Treatment of PMR in children using endoscopic correction is carried out at the MedicaMente clinic in Korolev. To correct vesicoureteral reflux in children, we use modern volume-forming drugs Urodex and Vantris. The operation is carried out in a One-Day Surgery format using equipment manufactured by Carl Storz (Germany), does not leave scars on the anterior abdominal wall and minimizes the period of hospitalization and recovery
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Treatment of PMR in children at MedicaMent
If a child has vesicoureteral reflux, this disease must be treated, otherwise irreversible changes in the kidney may result with loss of its function! Modern treatment PMR includes a set of measures (therapeutic and surgical) aimed at eliminating the cause of reflux and eliminating its consequences. To choose the right treatment tactics, a thorough examination of the child is necessary. The main method for diagnosing PMR is voiding cystography - X-ray examination bladder filled with contrast agent. Cystoscopy determines the form of reflux based on the condition of the ureteric orifices.
Pediatric urologists at the MedicaMente medical center have accumulated extensive experience in treating pediatric urological diseases and are ready to help your child. The specialized children's surgical hospital in Korolev is equipped with modern medical equipment, and the Center's pediatric surgeons are skilled in modern techniques in the field of urological endoscopy. Children admitted to the MedicaMente hospital with a diagnosis of vesicoureteral reflux are treated personally by the head physician of the clinic - Ph.D., pediatric urologist-andrologist with extensive experience and experience Nikitsky M.N.
Surgical operations for VUR in children have 2 main types. This (performed laparoscopically or through an incision in the abdomen on an open bladder) and. If surgery is necessary, the surgeon at the MedicaMente medical center gives preference to the most modern and less traumatic methods of treatment, namely: endoscopic correction of vesicoureteral reflux in a child. In our center, we can perform submucosal implantation of any volume-forming drug (Vantris, Urodex). However, it should be understood that the choice of treatment method depends on many factors and is carried out individually in each specific case. In some cases (with high degrees of reflux, after unsuccessful injection endoscopic corrections), preference may be given to traditional antireflux surgery on the open bladder.
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Vesicoureteral reflux in children
WHAT WE ARE READY TO OFFERIt doesn't hurt at all!
At any age, surgical treatment of vesicoureteral reflux in children is performed under anesthesia. The little patient falls asleep, and when he wakes up, all the troubles are over. The use of the latest generation anesthetic Sevoran makes recovery from anesthesia and return to a normal state quite quick and comfortable. At the MedicaMente Pediatric Surgery Center, in agreement with the surgeon, mom or dad can stay next to the child in the operating room until he falls asleep from anesthesia.
Comfortable hospital stay conditions
The high level of service in the hospital of the Medica Mente clinic and the possibility of sharing a stay with the child make the treatment process as comfortable as possible for parents and the young patient. Comfortable single and double rooms are equipped with imported medical furniture, private bathroom, TV, wireless internet(Wi-Fi). Each bed in the hospital is equipped with a “call” button to communicate with medical staff. Meals for hospital patients are organized individually...photo of hospital wards
No stress and no queues
It often happens that you have to wait in line for several months to undergo surgery for vesicoureteral reflux in a city hospital. Hospitalization in the hospital of the MedicaMente clinic is carried out at a time convenient for you and in the shortest possible time ... how hospitalization occurs
Just 1 day in the hospital
Endoscopic correction of VUR is characterized by minimal trauma and a short hospitalization period. As a rule, 2-4 hours after surgery the patient’s condition is completely normalized. One day after the control ultrasound, if the condition is satisfactory, the children are discharged for outpatient observation.
Antireflux surgery: traditional ureteral transplantation
Open surgical treatment of vesicoureteral reflux is a fairly serious operation. The duration of the surgical intervention is at least one and a half hours. The operation is performed under endotracheal anesthesia, requires an incision in the lower abdomen, a hospital stay (the duration of the uncomplicated hospital period after abdominal surgery averages from 7 days), catheterization of the bladder after surgery. Open surgery is recommended mainly for the treatment of high degrees of reflux with disruption of the anatomy of the ureteral orifice.
Endoscopic surgery for reflux in children
Endoscopic correction is an alternative to surgical treatment of vesicoureteral reflux. Unlike open bladder surgery with the endoscopic method, the procedure takes 30-40 minutes, leaves no scars, and is less postoperative complications and minimizes hospitalization and recovery time. As a rule, after 2-4 hours the patient’s condition is completely normalized. A day later, the child is discharged for outpatient observation.
