RU2790763C2 - Method for surgical treatment of microcystis in children with bladder extrophy at the stage of preparation for delayed primary closure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to pediatric urology. Mucosal polyps at the base of the protrusion are excised with a coagulator, hemostasis is performed, and the mucosal defect is sutured with an interrupted 5/0 vicryl suture. Further, along the edge of the bladder site, at 10, 12 and 2 o'clock position, the skin is cut in the radial direction in the area of the transition of the bladder mucosa to the skin of the anterior abdominal wall for 1.5 cm. Then the aponeurosis of the external oblique muscles of the abdomen is dissected, and under the control of the finger inserted into the cavity of the small pelvis, the bladder is immersed inward and the opening of the aponeurosis is further expanded with the help of two fingers, achieving maximum mobility of the bladder wall, the pressure on the upper and lateral surfaces of the anterior abdominal wall is checked and if the bladder comes out when pressed, filled with intestinal loops from the inside, the desired effect is achieved. After that, the holes in the aponeurosis are sutured with single 4/0 vicryl in the longitudinal direction and the skin is sutured with 5/0 vicryl. Next, reimplantation of the ureters is performed according to the Cohen method, the mouth is taken on a holder, a ureteral catheter 5 CH is installed and fixed to the holder with an interrupted suture. Then, the mouth of the ureter is isolated with a fringing incision and mobilized from the surrounding tissues for 3 cm, a submucosal tunnel is formed, directed upwards to the umbilical region 3 cm long, through which the ureter is passed along with the catheter, the mouths are formed with interrupted vicryl 5\0 sutures, the ureteral catheter is fixed to the bladder mucosa, after which a similar operation is performed with another ureter. Next, the holes in the bladder and sutured tightly in layers. Injections are made to the bladder wall in 10 points, in accordance with the scheme shown in Figure 5 - 1 ml of the botulinum toxoid type A solution 50 IU in 10 ml of saline. The ureteral drainage tubes are removed in 4 weeks, and 1 month after the surgery, mechanical stretching of the bladder is started: the bladder is gradually immersed with a finger into the small pelvis 2 times a day for 5 minutes, in 1 month, a Foley catheter with an inflated balloon is installed into the bladder instead of the finger and held the catheter starting with 5 minutes, increasing the duration to 10 minutes. The volume of fluid injected into the Foley catheter balloon is also gradually increased from 5 ml to 10 ml and 15 ml, and when the bladder wall is stretched to 5-6 cm, a delayed primary closure of the bladder is performed with neck plastic surgery.

EFFECT: method allows to excise all polypous growths protruding on the surface of the bladder mucosa and make it smooth; increase the size of the opening in the aponeurosis of the anterior abdominal wall for a free inward and outward movement of the bladder, due to this, any tension in the anterior abdominal wall fills the bladder with intestinal loops and squeezes out the bladder and helps to stretch gradually it, like when it is filled with urine; create an anti-reflux mechanism to prevent urinary reflux after primary bladder closure and increase the distance between the orifices and seminal tubercle to allow for a longer bladder neck during delayed primary closure; relieve bladder muscle spasm and enhance the effect of bladder distension.

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Description

The invention relates to medicine, namely pediatric urology, and can be used to treat patients with bladder exstrophy and microcystis.

