RU2836569C1 - Method for end-to-end anastomotic urethra repair in surgical treatment of bulbose urethra stricture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to urology. 5 ml of 0.5% aqueous solution of indocyanine green – ICG is introduced into a glans penis at distance of 1.0 cm from an external opening of the urethra. Fluorescence intensity is visually assessed when illuminating the spongy body – SB using a light source with wavelength of 0.75 to 1.4 mcm. SB fibrosis is detected in the area with fluorescence intensity less than 50% of the fluorescence intensity of normal SB tissue. Bulbous urethra is exposed in the area of the revealed fibrosis of the SB. Bulbous urethra stricture is detected in the area with fluorescence intensity less than 50% of the fluorescence intensity of normal urethral tissue. Thereafter, the SB is resected within the detected fibrosis zone and the bulbous urethra is resected within the detected stricture zone. Further, the urethral edges are spatulated with a longitudinal incision of each of them throughout 0.5-1.0 cm, and an anastomosis is applied between the ends of the urethra. In addition, after resection of SB and bulbous urethra, complete excision of SB fibrosis and bulbous urethra stricture is controlled by visual assessment of fluorescence intensity in SB and bulbous urethra edges formed after their resection. If observing the areas with fluorescence intensity less than 50% of the fluorescence intensity of the normal tissue of the SB and bulbous urethra, additional excision of SB fibrosis zones and/or bulbous urethra stricture is performed. When forming the anastomosis, a single-row suture is applied along the dorsal surface of the bulbous urethra and a double-row suture is applied along the ventral surface of the bulbous urethra.

EFFECT: method enables providing an adequate healing process in the area of the urethral anastomosis, which reduces the risk of postoperative complications, recurrence of the disease and the probability of recurrent surgical interventions.

3 cl, 1 ex

Description

The invention relates to medicine, and more specifically to urology, and can be used for the most accurate determination of the boundaries of fibrosis of the spongy body (SB), stricture of the bulbous section (BS) of the urethra and assessment of the blood supply of the resected edges of the SB and BS of the urethra by introducing indocyanine green (ICG) when performing end-to-end anastomotic urethral plastic surgery.

Urethral stricture implies the presence of abnormal narrowing of its lumen, which is accompanied by the process of fibrosis of the urethra. Depending on the etiology and length of the urethral stricture, different methods of surgical treatment are distinguished, but most often, for a stricture up to 2.0 cm long, an end-to-end anastomotic urethral plastic surgery is performed.

The following diagnostic methods are used to determine the boundaries and extent of the urethral stricture: retrograde urethrocystography, antegrade cystourethrography, urethroscopy and intraoperative introduction of methylene blue through the external opening of the urethra. However, none of the above methods allows for a comprehensive assessment of the extent of the urethral stricture (US) and fibrosis of the urethral stricture surrounding this section of the urethra, as well as an assessment of the degree of blood supply to the resected edges of the urethral stricture and the urethra of the urethra before anastomosis.

The prototype method chosen is one that involves retrograde administration of methylene blue through the external urethral opening to assess the length of the urethral stricture or into the corpora cavernosa to determine the presence or absence of fibrosis in the corpora cavernosa (Joshi P, Kaua S, Surana S, Desai DJ, Orabi H, Iyer S, Kulkarni SB. A novel method in decision making for the diagnosis of anterior urethral stricture: using methylene blue dye. Turk J Urol. 2017 Dec;43(4):502-506. doi: 10.5152/tud.2017.72368. Epub 2017 Dec 1. PMID: 29201515; PMCID: PMC5687215).

