RU2841225C1 - Method for ureteropyeloplasty with buccal flap with stricture of upper one-third of ureter and ureteropelvic junction segment in patients with single kidney in chronic kidney disease - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to urology. An involved portion of the ureter, a ureteropelvic junction and a portion of a pelvis are dissected laparoscopically with covering healthy tissues 0.5 cm from each side. A graft up to 5 cm in size is cut out from the buccal mucosa, which is further processed and split as shown in Fig. 3. Through the working channel, the graft is delivered to the operation area, with preliminary extracorporal sutures on both edges of the graft, as shown in Fig. 3. Then the graft is fixed with the mucosa inside to a proximal edge of the urinary incision: with one thread it is sutured to the lateral edge of the incision with a continuous suture with monofilament suture 4/0, after which the urinary tract is drained with an internal stent catheter N7, and the second suture is to the medial wall of the dissected ureteropelvic junction above the internal drainage stent by a continuous external suture with monofilament suture 4/0. Then, the omentum flap is cut out on the pedicle with a width corresponding to the length of the buccal graft, brought to the anastomosis and placed tension-free over the entire surface of the graft, omentum flap is fixed with single monofilament sutures 4/0 on the periphery of the graft with covering ureter tissue and with single monofilament sutures 4/0 directly to the graft.

EFFECT: method allows to replace extended sections of the stricture of the upper one-third of the ureter up to 8-10 cm with single-stage replacement of the ureteropelvic junction segment and part of the pelvis, increase efficiency of single-stage reconstruction of upper third of ureter and ureteropelvic junction segment, reducing intraoperative injuries, reducing the length of the surgical intervention, reducing the number of postoperative complications and recurrences in the patients with strictures of the upper one-third of the ureter of the ureteropelvic junction segment.

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Description

Field of technology to which the invention relates

The invention relates to the field of medicine, in particular to urology, and can be used to treat extended strictures of the proximal ureter in patients with a single kidney in chronic kidney disease.

State of the art

Surgical treatment of strictures of the proximal ureter currently remains a complex problem in urology [Paffenholz P. et al., 2021; Komyakov B. et al., 2020].

There is a known surgical technique of using one's own urinary tract, which is the preferred and most often the only option for restoring patency. However, it also has disadvantages, such as the formation of a hermetic anastomosis without tension, which is not always possible due to the deficiency of the upper urinary tract (UUT) tissues themselves, especially after previous operations and a long-term inflammatory process in this area [Nishimura Y. et al., 2017; Srivastava D. et al., 2017].

A method of kidney mobilization with reduction, plastic surgery with tubular and reconfigured intestinal segment or autotransplantation is known [Mogorovich A et al., 2018; Kapogiannis F et al., 2020; Xiong S et al., 2020]. The disadvantage of this method of intestinal substitution plastic surgery is a significant number of early and late complications associated with both high trauma due to intestinal resection and postoperative metabolic complications [Guliev BG et al., 2023], which limits the possibility of using this technique in patients with complicated somatic status.

A method of nephropexy is known, which allows to replace a ureter defect of about 4 cm in length [Lee Z et al., 2013; Hofer MD et al., 2016]. The disadvantage of this method is the resulting cicatricial changes in the paranephric tissue, which do not always allow mobilization of the kidney [Guliev B.G. et al., 2019].

Autotransplantation of the kidney, in turn, can be accompanied by complications such as vascular thrombosis and the formation of pseudoaneurysms, and therefore this technique is rarely used [Hofer MD et al., 2016; Ruiz M et al., 2017].

Due to the above-mentioned shortcomings of the currently known approaches to the problem under consideration, the search for alternative methods of reconstructing the proximal ureter and the ureteropelvic segment is currently ongoing.

The principle of these operations must meet such parameters as the creation of a hermetic, elastic and well-vascularized anastomosis.

Substitute plastic surgery of the ureter of the oral mucosa meets these requirements [Trapeznikova M.F. et al., 2014; Volkov A.A. et al., 2021].

A method for surgical treatment of extended ureteral strictures is known from the state of the art [Patent of the Russian Federation No. 2625782 C1], which includes longitudinal dissection of its stenotic part with an extension of the incision to healthy tissues by at least 0.5 cm in each direction and replacement of the resulting ureteral defect with a patch formed from an autograft of the buccal mucosa, characterized in that the patch formed from an autograft of the buccal mucosa is sutured to the ventral surface of the lumbar muscle with subsequent suturing of the edges of the dissected ureteral wall with the edges of the above patch and nephropexy is performed.

