RU2801335C1 - Method of forming a vesicourethral anastomosis with pelvic reconstruction after radical prostatectomy in the treatment of prostate cancer - Google Patents

Abstract

FIELD: medicine; operative urology; oncourology.

SUBSTANCE: flap is formed from the peritoneum of the posterior wall of the bladder in such a way that a transverse incision of the peritoneum 3–4 cm long is made in the vesico-rectal recess from the side of the abdominal cavity. From the corners of the incision, ventral and lateral vertical incisions of the peritoneum of the bladder 2–3 cm long are performed. The resulting trapezoidal flap is pulled behind the bladder in the bed of the removed prostate gland and sutured in tension with a continuous suture with the distal plate of the vesico-rectal fascia, connecting the remnants of the vesico-rectal fascia muscle and the distal plate of the vesico-rectal fascia with a continuous suture. A vesicourethral anastomosis is formed.

EFFECT: method allows to restore the defect of the vesico-rectal fascia, regardless of its length, to bring the neck of the bladder and the urethra closer together, reducing the tension in the anastomosis, restoring the normal anatomy of the small pelvis, without the formation of additional communication with the abdominal cavity, and the risk of abdominal complications, in addition, the method is technically easily reproducible and applicable for any surgical access, the risk of anastomotic leakage and strictures is reduced, and conditions are created for early recovery of urinary continence function in operated patients.

1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, namely to operative urology and oncourology. The invention can be applied in radical prostatectomy by robot-assisted, laparoscopic or retropubic methods.

Prostate cancer (PC) is one of the most common malignancies in developed countries, accounting for more than 26% of all new cancers in men. Radical prostatectomy (RP) is the main treatment for prostate cancer without distant metastases.

The most common early complication of RP is vesicourethral anastomotic leak (VPUA), which develops in 2.1-38.5% of cases, and its frequency remains high even in modern RP series. Patients who have undergone NPUA are more likely to experience pain, they require prolonged use of a urethral catheter, prolonged inpatient treatment, more time to restore urinary continence, this group of patients develops anastomotic strictures more often, and they often require repeated surgical interventions.

The most common late complication of RP is urinary incontinence, which is most pronounced in the first months after surgery and persists for a long time in 16-51% of men.

These complications significantly impair the patient's quality of life and are directly related to tension, leakage and instability of the vesicourethral anastomosis (PUA).

Tension during PUA formation occurs due to the significant distance between the urethra and bladder neck after prostate removal, and the limited mobility of the posterior bladder wall. Lack of tightness is associated with the difference in the diameters of the openings of the urethra and the neck of the bladder, with the eruption of sutures, as well as with the secondary healing of tissues under tension. PUA instability is associated with a deficiency of the intrapelvic and vesicorectal fascia, which are removed during RP.

Currently, there are various methods of formation of vesicourethral anastomosis and reconstruction of the small pelvis for the prevention of tension, leakage and instability, and, consequently, the prevention of NPUA and urinary incontinence after radical prostatectomy.

There is a known method of posterior reconstruction after open RP by suturing the distal and proximal remnants of Denonville's fascia in order to stabilize the posterior part of the PUA (described in Eur. Urol., 2007 Aug, 52(2), P.: 376-383). The disadvantage of this method is the impossibility of comparing these plates with a significant defect in the Denonville fascia with a large length of the prostate gland. In addition, this method does not increase the mobility of the posterior wall of the bladder, and to a greater extent pulls the wall of the rectum to the pelvic diaphragm, without bringing the bladder and its neck closer to the urethra, without reducing the tension of the anastomosis sutures.

Also known is the “Method for preventing urethrovesical anastomosis failure and urinary incontinence after radical prostatectomy” (RF Patent No. 2733694 dated 10/06/2020). With this method, the removal of the prostate gland is carried out simultaneously with areas of endopelvic and peritoneal-perineal fascia. Previously, a three-layer graft is prepared from the anterior abdominal wall in the patient, consisting of the parietal peritoneum, preperitoneal tissue and transverse fascia, at least 4 cm wide and at least 10 cm long, after which the fascial side of the graft is placed in the transverse direction on the anterior wall of the rectum in the defect zone of the peritoneal-perineal fascia and additionally the edges of the latter are sutured with an absorbable suture to the corresponding edges of the three-layer graft. Next, a urethrocystone anastomosis is formed, then the free ends of the three-layer graft are brought together over the anterior wall of the urethrovesical anastomosis and sutured to each other with an absorbable suture, while closing the fascial ring over the area of the urethrocystone anastomosis. Then, with separate absorbable sutures, the anterior semicircle of the graft is fixed to the pubo-prostatic ligaments and the bladder wall. The disadvantage of this method is the risk of necrosis of the free, devoid of blood supply, graft with the formation of coarse scar tissue around the anastomosis. In addition, this method does not allow to increase the mobility of the posterior wall of the bladder and bring the bladder and bladder neck closer to the urethra, and reduce the tension of the anastomosis sutures.