Exstrophy is the most severe combined defect of the urinary and reproductive systems, requiring a complex integrated approach for its correction. In addition to the surgical technique, the equipment of the clinic, the preparedness of the medical staff and parents, a balanced and careful selection of patients, depending on their initial anatomical data, plays an important role. There is an opinion that the small size of the bladder site is a poor prognostic sign for the treatment of exstrophy (Fig. 1a, b). Primary closure operations in newborns and infants with microcystis are much more likely to be accompanied by complications and relapses. With microcystis, due to the small size of the bladder site, it is not possible to perform reimplantation of the ureters to prevent the occurrence of vesicoureteral reflux and there are not enough tissues for plastic surgery of the bladder neck to create a holding mechanism, therefore, conditions are not created for the growth of the bladder in the future. Many authors recommend excision of the bladder in patients with microcystis and the formation of a reservoir from a segment of the intestine already in infancy (Gearhart JP: The bladder exstrophy-epispadias-cloacal exstrophy complex. In Pediatric Urology. Volume Chapter 32. Editedby: Gearhart JP, Rink RC , Mouriquand PDE Philadelphia: W. B. Saunders Co; 2001:511-546; Gearhart JP., Jeffs R. D.: The bladder exstrophy epispadias complex.// Campbell's Urology, 9th ed./ eds. P. S. Walsh et al. Philadelphia: W. B. Saunders, 2007. Ch.119; Menovshchikova L.B., Rudin Yu.E., Garmanova T.N., Shaderkina V.A. Clinical guidelines for pediatric urology-andrology / based on clinical recommendations ESPU / M.: Publishing house "Pero", 2015.-196-220; Mushtaq I., Garriboly M., Smeulders N. Et al. Primary bladder extrophy closure in neonates: challenging the traditions// J. Urol. 2014. Vol 191, NI.P. 193-197;Rensley F., Barretini A.Strategy and tactics of management of patients with bladder exstrophy.Pediatric urology.Modern operational techniques: from prenatal period to puberty / ed. M. Lima, J. Manzoni; per. from English. ed. S.G. Vrublevsky. - M.: GEOTAR-Media, 2018. p. 166-184). In this regard, the question remains debatable, is it possible to save one's own bladder with microcystis, stretch the bladder wall and restore function?

An important prognostic factor is not only the size of the bladder site, but also the ability of the bladder wall to stretch (its elasticity) (Gearhart JP: The bladder exstrophy-epispadias-cloacal exstrophy complex. In Pediatric Urology. Volume Chapter 32. Editedby: Gearhart JP, Rink RC, Mouriquand PDE, Philadelphia: W. B. Saunders Co, 2001:511-546, Yu. E. Rudin, Yu. Yu. Sokolov, A. Yu. 2020. No. 1, P.21-28 (1560-9510 (Print); 2412-0677; Rudin Yu.E. Epispadias and exstrophy of the urinary bladder. Chapter in "Urology" National Guide / Under the editorship of N.A. Lopatkin - M. "GEOTAR_Media" 2009. - 273-293; Rudin Yu.E., Marukhnenko D.V., Chekeridi Yu.E., Runenko V. I. Primary bladder plastic surgery in exstrophy in children Journal "Children's Surgery" No. 4, 2009, pp. 26-31).

A known method of surgical treatment of bladder exstrophy (RU 2106814 C1). The ureters are implanted by passing through a tunnel created in the submucosal layer of the wall of the section of the sigmoid colon, previously made in the form of a semi-isolated segment by creating an anastomosis between the proximal end of the sigmoid colon and the lateral surface of its distal section and forming a narrowed entrance to the segment using suturing sutures, after which they are peeled off and excised the mucous membrane of the bladder, the remaining muscle wall is collected in longitudinal folds with U-shaped shirring sutures, and the defect on the anterior abdominal wall is replaced with two skin flaps cut in the form of squares with rounded edges in the womb area, which, after mobilization, are turned into the defect zone and are sewn together, while in the process of isolating the flaps, the cavernous bodies of the penis are separated from the pubic bones.

However, the communication of intestinal contents with the reservoir from the segment of the sigmoid colon, where urine accumulates, the presence of gas reflux or reflux of infected urine into the ureters and kidneys leads to attacks of pyelonephritis and nephrosclerosis. (Gearhart JP: The bladder exstrophy-epispadias-cloacal exstrophy complex. In Pediatric Urology. Volume Chapter 32. Edited by: Gearhart JP, Rink RC, Mouriquand PDE. Philadelphia: W. B. Saunders Co; 2001:511-546; Gearhart JP., Jeffs R.D.: The bladder exstrophy epispadias complex.// Campbell's Urology, 9th ed./ eds. P. S. Walsh et al. Philadelphia: W. B. Saunders, 2007. Ch.119).