However, this method does not include flap replacement for stricture of the upper third of the ureter and ureteropelvic junction and does not describe the treatment outcomes for patients with a solitary kidney.

A method is known for assessing the effectiveness of reconstructive surgery on the upper urinary tract using a buccal transplant [Patent of the Russian Federation No. 2776556 C1], including a clinical and laboratory examination, determination of the glomerular filtration rate in the blood, in ml/min/1.73 sq. m, calculation of the maximum systolic blood flow velocity in the interlobar arteries of the kidney by the method of triplex scanning of the renal vessels, in cm/s, determination of the thickness of the renal parenchyma by ultrasound examination in mm, assessment of the vascularization of the buccal transplant by ureteroscopy and assessment of the presence of patient complaints of pain in the lower back.

The disadvantage of this method is that it was developed on the basis of substitution buccal ureteroplasty and does not include replacement with a flap in case of stricture of the upper third of the ureter and the ureteropelvic segment, and the technique proposed in this method does not describe the results of treatment of patients with a single kidney.

The closest to the proposed invention is a method of surgical treatment of extended strictures of the upper third of the ureter and the ureteropelvic segment [Patent of the Russian Federation No. 2738002 C1], including dissection of the cicatricial-stenotic part of the ureter and plastic surgery with a buccal autograft. This method was chosen as a prototype.

The disadvantages of the prototype are: lack of results of use in patients with previously unoperated ureteral and ureteropelvic stricture, lack of laboratory results and treatment effectiveness in patients with a single kidney, prolongation of the surgical intervention time, required additional technical equipment and possible complications associated with the endoscopic stage of the surgical intervention.

The proposed invention eliminates all the above-mentioned disadvantages of the prototype.

Unlike the prototype, the proposed method can be used in patients with previously operated stricture of the ureter and ureteropelvic segment, for the treatment of patients with a single (single functioning) kidney.

When using the proposed method, the time of surgical intervention is reduced (in the selected prototype, the operation time is 210 minutes), and there is no need for additional technical equipment and prevention of possible complications associated with the endoscopic stage of surgical intervention.

Thanks to the use of the proposed invention, it is possible to replace extended sections of stricture of the upper third of the ureter up to 8-10 cm with a one-stage replacement of the ureteropelvic segment and part of the renal pelvis by replacing the ureter defect using the buccal mucosa.

The technical result of the proposed invention is an increase in the efficiency of one-stage reconstruction of the upper third of the ureter and the ureteropelvic segment, a decrease in the trauma of the intervention, a decrease in the duration of the surgical intervention due to the absence of an endoscopic stage of the operation, a decrease in the number of postoperative complications and relapses in patients with strictures of the upper third of the ureter of the ureteropelvic segment.

The technical result is achieved in that the method of ureteropyeloplasty with a buccal flap for stricture of the upper third of the ureter and ureteropelvic segment in patients with a single kidney in chronic kidney disease, including dissection of the cicatricial-stenotic part of the ureter and plastic surgery with a buccal autograft, characterized in that the affected part of the ureter, ureteropelvic segment and part of the pelvis are laparoscopically dissected with the capture of healthy tissues by 0.5 cm on each side, a graft (flap) is cut out from the mucous membrane of the cheek up to 5 cm in size, which is subsequently processed, split and delivered to the surgical area through the working channel, after extracorporeal threads are applied to both narrow edges of the graft, which, after the mucous graft is inserted inside, are fixed to the proximal edge of the incision of the urinary tract: it is sutured to the lateral edge of the incision with one thread continuous suture with 4/0 monofilament thread, after which the urinary tract is drained with an internal catheter-stent No. 7, and with a second thread - to the medial wall of the dissected ureteropelvic region above the internal drainage stent with a continuous external suture with 4/0 monofilament thread, an omental flap is cut out on a feeding pedicle of a width corresponding to the length of the buccal graft, brought to the anastomosis and positioned without tension over the entire surface of the graft, the omental flap is fixed with several single sutures with 4/0 monofilament thread along the edges of the graft with the capture of ureteral tissue and several single sutures with 4/0 monofilament thread directly to the graft itself.

Achievement of the technical result is confirmed by studying and assessing the glomerular filtration rate in the postoperative period after removal of the catheter-stent.

The invention works as follows.

The operation is performed under endotracheal anesthesia. With the patient lying on the healthy side, a puncture of the abdominal cavity is performed with a Veress needle, and _CO2 is insufflated to 12 mm Hg. Then trocars are installed in the abdominal cavity. A 10 mm optical port is installed in the periumbilical region; additional trocars: 12 mm - in the epigastric region, 5 mm - along the edge of the rectus abdominis muscle on the right (left). The renal pelvis and the upper third of the ureter are isolated and visualized, minimal distal mobilization of the ureter is performed in its unchanged area.