The closest analogue is "Three-layer two-stage peritoneal posterior reconstruction during robotic radical prostatectomy to improve urinary continence recovery" (doi: 10.1089/end.2017.0410. Epub 2017 Nov. 20.). The method is as follows: after removal of the prostate, the peritoneum is dissected in the vesico-rectal cavity. Then the distal, proximal fragment of the Denonvilliers fascia and the edge of the peritoneum covering the anterior wall of the rectum are connected with continuous sutures. Next impose vesicourethral anastomosis. The undoubted advantage of the prototype is to increase the mobility of the posterior wall of the bladder by dissecting the peritoneum in the vesico-rectal recess and thereby reducing the tension of the anastomosis sutures. However, the prototype is not without drawbacks, which are: the impossibility of comparing the plates of the vesico-rectal fascia with a significant defect, this method to a greater extent pulls the wall of the rectum to the pelvic diaphragm than the neck of the bladder, not allowing to restore the normal anatomy of the small pelvis, and also due to dissection of the peritoneum of the vesico-rectal recess, an additional communication of the anastomosis with the abdominal cavity is formed, which increases the likelihood of abdominal complications in case of anastomosis failure.

The objective of our invention is aimed at creating a method for the formation of vesico-urethral anastomosis with reconstruction of the small pelvis after radical prostatectomy in the treatment of prostate cancer, which allows you to restore the defect of the vesico-rectal fascia, regardless of its length, to bring the bladder neck and urethra together, reducing tension in the anastomosis, restoring the normal anatomy of the pelvis, without the formation of an additional communication with the abdominal cavity, and the risk of abdominal complications, which reduces the risk of leakage, strictures of the anastomosis, and leads to an early restoration of urinary continence.

The solution to this problem is achieved in the way due to the following: Remove the prostate gland with seminal vesicles, if necessary, perform pelvic lymph node dissection. A flap is formed from the peritoneum of the posterior wall of the bladder as follows: in the vesico-rectal recess from the side of the abdominal cavity, a transverse incision of the peritoneum 3-4 cm long is made, vertical incisions of the peritoneum of the bladder 2-3 cm long are performed from the corners of the incision in the direction ventrally and somewhat laterally . The resulting trapezoidal flap is carried out behind the bladder in the bed of the removed prostate gland and sutured in tension with a continuous suture with the distal plate of the vesicorectal fascia. With severe diastasis between the urethra and the neck of the bladder, the transverse and vertical incisions of the peritoneum are extended for greater bladder mobility and lengthening of the flap. The remnants of the vesico-prostatic muscle and the distal plate of the vesico-rectal fascia are connected with the same thread with a continuous suture. A vesicourethral anastomosis is formed.

The technical result of the proposed method is to restore the defect of the vesico-rectal fascia, regardless of its length, to bring the neck of the bladder closer to the urethra, reducing the tension in the anastomosis, restoring the normal anatomy of the small pelvis, without forming an additional communication with the abdominal cavity, and the risk of abdominal complications . The method is technically easy to reproduce and applicable to any surgical access (retropubic, laparoscopic, robot-assisted). Thanks to the described method of reconstruction, the risk of anastomotic leakage and strictures is reduced, and conditions are created for the early restoration of urinary continence in operated patients.

The method of formation of vesicourethral anastomosis with reconstruction of the small pelvis after radical prostatectomy in the treatment of prostate cancer is as follows: the prostate gland with seminal vesicles is removed, if necessary, pelvic lymph node dissection is performed. A flap is formed from the peritoneum of the posterior wall of the bladder as follows: in the vesico-rectal recess from the side of the abdominal cavity, a transverse incision of the peritoneum 3-4 cm long is made, vertical incisions of the peritoneum of the bladder 2-3 cm long are performed from the corners of the incision in the direction ventrally and somewhat laterally . The resulting trapezoidal flap is carried out behind the bladder in the bed of the removed prostate gland and sutured in tension with a continuous suture with the distal plate of the vesicorectal fascia. With severe diastasis between the urethra and the neck of the bladder, the transverse and vertical incisions of the peritoneum are extended for greater bladder mobility and lengthening of the flap. The remnants of the vesico-prostatic muscle and the distal plate of the vesico-rectal fascia are connected with the same thread with a continuous suture. A vesicourethral anastomosis is formed.

The present invention is illustrated by illustrations, where:

in FIG. 1 - the prostate bed is presented after its removal, there is a pronounced diastasis between the neck of the bladder and the urethra (photo);

in FIG. 2 - shows a transverse section of the peritoneum in the vesico-rectal recess for the formation of the flap (photo);

in FIG. 3 - shows the formation of a flap from the peritoneum of the posterior wall of the bladder due to two vertical incisions (photo);

in FIG. 4 - shows the passage of the flap behind the bladder in the bed of the removed prostate gland (photo);

in FIG. 5-6 - fixation of the flap to the distal plate of the vesicorectal fascia with a continuous suture is shown (photo);

in FIG. 7 - shows the degree of convergence of the bladder neck and urethra after fixation of the flap (photo);

in FIG. 8 - shows the fixation of the remainder of the vesico-prostatic muscle to the distal plate of the vesico-rectal fascia (photo);

in FIG. 9 - shows the degree of convergence of the bladder neck and urethra in the final form (photo);

in FIG. 10 - the final view is shown: a vesicourethral anastomosis without tension is applied (photo).

in FIG. 11 - a schematic representation of the proposed reconstruction method is presented (figure). 1 - urethra, 2 - bladder, 3 - remnants of the vesico-prostatic muscle, 4 - distal plate of the vesico-rectal fascia, 5 - proximal plate of the vesico-rectal fascia, 6 - peritoneum covering the posterior wall of the bladder, 7 - peritoneum covering anterior wall of the rectum, 8 - formed flap from the peritoneum of the posterior wall of the bladder.