The method is low invasive. Correction of VUR is carried out using an endoscope under short-term inhalation (mask) anesthesia. Modern children's (very thin) (Germany) are used. The place where the ureter enters bladder, a special gel is injected to prevent urine from returning to the ureter. The implant used (volume-forming gel) has great value in endoscopic techniques for the treatment of bladder reflux in children. At the MedicaMente hospital, modern highly effective foreign-made drugs are used for endoscopic correction of vesicoureteral reflux. Up to 85% of patients get rid of VUR after the first procedure. Control cystography is performed after 6 months.
Tests before surgery for PMR in children
You can undergo a preoperative examination at a local clinic or at any commercial clinic. Scans of test results must be sent to our email address. Before the operation, you will need to provide the originals of tests, extracts and doctor’s reports. Check with your doctor for a list of tests and examinations before surgery, as in some cases concomitant pathology additional consultations and examinations are necessary.
- Analysis of urine
- blood analysis
- platelets, clotting time, bleeding (coagulogram)
- biochemical analysis: protein, bilirubin, urea, creatinine
- HIV, testing for hepatitis B and C
- ECG with interpretation or cardiologist's report
- blood type, Rh factor
Cost of vesicoureteral reflux surgery
*The cost of the operation includes:
- inpatient accommodation 1 day (double room with toilet, TV, cartoon channel)
- nutrition
- anesthesiological aid: anesthesiological apparatus Drager Fabius GS (Germany), anesthetic Sevoran
- cystoscopy, drug administration, drainage of the postoperative area
- performing an ultrasound of the kidneys and bladder 6 hours and 24 hours after administration of the drug
- local anesthesia urethra and bladder gel with lidocaine (catedgel, instillagel)
- all disposable surgical consumables and instruments
- constant telephone communication with the attending physician
- examination any day in the clinic within 30 days after surgery
From us you can also order and buy Urodex gel (the price of the drug is in the table above), Vantris.
Included in price surgical treatment not included:- preoperative examinations and tests (can be taken at the clinic at your place of residence, at our Center or any commercial clinic)
- diagnosis and treatment of concomitant diseases and their complications
** Compulsory medical insurance policy or paid: what to choose?
“Medica Mente” provides treatment for PMR in children within the framework of compulsory medical insurance. We are also ready to provide immediate hospitalization for a fee. The choice is always yours!
*** This is not a public offer agreement. Check the cost of services on the day of your request.
How is PMR treated?
Endoscopic correction of VUR is carried out during cystoscopy, under short-term inhalation (mask) anesthesia.
Preparing for surgery
You leave a request for an appointment in a way convenient for you - through the website or by phone. The surgeon contacts you and agrees on the date of the preliminary consultation. During the consultation, the pediatric surgeon will give you all the necessary recommendations for preparing for surgery and prescribe a preoperative examination. For out-of-town patients, remote consultation by phone and email is possible. Extracts, tests and other information can be sent to the pediatric surgeon’s email [email protected]
Operation
Cystoscopy is performed under general anesthesia. We allow one of the parents to accompany the child to the operating room until the anesthesia takes effect and the baby falls asleep. During cystoscopy, volume-forming drugs or a stent are introduced.
Postoperative period
After surgical manipulation observation of the child in the hospital for one day is required with ultrasound diagnostics performed over time to prevent complications. After a control ultrasound, if the condition is satisfactory, the children are discharged for outpatient observation. An extract with detailed recommendations is issued.
What you need to know
All children after treatment should be observed by a urologist for 3-5 years and periodically undergo follow-up examinations.
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Anesthesia
The operation to treat reflux in children is performed under short-term inhalation (mask) anesthesia. The operation is carried out using modern safe means under high-quality inhalation anesthesia SEVORAN, it is comfortably tolerated by patients.
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How long does PMR surgery take in children?
The average duration of the operation is 30-40 minutes, depending on the complexity and volume of the surgical procedure performed. A day after the operation, the child and his parents have the opportunity to return home.
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Postoperative period
After bladder reflux surgery, a restrictive regime should be observed for 3 days, and physical activity should be limited for 30 days. You can go for a walk with your child the next day. As a rule, a follow-up examination and evaluation of test results are carried out on days 7, 14, and 30 after surgery.
Our doctors
The consultation is conducted by pediatric doctors and surgeons at the Medica Mente center.
Pediatric surgeon, urologist-andrologist. KMN, doctor of the highest category. Associate Professor of the Department of Pediatric Surgery, Faculty of Medicine, Moscow State Medical University named after. A.I. EvdokimovaDo you want to write
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Specializes in pediatric surgery and pediatric uro-andrology. Accepts children with urological pathologies, diseases of the scrotal organs, inflammatory diseases, umbilical and inguinal hernias, treats hydronephrosis, vesicoureteral reflux. Owns operational methods treated...
