RU2846793C1 - Method for preventing lymphorrhea and lymphatic cysts in patients with prostate cancer after laparoscopic prostatectomy with pelvic lymphadenectomy - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to surgery and oncology. After pelvic lymphadenectomy, the wound surface of the lymphadenectomy region is treated with Lymphoblock solution in amount of 50 ml, which is introduced through the catheter on the previously laid gauze pads into the lymphadenectomy area from both sides. That is followed by a prostatectomy, and a urethrovesical anastomosis. After 50-55 minutes of the Lymphoblock solution exposure, the gauze pads are removed. Free medial edges of the parietal peritoneum opened above the iliac vessels when performing pelvic lymphadenectomy are anchored alternately from both sides in the Douglas space as shown in Fig. 10 with a single interrupted suture PGA 2/0. A pelvic cavity is drained with a Nelaton catheter No. 16.

EFFECT: method enables reducing a number of lymphatic complications, shortening the length of staying in hospital, reducing the number of readmissions and surgical interventions, reducing the length of postoperative rehabilitation of the patients.

1 cl, 13 dwg, 2 ex

Description

The invention relates to medicine, namely to oncology, and can be used to prevent lymphorrhea and the development of lymphatic cysts in patients with prostate cancer after laparoscopic prostatectomy (LPE) with pelvic lymphadenectomy (PLA).

A sclerotherapy method for preventing lymphorrhea after prostatectomy involves injecting a 10% povidone solution through the existing drain for 30 minutes, after which the drain is removed (Gilliant J. Det. et al., 1997). A disadvantage of this method is that the povidone solution is unevenly distributed across the retroperitoneal wound surface.

A known method (RU Patent No. 2674976) for the prevention of lymphorrhea and lymphocysts in patients with prostate cancer after surgical treatment involves performing a radical retropubic prostatectomy with extended pelvic lymphadenectomy. After removal of the prostate gland with the seminal vesicles, pelvic tissue with lymph nodes, and formation of a vesicourethral anastomosis, the parietal peritoneum is pulled out and the parietal layer is dissected using a monopolar coagulator along the transitional fold and the distal parts of the lateral canals. After this, lymph from the pelvic cavity is redistributed into the abdominal cavity and reabsorbed by the peritoneum. The pelvic cavity is then drained on the right and left, and the wound is sutured layer by layer. A disadvantage of this method is that the perivesical adipose tissue of the bladder contacts the vessels, creating a limited space at the site of lymphadenectomy. Lymph can accumulate in this space without access to the abdominal cavity for reabsorption, resulting in the formation of lymphatic cysts.

A method (RU Patent No. 2744352) for preventing the development of lymphatic cysts after radical prostatectomy with pelvic lymphadenectomy is known. Following RP with PLAE, the parietal peritoneum is incised laterally and along the medial umbilical folds, starting from the umbilical ring to the transitional peritoneal fold. The parietal peritoneum is separated from the anterior abdominal wall, forming a trapezoidal flap with its base located in the bladder area. The free end of the flap is incised longitudinally for 4 cm along the midline using a "dovetail" pattern, creating two free ends. The formed flap is then placed in the area of the urethrovesical anastomosis. The right free end of the flap is then secured with a suture to the stump of the right puboprostatic ligament, and the left free end of the flap is secured with a suture to the stump of the left puboprostatic ligament. The disadvantage of this method is its complexity and prolonged surgical time.

The use of the hemostatic sponge "TachoSil" is known for the prevention of lymphogenous complications [Simonato, A. The use of an surgical patch in the prevention of lymphoceles after extraperitoneal pelvic lymphadenectomy for prostate cancer: a randomized prospective pilot study / A. Simonato, V. Varca, M. Esposito [etal.] // J. Urol. - 2009. - N. 182. - P. 2285-90.] The disadvantage is the high cost and the need to use a large number of hemostatic sponges during extended pelvic lymphadenectomy.

