RU2831664C1 - Method for surgical correction of non-extended ureter stricture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical urology. Retroperitoneal space is approached by dissecting the mesentery of the colon from the appropriate side at the level of localization of the proposed constriction. Ureter is exposed at the level of the constriction over a length sufficient to open the ureter lumen. Ureter lumen is opened above the stricture and the incision is extended longitudinally in the distal direction to healthy tissues. Cicatricial mucosa is excised within the narrowing of the ureter, preserving the muscular layer and the adventitia. Edges of the mucous-submucosal layer of the dissected ureter are compared with separate interrupted sutures. Internal ureteral stent is inserted. Anterior wall of the ureter is closed with a continuous suture in a longitudinal direction. Internal ureteral stent is removed at the end of the postoperative period.

EFFECT: method provides complete excision of cicatrical tissues and preservation of maximum blood supply of tissues due to preservation of muscular layer and ureter adventitia, which provides an adequate physiological passage of urine along the upper urinary tract and allows minimizing the risks of recurrent ureteral stricture.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, more precisely to urology, and can find application in reconstructive plastic surgery, using laparoscopic access, for short ureteral strictures.

Ureteral stricture (US) is a pathological narrowing of the ureter lumen, leading to impaired urodynamics in the upper urinary tract, development of hydronephrosis and, as a consequence, renal failure. The most common causes of this condition are abnormalities in the development of the urinary system, urolithiasis, previous radiation therapy for diseases of the pelvic organs, trauma, retroperitoneal fibrosis (Ormond's disease), endometriosis, iatrogenic injury [1]. Iatrogenic strictures are of particular interest. Currently, according to available data, the incidence of ureteral stricture after endoscopic interventions on the upper urinary tract reaches 3.5% [2]. Risk factors for the development of SM during ureteroscopy are: traumatic damage to the ureteral wall during lithotripsy, especially in the case of urine extravasation into the paraureteral tissue, changes in the ureteral wall due to the “impact” and long-term presence of a calculus, the size and number of calculi, urinary tract infection, the time of ureteronephrolithotripsy, and the use of a ureteral sheath for retrograde nephroscopy [3].

In case of short primary ureteral strictures, the method of choice for surgical treatment is endoscopic correction of the narrowing zone, the effectiveness of which can reach 75% [3]. However, due to the fact that this method of treatment does not involve excision of the scar tissue, but rather dissection of the altered section of the ureteral wall, there remains a high probability of recurrence of SM.

In case of failure of endoscopic treatment option or when its implementation is not indicated, one of the methods of ureter reconstruction is considered. When choosing a surgical technique, the surgeon relies on two important indicators: localization and length of stenosis. Thus, in case of short (up to 2 cm) ureteral strictures in its upper and middle third, the operation of choice is an end-to-end anastomosis. In case of stricture of the lower third of the ureter, depending on the length and distance from the bladder, one of the ureterocystoanastomosis options is considered as the main treatment option: direct ureterocystoanatomosis, in case of short stenosis in the juxtavesical part of the ureter, or an anastomosis option with compensation of the ureteral length deficit due to the bladder (with fixation of the bladder to the lumbar muscle - psoas hitch, or plastic surgery with a tubularized bladder flap - Boari flap) [4].

There is also a method of intestinal plastic surgery, in which a segment of the ileum is used to replace the ureter. This type of surgical intervention is the most complex and is used for extended strictures, when other types of surgical treatment are impossible. Speaking about intestinal plastic surgery of the ureter, it is also worth mentioning that to replace the cicatricial part of the ureter, it is possible to use a vermiform appendix, as well as a reconfigured segment of the ileum (Yang-Monti plastic surgery).

All types of surgical interventions described earlier are possible through two classical approaches: laparotomic and laparoscopic.