The prototype method is performed as follows: the patient is placed in the lithotomy position and surgical access to the urethral BO is performed. To assess the length of the SU, a freshly prepared sterile solution of methylene blue in a volume of 5 ml, diluted in 10 ml of physiological solution (dosage 10 mg / ml) is introduced through the external opening of the urethra. Distal to the site of the suspected SU, a penile clamp is applied for 5 minutes to increase the contact time of methylene blue with the urethral mucosa. Then the lumen of the urethral BO is opened, and a visual assessment of the mucosa is performed. Localization and length of the SU is assessed by the greater degree of accumulation of methylene blue in the mucous membrane of the urethra, after which the SU is excised. Next, an anastomosis is applied between the healthy ends of the urethra and a silicone Foley catheter is installed, and finally the wound is sutured layer by layer. To assess the presence of fibrosis of the urethra in another group of patients, after performing surgical access to the urethral BO and determining the location of the SU, insulin needles are inserted in three places. The first needle is inserted into the urethra, proximal to the stricture, the second - at the level of the SU, and the third - distal to the SU. An atraumatic fixator is installed in the proximal part of the urethral BO to limit the blood flow from the bulbar artery. Then methylene blue is introduced through the first needle. The absence of methylene blue outflow in the third needle (proximal to the stricture) indicates the presence of fibrosis of the urethra.

Disadvantages of this method: lack of definition of the exact boundaries of fibrosis of the urethra corresponding to the urethral anastomosis, impossibility of assessing the degree of blood supply to the edges of the resected urethra and the urethral anastomosis before applying the anastomosis.

A method for determining the boundaries of the ureteral stricture is known by introducing 25 mg of ICG dissolved in 10 ml of injection water, retrogradely through an installed 6 Ch ureteral catheter or introducing 5 ml of dissolved ICG in the same concentration antegradely through a nephrostomy drainage and retrogradely through a ureteral catheter (Lee Z, Simhan J, Parker DC, Reilly C, Llukani E, Lee DI, Mydlo JH, Eun DD. Novel use of indocyanine green for intraoperative, real-time localization of ureteral stenosis during robot-assisted ureteroureterostomy. Urology. 2013 Sep;82(3):729-33. doi: 10.1016/j.urology.2013.05.032. PMID: 23987169.0).

However, the known method (introduction of ICG into the lumen of a tubular organ) cannot be used to determine the boundaries of the urethral stricture and the fibrosis of the urethra that accompanies it.

We have not found any information on the successful use of ICG to determine the boundaries of fibrosis of the urethra and stricture of the urethra by introducing it directly into the tissue.

Our goal is to ensure the prevention of postoperative complications and the development of recurrent SU by intraoperatively determining the boundaries of the urethral stricture and the fibrosis of the urethral septum that accompanies it, assessing the degree of blood supply to the edges of the resected urethral septum and the urethral septum before applying anastomosis using ICG administration.

The technical result achieved by implementing the invention is to ensure an adequate healing process in the area of the urethral anastomosis, which reduces the risk of postoperative complications, recurrence of the disease and the likelihood of repeated surgical interventions.

We have developed an algorithm for the introduction of ICG, which allows increasing the flow of this drug into the bloodstream of the penile tissues and thereby accelerating the time of onset of ICG luminescence in the near infrared spectrum (TsTear-infrared, MR).

The essence of the invention is as follows.

End-to-end anastomotic urethroplasty for surgical treatment of urethral stricture is performed as follows. 5 ml of 0.5% aqueous ICG solution is injected into the glans penis at a distance of 1.0 cm from the external urethral opening. Visual assessment of fluorescence intensity is performed by illuminating the urethra with a light source with a wavelength of 0.75 to 1.4 μm. Fibrosis of the urethra is detected in the zone with a fluorescence intensity of less than 50% of the fluorescence intensity of normal urethral tissue. The urethral urethra is opened by making a longitudinal incision up to 1.0 cm long along its dorsal surface in the zone of detected urethral fibrosis. Stricture of the urethral urethra is detected in the zone with a fluorescence intensity of less than 50% of the fluorescence intensity of normal urethral tissue. After that, resection of the urethral septum is performed within the boundaries of the identified fibrosis zone and resection of the urethral BO within the boundaries of the identified stricture zone. Next, spatulation of the urethral edges is performed with a longitudinal incision of each of them over a length of 0.5-1.0 cm, and an anastomosis is applied between the ends of the urethra.

Additionally, after resection of the urethral CT and BO, 2.5 ml of a 0.5% aqueous solution of ICG is injected into the glans penis at a distance of 1.0 cm from the external opening of the urethra and into the proximal end of the urethral BO. The completeness of excision of the CT fibrosis zones and urethral BO stricture is monitored by visually assessing the fluorescence intensity at the edges of the urethral CT and BO formed after their resection, while illuminating the resected edges of the urethral CT and BO using a light source with a wavelength of 0.75 to 1.4 μm. If areas with a fluorescence intensity of less than 50% of the fluorescence intensity of normal CT and urethral BO tissue are detected, additional excision of the CT fibrosis zones and/or urethral BO stricture is performed, respectively.