The use of the hemostatic matrix FloSeal for hemostatic and lymphostatic purposes is known [Waldert, M. FloSeal reduces the incidence of lymphoceles after lymphadenectomies in laparoscopic and robot-assisted extraperitoneal radical prostatectomy. M. Waldert, M. Remzi, T. Klatte [et al.] J. Endourol. - 2011. - N. 25 (6). - P. 969-73.]. The disadvantages of using this method are the high cost of the drug and the possible formation of adhesions in the area of use.

A method for preventing the development of lymphocele is known using the absorbable hemostatic powder Arista AH [Gilbert, D.R. Evaluation of Absorbable Hemostatic Powder for Prevention of Lymphoceles Following Robotic Prostatectomy With Lymphadenectomy / D.R. Gilbert, J. Angell, R. Abaza [et. al.] // Urology - 2016. - N. 98. - P. 75-80.] The disadvantages of this drug are its high cost, the likelihood of edema in the area of application and, as a consequence, the occurrence of tissue necrosis, which necessitates the extraction of excess volume of the drug.

A known method (RU Patent No. 2647620) for preventing lymphorrhea after radical prostatectomy involves tumor removal and ileo-obturator-pelvic lymphadenectomy. At the end of the surgery, the wound surface is treated with fibrin glue applied to a hemostatic sponge. The sponge is applied to the dry wound surface along the lymphadenectomy margins. After 2-3 minutes, the sponge is removed and the wound is sutured layer by layer. A disadvantage of this method is the formation of adhesions in the area where the fibrin glue is applied, the involvement of intestinal loops, and the risk of pulmonary embolism.

The closest approach to the claimed method is (RU Patent No. 2817487) for preventing lymphoceles during robot-assisted prostatectomy with pelvic lymphadenectomy. This method consists of fixing a free peritoneal flap to the pubic bone after robot-assisted prostatectomy with pelvic lymphadenectomy. The pelvic lymphadenectomy (PL) area is irrigated with Lymphobloc (25 ml on each side of the PL), the urethrocervical anastomosis area is drained with a silicone drain, and a clamp is applied for 10 minutes. A disadvantage of this technique is the risk of leakage of the lymphobloc through the drain with insufficient exposure.

The technical objective of the proposed solution is to develop a method for preventing lymphorrhea and the formation of lymphatic cysts in patients with prostate cancer after LAE with TLAE.

The technical result of the claimed solution is the development of a method for preventing lymphorrhea and the formation of lymphatic cysts in patients with prostate cancer after LAE with TLAE using the "Lymphobloc" solution (Surgical agent "Lymphobloc" in a bottle according to TU 21.20.23-003-68087337-2019 https://drive.google.com/file/d/1PhlQEu8UGsd4WdvfqpnWlTTsEZFiBM54/view) with suturing the free medial edges of the parietal peritoneum, opened above the iliac vessels when performing TLAE, alternately on both sides to the "Douglas space" with single interrupted sutures with PGA 2/0 thread in order to ensure free outflow of lymphatic fluid from the pelvic cavity into the abdominal cavity for absorption of lymph by the peritoneum.

The specified technical result is achieved by proposing a method for preventing lymphorrhea and lymphatic cysts. in patients with prostate cancer after LPE with PLND, including laparoscopic prostatectomy with pelvic lymphadenectomy, according to the decision, After pelvic lymphadenectomy, the wound surface of the lymphadenectomy is treated with 50 ml of Lymphobloc solution, which is introduced through a catheter onto previously placed gauze napkins into the lymphadenectomy area on both sides, then a prostatectomy is performed, a urethrovesical anastomosis is formed, after 50-55 minutes of exposure to the Lymphobloc solution, the napkins are removed, the free medial edges of the parietal peritoneum, opened above the iliac vessels during pelvic lymphadenectomy, are sutured alternately on both sides to the Douglas space with a single interrupted suture of PGA 2/0 thread in order to ensure free outflow of lymphatic fluid from the pelvic cavity into the abdominal cavity for absorption of lymph by the peritoneum, the pelvic cavity is drained with a Nelaton No. 16 catheter.