A known method for increasing the size of a split exstrophy bladder with a full-thickness defect and a device for its implementation (EN 2558980 C1). The device for increasing the size of the bladder is made in the form of a tissue expander with two retaining elements in the form of tapes, one of which has a longitudinal technological hole, ending with a Velcro fastener. The expander is installed on the bladder platform, it is fixed from the outside at the level of the body surface. Fluid is gradually pumped into the tissue expander under pressure until the required size of the bladder is reached. The liquid is injected during the first procedure in a volume of 15 to 30 ml. Leave the expander in place for a period of 3 to 5 hours. The liquid is removed, the expander is removed. A day later, the procedure is repeated. Inject a volume of liquid that exceeds the volume of the first procedure by 1 ml. The procedures are carried out until the volume of injected liquid reaches 50 to 70 ml. Method for stretching an exstrophy bladder site provides an increase in bladder capacity during primary surgical plastic surgery due to the use of a device in the form of a tissue expander, prevention of surgical complications of primary bladder plastic surgery during its exstrophy.

However, this method is used in adult patients, in children the fixation of this design is difficult due to the negative reaction to the introduction of any foreign bodies and severe pain, in addition, the installation of an expander with a volume of 15-30 ml is technically impossible with the size of the bladder site 2-3 cm. Expander analogs must be held by parents in the correct position for the entire period of stretching of the bladder site. The installation of the expander itself is impossible or very difficult due to the narrow aponeurosis ring (1 cm in diameter), which does not allow influencing that part of the bladder that is capable of potential tissue stretching in the future.

It is known that with microcystis it is recommended to perform delayed operations that are postponed for 3-5 months or several years (Gearhart JP: The bladder exstrophy-epispadias-cloacal exstrophy complex. In Pediatric Urology. Volume Chapter 32. Editedby: Gearhart JP, Rink RC, Mouriquand PDE Philadelphia: W. B. Saunders Co; 2001:511-546; Gearhart JP., Jeffs R. D.: The bladder exstrophy epispadias complex.// Campbell's Urology, 9th ed./ eds. P. S. Walsh et al. Philadelphia: W. B. Saunders, 2007 ch.119).

However, waiting in the hope of the growth of the child and his bladder is not always justified, since not all bladders, under the influence of tension in the anterior abdominal wall, protrude outward and stretch as the child grows. If the hole in the aponeurosis turns out to be small enough, and the polypous growths of the mucosa are large, the cystic platform is dense and practically does not change its size.

In the known literature, we have not found analogues of the operation aimed at improving the possibility of stretching the bladder wall at the stage of preparing patients for delayed operations of primary closure of the bladder.

EFFECT: creation of an effective method for surgical treatment of children with microcystis in case of bladder exstrophy by expanding the opening of the anterior abdominal wall aponeurosis and creating conditions for subsequent stretching of the bladder wall using mechanical dilators.

