RU2784180C2 - Laparoscopic retropubic adenomectomy supplemented by urethrocystoanastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, to operative urology. Endovideoscopic access is performed, optical and working trocars are installed in the retropubic space, carboxyperitoneum is created under general anesthesia, laparoscopy is performed - examination of the abdominal cavity. Adenomectomy is performed, the surface of the prostate gland is isolated, the capsule of the prostate gland is dissected in the transverse direction, and hemostasis is controlled. A layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate gland, adenomatous nodes are cut off from the urethra and placed in a container. In addition, the middle lobe of the prostate is removed, hemostasis control and vascular coagulation are carried out. The tissues of the bladder neck are compared with the urethra, the prostate gland capsule is sutured with a V-lock thread, then the container is removed. In this case, the specified adenomectomy is supplemented with stages of urethrocystoanastomosis. Laparoscopic access is performed, while 3 working trocars are installed pararectally in the right and left iliac regions. The anterior and lateral surfaces of the prostate are mobilized to the intrapelvic fascia after dissection of the prostate capsule and identification of the layer between the adenomotous nodes of the right and left lobes of the capsule and its inner surface. The nodes are isolated as a single block, the bladder neck is displaced with a predominance of blunt dissection. The bleeding vessels are coagulated. Then urethrocystoanastomosis is performed: after identifying the bladder neck, an anastomosis is performed with two V-lock 3/0 threads between the urethra and the bladder neck with a continuous suture, starting from the back wall, from 6 o'clock of the conventional dial, in opposite directions, until crossing on the anterior surface of the anastomosis at 12 o'clock of the conditional dial. After that, an N20 Foley urethral catheter is installed, 150 ml of saline is injected into the bladder, the prostate capsule is sutured with a continuous suture with a V-lock 3/0 thread, wound revision, hemostasis. The container with macropreparations is removed through supraumbilical access.

EFFECT: method provides accelerated recovery of the mucosa of the prostatic urethra and, accordingly, the best functional result of treatment, significantly reduces the volume of postoperative blood loss, while the hospital stay is reduced to 4 days, as a result, the quality of life of patients is improved.

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Description

The invention relates to medicine, in particular to urology, and can be used for surgical treatment of benign prostatic hyperplasia (BPH).

The problem of developing effective surgical methods for the treatment of benign prostatic hyperplasia (BPH) occupies a key position in the field of protection of the male urogenital area. Modern urology has a wide arsenal of techniques that can be used for surgical treatment of BPH, which allows you to restore the physiological trajectory of urine outflow in order to avoid overflow and rupture of the bladder, the development and progression of chronic kidney disease (CKD), obstruction of the vas deferens, restoration of proper sexual function, increase chances for achieving healthy longevity hyperplasia Calidad de vida y disfunción eréctil en pacientes con hiperplasia prostática benigna CirCir 2021;89(2):218-222 doi:10.24875/CIRU.20000071).

Transvesical adenomectomy is historically the oldest surgical approach in the treatment of BPH. The operation can be performed for any size of benign prostatic hyperplasia, which is ensured by a surgical incision in the direction from the pubic joint to the umbilical ring, as well as layer-by-layer dissection of tissues.

The main disadvantages of this technique are the need for cystotomy (bladder wall incision) to provide direct access to the prostate, which usually leads to the development of functional disorders of the bladder. Removal of prostate tissue by digital exfoliation is associated with the risk of massive bleeding from the retropubic venous plexus, as well as urinary incontinence due to damage to the sphincter. In addition, the remaining gaping wound surface often heals for a long time with the formation of a rough scar (/2/ Sergienko V.I., Petrosyan 3.A., Frauchi I.V. (under the general editorship of Yu.M. Lopukhin). Topographic anatomy and operative surgery. In 2 volumes. Volume 1: textbook /. 3rd edition, revised - Moscow: GEOTAR - Media, 2014. - P. 371).

