RU2829267C1 - Method of laparoscopic caecoappendicular plasty in extended structure of proximal ureter - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to urology, and can be used for ureter replacement in case of an extended stricture of its proximal part. Extensive mobilization of the pathological portion of the pelvis and ureter is performed. Ureter stricture is excised, an appendix with a section of the dome of the caecum on the mesentery is mobilized. At distance of 20 mm from the base of the appendix, a purse-string suture is applied on the dome of the caecum; the dome of the caecum and an apex of the appendix are dissected away. Appendix is transposed in an isoperistal position so that the dissected dome of the caecum is directed to the pelvis and the appendix is directed to the ureter. Posterior lip of a caecopieloanastomosis is formed, an antegrade of an appendix and a ureter is performed through an anastomosis, an anterior lip of the caecopieloanastomosis is formed, followed by a posterior lip of the appendicoureteroanastomosis. Intubator is delivered into bladder and anterior lip of appendicoureteroanastomosis is formed, peritoneum is closed.

EFFECT: method provides an increase in the effectiveness of treatment by creating a communication with a diameter equal to the physiological one, along its entire length, as well as a physiological outflow of urine in the area of the pyelourethral segment, reduced risks of stricture development in the area of anastomoses, low traumatism of surgical intervention, reduced frequency of various complications in remote period, as well as short hospital period.

1 cl, 3 dwg, 2 ex

Description

The invention relates to medicine, namely to urology, and can be used to replace the ureter in the case of an extended stricture of its proximal part caused by recurrent hydronephrosis, iatrogenic damage to the ureter, trauma, tumor processes, and can be used in medical and preventive institutions.

The group of pathological conditions for the treatment of which the replacement of the proximal part of the ureter is used is extensive and includes all diseases, both congenital and iatrogenic, which can cause structural damage to the ureter. Thus, when removing a volumetric formation located in the pyeloureteral segment, a pronounced deficit in the length of the ureter may occur, which leads to the impossibility of forming an anastomosis using classical techniques and is an indication for the use of replacement technologies. The main pathology leading to the formation of an extended stricture and, as a consequence, requiring replacement of the proximal part of the ureter in pediatric practice is recurrent hydronephrosis, which, despite the high efficiency of the classical Hines-Anderson operation, is up to 10%. Recurrence of this disease is a complex problem, in which it is often impossible to re-form a direct anastomosis between the pelvis and ureter, which leads to the need to search for surgical techniques to eliminate the ureteral defect.

Currently, the most common attempts are to form a ureterocalicoanastomosis, flap plastics, replacement of a section of the ureter using the mucous membrane of the cheek, or autotransplantation of the kidney. The main disadvantages of the above methods are the high frequency of stenosis, the limitation in the length of the replaced section, which causes excessive tension in the anastomosis area. In addition to the described disadvantages, after such surgical interventions, pronounced cicatricial-stenotic changes occur, which leads to the phenomena of recurrent pyelonephritis caused by a pronounced violation of the outflow of urine from the kidney, or anastomotic failure, which ultimately leads to the loss or significant decrease in kidney function.

The above-mentioned shortcomings determine the relevance of the search, development and implementation of new minimally invasive, progressive methods of reconstruction of the urinary tract in the presence of a pronounced deficit in the length of the ureter, with the formation of an anastomosis that has adequate patency, physiological outflow of urine, and minimal risks of stenosis in the anastomosis area.

There is a known method of surgical treatment of extended strictures of the ureter (Komyakov Boris Kirillovich (RU), Al-Attar Talat Hasan Muhammad (RU), Dorofeev Sergey Yakovlevich (RU), Semeyko Dmitry Pavlovich (RU), RF patent 2744022, IPC A61B 17/00, publ 03/02/2021).

This method is carried out as follows - a small intestinal transplant is used, and a pyeloileal anastomosis and ileocystoanastomosis are formed. Before forming anastomoses along the entire length of the intestinal tube, which is 25 cm, the mesentery is crossed in its intervascular zones in the amount of 7-10. After this, the height of the mesentery decreases, and the diameter increases, which helps straighten the segment. After which a pyeloileal anastomosis and ileocystoanastomosis are formed.

This method has the following disadvantages:

1. When using ureteral substitution with intestine in the delayed period, metabolic disorders are most often observed due to the large diameter and thickness of the intestinal transplant.