The technical result is achieved due to the fact that the polyps of the mucosa in the region of the base of the protrusion are excised with a coagulator, hemostasis is performed and the defect of the mucous membrane is sutured with an interrupted suture 5/0 Vicryl, then along the edge of the vesical platform, at 10, 12 and 2 o'clock of the conditional dial, the skin is cut in the radial direction in the area of the transition of the mucous membrane of the bladder to the skin of the anterior abdominal wall for 1.5 cm, then the aponeurosis of the external oblique muscles of the abdomen is dissected and under the control of a finger inserted into the cavity of the small pelvis - the bladder is immersed inside and with the help of two fingers the opening of the aponeurosis additionally expand, achieving maximum mobility of the bladder wall, check the pressure on the upper and lateral surfaces of the anterior abdominal wall, and if, when pressed, the bladder comes out, filled from the inside with intestinal loops, then the desired effect is achieved, after which the holes in the aponeurosis are sutured with single vicryl sutures 4\ 0 in the longitudinal direction and the skin is sutured with 5/0 vicryl, then the ureters are reimplanted according to the Cohen method, the orifice is taken on a holder, a ureteral catheter 5 CH is installed and fixed to the holder with an interrupted suture, then the orifice of the ureter is isolated with a bordering incision and mobilized from the surrounding tissues for 3 cm, a submucosal tunnel is formed, directed upwards to the umbilical region 3 cm long, through which the ureter is passed along with the catheter, the orifices are formed with interrupted vicryl 5\0 sutures, the ureteral catheter is fixed to the bladder mucosa, after which a similar operation is performed with another ureter, then holes on bladder and sutured tightly in layers, the bladder wall is cut off at 10 points, in accordance with the scheme, as in figure 5 - 1 ml of a solution of botulinum toxoid type A 50 IU in 10 ml of saline, the ureteral drainage tubes are removed after 4 weeks and after 1 one month after the operation, mechanical stretching of the bladder is started: the bladder using a finger, gradually immerse in the small pelvis 2 times a day for 5 minutes, after 1 month, instead of a finger, a Foley catheter with an inflated balloon is placed in the bladder and the catheter is held, starting from 5 minutes, increasing the duration to 10 minutes, the volume of fluid injected into the catheter balloon Foley is also gradually increased from 5 ml to 10 ml and 15 ml, and when the bladder wall is stretched to 5-6 cm, a delayed primary closure of the bladder with neck plastic surgery is performed.

The method is explained by a detailed description, clinical examples and illustrations, which show:

Figure 1 - photo illustration of a child D., 6 days old, with exstrophy of the bladder (EMI): a) microcystis, multiple polypous growths; bubble pad size 2.5 cm; b) a schematic representation of polypous growths of the mucosa, giving the impression of a bladder volume, in reality there is no bladder volume.

Figure 2 - photo illustration of a child, 6 days old, during the operation: numerous polypous growths of the bladder mucosa are brought out; the mouths of the ureters open into polyposis growths; ureteral catheters 5 CH, installed in the mouth.

Figure 3 - Photo illustration of a child, 6 days old: a) scheme of excision of polypous growths; the ureters were mobilized and the ureters were reimplanted with the creation of a submucosal tunnel into the bottom of the bladder; incisions were made in the skin and aponeurosis of the external oblique muscles of the abdomen at 10, 12, 2 o'clock of the conventional dial, in the area of transition of the bladder mucosa to the skin of the anterior abdominal wall; b) view of the bladder site after the operation.

Fig.4 - the course of the operation: a) scheme of microcystis with exstrophy of the bladder; aponeurosis ring and polyposis growths make it difficult to stretch the bladder site; b) the edges of the aponeurosis are dissected, polyposis growths are excised; the bubble is immersed into the pelvic cavity with a finger; c) the bubble platform is easily immersed in the cavity of the small pelvis; d) a schematic representation, when, with an increase in intra-abdominal pressure, the intestinal loops protrude the bladder platform outward, creating the effect of stretching the bladder platform.

Figure 5 - scheme of chipping the bladder wall with botulinum toxoid type A 50 IU at ten points, in a checkerboard pattern of 1 ml. in a 1:10 dilution of saline.

Fig.6 - photo illustration of a child D., aged 1.5 years, with EMT and microcystis: a) immersion of the Foley catheter with an inflated balloon into the bladder cavity; b) there is a positive effect from the stretching of the bladder wall, the bladder platform has grown to 3.5 cm.

Fig.7 - photo illustration of a child D., 2.5 years old, with EMT and microcystis, after preoperative preparation: a) performed primary delayed closure of the bladder, bladder neck plastic in combination with iliac supraacetabular osteotomy to reduce the pubic pelvic bones; b) the appearance of the child after the end of the operation.