The previously mentioned surgical method of treating SM, ureteroureterostomy "end-to-end" in the laparoscopic version, is currently widely used as a method of surgical treatment for strictures of the proximal ureter, up to 2 cm in length [6]. The essence of this method consists of the following steps. Under endotracheal anesthesia, the patient is placed on the healthy side at an angle of 45°. Three trocars of 5/10 mm are inserted into the abdominal cavity, pneumoperitoneum is created. Then, access to the retroperitoneal space is achieved by blunt and sharp means. The segment of the ureter expanded above the site of narrowing is visualized. The latter is isolated from the surrounding tissues above and below the site of narrowing. The cicatricially altered part of the ureter is excised within the healthy tissues. Spatulation of the ends of the ureter is performed. The edges of the resected ureter are sutured with absorbable thread 4-0. Until the lumen of the ureter is completely closed, an internal ureteral stent is installed in the latter. Then, after 6 weeks, the internal ureteral stent is removed [5]. This type of surgical intervention demonstrates satisfactory results in terms of the absence of relapse, but it should be noted that it is not without its drawbacks. The first of these is the impossibility of visually assessing the true extent of the stricture during surgery, so the surgeon is not immune from making a mistake in choosing a surgical tactic. The second is the very fact of complete intersection of the ureter, which can negatively affect the trophism of tissues in the anastomosis area and thus determine a certain share of failure of surgical treatment.

Speaking about reconstructive surgery in urology, it is possible to draw an analogy between the methods of surgical treatment of ureteral and urethral stenosis. Both structures are hollow organs, the main task of which is to ensure adequate passage of urine. Both the ureter and urethra are lined with urothelium, contain submucosal, muscular layers and are covered with adventitia on the outside. It is logical that the approach to ureteral reconstruction strongly resembles that in urethral reconstructive surgery. Thus, in case of primary urethral stricture up to 1 cm long, endoscopic dissection of the latter can be initially performed. In case of urethral stricture up to 2 cm, anastomotic urethroplasty with transection of the spongy body is performed, by analogy with which the ureteroureteral anastomosis described earlier is performed. In case of extended urethral strictures or narrowing of the penile section, augmentation (increasing the lumen of the narrowed area) urethroplasty is performed, where the most frequently used reconstructive material is the oral mucosa. It is not surprising that, by analogy with urethral augmentation, in the last decade, augmentation plastic surgery using the buccal mucosa has been introduced into clinical practice to correct ureteral strictures longer than 2 cm.

The idea for the patented method of surgical correction of non-extended ureteral stricture is based on two surgical techniques. The first of them is anastomotic plasty of the bulbous urethra without transection of the spongy body using the Mundy technique. Currently, there are no publications in the medical literature demonstrating a similar technique for correcting ureteral stricture. The technique of surgery on the urethra is described in the source [8]. The essence of this analogous method is as follows. Under spinal anesthesia, after placing the patient in the lithotomy position, a longitudinal incision of the perineal skin of 8-10 cm in length is made. Layer-by-layer, blunt and sharp access is achieved using mono- and bipolar coagulation. Next, proximal (to the membranous part of the urethra) and distal (to the penoscrotal angle) mobilization of the spongy body is performed. The spongy body is freed from adjacent tissues. A 16CH urethral catheter is passed through the urethra to the level of the obstruction. At this level, a longitudinal incision is made in the spongy body and urethra along the dorsal surface with a transition to the narrowed part. Then, the urethrotomy is extended proximally to healthy tissue. Using thin scissors or a scalpel, the cicatricially altered mucous membrane of the urethra is excised, after which nodular sutures are applied along the ventral surface to match the ends of the healthy mucous membrane with a 6/0 monofilament absorbable thread. The dorsal semicircle of the urethra and the spongy body are sutured according to the well-known Heineke-Mikulicz principle. The wound is sutured layer by layer, and a 14CH silicone urethral catheter is inserted into the bladder.