Using a scalpel blade on a needle holder, the affected part of the ureter, the ureteropelvic segment and part of the pelvis to healthy tissues with an extension of 0.5 cm in both directions are dissected. Antegradely, using an aspirator, a guidewire is inserted through a 12 mm port, and a ureteral stent for internal drainage No. 7 Ch is installed along the guidewire. The length of the UUT defect is determined.

The internal drainage catheter-stent No. 7 is used. Compared to the catheter-stent No. 6 used in the prototype, stent No. 7 has a larger diameter, which allows for adequate splinting of the ureter.

The second team of surgeons, using the generally accepted method, takes the buccal mucosa from the oral cavity. After treating it with an antiseptic and hydropreparing the mucosa, a buccal graft of the required size is taken from the buccal mucosa within the submucosal layer. Hemostasis of the oral cavity wound is performed. The flap is processed, and elements of the submucosal layer are removed.

The buccal graft is delivered to the surgical site through a 12 mm trocar, then the mucosal graft is fixed inward with one thread using a continuous 4/0 monocryl suture to the medial edge of the incision, and the graft is sutured to the lateral wall of the incised ureteropelvic segment above the internal drainage stent using a continuous 4/0 external monocryl suture with a second thread. An omental flap is cut out on a feeding pedicle of a width corresponding to the length of the buccal graft, brought to the anastomosis and positioned without tension over the entire surface of the graft, the omental flap is fixed with several single 4/0 monocryl sutures along the edges of the graft, capturing the ureteral tissue and several single 4/0 monocryl sutures directly to the graft itself.

A safety drain is placed through a 5 mm port in the iliac region.

Ureteral stenting is performed over a period of 4 weeks.

The invention is explained by drawings and diagrams.

Fig. 1 shows a collection of 1 flap (graft) from the buccal mucosa - 2, 5 cm in size.

In Fig. 2, the arrows show the area of preliminary fixation of 4/0 monofilament threads to the graft and lengthening by splitting the graft to a size of 8-10 cm.

Fig. 3 shows the fixation of the transplant to one edge of the urinary tract incision.

Fig. 4 shows the insertion of a catheter-stent, where: transplant - 2, catheter-stent - 3, aspirator - 4.

Fig. 5 shows the fixation of the graft to the wall of the dissected ureteropelvic region above the internal drainage stent with a continuous external 4/0 monocrylic suture.

The invention is confirmed by a clinical example.

Patient M., 63 years old, came to the Clinic of Urology and Reproductive Health of I.M. Sechenov First Moscow State Medical University. It is known from the anamnesis that the patient has been suffering from urolithiasis for a long time. He repeatedly noted the passage of stones from the right and left kidneys, attacks of acute pyelonephritis. In 2022, laparoscopic nephrectomy was performed on the left due to hydronephrotic transformation of the latter. On 04/26/2023, postrenal anuria occurred, the patient was urgently hospitalized to the hospital at his place of residence, where, according to emergency indications, percutaneous puncture nephrostomy on the right was performed. On 06/06/2023, ureteroscopy was performed on the right, nephrostomy was replaced on the right under endotracheal anesthesia, according to which a stricture of 1/3 of the right ureter of the only right kidney was diagnosed. He came to the Urology and Reproductive Health Clinic of I.M. Sechenov First Moscow State Medical University with complaints of the presence of a nephrostomy drainage on the right. After a course of antibacterial therapy, the patient was further examined, and a diagnosis was made - an extended stricture of the upper third of the right ureter and the ureteropelvic junction. Given the localization of the stricture, its extent and the patient's complex comorbid status, due to the patient having a single kidney, CKD C4 CKD-EPI, the eGFR before surgery was 27 ml/min/1.73 ^m2 , creatinine before surgery was 215 μmol/l.

A decision was made to perform laparoscopic buccal onlay ureteroplasty using the method proposed by the present invention.