The possibility of carrying out the proposed method is confirmed by a clinical example of such an operation.

Clinical example

Patient L., 69 years old. Date of admission - 28.04.2022

Diagnosis: Prostate adenocarcinoma cT2cNxM0 Gleason 9(5+4). G5. II Art. II class. gr. PSA level: 11.41 ng/ml. Results of multifocal biopsy of the prostate gland: in 6 tissue columns a picture of acinar adenocarcinoma of the prostate gland was revealed, the sum of the Gleason scores was 5+4=9, Grade 5, with foci of perineural growth. М8140/3. According to TRUS, the volume of the prostate gland is 55 cm3. According to magnetic resonance imaging of the small pelvis in the right lobe of the peripheral zone of the apical region, an altered signal area with fuzzy contours measuring 16×11×13 mm is determined. There were no signs of extracapsular extension of the tumor, damage to the seminal vesicles, or lymph nodes. Skeletal bone scintigraphy revealed no signs of secondary skeletal bone damage.

On 05/04/22, an operation was performed - laparoscopic radical prostatectomy. The first optical port was placed under the ETN through the skin incision above the umbilicus. After pneumoperitoneum, examination of the abdominal cavity, 4 working trocars were installed in typical places. Adhesions in the pelvis on the right after appendectomy and on the left in the area of the sigmoid colon. The spikes are separated. The first step was pelvic lymph node dissection on both sides. Further, the Retzian space is exposed. Gently blunt the prostate and the neck of the bladder is freed from adipose tissue. The endopelvic fascia was dissected to the right and left of the prostate. The Santorini venous plexus was treated with bipolar coagulation. Selected, opened and cut off from the base of the prostate bladder neck. Infiltration of the neck of the bladder and legs of the prostate is noted. The vas deferens were isolated and transected. The seminal vesicles were isolated from the surrounding tissues. The arteries and veins of the vas deferens are coagulated. The DenonVilliers fascia was opened. The surface of the prostate was mobilized along the fascia of Denonville. The vascular pedicles of the prostate are coagulated. The urethra was cut at the border with the apex of the prostate. The prostate, along with the seminal vesicles, is removed and placed in a container. Hemostasis by coagulation. Taking into account the diastasis of the neck and urethra, the tension of the anastomosis - a posterior reconstruction was performed in a modification: a transverse incision of the peritoneum 4 cm long was made in the vesicorectal cavity from the side of the abdominal cavity; . The resulting trapezoidal flap was carried out behind the bladder in the bed of the removed prostate gland. The flap is fixed in tension with a continuous suture to the distal plate of the vesicorectal fascia. The same thread connected the remnants of the vesico-prostatic muscle with the distal plate of the vesico-rectal fascia with a continuous suture. Vesicourethral anastomosis was performed with a continuous Vicryl 3-0 suture with two threads. The tightness of the sutures was checked by filling the bladder with 100 ml of physiological NaCl solution through a Foley catheter. Control drainage into the pericystic space on the left and into the space of Douglas. The final hemostasis is dry. The prostate and lymph nodes in the container are removed through an incision in the navel. The wounds are sutured in layers. Ac. Bandage. Macropreparation: the prostate is enlarged in solutions, dense. Enlarged lymph nodes.

postoperative period. On the first day, there is scant discharge through the drains. Removed drainage from prevesical space. On the second day, there is no discharge from the drainage. Removed drainage from Douglas space. On the 7th day of the postoperative period, cystography was performed in two projections, according to which the vesicourethral anastomosis was hermetic, the urethral catheter was removed. Independent urination restored. The patient brings all the urine to the toilet, urinates on his own. On the 9th day, a control ultrasound of the bladder was performed - there was no residual urine. The patient was discharged from the hospital on the 12th day of the postoperative period.

Claims (1)

A method for forming a vesicourethral anastomosis with reconstruction of the small pelvis after radical prostatectomy in the treatment of prostate cancer, including the formation of a flap from the peritoneum of the posterior wall of the bladder in such a way that a transverse incision of the peritoneum 3-4 cm long is made in the vesico-rectal cavity from the side of the abdominal cavity , from the corners of the incision, vertical incisions are made in the peritoneum of the bladder 2-3 cm long in the direction of the ventrally and laterally, the resulting trapezoidal flap is carried out behind the bladder in the bed of the removed prostate gland and sutured in tension with a continuous suture with the distal plate of the vesico-rectal fascia, connecting the remnants of the vesico-rectal fascia - the prostatic muscle and the distal plate of the vesico-rectal fascia with a continuous suture, form a vesico-urethral anastomosis.