The second surgical technique that formed the basis of the patented method is the technique of augmentation plastic surgery of the ureter using a buccal mucosa transplant. The method for performing this operation, based on a combination of similar essential features, is the closest prototype analogue of the patented method. The technique of the surgical aid for performing the prototype method is described in the source [7]. The essence of the prototype method is as follows. In the lithotomy position under endotracheal anesthesia (ETA), a guidewire is inserted into the affected ureter and passed into the pelvis of the corresponding kidney. Next, with the patient lying on the healthy side, 4 trocars are installed in the abdominal cavity. Blunt and sharp access is performed to the retroperitoneal space by forming a window in the mesentery of the colon, after which the altered part of the ureter is isolated. Minimal proximal and distal mobilization of the ureter is performed. In the area of narrowing, the anterior surface of the ureter is dissected longitudinally with the incision extended proximally and distally to healthy tissues. A 6CH internal ureteral stent is installed retrogradely along a previously inserted string. The length of the dissected section of the ureter is assessed. Next, using the standard technique, a graft is taken from the buccal mucosa, the dimensions of which correspond to the length of the ureterotomy. The flap is processed using miniature scissors, and elements of the submucosal base are removed from the latter. The flap is inserted into the abdominal cavity through one of the trocars and placed in place as a ureteral "patch". The proximal and distal edges of the flap are fixed to the edges of the ureterotomy with stay sutures. Next, the flap is fixed first to the medial and then to the lateral wall of the incision with a continuous 5/0 absorbable monofilament thread. A flap on a feeding pedicle is cut out of the omentum, placed at the site of the surgical intervention and fixed with interrupted sutures of absorbable monofilament 4/0 thread to the graft. The main and significant disadvantage of the prototype method is the need to use a graft of the oral mucosa, which determines the complexity of the intervention, its duration, as well as a higher percentage of relapse than with direct ureteroureteroastomosis.

The claimed invention “Method for surgical correction of non-extended ureteral stricture” aims to improve the results of surgical treatment of patients with non-extended ureteral stricture and improve their quality of life in the postoperative period.

The technical (clinical) result of the invention consists in the restoration of adequate lumen of the upper urinary tract in the postoperative period.

The essence of the claimed method, ensuring the achievement of the claimed result, consists in the sequential execution of the following steps:

- access to the retroperitoneal space is achieved by dissecting the mesentery of the colon on the corresponding side at the level of localization of the suspected narrowing;

- the ureter is isolated at the level of narrowing for a length sufficient to open the lumen of the ureter;

- open the lumen of the ureter above the stricture and extend the incision longitudinally in the distal direction to healthy tissue;

- excision of the cicatricially altered mucosa in the area of narrowing of the ureter lumen is performed, preserving the muscular layer and adventitia;

- the edges of the upper and lower layers of the dissected ureter are compared using separate interrupted sutures;

- perform installation of an internal ureteral stent;

- the anterior wall of the ureter is sutured with a continuous suture in the longitudinal direction;

- removal of the internal ureteral stent is performed at the end of the postoperative period.

The essence of the patented method, designated by the above essential features, is related to the claimed technical (clinical) result as follows. The stable preservation of the diameter (lumen) of the ureter sufficient for adequate passage of urine through the upper urinary tract in the postoperative period is achieved due to the fact that due to the complete excision of scar tissue and the absence of a provoking factor, repeated narrowing of the compromised section of the ureter does not occur. Due to this, the lumen of the ureter remains wide and sufficient for adequate passage of urine through the upper urinary tract.

The essence of the patented method of surgical correction of a short ureteral stricture is explained by drawings.

Fig. 1 shows a diagram with an endoscopic view of a non-extended ureteral stricture.

Fig. 2 shows a diagram with an endoscopic view typical for the process of longitudinal dissection of the ureter and scar tissue along the anterior wall.

Fig. 3 shows a diagram with an endoscopic view of the ureter after its dissection.

Fig. 4 shows a diagram with an endoscopic view of the ureter after excision of the cicatricially altered area of the mucosa.

Fig. 5 shows a diagram of the anastomosis of healthy edges of the mucosal-submucous layer of the ureter wall.

Fig. 6 shows a diagram with an endoscopic view after suturing the edges of the mucosal-submucosal layer of the ureter wall.

Fig. 7 shows a diagram with an endoscopic view of the ureter after installation of an internal ureteral stent in the latter.

Fig. 8 shows a diagram with an endoscopic view of the ureter after suturing the anterior wall of the latter in the longitudinal direction.

The implementation of the method of surgical correction of a short ureteral stricture can be conditionally divided into 3 stages.