In the case of a combination of a large size of hyperplastic prostate tissue and an extravesical direction, when transcystic access does not allow full access, a retropubic adenomectomy is performed. In this case, there is no need to open the wall of the bladder, because. after layer-by-layer dissection, the surgeon gets the opportunity to fully excise adenomatous nodes and not injure the urinary structures. With this operation, there is a serious risk of damage to the retropubic venous plexus with the possibility of high blood loss (See 121 Sergienko V.I. ...).

Transurethral resection of prostatic hyperplasia - TUR (See ibid.), once considered the "gold standard" for the treatment of BPH, has its drawbacks. Its high popularity was due to relatively low invasiveness at the time of introduction (40-50s of the XX century) into widespread practice (/3/ Sauer JS, Greenwald RJ, Bovard MA, et al. Morcellator. US Patent No. 5562694. 1996 Oct 8 , 1996), as well as the ability to perform it in patients with complicated somatic status and under spinal anesthesia. The technique is based on manipulation of the prostate tissue through observation through a guidewire previously inserted into the urethra; which eliminates the need for traumatic incisions (see /2/, /4/ Stormont G, Chargui S. Transurethral Resection Of The Prostate. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 19, 2021). The disadvantages of this approach is the risk of damage to the urethra, which by its histological nature is a delicate structure prone to the formation of post-traumatic strictures. TUR itself is not a radical technique, so BPH potentially retains the ability to recur, which increases the risk of re-intervention. After TUR, a serious complication known as TUR syndrome is possible, characterized by the development of hyponatremia, hypoosmolarity, hypervolemia, congestive heart failure, pulmonary and cerebral edema, hemolysis and intoxication with the components of the irrigation fluid (glucose) (/5/ Kumar V, Vineet K, Deb A. TUR syndrome - A report Urol Case Rep. 2019 Jul 26;26:100982 doi: 10.1016/j.eucr.2019.100982 PMID: 31388497; PMCID: PMC6677916).

The modern method of surgical treatment of BPH is transurethral laser enucleation of BPH. The method is based on the introduction of laser conductors-light guides into the urethra, which provide a cauterizing effect on the prostate tissues to be removed. Its advantages include the possibility of use in patients with virtually any volume of the prostate gland (up to 200 cm3 and above); and a relatively short rehabilitation period (2-3 days) compared with TU (5 days) and open interventions (7 days) (/6/ Lerner LB, Rajender A. Laser prostate enucleation techniques. Can J Urol. 2015; 22 Suppl 1 :53-59).

The disadvantages of laser-mediated interventions include their high cost, low availability for public health and high duration of training. Due to the implementation of operational access through the urethra, patients may experience strictures of the urethra, requiring subsequent bougienage {/7/ Rivera ME, Lingeman JE, Krambeck AE. Holmium Laser Enucleation of the Prostate. J Endourol. May 2018; 32(S1):S7-S9. doi: 10.1089/end.2017.0710. PMID. 29774816).

A known method for the prevention of intraoperative bleeding during endovideosurgical adenomectomy (/8/ RF Patent No. 2763253, priority dated 07/05/2021). The method consists in the fact that after performing a retropubic access to the prostate by introducing an optical trocar and two working trocars into the retropubic space and carbon dioxide insufflation into the retropubic space, the anterior surface of the prostate gland is isolated with a transition to the pelvic fascia laterally on both sides, the pelvic fascia is dissected along the lateral surface of the prostate gland to the puboprostatic ligaments on one side and the other, the area of the dorsal vascular-venous complex of the prostate gland is mobilized, on which a vascular clamp is applied through a 10 mm trocar, then a transverse incision of the anterior surface of the prostate capsule is made by 1.5-2 cm below and 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, in a blunt way and with the help of the THUNDERBEAT apparatus, adenomatous nodes are cut off, the nodes are immersed in a container; then, small vessels are coagulated by bipolar coagulation, after 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, “trigonization” of the posterior bladder wall is performed, followed by puncturing the needle on the front 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 front surface, symmetrically suturing the tissues on the left side; removing the vascular clamp from the dorsal complex; 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.