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Successfully conducts comprehensive diagnostics and treatment of andrological and urological diseases in children. To the pediatric urologist, surgeon M.N. Nikitsky receives patients diagnosed with cryptorchidism, spermatocele, phimosis, hydronephrosis, vesicoureteral reflux, enuresis and others. He has a lot of op...
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Anatoly Shishigin
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During reconstruction urinary tract specialists achieve patient control over urination, maintaining kidney function for a long time and minimal complications. Reimplantation of the ureter into the bladder allows to ensure the patient’s quality of life, his social and medical rehabilitation.
Heterotopic cystoplasty is intended to create an artificial reservoir for urine from different departments intestinal tract, and the outflow of urine is done through a catheter that is discharged into the stoma of the anterior wall of the peritoneum. This method is ideal especially for those patients who have contraindications for an orthotopic artificial urinary bladder and the impossibility of independent deurination through the native urethral canal.
Why are continental ostomies performed?
Formation of a stoma in skin The continental type requires a valve for urine drainage that is reliable and stable enough to contain the liquid inside without leaking out. Catheterization in this way is very simple. Among the methods for forming such stomas, there are 4 main ones, which differ in their mechanisms of action:
- an antiperistaltic directed segment of the tubular type (from the rectum) is used in relation to the outlet stoma. Used in combination with an ileocecal valve, which prevents urine from leaking out of an artificial bladder;
- narrowing in the lumen of the part of the ileum that is used as a continental urinary mechanism. In this way, passive sponge-type resistance is artificially created along the movement of urine from the urea;
- continental stomas based on the principle of pressure distribution, which is achieved using release valves in the ileum, a hydraulic “ink” valve, and also a fluctuating one;
- valve-type flaps, which create tubular-type invagination structures in the walls of an artificial organ, etc.
Ideally, the urine output mechanism should be formed without additional synthetic fabrics and materials. This is necessary for long-term prospects, since it provides:
- containment of urine at any pressure in the reservoir area;
- ease of catheterization;
- the possibility of conducting examinations using endoscopic methods;
- minimal complications and no need for re-intervention.
The initially invented stoma was modified over time with metal clips, which led to an increase in pressure inside the lumen, narrowing it to acceptable levels. Reliability of fluid retention in this case reaches 95% of all cases.
In other cases, the principle of formation is the same, but the length of the colon segment differs. The terminal section in the ileum is narrowed and strengthened by the ileocecal valve.
With a hydraulic valve, the contents in a reservoir are filled between a pair of inlet holes, thereby compressing the inner layer. The technique of such arrangement is not currently used in the wide practice of urologists, since the effect is too short-lived. Complications in this method reach 40%.
Since the end of the last century, diverting stoma and its various modifications have gained the greatest popularity. With this method, a special mechanism is made on the skin that holds the system on the principle of intussusception of part of the ileum in the ileocecal segment. There is an unusual modification of this method, the vermiform appendix, which forms the ileocecal segment in isolation.
Part of the segment is implanted into the submucosal surface of the intestine, which allows urine to be retained in 90% of all cases. Only a tiny percentage of all operations require a repeat procedure due to stoma stenosis and the impossibility of catheter placement.
It is possible to divert urine from an artificial reservoir through the appendicostomy. This method is effective; the patient retains urine for 24 hours, and after surgery, catheterization is extremely easy. If a continental stoma is inserted near the navel, then a skin flap transferred from another segment of the intestine must be sewn into its distal section. This minimizes stenoses that occur in the stoma and its terminal section.
What problems arise during ureteral reimplantation?
Ideally, the technique of implanting ureters using part of the intestine occurs without complications or difficulties. This method is distinguished by both technical simplicity and surgical versatility, which makes it applicable to any possible pathology ureter. When creating, the main goal is taken into account - the flow of urine in one direction without obstruction, and all rules against the formation of stenosis or the need for re-intervention are also observed.
It is important to avoid auxiliary synthetic materials of a non-absorbable type during the operation. The anti-reflux mechanism is formed from the shortest intestinal fragment. It is also important to consider the possibility of retrograde endoscopic examination in the future to examine the ureters.