1. Creation of access to the reconstruction zone. This stage includes the following three consecutive steps, defined in the section "essence of the invention" by the following essential features:

- access to the retroperitoneal space is achieved by dissecting the mesentery of the colon on the corresponding side at the level of localization of the suspected narrowing;

- the ureter is isolated at the level of narrowing for a length sufficient for subsequent longitudinal opening of the ureter lumen.

- open the lumen of the ureter above the stricture and extend the incision longitudinally in the distal direction through the narrowing zone to healthy tissue.

To perform this stage, the patient is placed in a position on the healthy side at an angle of 45° to the operating table. A paraumbilical incision of the abdominal skin is made 1 cm long on the corresponding side of the abdomen. A 10 mm trocar is inserted into the abdominal cavity through the created opening. Through the trocar, insufflation of carbon dioxide under a pressure of 12 mm Hg begins into the formed space. Laparoscopy is performed using a laparoscope inserted into the trocar. Then, under optical control, three more trocars are inserted into the abdominal cavity on the affected side. A 10 mm trocar in the iliac region along the midclavicular line at the level of the iliac crest, a 5 mm trocar in the iliac region at the level of the anterior superior iliac wing spine along the pararectal line, a 5 mm trocar along the pararectal line 2 cm below the costal arch. At the level of the suspected stenosis, the mesentery of the colon is opened on the corresponding side using an ultrasonic scalpel with the gonadal vein as a reference point. The lateral edge of the dissected parietal peritoneum (1) is sutured with stay sutures (2) brought out through the anterior abdominal wall. After tensioning the stay sutures, dissection is performed in the retroperitoneal space lateral to the gonadal vein to visualize the ureter (3). If the latter is detected, the anterior surface of the ureter (3) is separated from the adjacent tissues over a length of 5-8 cm using a laparoscopic ultrasonic scalpel and a laparoscopic bipolar clamp, as a result of which the area of stenosis (4) of the lumen (5) of the ureter (3) becomes available for visual inspection (see Fig. 1). A flexible ureteropyeloscope 9CH is inserted into the renal pelvis-calyceal system through the previously formed nephrostomy fistula and then antegradely advanced into the lumen (5) of the ureter (3) to the level of the stenosis zone (4), thereby accurately determining the proximal border of the stenosis zone (4). Using the light of the fiberscope as a guide, with the help of endoscopic scissors (6), the ureter (3) is opened above the proximal border of the stenosis zone (4) of the lumen (5) (see Fig. 2). Then, with the scissors, the incision is extended longitudinally in the caudal direction through the stricture zone to healthy tissue, as a result of which the entire stenosis zone (4) of the lumen (5) of the ureter (3) and directly the cicatricially altered area of the mucosa (7) (see Fig. 3) become available for visual inspection. This completes the first stage.

2. Excision of the scar-altered section of the ureteral mucosa and restoration of the integrity of the upper urinary tract. This stage includes the following four consecutive steps, defined in the section "essence of the invention" by the following essential features:

- excision of the cicatricially altered area of the mucosa in the area of narrowing of the ureter lumen is performed, preserving the muscular layer and adventitia.

- the edges of the upper and lower layers of the dissected ureter are compared using separate interrupted sutures

- perform the installation of an internal ureteral stent

- the anterior wall of the ureter is sutured with a continuous suture in the longitudinal direction.

To perform this stage, the following actions are performed. Using endoscopic scissors, excise the cicatricial section of the ureter (3) to the muscular wall (8) within the mucous and submucous layers (see Fig. 4). Apply a U-shaped matching mattress suture (9) along the center of the posterior surface of the ureter (3) with a 5/0 Monocryl thread (see Fig. 5). Then, using 6-8 separate interrupted sutures (10) with a 5/0 Monocryl thread, match the edges of the mucous-submucous layer of the ureter (see Fig. 6). Antegradely, a hydrophilic guidewire is passed through the nephrostomy fistula into the ureter through the anastomosis zone and then distally, installing the guidewire in the urinary bladder. Next, the internal ureteral stent 7CH (11) is inserted antegradely in the caudal direction along the guidewire into the urinary bladder until the proximal end of the stent (11) is visualized in the area of ureteral dissection. The hydrophilic guidewire is removed, the proximal end of the internal stent is inserted into the collecting system of the kidney using an endoscopic clamp along the lumen of the ureter, forming a curl (see Fig. 7). The opened ureter is sutured in the longitudinal direction, starting from the proximal edge of the incision with a continuous suture (12) of Monocryl 5/0 thread, as a result of which the continuity of the upper urinary tract is restored (see Fig. 8). This completes the second stage.