Here, “trigonization” (Trigonal [lat.trigonalis] - triangular. Dictionary of foreign words. - M .: Ed. Russ. yaz., 1986, p. 507) means “point” fixation of the bladder mucosa from the triangular region of Lieto - at the back wall of the bladder - to the urethra, such fixation, by definition, is a partial or point fixation of the bladder mucosa.

Disadvantages of analogue When the dorsal vascular-venous complex is exposed, there is a risk of damage to fragile vessels, which can lead to additional bleeding.

The solution proposed in the analog to reduce intraoperative blood loss is not anatomically justified and does not prevent the reduction of bleeding, these vessels are peripheral structures relative to the prostate gland. Therefore, the main sources of intraoperative bleeding remain. At the same time, persistent bleeding during surgical procedures leads to significant (up to 500-700 ml) blood loss, and as a result, to a longer rehabilitation period, in some cases, there remains the need for hemotransfusion (blood transfusion), the possibility of a heart attack or stroke.

The disadvantage of trigonization is that, due to incomplete closure of the wound surface, bleeding into the lumen of the bladder persists in the postoperative period, which is difficult to control and requires the patient to be kept in the intensive care unit. Accordingly, the required long-term catheterization (postoperatively 7-14 days) in comparison with the proposed method (with hermetic anastomosis and catheterization up to 4-5 days) leads to an increase in hospitalization, which increases the financial costs for the patient.

In connection with the continuing high blood loss, a longer disability of the patient persists.

A known method of extraperitoneoscopic adenomectomy of the prostate gland with a volume of more than 80 cm3 (/9/ Patent of the Russian Federation No. 2667612, priority dated 28.02.2017), adopted as a prototype. The method includes access to the prostate adenoma and removal of the adenoma, while before performing extraperitoneoscopic adenomectomy, the volume of the prostate gland, its shape, the fact of the presence of a "middle lobe" are determined, the condition of the bladder and upper urinary tract is assessed, then, with the patient in the supine position, under under general combined anesthesia, a urethral catheter is installed under sterile conditions, a 2 cm long incision of the skin, subcutaneous tissue and aponeurosis is made below the umbilical ring along the midline, in which a cavity is formed with the index finger in the preperitoneal space in the direction of the pubic articulation, the formation of which is completed using a balloon - dissector, after removal of which a 10 mm optical trocar is installed in the formed cavity in the preperitoneal space, a Z-shaped suture is applied to the incision of the aponeurosis and tightened, carbon dioxide is supplied through the installed 10 mm optical trocar into the preperitoneal space under pressure 12-14 mm Hg. and an endoscope with a video camera is inserted that provides control over the course of the surgical intervention, the image from which is displayed on monitors, then, without damaging the lower epigastric vessels, a 10 mm trocar is installed on the left along the midclavicular line 2-4 cm below the installed 10 mm optical trocar and placed in it ultrasonic dissector, additionally install three 5 mm instrumental trocars with the possibility of installing a laparoscopic clamp in the upper of them, an aspirator in the lower of them, then using an ultrasonic dissector, the anterior surface of the prostate gland is mobilized from fatty tissue, an incision of its capsule is made in the middle part of the prostate gland transverse direction 5-7 cm long with simultaneous ultrasonic coagulation of small vessels and bipolar coagulation of large vessels, along the entire length of the incision, the capsules form a space between the prostate capsule and adenoma nodes with coagulation of vessels and visualization of the surgical field with and using an aspirator, sequential enucleation of adenomatous nodes is performed from the base, lateral surfaces and top of the prostate capsule from its right and left sides with coagulation of the prostatic arteries and smaller vessels and with traction of the nodes with a laparoscopic clamp alternately to the right, left, up and down in the area of the base of the prostate and bladder neck, after removal of the urethral catheter, the prostatic urethra is removed with monopolar coagulation of the adenoma bed with a buttoned electrode in the "spray" mode, the posterior semicircle of the bladder neck is sutured to the lower semicircle of the urethra with trigonization of the prostate bed, the urethral catheter is re-installed, and sutured an incision of the prostate capsule with an intracorporeal suture, the preperitoneal space is drained, the enucleated nodes of prostate adenoma are placed in an endoscopic plastic container, which is then removed after removal of the optical trocar through an expanded paraumbilical incision, all instruments and trocars are removed, a layer-by-layer suture is applied to the wounds. In addition, the removal of the middle lobe of the prostate is performed through the incision of the prostate capsule, due to the gradual traction to the right, left, up and down, when the middle lobe is removed, the part of the bladder mucosa remaining on the middle lobe is cut off, with coagulation of the vessels and control of the orifices of the ureters.