Fig.8. - photo illustration of child S., 12 days old: a) bladder exstrophy and microcystis before surgery; b) a child at the age of 3 months: view of the bladder after the proposed operation and stretching of the bladder wall; the bladder is enlarged and with tension of the anterior abdominal wall there is a protrusion of the bladder.

Figure 9 - photo illustration of a child S., 11 months old, with EMT 6 months after surgery and stretching of the bladder site, there is a noticeable stretching.

The method is carried out as follows.

Surgical intervention is performed in all children under endotracheal anesthesia. The position of the child on the back with a roller under the buttocks. Mucosal polyps are excised with a coagulator at the base of the protrusion (Figure 1b, Figure 2, Figure 3a), hemostasis and closure of the mucosal defect with interrupted vicryl 5/0 suture are performed. Along the edge of the bladder site, in the area of transition of the bladder mucosa to the skin of the anterior abdominal wall, the skin is cut in the radial direction for 1.5 cm at 10-12-2 hours of the conventional dial (Fig.3a). The skin incision continues deeper, dissecting the aponeurosis (Fig.4a, b) of the external oblique muscles of the abdomen, under the control of a finger inserted into the cavity of the small pelvis with the bladder immersed inside. After all three incisions are made with the help of two fingers, the opening of the aponeurosis is further expanded, achieving maximum mobility of the bladder wall (Fig. 4c, d). The effect of bladder mobilization is checked by pressure on the upper and lateral surfaces of the anterior abdominal wall. If, when pressed, the bladder comes out and is filled from the inside with intestinal loops, then the desired effect has been achieved. The holes in the aponeurosis are sutured with single 4/0 Vicryl sutures in the longitudinal direction. Seams on the skin 5/0 vicryl. Reimplantation of the ureters is performed according to the standard Cohen technique. The mouth is taken on a holder (4\0 vicryl ligature), a ureteral catheter 5-6 SN is installed, fixed to the holder with an interrupted suture. The mouth of the ureter is isolated with a fringing incision, mobilized from the surrounding tissues for 3 cm, a submucosal tunnel is formed, directed upwards to the umbilical region, 3 cm long, through which the ureter is passed along with the catheter. Orifices are formed with 5/0 Vicryl interrupted sutures. The ureteral catheter is fixed to the bladder mucosa. A similar operation is performed with the other ureter (Fig.3b). The holes in the bladder are sutured tightly in layers. The bladder wall is cut off at 10 points in 1 ml solution of botulinum toxoid type A 50 IU in 10 ml of saline. In the postoperative period, to protect against damage, the bladder mucosa is covered with a thin polyethylene film with pinholes in the center, 1-2 mm in diameter, the ureteral drainage tubes are removed after 4 weeks. Further, 1 month after the operation, mechanical stretching of the bladder is started by first inserting a gloved finger into the bladder 2 times a day for 5 minutes, immersing the finger gradually deeper into the small pelvis. After 1 month instead of a finger, a Foley catheter with an inflated balloon is inserted into the bladder and the catheter is held for 5 minutes gradually, increasing the duration to 10 minutes. The procedure is carried out daily, gradually increasing the volume of fluid injected into the Foley catheter balloon from 5 ml to 10 ml and 15 ml. For the convenience of long-term retention, the immersed Foley catheter is fixed with a plaster to the anterior abdominal wall. After a period of 8 months to 2 years (for different children this period is different), after stretching the wall of the bladder to a size of 5-6 cm (Fig.6a, b) perform a delayed primary closure of the bladder with neck plastic (Fig.7a, b ). No recurrence of exstrophy or divergence of the bladder neck was found in these patients. Urinary retention and a further increase in detrusor volume are noted. Children who have not achieved the desired stretch continue treatment and are monitored.