The anastomosis between the ends of the urethral BO can be performed as follows. A single-row suture is placed along the dorsal surface of the urethral BO and a double-row suture is placed along the ventral surface of the urethral BO.

The method is carried out as follows.

The patient is placed in the lithotomy position, a midline approach is made to the perineum, and the bulbospongiosus muscle is dissected. Next, the urethral BO surrounded by the CT is isolated, distally to the penoscrotal angle, proximally to the membranous part of the urethra. Next, the urethral BO is mobilized together with the surrounding CT, which allows for further reduction of tension in the anastomosis area.

5 ml of 0.5% aqueous ICG solution is injected into the head of the penis at a distance of 1.0 cm from the external opening of the urethra using a 21G needle. In the NIR spectrum, the wavelength of electromagnetic radiation of which is from 0.75 to 1.4 μm, a visual assessment of the degree of ICG luminescence in the CT is first made. The CT fibrosis zone is considered to be the area in which the intensity of ICG luminescence is less than 50% of the luminescence level of normal CT tissue. Thus, it is possible to determine the area of CT fibrosis corresponding to the SU.

Immediately along the dorsal surface of the urethra, in the center of the previously visualized site of fibrosis of the urethra, a longitudinal incision of up to 1.0 cm is made, the urethral BO is opened and the SU boundaries are assessed in the NIR spectrum. The SU zone is considered to be the area in which the ICG luminescence intensity is less than 50% of the luminescence level of normal urethral tissue. Then, the urethral BO with fibrosis and the urethral BO with stricture are resected.

Then, 2.5 ml of 0.5% aqueous ICG solution is injected into the head of the penis at a distance of 1.0 cm from the external opening of the urethra and into the proximal end of the urethral BO using a 21G needle. In the NIR spectrum, the wavelength of electromagnetic radiation of which is from 0.75 to 1.4 μm, a control assessment of the degree of ICG luminescence of the edges of the resected CT and BO of the urethra is made. The second injection of ICG is performed to confirm complete excision of CT and SU fibrosis; if the ICG luminescence intensity is less than 50% of the luminescence level of normal CT and urethral tissue, additional excision of CT and SU fibrosis is performed, thereby reducing the risk of SU recurrence.

Next, spatulation of the edges of the urethra is performed (a longitudinal incision of the ends of the urethra over a length of 0.5-1.0 cm) in order to maintain patency in the area of the upcoming anastomosis.

Using monofilament suture material, an anastomosis is created between the healthy ends of the urethra (single-row on the dorsal surface and double-row on the ventral surface) to ensure uniform tension distribution in the anastomosis area. A 14-16 Ch silicone Foley catheter is then inserted into the bladder to reduce trauma to the mucous membrane of the urethra and bladder. At the end of the operation, the integrity of the bulbospongiosus muscle is restored and the wound is sutured layer by layer.

The proposed method is illustrated by the following example.

Patient K., 64 years old. Diagnosis: Stricture of the urethral urethra.

It is known from the anamnesis that 6 months ago there was a blow to the perineum area when falling from a bicycle, after which the patient began to notice a deterioration in urination.

According to questionnaires: IPSS (International Prostate Symptom Scor, International Prostate Symptom Score): 23 points, IIEF-5 (International Index of Erectile Dysfunction): 16 points.

According to uroflowmetry data: maximum urination rate is 7 ml/sec, average urination rate is 4.2 ml/sec, emptying time is 74 sec, volume of excreted urine is 309 ml.

According to retrograde urethrography data: a filling defect (stricture) in the urethral BO with a length of 2.0 cm is determined.

According to urethroscopy data: a concentric narrowing is visualized in the proximal urethral BO, impassable for a 16 Ch flexible urethrocystoscope.