The technical result can be achieved by first performing TLAE and then LPE. After performing TLAE on the right (Fig. 1) and left (Fig. 2), gauze pads (Fig. 3), observing aseptic rules, are placed in the lymphadenectomy area on both sides (Figs. 4, 5), then the pads are impregnated with Lymphobloc solution in a volume of 25 ml on each side, the solution is introduced using a Nelaton catheter No. 10 through the right and left lateral trocars, respectively (Figs. 6, 7), then transperitoneal antegrade prostatectomy is performed (Montsouris technique). After the formation of the urethrovesical anastomosis, after 50-55 minutes of exposure to the Lymphobloc solution, the pads are removed, thus achieving the maximum exposure time of the drug. Due to the ability of the matrix structure of the Lymphobloc solution to cooperatively bind proteins of various biological fluids, in particular lymph, a gradually absorbable surface film is formed on the surface of the damaged area of biological tissue, which helps to reduce lymphorrhea.

The essence of the technique is explained by figures, which depict:

Fig. 1. - Right pelvic lymphadenectomy.

Fig. 2. - Left pelvic lymphadenectomy.

Fig. 3. - Gauze napkins.

Fig. 4. - Gauze napkin in the lymphadenectomy area on the right.

Fig. 5. - Gauze napkin in the lymphadenectomy area on the left.

Fig. 6. - Impregnation of a gauze napkin with the “Lymphobloc” solution in the lymphadenectomy area on the right.

Fig. 7. - Impregnation of a gauze napkin with the “Lymphobloc” solution in the lymphadenectomy area on the left.

In order to ensure free outflow of lymphatic fluid from the pelvic cavity into the abdominal cavity for absorption of lymph by the peritoneum, the free medial edge of the parietal peritoneum, opened above the iliac vessels (Fig. 1), is alternately sutured to the Douglas cul-de-sac on both sides (Fig. 2; Fig. 3; Fig. 4; Fig. 5) with a single interrupted suture using PGA 2/0 thread (Fig. 6). This ensures drainage of the pelvic lymph node dissection area on both sides into the abdominal cavity, where the lymphatic discharge is absorbed by the peritoneum, which in turn minimizes the risk of lymphocele formation in the pelvis. The pelvic cavity is drained with a Nelaton No. 16 catheter to control the discharge.

The essence of the invention is explained by the figures:

Fig. 8. - Condition after pelvic lymphadenectomy, laparoscopic prostatectomy, napkins with lymph block removed.

Fig. 9. - Formation of a suture, with suturing of the parietal peritoneum on the left side.

Fig. 10. - A suture has been formed, the parietal peritoneum on the left side has been sutured to the “Douglas’s space”.

Fig. 11. - Formation of a suture, with suturing of the parietal peritoneum on the right side.

Fig. 12. - A suture is formed, the parietal peritoneum on the right side is sutured to the “Douglas’s space”.

Fig. 13. - Final view, the parietal peritoneum on both sides is sutured to the “Douglas’s space”.

Clinical example 1

Patient S., 68 years old. During the examination, the PSA was 16.8 ng / ml, according to TRUS, the prostate gland is 56x46x58 mm, the volume is 74 ml, the capsule is traced along its entire length, the contour is smooth, a hypoechoic node of 11 mm is visualized along the periphery in the left lobe, residual urine is 32 ml. Rectally - the sphincter is normotonic, the ampulla of the rectum is free, the rectal mucosa is mobile, the prostate is enlarged, the interlobar groove is smoothed out, dense and elastic, the contour is clear, painless, a seal of about 1.5 cm in diameter is palpated in the left lobe. Multifocal biopsy of the prostate gland under ultrasound control was performed. Morphologically, there is adenocarcinoma in the left lobe of the prostate, the Gleason index is 7 (4 + 3) with damage to less than 50% of the columns. Further examination revealed no generalization of the process. Bone scan revealed no evidence of metastatic skeletal involvement. Magnetic resonance imaging of the pelvic organs revealed an area of hypointensive signal without clear contours in the peripheral zone of the left prostate lobe, measuring 14 x 11 x 13 mm. The prostate capsule is not involved in the tumor process. According to D'Amico, the prognosis is intermediate. Nomogram: the probability of lymph node metastases is 15%.