Flaws. In the prototype, another problem is solved - extraperitoneoscopic (extraperitoneal) access to the prostate region is carried out, in the claimed solution, laparoscopic access is performed, due to which there is more room for maneuver and ergonomics of the movement of the instrument, the difference in the volume of the cavity filled with gas allows it to be filled more evenly or reduce volume.

The disadvantage of trigonization or incomplete closure of the wound surface is that bleeding into the lumen of the bladder persists in the postoperative period, which is difficult to control and requires the patient to be kept in the intensive care unit. This may require a blood transfusion (blood transfusion), and there is the possibility of a heart attack or stroke.

The method according to the prototype can not be used in patients suffering from coagulopathy, or receiving blood-thinning drugs (patients with atherosclerosis and/or suffering from cardiovascular disease), as there is a risk of bleeding in the postoperative period.

Long-term catheterization (postoperatively 7-14 days) compared with the proposed method (4-5 days) leads to an increase in the duration of hospitalization, which increases the financial costs for the patient. In connection with the continuing possibility of high blood loss, a longer disability of the patient remains.

The objective of the invention is to provide the patient with an optimal surgical aid corresponding to his status in terms of anamnesis and diagnostic indicators (see explanation below), reducing trauma with a subsequent shortening of the rehabilitation period, reducing postoperative blood loss of a surgical wound from the prostate tissue, minimizing urine leakage.

In this invention, the authors propose a new way to perform the operation: laparoscopic retropubic adenomectomy, supplemented by urethrocystoanastomosis.

The study was conducted at the Federal State Budgetary Institution "NMITs Endocrinology" of the Ministry of Health of Russia, Moscow, from 2020 to the present. Informed consent of patients to participate in the study was obtained.

The criteria for not being included in the study are: refusal to participate in the study, contraindications to surgical treatment, malignant neoplasms of the genital organs and confirmed oncological diseases, end-stage chronic diseases, acute phase and exacerbation of chronic infectious diseases.

Patients can be excluded from the study at any stage of its implementation (the presence of general somatic concomitant chronic diseases in the decompensation phase).

Due to the large number of factors that determine the choice of one or another method or approach to the surgical treatment of patients with BPH, a technique has not yet been developed that fully satisfies the task of the surgeon to perform adenomectomy, and, accordingly, there are no clear standards for choosing the type of these operations.

Therefore, an important indicator of the appointment and applicability of this invention to each patient are the indications and contraindications for performing this method. Taking into account them, a category of patients was determined who were recommended to perform laparoscopic retropubic adenomectomy, supplemented by urethrocystoanastomosis.

Indications for the operation:

Obstructive urination due to BPH.

Chronic urinary retention due to BPH.

Contraindications:

Obstructive urination not due to BPH (urethral stricture, neurogenic bladder).

Somatic contraindications (acute inflammatory diseases, impossibility of general anesthesia).

Specific contraindications to the patient, characterizing the boundaries of the application of the method with urethrocystoanastomosis, are.

The severity of the patient's condition (unstable state, hypercopnia, ischemic manifestations), which does not allow performing the stages of urethrocystoanastomosis (according to the specific condition of the patient in the current period, the surgeon determines the duration and the possibility of performing or not performing urethrocystoanastomosis).