This method operated on 7 children aged 4 to 18 days, we did not observe any complications of this surgical intervention. Four patients underwent delayed primary closure of the bladder with neck plastic surgery after stretching the bladder wall. No recurrence of exstrophy or divergence of the bladder neck was found in these patients. Urinary retention and a further increase in detrusor volume are noted. Three children are in the stage of bladder distension to a diameter of 6 cm.

Clinical examples.

Example 1

Child D., 11 days old, was admitted with a diagnosis of bladder exstrophy, microcystis. When viewed from the vesical site of the bladder reduced size, 25×30 mm in diameter (Fig.1a, b).

The operation was carried out according to the proposed method.

Under intubation anesthesia in the position of the patient on the back with a roller under the buttocks, polyposis growths are brought out. The bladder wall is rigid, does not stretch, does not sink into the pelvic cavity, the orifices of the ureters open into polyps (Figure 2). Performed excision of polyps of the mucous membrane at the base. The mucosal defect was sutured with 5/0 Vicryl interrupted sutures. Reimplantation of the ureters was performed according to the standard Cohen technique. The mouth is taken on the holder (4\0 vicryl ligature), a ureteral catheter 5 CH is installed, fixed to the holder with an interrupted suture (Fig.3a). The mouth of the ureter is isolated with a fringing incision, mobilized from the surrounding tissues for 4 cm, a submucosal tunnel is formed, directed upwards to the umbilical region 3 cm long, through which the ureter is passed along with the catheter. The orifice was formed with 5/0 Vicryl interrupted sutures. The ureteral catheter is fixed to the bladder mucosa (Figure 3a, b). A similar operation was performed with the other ureter. Holes in the area of the old mouth on the bladder are sutured tightly in layers.

Along the edge of the bladder site, in the transition area of the bladder mucosa to the skin of the anterior abdominal wall, the skin was dissected in the radial direction at a distance of 1.5 cm at 10-12-2 hours of the conventional dial (Fig.3a). The skin incision is continued in depth, the aponeurosis of the external oblique muscles of the abdomen is dissected, under the control of a finger inserted into the cavity of the small pelvis with the bladder immersed inward. After performing all three incisions with one or two fingers (depending on the size of the site) the opening of the aponeurosis is further expanded, the maximum mobility of the bladder wall is achieved (Fig. 4b, c, d). The effect of bladder mobilization was tested by increasing intra-abdominal pressure by pressing on the upper and lateral surfaces of the anterior abdominal wall, if the bladder comes out when pressed, then the result is achieved (Fig. 4d). The holes in the aponeurosis are sutured with single 4/0 Vicryl sutures in the longitudinal direction. Seams on the skin 5/0 vicryl.

The wall of the bladder was punctured at 10 points, according to the scheme (Figure 5), 1 ml solution of botulinum toxoid type A 50ED diluted in 10 ml of saline. To ensure denervation of the bladder and more effective stretching of the muscle wall.

After the operation, the bladder mucosa was covered with a thin polyethylene film with pin holes in the center, 2 mm in diameter, to protect against external damage. The ureteral drainage tubes were removed after 4 weeks.

Further, 1 month after the operation, mechanical stretching of the bladder was started, the technique was previously shown in detail to the mother of the child. By gradually immersing the bladder into the small pelvis with a finger immersed in the bladder (gloved) - 2 times a day for 5 minutes, increasing to 10 minutes. After 1 month, when it was possible to slightly increase the bladder, instead of a finger, a Foley catheter with an inflated balloon was installed in the bladder, which was kept submerged for 5 minutes further up to 10 minutes (Fig.6a). The procedure was performed daily, gradually increasing the volume of fluid injected into the balloon of the Foley catheter from 5 ml to 10 ml, and at the age of 11 months - 15 ml.

The separated result was evaluated 11 months after the operation. An increase in the size of the bubble platform from 2.5 cm to 3.5 cm was achieved (Fig. 6b). When a child cries, the bladder platform comes out, eventriates, protruding outward from the abdominal cavity. At the age of 1 year 3 months, the bladder wall was stretched to the size of the bladder site of 5 cm - the child underwent delayed primary closure of the bladder with bladder neck plastic surgery and bilateral iliac osteotomy of the pelvic bones with a good result (Fig. 7a, b ).