The diagnosis was:

Main diagnosis: Prostate cancer Stage II. T2bN0M0 Clinical group 2.

The oncology council decided to perform a laparoscopic prostatectomy with extended pelvic-iliac lymphadenectomy for the patient.

Under endotracheal anesthesia, the patient underwent transperitoneal antegrade prostatectomy (Montsouris technique) with extended pelvic-iliac lymphadenectomy.

Description of the procedure: A bilateral extended pelvic-iliac lymphadenectomy was performed (the upper border was the bifurcation of the ureter with the iliac vessels). Following PLAS, gauze pads were placed in the lymphadenectomy area, specifically the iliac vessels on both sides, observing aseptic technique. The pads were then impregnated with 25 ml of Lymphobloc solution on each side, which was introduced using a Nelaton No. 10 catheter through the right and left lateral trocars, respectively. A transperitoneal antegrade prostatectomy was then performed (Montsouris technique). After the urethrovesical anastomosis was completed, after 50 minutes of exposure , the pads with Lymphobloc solution were removed.

In order to ensure free outflow of lymphatic fluid from the pelvic cavity into the abdominal cavity for absorption of lymph by the peritoneum, the free medial edges of the parietal peritoneum, opened above the iliac vessels, are alternately sutured on both sides to the “Douglas space” with a single interrupted suture of PGA 2/0 thread.

The specimens were removed from the abdominal cavity. A drainage tube (Nelaton No. 16 catheter) was placed in the pelvis at the anastomosis site to monitor the drainage. The wound was sutured layer by layer. The surgery lasted 145 minutes, and the blood loss was 110 ml.

The following day, following a pelvic ultrasound and creatinine monitoring of the discharge, the drainage was removed (20 ml of serous discharge was observed during the first 24 hours). The postoperative period was uneventful. The urethral catheter was removed on the 8th day. An abdominal and pelvic ultrasound revealed no lymphocysts. The patient was discharged from the hospital on the 9th day.

Histological examination of the surgical material: the resection margin of the bladder neck and urethra - tumor growth is not determined, the prostate gland is adenocarcinoma, Gleason index 7 (4+3), occupies more than half of the left lobe, no metastatic lesions were found in the removed lymph nodes (a total of 17 pieces).

Diagnosis established based on the results of surgery and histological findings: C61.0 - Prostate cancer StII T2bNоMo. Cl. group 3

Clinical example 2

Patient M., 62 years old. During examination, PSA was 14.3 ng / ml, according to TRUS, the prostate gland is 54x51x58 mm, volume is 83 ml, the capsule is traceable along its entire length, the contour is smooth, a hypoechoic node of 13 mm is visualized along the periphery in the right lobe, residual urine is 44 ml. Rectally - the sphincter is normotonic, the ampulla of the rectum is free, the rectal mucosa is mobile, the prostate is enlarged, the interlobar groove is smoothed out, dense-elastic, the contour is smooth, moderately painless, a node of 1.0 cm in diameter is palpated in the right lobe, in the left lobe there is an area of \u200b\u200bcompact of about 2 cm. Multifocal prostate biopsy under ultrasound control was performed. Morphologically, the right lobe of the prostate reveals adenocarcinoma, Gleason score 7 (3+4), with less than 50% of the columns affected. Further examination revealed no generalization of the process. Bone scintigraphy revealed no evidence of metastatic bone involvement. Magnetic resonance imaging of the pelvic organs revealed a hypointense signal area in the peripheral zone of the right lobe of the prostate without clear contours, measuring 12x14x14 mm. The capsule of the gland is not involved in the tumor process. According to D'Amico, the prognosis is intermediate. Nomogram shows the probability of lymph node metastases is 9%.

The diagnosis was:

Main diagnosis: Prostate cancer Stage II. T2bN0M0 Clinical group 2.