Technical impossibility to perform the anastomosis due to anatomical or ergonomic reasons (narrow pelvis of the patient, limitations in instrument manipulation).

Difficult visualization and a high probability of stitching during the anastomosis, due to the proximity of the orifices of the ureters to the anastomosis zone.

Technical result. In the claimed solution, the method is based on laparoscopic access, which, due to a significant volume of filling the cavity with gas, provides more room for maneuver and ergonomics of the movement of the instrument compared to analogues, the indicated larger volume of CO2 allows filling the cavity more evenly or reducing its volume).

The main advantage of urethrocystoanastomosis is the restoration of the mucosa of the prostatic urinary tract, which prevents cicatricial, sclerotic changes in this area. The absence of stenoses and strictures of this area is ensured, as a result, the normal functioning of the urethra is restored. Also, due to the fact that as a result of the operation, the wound defect is localized (the open wound surface of the bed of adenomatous nodes is closed by anastomosis), the time required for catheterization of the urethra is reduced to 4-5 days, which affects the recovery time of the patient, his rehabilitation. In addition, the possibility of bleeding in the postoperative period is prevented, which makes it possible to predict and reduce the rehabilitation time of the patient. In this regard, this method can be used for patients who suffer from coagulopathy or receive blood-thinning drugs, patients with atherosclerosis and/or suffering from cardiovascular diseases.

As a result, the proposed method provides rapid activation and reliable rehabilitation of such patients, which has not only medical but also social significance - improves the health and quality of life of patients.

The method of laparoscopic retropubic adenomectomy is characterized by the following steps. In the preoperative period, the patient signs a consent to the operation, supplemented by urethrocystoanastomosis.

Preliminary determine the volume of the prostate gland, its shape, the fact of the presence of the middle lobe, assess the condition of the bladder and upper urinary tract, the presence of diverticula, calculi and possible neoplasms of the bladder.

Endovideoscopic access is performed, optical and working trocars are installed in the retropubic space, carboxyperitoneum is created under general anesthesia, laparoscopy is performed - examination of the abdominal cavity, adenomectomy is performed, the surface of the prostate gland is isolated, the prostate capsule is dissected in the transverse direction, hemostasis is controlled, the layer between the capsule is isolated and adenomatous tissue of the right and left lobes of the prostate gland, adenomatous nodes are cut off from the urethra and placed in a container, in addition, if available, the middle lobe of the prostate is removed, hemostasis control and vascular coagulation are carried out, bladder neck tissues are compared with the urethra, the prostate capsule is sutured continuous suture with V-lock thread, then the container is removed.

The method differs in that said adenomectomy is supplemented with stages of urethrocystoanastomosis,

perform laparoscopic access while installing 4 working trocars pararectally in the right and left iliac regions,

perform mobilization of the anterior and lateral surfaces of the prostate gland to the intrapelvic fascia, after dissection of the prostate capsule and identification of the layer between the adenomatous nodes of the right and left lobes of the capsule and its inner surface, the nodes are isolated as a single block, the bladder neck is displaced with a predominance of blunt dissection, in the presence of bleeding vessels carry out their coagulation,

then urethrocystoanastomosis is performed: after adequate identification of the bladder neck, an anastomosis is performed with two V-lock 3/0 threads, between the urethra and the bladder neck with a continuous suture, starting from the back wall, from 6 o'clock of the conventional dial, in opposite directions, until crossing on the anterior surface of the anastomosis at 12 o'clock of the conventional dial,

after that, a Foley urethral catheter No. 20 is installed, 150 ml of saline is injected into the bladder, in order to check the tightness of the anastomosis of the bladder neck, the prostate capsule is sutured with a continuous suture with a V-lock 3/0 thread, revision of the wound, hemostasis, the container with macropreparations is removed through the supraumbilical approach.

Insurance drainage is installed into the small pelvis through the counter-opening. The wound is sutured in layers. Aseptic sticker.