3. Restoration of physiological passage through the upper urinary tract. The stage includes the last, final step, defined in the section "essence of the invention" by the following essential features.

- removal of the internal ureteral stent is performed at the end of the postoperative period.

Taking into account a number of factors (age of the patient, condition of the tissues during the operation), the surgeon decides on the timing of the removal of the internal ureteral stent and restoration of the physiological passage of urine through the upper urinary tract, usually this period is 3 weeks. After the specified time, the patient comes to an outpatient appointment to remove the stent. At the appointment, immediately after the stent removal, a primary assessment of the passage of urine through the upper urinary tract is carried out by performing an ultrasound of the kidneys.

The patented method of surgical correction of short ureteral stricture meets the criterion of “industrial applicability”, since all the necessary materials, equipment and instruments are available for its implementation in modern medical institutions with surgical hospitals and it does not require large financial costs.

The patented method, in comparison with previously known ones, has a number of advantages directly related to the claimed technical result. Complete excision of scar tissue and preservation of maximum tissue blood supply due to preservation of the muscular layer and adventitia of the ureter ensures adequate physiological passage of urine through the upper urinary tract, which allows minimizing the risks of recurrence of ureteral stricture, and, as a result, after reconstructive surgery performed using the claimed method, the quality of life of patients with non-extended ureteral stricture is significantly improved.

In addition, a valuable distinctive feature of this method is the ability to assess the length of the stricture after longitudinal opening of the ureteral lumen. This distinctive feature of the operation allows for an easy transition to performing augmentation (buccal) ureteral plastic surgery in the event of technical impossibility of performing the patented method, which is possible when the length of the stricture exceeds 2 cm.

The method was developed at the Department of Urology and Andrology of the Russian National Research Medical University named after N.I. Pirogov (Moscow) in the Urology Department of the State Budgetary Healthcare Institution “V.M. Buyanov City Clinical Hospital of the Health Department of Moscow” and has so far been tested in 3 patients with non-extended ureteral stricture with a positive result.

Example: Patient V., 45 years old, was hospitalized in the city clinical hospital on a planned basis with the diagnosis: Stricture of the upper third of the left ureter, hydronephrosis on the left, nephrostomy on the left.

Medical history: The patient had been reporting discomfort in the lumbar region on the left for a long time. According to the results of CT scan of the urinary tract dated 01/06/2022, a stone was found in the upper third of the left ureter, measuring 15x10x7 mm with a density of 1300 units. The calyces of the left kidney are dilated to 20 mm, the renal pelvis is 34 mm, the ureter is dilated in the upper third to 13 mm. On 01/07/2022, due to intractable renal colic on the left, endoscopic installation of an internal ureteral stent was performed on the left. Against the background of drainage of the upper urinary tract on the left with an internal stent, the patient continued to have signs of urodynamic impairment in the upper urinary tract and pain syndrome. On 01/11/2022, the operation "Removal of the internal ureteral stent on the left, contact ureterolithotripsy on the left, installation of an internal ureteral stent on the left" was performed. Intraoperative: During lithotripsy, migration of a 3 mm calculus into the left renal pelvis was noted, which was not visualized during rigid retrograde nephroscopy on the left. During endoscopic assessment of the ureteral wall after lithotripsy, residual fragments of the calculus were not visualized, mucosal edema was determined in the area where the calculus was located, and the ureteral mucosa had gross inflammatory and trophic changes.

On 02/15/2022, due to persistent hydronephrosis on the left, a control CT scan of the urinary system was performed, according to the results of which: hydronephrosis on the left (pelvis 25 mm, calyces 16 mm), against the background of an internal ureteral stent on the left, a chain of small stones with a diameter of up to 3 mm is determined in the upper third of the left ureter. On 02/16/2022, the internal ureteral stent was removed on the left, ureterolithoextraction on the left was performed. Due to severe bullous edema of the ureteral mucosa in the area where the stone was previously located, a repeated installation of the internal ureteral stent on the left was performed.