2. The need to resect a section of the intestine leads to the possibility of developing complications such as anastomotic failure, obstruction, peritonitis, and ischemia.

3. The diameter of the intestinal segment implanted instead of the ureter should correspond to the diameter of the ureter, but this may lead to the formation of a stricture in the anastomosis area.

The closest in technical essence to the proposed method is a method of surgical treatment of extended strictures of the pelvic ureter (Komyakov Boris Kirillovich (RU), Guliev Bakhman Gidayatovich (RU), Dorofeev Sergey Yakovlevich (RU), Burlak Oleg Olegovich (RU), RF patent 2308893, IPC A61B 17/00, publ. October 27, 2007).

This method is performed as follows - the defect of the vermiform appendix is replaced while preserving its blood supply and resecting the apex of the appendix. The vermiform appendix is resected together with a segment of the cecum, after forming an opening in the wall of the bladder, the resulting segment of the cecum with the vermiform appendix is implanted end-to-side. The distal end is resected and anastomosed end-to-end with the ureter.

This method has the following disadvantages:

1. When performing an anastomosis between the apex of the appendix and the proximal part of the ureter, especially near the pyelourethral segment, the risk of developing a stricture in the anastomosis area increases significantly.

2. The impossibility of replacing the proximal part of the ureter with the formation of an adequate anastomosis in the distal part between the ureter and the dome of the cecum due to a significant difference in diameter.

3. It is not possible to use the graft to replace the stricture of the proximal ureter, since the diameter of the distal part of the graft contains the cecum and will not allow the formation of an anastomosis with a ureter of the same diameter.

The technical result of the invention is an increase in the effectiveness of treatment due to the creation of a communication with a diameter equal to the physiological one along its entire length, as well as a physiological outflow of urine in the area of the pyelourethral segment, a decrease in the risk of developing stricture in the area of anastomoses, low trauma of surgical intervention, a decrease in the frequency of various complications in the late period, as well as a short hospital period.

A method of laparoscopic cecoappendicoureteroplasty for extended stricture of the proximal ureter is proposed. The difference is that extensive mobilization of the pathological area of the renal pelvis and ureter and excision of the ureteral stricture are performed in conjunction with mobilization of the appendix and part of the dome of the cecum, which is cut off after applying a purse-string suture at a distance of 20 mm from the base of the appendix, then after transposition of the appendix in an antiperistaltic position in the direction of the dome of the cecum to the pelvis, then the posterior lip of the proximal cecopyeloanastomosis is formed, then intubation of the appendix and ureter is performed, the anterior lip of the proximal anastomosis is formed, which ultimately ensures adequate urodynamics in the pyelourethral segment, distally, the posterior lip of the appendicoureteral anastomosis is formed, then an intubator is inserted into the ureter and then the bladder and the anterior lip of the distal anastomosis is formed, after which the peritoneum is sutured over the surgical area.

The specified technical result is achieved by the fact that the proposed method of laparoscopic cecoappendicopyeloplasty for an extended stricture of the proximal ureter is performed using high-precision equipment with multiple optical magnification, isolation of the pathological section of the ureter, mobilization of the appendix with a section of the dome of the cecum on the mesentery with subsequent formation of a cecopyeloanastomosis, which ensures a wide anastomosis between the renal pelvis and a section of the dome of the cecum, a distal anastomosis between the appendix and a ureter of similar diameter, the use of atraumatic laparoscopic instruments, intraoperative placement of a ureteral intubator, which reduces the risk of developing long-term complications and reduces the risks of developing a recurrence of stricture.

The method is illustrated by the figures, where Fig. 1 is a view of the surgical field after mobilization of the ureter with visualization of the length of the ureteral stricture and the mobilization zone of the appendicular process, the letters A1 and A2 indicate the future zone of the anastomosis between the renal pelvis and the dome of the cecum, B1 and B2 the zone of the anastomosis between the appendix and the ureter, Fig. 2 is the appendix with a section of the cecum after cutting off from the dome of the cecum on the mesentery is transferred to an isoperistaltic position for the formation of anastomoses, Fig. 3 is the process of forming the proximal cecopyeloanastomosis and distal appendiureteral anastomosis, as well as the insertion of the intubator.

