - on the left with a diameter of 10 mm, on the right - 5 mm; 3 cm medially and above the latter, without damaging the epigastric vessels, 2 port-trocars, the diameter of which is 5 mm; the anterior surface of the prostate gland is exposed, the pelvic fascia is not opened. With the help of a puncture needle, the anterior abdominal wall is punctured in the area of the pubic symphysis through all layers of tissues. After visualizing the tip of the needle in the operating space, tissue is punctured in the area of the dorsal complex of the prostate to the right of the urethra and 2.5 ml of remestip solution is injected (up to 10 ml of 0.9% saline is added to 0.4 mg of remestip), then another 2 5 ml of solution symmetrically to the left of the urethra. Then 2.5 ml of the solution is injected into the region of the neurovascular bundles of the prostate on the right and left. The puncture needle is removed. After 3-5 minutes, a transverse incision of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate gland; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off. Small vessels are coagulated by bipolar coagulation. Adenomatous nodes are immersed in a container. After the removal of adenomatous tissues, the posterior wall of the bladder is fixed with the urethra proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long, the posterior wall of the bladder is “trigonized”, followed by the removal of the needle on the anterior surface of the upper leaf capsule of the prostate gland and suturing is performed along the right semicircle of the capsule of the prostate gland with the capture of the wall of the bladder along the side, with the transition to the front surface, suturing the tissues on the left side is symmetrically performed; control the tightness of the anastomosis; this allows the taper of the bladder neck and eliminates the formation of the so-called "prebladder"; then the container is removed; tubular drainage is installed in the back of the pubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.

The operation time was 45 minutes. The volume of blood loss is 50 ml. The mass of enucleated adenomatous tissue is 72 grams.

The postoperative period proceeded without complications. The drainage was removed on the 2nd day after the operation. Independent urination was restored after removal of the urethral catheter on the 5th day. The sutures were removed on the 9th day. The patient was discharged from the clinic on the 6th day. At subsequent control examinations 1 and 3 months after the operation, no subjective complaints and objective data for infravesical obstruction were obtained.

Claims (1)

A method for preventing intraoperative bleeding during endovidiosurgical adenomectomy, characterized in that after retropubic access to the prostate, carbon dioxide is insufflated into the retropubic space, then, using a puncture needle, the anterior abdominal wall is punctured in the area of the pubic symphysis through all layers of tissues, after visualization of the tip needles in the operating space puncture tissues in the dorsal complex of the prostate to the right of the urethra and inject 2.5 ml of the prepared remestip solution, namely, to 0.4 mg of remestip, add up to 10 ml of 0.9% saline, then inject another 2.5 ml of the solution symmetrically to the left of the urethra, then 2.5 ml of the solution is injected into the region of the neurovascular bundles of the prostate on the right and left, and the puncture needle is removed; after 3-5 minutes, a transverse incision of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and adenomatous tissue of the right and left prostate lobes; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off, then small vessels are coagulated by bipolar coagulation, adenomatous nodes are immersed in a container, after removal of adenomatous tissues, the posterior wall of the bladder with the urethra is fixed proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long , “trigonization” of the posterior wall of the bladder is performed, followed by needle puncture on the anterior surface of the upper leaf of the prostate capsule and suturing along the right semicircle of the prostate capsule with the capture of the bladder wall along the side, with the transition to the anterior surface, suturing tissues from the left side symmetrically sides; control the tightness of the anastomosis; then the container is removed; tubular drainage is installed in the retropubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.