There are several main principles in surgery that must be followed when arranging anastomoses of the ureteric-intestinal type. Ureteral reimplantation should be performed in accordance with the following rules:
- thermal coagulation in in this case not applicable;
- the site of the anastomosis must be fixed so that the ureteral canal tube does not rotate during its artificial formation;
- if mobilization of the ureter is needed, then it is necessary to move the intestine towards it, but not vice versa;
- the anastomosis is peritoneized whenever possible;
- when performing intubation of the ureteral tube, a stent made of soft materials of the required size must be used;
- The spatulation should be adequate and wide, which will prevent stenosis and stricture and reduce urinary leakage.
Why is it important to prevent reflux?
As is known, the main factor in protecting the UMP is the prevention of the formation of reflux against the background of infection in the skin reservoir with a continental stoma. There is some controversy regarding the need to protect against reflux in patients with continental urine derivation.
Experts who are against antireflux actions insist on the following factors:
- the neobubble during detubulation is a zone of low pressure;
- all work performed for anti-reflux protection is too labor-intensive and painstaking;
- the mechanism of preventing reflux causes a high risk of complications, in particular, lumen obstruction;
- Damage to the renal system has only been proven in animal experiments.
Those who insist on reflux practically prove that if you prevent its occurrence, then there will be no uncontrolled deurination in all patients with continental urine diversion and plans for long life. The feasibility of antireflux protection during surgery to form a bladder (neobladder) is made only after a thorough examination of the patient based on similar cases and their successful outcome.
21 State Educational Institution of Higher Professional Education "Samara State Medical University"
2 GBUZ "Samara Regional clinical Hospital them. V.D. Seredavina"
The article presents an assessment of the results of surgical treatment of children with congenital obstructive megaureter in the urology department of the pediatric building of the Special Clinical Hospital named after. V.D. Seredavina. Most full recovery anatomy and function urinary tract was achieved in children who underwent drainage of the urinary tract on the affected side and correction of bladder dysfunction. According to our results, intravesical ureteral transplantation has advantages over extravesical transplantation, which is primarily due to the technical ability to maintain the required ratio of the diameter of the ureter to the length of the submucosal “tunnel” during transplantation.
megaureter
obstruction
pyelostomy
1. Babanin I.L. Rationale and effectiveness of endosurgical treatment of obstructive megaureter in children: Abstract of thesis. dis. . Ph.D. honey. Sci. – M., 1997.
2. Guliev B.G. Reconstructive operations for organic obstruction of the upper urinary tract: Abstract of thesis. doc. honey. Sci. / B.G. Guliev; St. Petersburg, 2008. – 45 p.
3. Menovshchikova L.B. Assessment of the condition of the upper urinary tract in obstructive uropathy in children and methods for correcting identified disorders: Doctoral dissertation. honey. Sci. / L.B. Menovshchikov. – M., 2004. – 194 p.
4. Wise I.S. Functional status upper urinary tract in urological diseases: abstract. dis...doct. honey. Sci. 14.00.35. – M., 2002. – 50 p.
5. Sabirzyanova, Z.R. Impaired contractility of the ureter with obstructive megaureter and the possibility of their correction in children early age: Dis... cand. honey. Sci. 14.00.35. Federal State Institution Moscow Research Institute of Pediatrics and Pediatric Surgery of the Russian Ministry of Health. – M., 2004. – 137 p.
6. Dawn L., McLellan, Retik Alan B., et al Rate and predictors of spontaneous resolution of prenatally diagnosed primary nonrefluxing megaureter. // J. Urol. – 2002. – Vol. 168. – P. 2177–2180.