The method is performed as follows. The patient is positioned on his side with a cushion placed under the lumbar region, forming an angle of 45 degrees between the patient and the operating table. The first 5 mm trocar is installed in an open manner above the navel using a blunt stylet. Two 5 mm trocars for manipulators are installed along the midclavicular line - one in the hypochondrium, the second in the iliac region using a pointed stylet. Using monopolar coagulation, the parietal peritoneum is dissected and the ascending colon is mobilized to provide access to the kidney and ureter. Next, the kidney, pelvis, pyelourethral segment and ureter are mobilized along the length, then the pathological area is excised along lines A1 and B2 using 5 mm laparoscopic scissors (Fig. 1). The appendix is mobilized - a window is formed in the mesentery between the appendix and the dome of the cecum using a blunt dissector of 5 mm, after which, retreating 20 mm from the base of the appendix, a purse-string suture is applied to the dome of the cecum, the purse-string suture is tightened and ligated. Along the incision line A2, the dome of the cecum is excised using laparoscopic 5 mm scissors, then the apex of the appendix is excised along the line B2 (Fig. 1). The appendix is transposed to an aperistaltic position on the mesentery in the direction of the dome of the cecum to the pelvis, and the apex of the appendix is transposed to the distal part of the ureter (Fig. 2). The posterior lip of the cecopyeloanastomosis is formed using a continuous suture (Fig. 3), then an intubator - Nelaton Ch 8 catheter is inserted antegradely through the formed defect in the pelvis through the anastomosis zone, after which the anterior lip of the cecopyeloanastomosis is formed. After that, the ureter is spatulated in the distal part to form the distal appendicoureteroastomosis. The posterior lip of the appendicoureteroastomosis is formed using interrupted sutures, the previously inserted intubator is passed distally into the bladder and the anterior lip of the anastomosis is formed using interrupted sutures (Fig. 3). The integrity of the parietal peritoneum is restored. A drain is installed in the small pelvis, which is removed on the 2nd postoperative day. Drainage of the bladder with a urethral catheter is carried out for 5 days after surgery. The intubator is removed 4 weeks after the surgical treatment.

The distinctive advantages of the claimed method are:

1. Laparoscopic access allows for extensive mobilization of the pathological area of the renal pelvis and ureter in combination with mobilization of the appendix, which makes it possible to perform replacement ureteral plastic surgery with minimal trauma and reduce the patient's recovery time in the postoperative period.

2. Formation of a cecopyeloanastomosis corresponding to the diameter of the lower third of the renal pelvis allows avoiding such a complication as the formation of a postanastomotic stricture.

3. Preservation of the anatomical transition of the dome of the cecum at the base of the appendix allows for the formation of a replacement for the pyelourethral segment, which in turn ensures adequate and anatomically correct urodynamics in this area and allows for a significant reduction in the likelihood of stricture formation.

The possibility of practical use of the claimed method is illustrated by an example of its implementation in clinical practice.

Example 1. Patient P., 1 year old, was admitted to the clinic with the diagnosis of left-sided hydronephrosis, relapse. At the age of 6 months, the child was diagnosed with left-sided hydronephrosis based on the examination (intravenous urography, ultrasound, voiding cystography) and underwent retrograde balloon dilation of the pyelourethral segment stricture. At the age of 7 and 8 months, repeated balloon dilations were performed due to the recurrence of the pyelourethral segment stricture and the formation of multiple strictures of the proximal ureter. Against the background of the renal block at the place of residence, nephrostomy of the left kidney was performed. Upon admission, antegrade and retrograde counter pyeloureterography was performed - an extended stricture of the proximal ureter (about 5 cm) was visualized. After preoperative preparation, the patient underwent surgery: laparoscopic cecoappendicoureteroplasty in conditions of an extended stricture of the proximal ureter. After mobilization of the renal pelvis and ureter and excision of the pathological section of the ureter, the deficit of the latter was 7 cm. The ureter was mobilized, a purse-string suture was applied to the dome of the cecum 20 mm distal to the base of the appendix, a section of the dome of the cecum was cut off, the appendix was transferred to the left position through the defect in the mesentery and then to an isoperistaltic position. The length of the vermiform appendix with a section of the dome of the cecum is 7 cm, which allows for an adequate anastomosis without tension. The proximal pyelocele and distal appendicoureteral anastomosis were formed using the Nelaton Ch 8 intubator. The integrity of the peritoneum was restored, and drainage was installed in the small pelvis. The drainage was removed on the 2nd postoperative day. The patient was discharged from the clinic in a satisfactory condition on the 7th postoperative day. On the 28th day, the patient was hospitalized again, and the intubator was removed. The nephrostomy was removed on the 38th postoperative day. One month after the nephrostomy removal, the patient underwent a comprehensive examination; emptying of the contrast agent from the renal collecting system was noted by 60 minutes during excretory urography. One year after the operation, the condition remained satisfactory, no complications were noted.