Anesthesia method - endotracheal anesthesia. With the patient in the left lateral position, the abdominal cavity was punctured with a Veress needle, _CO2 was insufflated to 12 mm Hg. Then, trocars were inserted into the abdominal cavity. A 10 mm optical port was installed in the periumbilical region; additional trocars: 12 mm - in the epigastric region, 5 mm - along the edge of the rectus abdominis muscle on the right. A pronounced adhesive process was visualized. Separation of the adhesive process parallel to the ascending colon was performed with particular technical difficulties. The renal pelvis, ureteropelvic segment and right ureter were isolated. No additional renal vessels were found. The upper third of the ureter is narrowed for about 10 cm. The tissue of the upper urinary tract is dissected to healthy tissues by 0.5 cm in each direction. Antegradely, using an aspirator, a guidewire is inserted through a 12 mm port, and a ureteral stent for internal drainage No. 7 Ch is installed along the guidewire. The second team of surgeons collected a flap from the oral cavity. After its treatment with an antiseptic, hydropreparation of the buccal mucosa was performed, and a buccal graft was taken within the submucosal layer according to generally accepted rules. The flap was processed, and elements of the submucosal layer were removed. Hemostasis of the oral cavity wound was performed. The buccal graft was delivered to the surgical area through a 12 mm port. First, two threads are applied to one of the narrow edges of the flap, with which, after insertion through the trocar, it is sutured to the proximal edge of the urinary tract incision; with one of the threads, the graft is fixed with the mucosa inside with a continuous 4/0 monocrylic suture to the medial edge of the incision; with the second thread, the graft is sutured to the lateral wall of the dissected ureteropelvic region above the internal drainage stent with a continuous external 4/0 monocrylic suture.

A flap of omentum on a feeding pedicle was cut out, brought to the anastomosis over the entire surface of the transplant, and fixed with two single sutures with 4/0 monocryl directly to the transplant itself.

The safety drainage is installed through a 5 mm port.

The operation time was 195 min, blood loss was less than 100 ml. The patient had no intra- and postoperative complications. In the postoperative period, spasmoanalgesic, gastroprotective, anticoagulant, antibacterial, infusion therapy (taking into account the SCF) was performed. The insurance drainage and urethral catheter were removed on the 1st day. The patient was discharged from the hospital in a satisfactory condition on the 7th day. Four weeks after the operation, the patient noted spontaneous discharge of the nephrostomy drainage on the right. He was hospitalized in the urology clinic of I.M. Sechenov First Moscow State Medical University. Ultrasound diagnostics did not reveal any data on the expansion of the renal pelvis and calyces on the right.

The ureteral stent was removed 5 weeks after the surgery. Dynamic ultrasound diagnostics performed after the stent removal confirmed the patency of the ureteral urinary tract. Dynamic monitoring of laboratory parameters of renal function did not reveal any evidence of progressive decline in the latter. No postoperative complications or relapses of the disease were observed over a period of 9 months.

CKD-EPI eGFR after surgery - 28.7 ml/min/1.73 ^m2 , creatinine after surgery - 206 μmol/l.

Thus, the proposed method of surgical treatment of extended strictures of the upper third of the ureter and ureteropelvic segment in patients with a single kidney ensures a reduction in the trauma of the intervention and a stable therapeutic effect for more than 9 months (observation period).

The proposed invention is applicable in a hospital setting for the purpose of maintaining the functional reserve of the kidney in patients with chronic kidney disease and can improve the quality of life of patients with extended strictures of the proximal ureter with a single (single functioning) kidney, as well as reduce the rehabilitation period, duration and cost of inpatient treatment.

The proposed method has proven its effectiveness, applicability and is recommended for use in the treatment of extended strictures of the proximal ureter.

Claims (1)

A method of ureteropyeloplasty with a buccal flap for stricture of the upper third of the ureter and ureteropelvic segment in patients with a single kidney in chronic kidney disease, including dissection of the cicatricial-stenotic part of the ureter and plastic surgery with a buccal autograft, characterized in that the affected part of the ureter, ureteropelvic segment and part of the pelvis are laparoscopically dissected with the capture of healthy tissues by 0.5 cm on each side, a graft is cut out from the mucous membrane of the cheek up to 5 cm in size, which is subsequently processed and split, as shown in Fig. 3; the graft is delivered to the surgical site through the working channel, with threads first being applied extracorporeally to both edges of the graft, as shown in Fig. 3, then the graft is fixed with the mucosa inward to the proximal edge of the urinary tract incision: with one thread it is sewn to the lateral edge of the incision with a continuous suture of 4/0 monofilament thread, after which the urinary tract is drained with an internal N7 catheter-stent, and with the second thread - to the medial wall of the dissected ureteropelvic region above the internal drainage stent with a continuous external suture of 4/0 monofilament thread; then a flap of omentum is cut out on a feeding pedicle of a width corresponding to the length of the buccal graft, brought to the anastomosis and positioned without tension over the entire surface of the graft, the flap of omentum is fixed with single sutures of 4/0 monofilament thread along the edges of the graft, capturing the ureter tissue and single sutures of 4/0 monofilament thread directly to the graft itself.