7. Suzuki Y., Eirnasson J.I. Congenital Megaureter // Rev. Obstet, Gynecol. 2008.1(4):152–153.
Congenital megaureter is an enlargement of the ureter, accompanied by a violation of its emptying. Currently, congenital megaureter is included in the collective concept of “obstructive uropathy” and often leads to significant impairment of renal function with outcome in chronic illness kidneys, especially with bilateral damage. According to the urological department of the pediatric building of the Special Clinical Hospital named after. V.D. Seredavin, in recent years the number of children with congenital megaureter has been increasing. This is due to the constantly increasing congenital pathology urinary system in children, as well as with good pre- and postnatal diagnostics. The term “megaureter” was first introduced in 1923 by J. Coulk, and to date there are more than 20 working classifications of megaureter. In our daily work we adhere to the consolidated international classification, adopted in 1977, which distinguishes three forms of megaureter: obstructive, refluxing and bladder-dependent. Each form can be primary or secondary. For obstructive megaureter, we use the classification proposed in 1978 by Pfister R.C. and Hendren W.H., who distinguish three stages of disease development: achalasia of the ureter, development of megaureter, without expansion of the calyx - pelvic system(CHL), ureterohydronephrosis (UH) with significant expansion of the ChHL and thinning of the kidney parenchyma. Radical treatment Severe forms of congenital obstructive megaureter require surgical treatment only. The main type of surgery performed for megaureter is called ureteral reimplantation. The purpose of the operation is to cut off the ureter from the bladder above the narrowing, and create a new anastomosis that freely passes urine from the ureter into the bladder and prevents the backflow of urine (reflux) into the kidney. To prevent reflux, the distal portion of the ureter is placed in a “tunnel” under the lining of the bladder, resulting in a valve that closes when the bladder fills. The operation can be performed both intravesically and extravesically. It is very important to promptly and accurately remove the dysplastic section of the ureter and restore emptying of the ureter and pelvis. The method of surgical treatment was determined based on the diameter of the ureter and the location of the obstruction. If the diameter of the ureter exceeds 1.5 cm, then preference is given to extravesical transplantation. If the ureter was smaller in diameter and less tortuous, intravesical grafting was performed (Cohen's method). Radical surgery for megaureter is technically possible to perform on a bladder of sufficient volume and after correction of neuromuscular dysfunction of the bladder. This significantly extends the time frame and makes it possible to operate on children, often after one year. But in a significant proportion of children, especially with ureterohydronephrosis, delay in surgical correction leads to irreversible damage to the renal parenchyma, with loss of kidney function, and at 1 year of age “there is nothing left to save.” We try to drain the urinary system for such children. different ways. Most often this is pyelo- or ureterostomy, or endoscopic drainage distal section ureter with vesicoureteral stents.
Purpose of the study
To conduct a comparative analysis of the results of extravesical and intravesical ureter transplants in children with congenital obstructive megaureter in the urology department of the pediatric building of the Special Clinical Hospital named after. V.D. Seredavina.
Materials and research methods
From 2008 to 2013, 95 children diagnosed with congenital megaureter were operated on in the Urology Department of the PC. Of these, children with refluxing megaureter accounted for 35% (33 children), with ureterohydronephrosis - 26% (25 children), with obstructive megaureter - 39% (37 children). The bulk are boys - 74% (70 children), girls - 26% (25 children). Preoperative urine diversion through a pyelo-, ureterostomy, or distal vesicoureteral stent was performed in 26% (25 children). Preoperative drainage was required only in children with severe ureterohydronephrosis, under the age of 1 year, due to progressive renal dysfunction. The children's ages ranged from 8 months to 15 years. The operations were performed under general anesthesia using combined intubation anesthesia. Preference was given to drugs with the least nephrotoxic effect (sevoflurane, fentanyl, propofol). During induction of anesthesia, preference was given to sevoflurane; for children under 3 years of age, propofol was used for older children. Intraoperative analgesia was provided with fentanyl. This anesthetic management resulted in a minimal risk of complications during anesthesia. All children are divided into 2 groups, depending on the type of operation performed. The first group consisted of children who underwent intravesical transplantation (N = 46). The second group included children operated on using the extravesical technique (N = 49). During the operation, all children underwent histological examination of the excised distal segment of the ureter. IN postoperative period All children underwent ultrasound examination of the kidneys and bladder 1, 3 and 6 months after surgery to assess ureteric emptying and CL. A follow-up examination was performed on all children 6 to 8 months after surgery in the urology department of the PC. The examination consisted of excretory urography, voiding cystography, cystoscopy, ultrasound of the kidneys and bladder, qualitative and quantitative analyzes urine.
Research results and discussion
In group 1, complete recovery was observed in 82% (38 children) - adequate emptying of the ureter and CL with restoration of kidney function according to excretory urography, absence of vesicoureteral reflux (VUR), according to voiding cystography. Relapse of megaureter was noted in 2% (1 child). VUR was observed in 16% (7 children). In the second group, complete recovery was observed in 62% (30 children). Relapse of megaureter was observed in 8% (5 children). VUR in 30% (15 children). In children who underwent preoperative drainage of the ureter (25 children), we noted adequate emptying of the ureter and CLS on the drainage before surgery; after surgery, there were no relapses in this group of children. The degree of VUR after surgery varied from grade 1 to grade 3. During the year, we noted recovery from PMR against the background conservative therapy in 12 children. The lack of positive dynamics against the background of conservative therapy made it possible for 10 children to undergo endoplasty of the ureteric orifice with the volume-forming substance “Vantris” with good result. According to the results histological examination, in 80% of cases, focal fibrosis of the submucosal and muscular layers, elements of the nervous and muscle tissue presented singly. The size of the excised distal ureter was determined from the technical feasibility of mobilizing the ureter during surgery to create a submucosal “tunnel.” Repeated radical surgery was required in all children with relapse of megaureter. Relapse of the megaureter after surgery was due to a large area of ureteral dysplasia (according to the results of repeated histological examination) and the technical impossibility of removing the entire dysplastic section during the first operation.