The implementation of the proposed method of laparoscopic retropubic adenomectomy, supplemented by urethrocystoanastomosis, is illustrated by the following clinical example (see schematic images in Fig. 1-6).

In FIG. 1 shows a diagram of the relationship of the bladder, prostate and iliac vessels before surgery and highlighting anatomical structures.

Notation (applies to all figures):

1 - bladder, 2 - bladder neck, 3 - prostate gland, 4 - urethra, 5 - trocar insertion points, 6 - prostate incision zone 3, 7 - adenomatous nodes that can be isolated, 8 - adenomatous tissue removed, 9 - prostate bed glands 3, 10 - section of the neck 2 of the bladder, pulled up to the urethra 4 for anastomosis, 11 - urethrocystoanastomosis zone, 12 - urethral catheter, 13 - suture line of the prostate capsule 3.

In FIG. 2 shows the stage and area of the cut 6 of the capsule of the prostate gland 3.

In FIG. 3 shows the stage of isolation of adenomatous nodes 7.

In FIG. 4 shows the stage of removal of adenomatous nodes (tissue) 8 and the view of the bed 9 of the prostate gland 3.

In FIG. 5 shows the stage of applying urethrocystoanastomosis.

In FIG. 6 shows the stages of completion of the operation with suturing (suture 13) of the capsule of the prostate gland 3, with the installation of the urethral catheter 12.

Clinical example. Patient S., 65 years old, was admitted to the clinic with a diagnosis of prostate adenoma grade 3, severe atherosclerosis. Complaints of weakened, difficult urination, also in the morning. The volume of the prostate gland, its shape, the fact of the presence of a "middle lobe" were determined by ultrasound diagnostics, the condition of the bladder and upper urinary tract was assessed, as well as the presence of diverticula, calculi and possible neoplasms of the bladder. Prostate adenoma up to 150 cm3, the kidneys are usually located, with clear, even contours, the thickness of the parenchyma is within the age norm. Urodynamics of both kidneys is not disturbed. The ureters are not visualized. The bladder with clear, even contours, does not contain pathological formations. The prostate has clear, even contours of a spherical shape, the structure is heterogeneous due to hypoechoic nodes.

The patient underwent laparoscopic retropubic adenomectomy, supplemented by urethrocystoanastomosis.

Under general anesthesia in the paraumbilical region with a Veress needle, a carboxyperitoneum is created and an optical port is installed. Laparoscopy is performed. In the right and left iliac regions, 4 working trocars are installed pararectally (in Fig. 1-6. Points 5 for installing trocars are shown with crosses). Perform mobilization of the anterior and lateral surfaces of the prostate 3 to the intrapelvic fascia. The capsule of the prostate gland 3 is cut in the transverse direction (Fig. 2), incision zone 6. Control of hemostasis is carried out. After identifying the layer between the capsule of the prostate 3 and the adenomotous node, the nodes 7 are isolated as a single block (Fig. 3) together with the middle lobe, the bladder neck 2 is displaced with a predominance of blunt dissection. Adenomatous nodes 7 are cut off from the urethra 4, placed in a container (removable adenomatous tissue - 8), Fig. 4. After adequate identification of the bladder neck 2, an anastomosis is performed, with two V-lock 3/0 threads, between the urethra 4 and the bladder neck 2 with a continuous suture 11, starting from the back wall (6 o'clock of the conditional dial) in opposite directions, until the intersection on the anterior surface of the anastomosis (12 o'clock of the conditional dial), Fig. 5. After that, a Foley urethral catheter No. 20 (marked 12) is installed. 150 ml of physiological saline is injected into the bladder to check the tightness of the anastomosis.

The prostate capsule is sutured with a continuous suture 13 with a V-lock 3/0 thread (Fig. 6). Wound revision, hemostasis. The container with macropreparations is removed through supraumbilical access. Blood loss: 230 ml. Insurance drainage is installed into the small pelvis through the counter-opening. The wound is sutured in layers. Aseptic sticker.