Example 2. Patient A., aged 7, was admitted to the clinic with the diagnosis of recurrent right-sided hydronephrosis. At the age of 5, the child was examined for hydronephrosis (ultrasound, intravenous urography, voiding cystography), the diagnosis was confirmed, after which open pyeloplasty according to Hines-Anderson was performed. In the postoperative period, persistent dilation of the renal pelvis and calyces was noted. At the age of 6, balloon dilation was performed for a recurrent stricture in the pyelourethral segment. Upon admission, additional examination was performed (excretory urography, retrograde ureteropyelography) - the diagnosis of an extended stricture of the proximal ureter was confirmed. After confirmation of the diagnosis, surgical treatment tactics were determined and laparoscopy, mobilization of the extended stricture of the right ureter and its excision were performed. The vermiform appendix with a section of the dome of the cecum, after its dissection from the cupula, was transferred to an isoperistaltic position on the mesentery to form a substituting plasty. The posterior lip of the pyelocecoanastomosis was formed using a continuous suture, then through the formed defect in the pelvis, through the counter-opening in the lumbar region, a Nelaton Ch 8 intubator was inserted antegradely. The anterior lip of the anastomosis was formed using a continuous suture. In the distal part, an end-to-end appendicoureteroastomosis was formed on the intubator. The integrity of the peritoneum was restored using interrupted sutures, an insurance drainage was installed in the small pelvis. The insurance drainage was removed on the 2nd postoperative day. The patient was discharged from the clinic on the 8th postoperative day in a satisfactory condition. On the 28th postoperative day, the intubator was closed on an outpatient basis. On the 35th day, the intubator was removed, after which the ultrasound showed a slight expansion of the renal pelvis. During the control examination after 1 year, adequate passage of the contrast agent was noted during excretory urography - complete evacuation by 60 minutes. There was no evidence of relapse of the disease, no complications were noted in the early and late periods.

The proposed method of laparoscopic cecoappendicoureteroplasty for extended stricture of the proximal ureter in conditions of ureter length deficiency was used in 7 patients. There was no hospital mortality. No postoperative complications were observed. Infectious complications and relapses of the disease were not detected.

Thus, the application of the claimed method allows solving one of the most difficult problems in pediatric urology - to perform highly effective replacement plastic surgery of the proximal part of the ureter with the formation of a wide anastomosis between the renal pelvis and the cecum to ensure adequate urodynamics in the pyelourethral segment and anastomosis of normal diameter between the ureter and appendix. At the same time, due to the use of laparoscopic technologies, the duration of hospital stay, trauma and the likelihood of severe complications in both the early and late postoperative periods are reduced.

Socioeconomic significance. The developed method allows to significantly reduce the duration of hospital stay after the performed surgical intervention, to improve the treatment results of children who need operations against the background of an extended stricture of the proximal ureter in conditions of ureter length deficiency.

Claims (1)

A method of laparoscopic cecoappendicoureteroplasty for an extended stricture of the proximal ureter, characterized in that extensive mobilization of the pathological section of the renal pelvis and ureter is performed, the ureteral stricture is excised, the appendix is mobilized with a section of the dome of the cecum on the mesentery; then, 20 mm from the base of the appendix, a purse-string suture is applied to the dome of the cecum, the dome of the cecum and the apex of the appendix are cut off, the appendix is transposed in an isoperistaltic position so that the excised dome of the cecum is directed toward the pelvis, and the appendix toward the ureter; the posterior lip of the cecopyeloanastomosis is formed, the appendix and ureter are intubated antegradely through the anastomosis zone, the anterior lip of the cecopyeloanastomosis is formed, then the posterior lip of the appendicoureteral anastomosis, an intubator is inserted into the bladder and the anterior lip of the appendicoureteral anastomosis is formed, the peritoneum is sutured.