According to our results, intravesical ureteral transplantation has advantages over extravesical transplantation, which is due, first of all, to the technical ability to maintain the required ratio of the diameter of the ureter to the length of the submucosal “tunnel” during transplantation. The technical difficulty in forming a submucosal “tunnel”, while maintaining the ratio of the diameter of the ureter to the length of the “tunnel” (1:4 - 6), determines the presence of VUR after the operation. Regression of VUR in half of the children during conservative therapy is associated with contractility of the ureter after surgery and a decrease in its diameter in the submucosal “tunnel”. Adequate restoration of the anatomy and function of the urinary tract in severe forms of ureterohydronephrosis was achieved in children who underwent preoperative drainage of the urinary tract on the affected side and correction of neuromuscular dysfunction of the bladder.
Bibliographic link
Barskaya M.A., Gasanov D.A., Gasanov D.A., Teryokhin S.S., Melkumova E.G., Bastrakov A.N., Alekseeva I.N., Kartavtsev S.F., Eremin P .IN. APPROACH TO SURGICAL TREATMENT OF CONGENITAL OBSTRUCTIVE MEGAURETER IN CHILDREN // International Journal of Applied and basic research. – 2015. – No. 12-8. – pp. 1417-1419;URL: https://applied-research.ru/ru/article/view?id=8162 (date of access: 07/18/2019). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences" Ureteral grafts can be done into the skin, bladder, and bowel.
Ureteral skin graft
The ureters are transplanted to the lumbar or suprapubic region. The operation is performed extraperitoneally.
Operation technique
Having exposed the retroperitoneal space, the ureter is isolated in the required place. A ligature is placed on the ureter, above which it is crossed. The central end of the ureter is brought out into the lumbar wound; Separate catgut sutures fix it to the aponeurosis and lavsan sutures to the skin. The ureter should stand 1-2 cm above the surface of the skin. A vinyl chloride tube is inserted into the ureter and a urinal bag is fitted. For better adaptation of the urinal N.N. Elansky proposed creating a canal-coupler around the ureteral opening from the skin, and N.A. Lopatkin uses the Filatov stem. The coupling channel and the Filatov stem serve as a conductor of urine to the urinal, protecting the skin from maceration by urine.
Transplantation of ureters into the bladder
Transplantation of the ureters into the bladder (ureterocystoneostomy) is performed when there is a violation of the patency of the pelvic section of the ureter, or when its mouth is ectopic.
The end of the ureter is most often sutured into the apex of the bladder. Strictures or vesicoureteral reflux are common after ureteral neostomy. To avoid these complications, many have been proposed various methods ureteroneostomy. Some authors recommend neostomy with the formation of a “papilla” from the distal segment of the ureter, protruding into the cavity of the bladder by 1.5-2 cm, others indicate the need for splitting or an oblique cut of the distal end of the ureter.
Operation Mathisen-Gilla
After exposing the pelvic ureter and the corresponding part of the bladder, a rectangular flap is cut out from the latter. The flap is folded into the cavity of the bladder and the ureter is placed on it. The end of the ureter along its anterior wall is incised in the longitudinal direction and fixed to the formed flap. The defect in the bladder wall is sutured, creating the ureteral orifice in the form of a “nipple”. Urine is drained through the suprapubic fistula.
Operation Boari
After mobilizing the corresponding half of the bladder and the pelvic ureter, it is transected within healthy tissue.
Its distal end is bandaged. A thin drainage tube is inserted into the central end, which is fixed to the ureter with interrupted sutures at its very edge. Following this, a flap is cut out along the anterolateral surface of the corresponding half of the bladder for 2.5-3 cm in the transverse direction, the pedicle of which lies on the posterolateral wall of the bladder. The flap is turned upward, its length is adjusted and a tube is formed from it, the diameter of which must correspond to the diameter of the ureter. Next, they proceed to the most crucial moment of the operation - connecting the ureter with the bladder flap. The ureter is placed on the edge of the flap and fixed to the bladder mucosa. Then the flap is rolled into a tube and stitched with interrupted catgut sutures. The bladder defect is sutured with interrupted catgut sutures in the longitudinal direction, passed through all layers of the bladder wall. The drainage tube is left in the ureter for 10-12 days. In women, its distal end is removed through the urethra, in men - through an additional incision on the anterior wall of the bladder.