Example 2

Child S., 12 days old, was admitted with a diagnosis of exstrophy of the bladder and microcystis (Fig.8a).

The operation was performed according to the proposed method.

Mucosal polyps were excised with a coagulator at the base of the protrusion (Figure 1b, Figure 2, Figure 3a), hemostasis and suturing of the mucosal defect with an interrupted suture 5/0 Vicryl, then along the edge of the bladder site, dissect the skin in the radial direction for 1 .5 cm at 10, 12, 2 hours of the conventional dial in the transition area of the bladder mucosa to the skin of the anterior abdominal wall (Fig. 3a), then the aponeurosis of the external oblique muscles of the abdomen is dissected, under the control of a finger inserted into the cavity of the small pelvis - the bladder is immersed in inside, after performing all three incisions with the help of one or two fingers, the opening of the aponeurosis is further expanded (Fig. 4a, b), reaching the state of maximum mobility of the bladder wall, check this effect by increasing intra-abdominal pressure by pressing on the upper and lateral surfaces of the anterior abdominal wall and if, when pressed, the bladder comes out (Fig. 4b, c, d) filled from the inside with intestinal loops, then the desired effect was reached (Figure 4d), after which the holes in the aponeurosis are sutured with single 4\0 vicryl sutures in the longitudinal direction and the skin is sutured with 5\0 vicryl, then the ureters are reimplanted according to the Cohen method, the mouth is taken on a handle and a ureteral catheter 5 is installed Sn and fixed to the holder with an interrupted suture, then the mouth of the ureter is isolated with a bordering incision and mobilized from the surrounding tissues for 3 cm, a submucosal tunnel is formed, directed upwards to the umbilical region 3 cm long, through which the ureter is passed along with the catheter, the mouths are formed with interrupted vicryl sutures 5\0 (Fig.3a, b), the ureteral catheter is fixed to the bladder mucosa. a similar operation is performed with another ureter (Fig.3b), after which the holes on the bladder are sutured tightly in layers, the bladder wall is chipped at 10 points with 1 ml of a solution of botulinum toxoid type A 50 IU in 10 ml of saline (Fig.5), ureteral drainage tubes were removed after 4 weeks. One month after the operation, mechanical stretching of the bladder was started: using the tip of a finger (in a glove), the bladder was gradually immersed in the small pelvis 2 times a day for 5 minutes. After 1 month, instead of a finger, a Foley catheter with an inflated balloon was placed in the bladder and kept for 5 minutes, gradually increasing to 10 minutes. The procedure was performed daily, gradually increasing the volume of fluid injected into the balloon of the Foley catheter from 5 ml to 10 ml and at the age of 11 months - 15 ml (Fig.6a). For the convenience of long-term retention, the immersed Foley catheter was fixed with a plaster to the anterior abdominal wall.

The detached result was evaluated after 3 months - a slight increase in the size of the bladder site from 2.5 cm to 3.5 cm was achieved (Fig.8b). When a child cries, the bladder platform comes out, eventriates, protruding outward from the abdominal cavity.

After a period of 6 months, there is a noticeable stretching (Fig.9). After stretching the bladder wall to a size of 6 cm, a delayed primary closure of the bladder was performed with neck plastic surgery. There was no recurrence of exstrophy or divergence of the bladder neck in the patient. Urinary retention and a further increase in detrusor volume are noted.

The proposed method of surgical treatment of microcystis in children with bladder exstrophy at the stage of preparation for delayed primary closure allows creating the most favorable conditions for wall stretching and enlargement of a small bladder for subsequent full-fledged delayed primary detrusor closure with the possibility of bladder neck formation.