The early postoperative period is smooth. After removal of the urethral catheter on the fourth day, spontaneous urination of good quality was restored. According to the control ultrasound examination after 2 weeks, there is no disturbance in the urodynamics of both kidneys. There is no residual urine in the bladder.

Bibliography

1. Montiel-Jarquín Áj, Gutiérrez-Quiroz CT, Pérez-Vázquez AL, Ortiz-Agustín JJ, García-Galicia A, Loría-Castellanos J. Quality of life and erectile dysfunction in patients with benign prostatic hyperplasia. Calidad de vida y disfunción eréctil en pacientes con hiperplasia prostática benigna. CirCir. 2021;89(2):218-222.

doi: 10.24875/CIRU.20000071.

2. Sergienko V.I., Petrosyan E.A., Frauchi I.V. (under the general editorship of Yu.M. Lopukhin). Topographic anatomy and operative surgery. In 2 volumes. Volume 1: textbook / .3rd ed., corrected. - Moscow: GEOTAR - Media, 2014. - p. 370-374.

3. Sauer JS, Greenwald RJ, Bovard MA, et al. Morcellator. US Patent No. 5562694. 1996 Oct 8, 1996.

4. Stormont G, Chargui S. Transurethral Resection Of The Prostate. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 19, 2021.

5. Kumar V, Vineet K, Deb A. TUR syndrome - A report. Urol Case Rep.2019 Jul 26;26:100982. doi: 10.1016/j.eucr.2019.100982. PMID: 31388497; PMCID: PMC6677916.

6. Lerner LB, Rajender A. Laser prostate enucleation techniques. Can J Urol. 2015;22 Suppl 1:53-59.

7. Rivera ME, Lingeman JE, Krambeck AE. Holmium Laser Enucleation of the Prostate. J Endourol. May 2018;32(S1):S7-S9. doi: 10.1089/end.2017.0710. PMID: 29774816.

8. RF patent No. 2763253, priority dated 07/05/2021. A method for preventing intraoperative bleeding during endovideosurgical adenomectomy.

9. RF patent No. 2667612, priority dated February 28, 2017. The method of extraperitoneoscopic adenomectomy of the prostate gland with a volume of more than 80 cm3.

Claims (2)

The method of laparoscopic retropubic adenomectomy, which consists in the following: endovideoscopic access is performed, optical and working trocars are installed in the retropubic space, carboxyperitoneum is created under general anesthesia, laparoscopy is performed - examination of the abdominal cavity, adenomectomy is performed, the surface of the prostate gland is isolated, the prostate capsule is dissected transversely direction, hemostasis control is carried out, a layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate gland, adenomatous nodes are cut off from the urethra and placed in a container, in addition, the middle lobe of the prostate is removed, hemostasis control and vascular coagulation are carried out, bladder neck tissues are compared with the urethra, the prostate capsule is sutured with a V-lock thread, then the container is removed, characterized in that said adenomectomy is supplemented with stages of urethrocystoanastomosis, laparoscopic access is performed, while 3 working trocars are installed pararectally in the right and left iliac regions, the anterior and lateral surfaces of the prostate gland are mobilized to the intrapelvic fascia after dissection of the prostate capsule and identification of the layer between the adenomotous nodes the right and left lobes of the capsule and its inner surface, the nodes are isolated as a single block, the bladder neck is displaced with a predominance of blunt dissection, the bleeding vessels are coagulated, then urethrocystoanastomosis is performed: after identifying the bladder neck, an anastomosis is performed with two V-lock 3/0 threads between urethra and bladder neck with a continuous suture, starting from the back wall, from 6 o'clock of the conditional dial, in opposite directions, until crossing on the anterior surface of the anastomosis at 12 o'clock of the conditional dial, after that, setting a urethral Foley catheter No. 20 is poured, 150 ml of saline is injected into the bladder, the prostate gland capsule is sutured with a continuous suture with a V-lock 3/0 thread, the wound revision, hemostasis, the container with macropreparations is removed through the supraumbilical access.

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