Transplantation of ureters into the intestine
Operation P.I.
Tikhova
An incision along the midline from the navel to the symphysis pubis is used to open the abdominal cavity. The intestines are pushed upward and fixed in this position with gauze napkins. The edges of the wound are spread wide and the ureter is found, which is visible through the posterior layer of the peritoneum in the form of a white, periodically contracting cord. Above the ureter, at the place of its intersection with the iliac vessels, the posterior layer of the peritoneum is dissected for 5-6 cm. The ureter is bluntly isolated from the surrounding tissue by 6-8 cm and bandaged as close as possible to the bladder. The ureter is fixed to the pelvic part of the rectum with two or three sutures, suturing only its adventitia and the seromuscular layer of the intestine. After this, the ureter is dissected over the bandaged area. Its bladder segment is lowered into the tissue. A piece of parietal peritoneum is sutured to the lateral wall of the intestine. Then the serous-muscular layer of the intestine is opened to the mucosa for 2-2.5 cm. In the lower corner, the intestinal mucosa is opened for up to 0.5 cm, where the end of the ureter is inserted.
Above it, the intestinal wall is sutured with interrupted sutures, capturing the outer layers of the ureteral wall. The ureter should protrude into the intestinal lumen by 0.6-1 cm. The outer edge of the incision of the parietal peritoneum is stretched and sutured over the site of ureter transplantation.
A similar operation is performed on the opposite side. The ureters must be transplanted at a distance of at least 10 cm from each other. IN anus a urinary drainage tube is inserted.
Operation S.R. Mirotvortseva
After dissecting the posterior layer of the peritoneum, the ureter is isolated, ligated and crossed, as in the operation P.I. Tikhova. The end of the central segment is cut longitudinally by 1-1.5 cm and placed on the lateral side of the sigmoid or pelvic part of the rectum. Above the ureter, the folds of the serous membrane of the intestine are sutured with interrupted sutures, including the adventitia of the ureter in the suture. The parietal peritoneum is sutured to the intestinal wall. At the end of the ureter, the seromuscular membrane of the intestine is dissected for 1 cm. The mucosa is grabbed with tweezers and cut so that an oval hole is formed in it. The end of the ureter is sutured into the intestinal lumen in an end-to-side manner, followed by peritonization of the anastomosis. If indicated, a similar operation is performed on the opposite side.
Sometimes the ureter is removed over a long distance, which eliminates the formation of an anastomosis with bladder without tension. This usually happens in cases of narrowing of the ureter after radiation therapy. Instead of creating an anastomosis with the risk of tension and subsequent stenosis and hydronephrosis, it is better to resort to cutting out a bladder flap that is long enough to connect to the excised ureter. That's why this operation begin by measuring the distance between the bladder wall and the proximal ureter. This distance, usually 8-9 cm, is marked with a solution of brilliant green on the back wall of the bladder in the area where the superior vesical artery approaches the bladder. The intended flap is excised using scissors or a scalpel. The width of the base of the flap should be greater than its length. A soft, indwelling 8-gauge catheter is inserted into the ureter up to the renal pelvis.
20 The flap is retracted towards the proximal portion of the ureter. You need to be sure that there will be no tension when forming the anastomosis. If the initially cut flap is insufficient, the incisions can be widened towards the base of the flap. The flap is rolled into a tube and sutured over the catheter with interrupted sutures using a 4/0 synthetic absorbable thread. Now an anastomosis is performed between the proximal end of the ureter and the tube formed from the flap using interrupted synthetic absorbable sutures using a 4/0 thread. One row of interrupted synthetic absorbable sutures is applied to the tube being formed using 4/0 thread, stitching through all layers of the tube. Change traditional way suturing the bladder in two rows is due to the fact that this method can lead to tube stenosis.
21 Bladder wall defect from
the cut flap is sutured in two
layer, with the first row of sutures applied to the mucous layer, and the second - to the muscular and serous ones (as in Fig. 16 and 17). To the area of anastomosis from the lower quadrant of the anterior abdominal wall a closed drainage is provided for aspiration of the discharge. The catheter is left in the ureter for at least 2-3 weeks. It is removed during cystoscopy.
In some patients suffering from malignant diseases, during extensive operations in the pelvis, resection of the terminal portion of the ureter is performed. In such cases, urine passage can be preserved by transplanting the ureter into the bladder or by transperitoneal transplantation of the ureter into the ureter.