Considering the traumatic etiology of the urethral stricture, a high score on the IPSS questionnaire, a decrease in the maximum urinary flow rate to 7 ml / sec, localization of the stricture in the urethral BO with a length of 2.0 cm, a decision was made to perform surgical intervention in the volume: excision and primary anastomosis of the urethra "end-to-end" according to the proposed method.

The early postoperative period was uneventful. Moderate swelling and hyperemia of the wound edges were noted in the first days. The safety drainage was removed on the 1st day.

Upon discharge from the hospital on the 7th day: the edges of the wound have no signs of suppuration, diuresis is adequate, urine is light.

On the 12th day after surgery, according to retrograde pericatheter urethrography, no leakage of the X-ray contrast agent was observed, the urethral catheter was removed. According to uroflowmetry on the 12th day after surgery: maximum urination rate - 19 ml/sec, average urination rate - 16 ml/sec, emptying time - 25 sec, volume of excreted urine 401 ml.

At examination on the 6th month after surgery. According to the questionnaire: IPSS - 4 points. According to retrograde urethrography: urethral patency is preserved throughout. According to uroflowmetry: maximum urination rate - 21 ml/sec, average urination rate - 18 ml/sec, emptying time - 27 sec, volume of excreted urine 486 ml.

At examination on the 12th month after surgery. According to the questionnaire: IPSS - 2 points. According to retrograde urethrography: urethral patency is preserved throughout. According to uroflowmetry: maximum urination rate - 23 ml/sec, average urination rate - 19 ml/sec, emptying time - 31 sec, volume of excreted urine 589 ml.

The proposed method was used in 9 clinical cases; in each of them it was possible to visualize the boundaries of the fibrosis of the urethra, and after opening the lumen of the urethra - the boundaries of the stricture of the urethral BO, to ensure complete excision of the altered tissues, to control the adequacy of the blood supply to the edges of the urethra and the cut urethral BO, which created better conditions for the healing process in the area of the urethral anastomosis.

The method allows:

- to most accurately determine the boundaries of fibrosis of the urethra before its intersection and stricture of the urethral lumen after opening the lumen of the urethra;

- assess the degree of blood supply to the edges of the resected urethral CT and BO before applying the anastomosis.

Claims (3)

1. A method of end-to-end anastomotic urethral plasty in the surgical treatment of stricture of the bulbous section - BS of the urethra, characterized in that 5 ml of a 0.5% aqueous solution of indocyanine green - ICG are injected into the glans penis at a distance of 1.0 cm from the external opening of the urethra, a visual assessment of the fluorescence intensity is performed when illuminating the spongy body - BS using a light source with a wavelength of 0.75 to 1.4 μm; fibrosis of the BS is detected in the zone with a fluorescence intensity of less than 50% of the fluorescence intensity of normal BS tissue; the BS of the urethra is opened, making a longitudinal incision up to 1.0 cm long along its dorsal surface in the zone of detected fibrosis of the BS; The urethral BO stricture is identified in the zone with a fluorescence intensity of less than 50% of the fluorescence intensity of normal urethral tissue; after which the ST is resected within the boundaries of the identified fibrosis zone and the urethral BO is resected within the boundaries of the identified stricture zone; then the edges of the urethra are spatulated with a longitudinal incision of each of them over a length of 0.5-1.0 cm, and an anastomosis is applied between the ends of the urethra. 2. The method according to claim 1, characterized in that after resection of the urethral CT and BO, 2.5 ml of a 0.5% aqueous solution of ICG are injected into the head of the penis at a distance of 1.0 cm from the external opening of the urethra and into the proximal end of the urethral BO, the completeness of excision of the CT fibrosis zones and urethral BO stricture is monitored by visually assessing the fluorescence intensity at the edges of the urethral CT and BO formed after their resection, while illuminating the resected edges of the urethral CT and BO using a light source with a wavelength of 0.75 to 1.4 μm; if areas with a fluorescence intensity of less than 50% of the fluorescence intensity of normal CT and urethral BO tissue are detected, additional excision of the CT fibrosis zones and/or urethral BO stricture is performed, respectively. 3. The method according to item 1, characterized in that when applying an anastomosis between the ends of the urethral BO, a single-row suture is applied along the dorsal surface of the urethral BO and a double-row suture is applied along the ventral surface of the urethral BO.