In addition, by increasing the size of the bladder site, it was possible to significantly reduce the number of complications such as bladder neck dehiscence or recurrence of exstrophy after primary bladder closure. Excision of polyps allows clearing the mucosa, creating conditions for better stretching of the dertuzor wall, and increasing the internal volume of the bladder during primary closure. Dissection of the wall of the aponeurosis of the muscles of the anterior abdominal wall increases the mobility of the bladder, immersion in the small pelvis and the release of the bladder to the outside with an increase in intra-abdominal pressure. Reimplantation of the ureters in the bottom of the bladder at the preliminary stage increases the distance from the orifices of the ureters to the seminal tubercle, allows the next stage to perform a better formation of an extended bladder neck to ensure retention of urine and further growth and stretching of the bladder, reduces the volume and duration of the operation of delayed primary closure.

The use of the invention allows to obtain the following technical result:

- excise all polyposis growths protruding on the surface of the bladder mucosa and make it smooth;

- increase the size of the opening in the aponeurosis of the anterior abdominal wall for free movement of the bladder in and out, due to this, any tension in the anterior abdominal wall fills the bladder with intestinal loops and squeezes out the bladder and helps it to gradually stretch, as when filling it with urine;

- create an anti-reflux mechanism to prevent urinary reflux after primary closure of the bladder and increase the distance between the orifices and the seminal tubercle to be able to create a longer bladder neck during delayed primary closure;

- relieve spasm of the bladder muscles and achieve a more complete effect of bladder stretching.

Claims (1)

A method of surgical treatment of microcystis in children with bladder exstrophy at the stage of preparing patients for delayed primary closure of the bladder, characterized in that the mucosal polyps in the area of the base of the protrusion are excised with a coagulator, hemostasis is performed and the mucosal defect is sutured with an interrupted vicryl 5/0 suture, then along edge of the bladder site, dissect the skin in the radial direction for 1.5 cm at 10-12-2 hours of the conditional dial in the transition area of the bladder mucosa to the skin of the anterior abdominal wall, then dissect the aponeurosis of the external oblique muscles of the abdomen and under the control of a finger inserted into the cavity small pelvis - the bladder is immersed inward and with the help of two fingers the opening of the aponeurosis is further expanded, achieving maximum mobility of the bladder wall, the pressure on the upper and lateral surfaces of the anterior abdominal wall is checked, and if, when pressed, the bladder comes out, the intestines filled with loops from the inside a, the desired effect is achieved, after which the holes in the aponeurosis are sutured with single 4/0 vicryl sutures in the longitudinal direction and the skin is sutured with 5/0 vicryl, then the ureters are reimplanted according to the Cohen method, the mouth is taken on a holder, a ureteral catheter 5 CH is installed and fixed to the holder with an interrupted suture, then the mouth of the ureter is isolated with a bordering incision and mobilized from the surrounding tissues for 3 cm, a submucosal tunnel is formed, directed upwards to the navel region 3 cm long, through which the ureter is passed along with the catheter, the mouths are formed with interrupted vicryl sutures 5 \0, the ureteral catheter is fixed to the bladder mucosa, after which a similar operation is performed with another ureter, then the holes on the bladder and sutured tightly in layers, the bladder wall is chipped at 10 points, in accordance with the diagram in figure 5 - 1 ml of solution botulinum toxoid type A 50 units in 10 ml of saline, ureteral drainage th tubes are removed after 4 weeks and 1 month after the operation, mechanical stretching of the bladder is started: the bladder is gradually immersed with a finger into the small pelvis 2 times a day for 5 minutes, after 1 month, instead of a finger, a Foley catheter with an inflated balloon is inserted into the bladder and hold the catheter starting from 5 and gradually increasing to 10 minutes, gradually increasing the volume of fluid injected into the Foley catheter balloon from 5 ml to 10 ml and 15 ml, and when the bladder wall is stretched to 5-6 cm, delayed primary closure of the bladder is performed with neck plastic.

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