If the opposite ureter is healthy and normal, and the distance between the excised ureter and the bladder is too large, then it is better to perform a transperitoneal ureteral union operation. The tension of the sutures during transplantation of the ureter into the bladder often leads to a narrowing of the anastomosis in the postoperative period. Therefore, in these cases, a side-to-end ureteral connection operation is preferable, allowing sutures to be placed on the anastomosis without tension.
Transperitoneal transplantation, especially in situations associated with post-radiation trauma, makes it possible to direct the course of the ureter outside the irradiated areas, thereby avoiding the development of anastomotic stenosis in the area damaged by radiation.
The basic principle of this operation is to pass the ureter across the abdominal cavity, under the mesentery small intestine to the healthy ureter on the opposite side and connect them. We prefer to perform such operations using a ureteral catheter, which remains in the anastomotic area for almost 2 weeks.
The goal of the operation is to save a kidney whose ureter is damaged or blocked by transplanting that ureter into a healthy ureter on the opposite side. After surgery urine
receives the possibility of free outflow from both kidneys through one ureter into the bladder.
Physiological consequences. If, when performing an anastomosis, it is possible to avoid narrowing and there are no stenoses in the terminal part of the receiving ureter, then no physiological changes may occur. One ureter is capable of carrying the flow of urine from both kidneys. Any pathological process, which caused a narrowing of the ureter on one side, is quite capable over time of leading to the same changes in the other ureter, which will require repeated transposition of the ureter, this time into the ileal loop.
Warning. The affected area of the ureter must be excised with great care. The remaining portion of the ureter should be handled very carefully so as not to damage the vascular network under the membrane that supplies the entire length of the ureter. A section of the wall of the receiving ureter measuring 1.0 x 0.5 cm is marked and excised; i.e., the hole for the anastomosis is created precisely by excision, and not by a simple incision. We believe that this method significantly reduces the likelihood of postoperative narrowing of the anastomosis. We prefer: 1) to prevent circular stenosis of ureteral anastomoses, increase the cross-sectional area of the anastomosis opening by making an oblique cut on the implanted ureter; 2) form anastomoses on the inserted permanent urinary catheter. The area of the formed anastomosis after surgery must be drained through the lower quadrant of the anterior abdominal wall.
TRANSPERITONEAL CONNECTION OF THE URETER (END TO SIDE ANASTOMOSIS)
(CONTINUATION)
METHOD:
1 The patient lies on the operating table
on the back, in the stone-cutting position.
There is a Foley catheter in the bladder.
Abdomen opened by the lower middle
with a cut.
The parietal peritoneum on the affected side, above the common iliac vessels, is opened with scissors and raised, while the pathologically altered area of the ureter is completely exposed. The boundaries of this area have been precisely defined. The distal segment of the ureter, suitable for the bladder, is clamped and ligated with synthetic absorbable suture 0. The proximal segment of the ureter, intended for transplantation, is carefully mobilized, taking care not to damage the membrane and underlying blood vessels. It is necessary to remove all damaged areas of the ureter, and in case of radiation injury, the entire area affected by radiation. The peritoneum covering the mesentery of the colon is opened and a tunnel is formed under this mesentery. This should be done carefully so as not to damage the blood vessels of the mesentery.
The receiving ureter is elevated on a soft support. An implantable ureter is placed close to it in a convenient place. At this stage, it is necessary to be sure that both structures have sufficient mobility, and that the sutures can be placed without tension.
TRANSPERITONEAL CONNECTION OF THE URETER (END TO SIDE ANASTOMOSIS)
(ENDING)
When the guidewire is removed from the bladder, a catheter is pulled into the bladder after it. One of the arms of the catheter enters the proximal limb of the receiving ureter.
The edges of the ureter-ureteric anastomosis are sutured with interrupted synthetic absorbable sutures through all layers (4/0 thread), connecting the mucous membranes of both ureters. Increasing the area of the anastomotic opening due to an oblique cut of the implanted ureter reduces the likelihood of circumferential stenosis.
Suturing the peritoneum over the formed anastomosis. A tube for aspiration drainage is placed at the site of anastomosis retroperitoneally through the lower quadrant of the abdominal wall. It should stand as long as discharge comes out of it. After 2-3 weeks, cystoscopy is performed and the ureteral T-shaped catheter is removed. At the same time, intravenous pyelography is performed, which can then be repeated every 2 months until the surgeon is completely satisfied with its results.