The oncology council decided to perform a laparoscopic prostatectomy with extended pelvic-iliac lymphadenectomy for the patient.

Under endotracheal anesthesia, the patient underwent transperitoneal antegrade prostatectomy (Montsouris technique) with extended pelvic-iliac lymphadenectomy.

Description of the procedure: A bilateral extended pelvic-iliac lymphadenectomy was performed (the upper border was the bifurcation of the ureter with the iliac vessels). Following PLAS, gauze pads were placed in the lymphadenectomy area, specifically the iliac vessels on both sides, observing aseptic technique. The pads were then impregnated with 25 ml of Lymphobloc solution on each side, which was introduced using a Nelaton No. 10 catheter through the right and left lateral trocars, respectively. A transperitoneal antegrade prostatectomy was then performed (Montsouris technique). After the urethrovesical anastomosis was completed, after 55 minutes of exposure , the pads with Lymphobloc solution were removed.

In order to ensure free outflow of lymphatic fluid from the pelvic cavity into the abdominal cavity for absorption of lymph by the peritoneum, the free medial edges of the parietal peritoneum, opened above the iliac vessels, are alternately sutured on both sides to the “Douglas space” with a single interrupted suture of PGA 2/0 thread.

The specimens were removed from the abdominal cavity. A drainage tube (Nelaton No. 16 catheter) was placed in the pelvis near the anastomosis site to monitor drainage. The wound was sutured layer by layer. The surgery lasted 167 minutes, with a blood loss of 155 ml.

The following day, following a pelvic ultrasound and creatinine monitoring of the discharge, the drainage was removed (45 ml of serous discharge during the first 24 hours). The postoperative period was uneventful. The urethral catheter was removed on the ninth day. An abdominal and pelvic ultrasound revealed no lymphocysts. The patient was discharged from the hospital on the 10th day.

Histological examination of the surgical material: the resection margin of the bladder neck and urethra - tumor growth is not determined, the prostate gland is adenocarcinoma, Gleason index 7 (3+4), occupies more than half of the right lobe, no metastatic lesions were found in the removed lymph nodes (a total of 16 pieces).

Diagnosis established based on the results of surgery and histological findings: C61.0 - prostate cancer StII T2bNоMo. Class group 3

Eight (8) patients underwent surgery using the original technique. No complications were observed during the postoperative period or during follow-up (pelvic MRI) for six months.

Conclusion: thus, the technical problem is solved: development of a structurally simple method for prevention of lymphorrhea and formation of lymphatic cysts in patients with prostate cancer after LPE with TLAE using the "Lymphobloc" solution, with suturing of free medial edges of the parietal peritoneum, opened above the iliac vessels during TLAE, alternately on both sides to the "Douglas space" with single interrupted sutures of PGA 2/0 thread in order to ensure free outflow of lymphatic fluid from the pelvic cavity into the abdominal cavity for absorption of lymph by the peritoneum, which allows to reduce the number of lymphatic complications, shorten the length of patient's hospital stay, reduce the number of re-hospitalizations and surgical interventions, shorten the duration of postoperative rehabilitation of patients.

Claims (1)

A method for the prevention of lymphorrhea and lymphatic cysts in patients with prostate cancer after laparoscopic prostatectomy - LPE with pelvic lymphadenectomy - TLAE, characterized by the fact that after pelvic lymphadenectomy, the wound surface of the lymphadenectomy area is treated with a "Lymphobloc" solution in a volume of 50 ml, which is introduced through a catheter onto previously laid gauze napkins in the lymphadenectomy zone on both sides, then a prostatectomy is performed, a urethrovesical anastomosis is formed, after 50-55 minutes of exposure to the "Lymphobloc" solution, the napkins are removed, the free medial edges of the parietal peritoneum, opened above the iliac vessels when performing pelvic lymphadenectomy, are sutured alternately on both sides in the "Douglas space" zone, as shown in Fig. 10, with a single interrupted suture with a PGA 2/0 thread, the cavity of the small The pelvis is drained using a Nelaton N16 catheter.