According to the description of the CT scan of the urinary bladder from 03/21/2022: the condition after the IUD installation on the left, the pelvis is 39x22 mm, the calyces are up to 19 mm, the walls of the upper third of the left ureter are thickened, the presence of small stones in the wall of the upper third of the left ureter cannot be excluded. On 03/23/2022, due to the clinical picture of acute obstructive pyelonephritis, percutaneous puncture nephrostomy was performed on the left. Against the background of the treatment, the clinical symptoms of pyelonephritis were relieved.

On 04/05/2022, the operation "Removal of the internal ureteral stent on the left, ureteroscopy on the left, ureterolithoextraction on the left, ante-retrograde ureteropyelography on the left" was performed. Intraoperatively: during endoscopic assessment of the upper third of the ureter, a narrowing of the lumen of up to 2 mm is determined. According to the results of antegrade pyeloureterography on the left, a narrowing at the level of the upper third of the left ureter, up to 20 mm in length, is determined. The situation is assessed as ureteral stricture. Endoscopic laser ureterotomy was performed, an internal ureteral stent was installed on the left, and the nephrostomy drainage was removed on the left.

On 04/28/2023, the internal ureteral stent was removed, after which the patient developed intractable renal colic on the left. On 04/29/2022, an internal ureteral stent was installed on the left (long-term).

According to the results of CT MIS from 06.11.2022: stones in the left ureter are not detected, against the background of the IUD on the left, the pelvis of the left kidney is 18 mm, calyces are 12 mm; the ureter in the upper third is 10 mm with areas of calcification of the wall of the latter.

On November 7, 2022, the internal ureteral stent was removed on the left, after which the patient developed a clinical picture of intractable renal colic on the left. On November 7, 2022, percutaneous puncture nephrostomy was performed on the left. An ante-retrograde ureterography was performed, according to which a stricture of the upper third of the left ureter with a length of 3 cm was diagnosed.

On December 15, 2022, laparoscopic plastic surgery of the upper third of the left ureter without intersection was performed, an internal ureteral stent was installed on the left. Intraoperatively: after ureterotomy, an area of cicatricial changes in the ureter was visualized, the length of which was up to 20 mm. It was decided to refrain from performing augmentation buccal ureteroplasty in favor of ureteroureteroanastomosis without intersection of the ureter. The postoperative period was uneventful. During her hospital stay, the nephrostomy drainage was removed, the fistula healed. Discharged for outpatient treatment.

Three weeks after the surgery, endoscopic removal of the IUD was performed on the left. According to the results of the control ultrasound of the kidneys, urodynamics in the upper urinary tract is not impaired.

In order to assess the passage through the UMP, a CT scan of the urinary bladder with intravenous contrast was performed on March 14, 2023, according to the description of which: the renal pelvis of both kidneys is not dilated, on the right, the UMP contrast is timely, on the left - at 7, 60, 90 minutes the ureter is not contrasted, at 180 minutes it is contrasted fragmentarily.

Subjectively, a year after the surgical intervention, the patient feels well, does not have pain in the lumbar region, and has not been hospitalized in a urological hospital for a year.

List of references

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Claims (9)

A method of surgical correction of a non-extended ureteral stricture, which consists of the sequential implementation of the following steps: - access to the retroperitoneal space is achieved by dissecting the mesentery of the colon on the corresponding side at the level of localization of the suspected narrowing; - the ureter is isolated at the level of narrowing over a length sufficient to open the lumen of the ureter; - open the lumen of the ureter above the stricture and extend the incision longitudinally in the distal direction to healthy tissue; - excision of the cicatricially altered mucosa in the area of narrowing of the ureter lumen is performed, preserving the muscular layer and adventitia; - the edges of the mucosal-submucosal layer of the dissected ureter are aligned using separate interrupted sutures; - perform installation of an internal ureteral stent; - the anterior wall of the ureter is sutured with a continuous suture in the longitudinal direction; - removal of the internal ureteral stent is performed at the end of the postoperative period.