Treatment and plastic of the bladder. Intestinal plasty of the bladder. How is bladder plastic surgery performed?

INTESTINAL BLADDER PLASTY

Nesterov S.N., Khanaliev B.V.,. Rogachikov V.V., Pokladov N.N., UDC 616.62-089.844

Bonetsky B.A.

National Medical and Surgical Center. N.I. Pirogova, Moscow

INTESTINAL PLASTIC BLADDER

Nesterov S.N., Hanaliev B.V.,. Rogachikov V.V, Pokladov N.N., Boneckij B.A.

In urological practice, it is often necessary to replace the bladder with isolated segments of the small or large intestine.

Bladder replacement surgery is mainly associated with radical cystectomy for invasive bladder cancer or pelvic evisceration for rectal tumors and other diseases of the genitourinary system. Also, replacement plastic is performed for congenital anomalies in the development of the genitourinary system (exstrophy of the bladder), the condition after ureterosigmostomy, and other conditions (microcystis, bladder injuries, bladder tuberculosis, post-radiation cystitis).

Due to the permanent need for artificial diversion of urine (with cutaneo-, ileostomy) or with urinary intestinal reservoirs that require systematic catheterization, there is a discrepancy between the high survival rates of patients after radical cystoprostatectomy and the low quality of life after surgery.

bladder cancer

Every year in Russia, bladder cancer is diagnosed in 1.5 thousand people. Its frequency reaches 10-15 cases per 100 thousand people per year. About 80% of patients belong to the age group of 50-80 years. Approximately 30% of newly diagnosed bladder tumors are muscle-invasive. The mortality rate from this disease in many industrialized countries ranges from 3% to 8.5%.

In the Russian Federation, there is a steady increase in the incidence of bladder cancer. Incidence rate between 1998 and 2008 increased from 7.9 cases per 100 thousand population to 9.16 cases per 100 thousand population. The overall increase in this indicator is observed among both men and women. Among all oncological urological diseases, the share of bladder cancer is 4.5%, coming in second place after prostate cancer.

The frequency of primary diagnosis of bladder cancer in the superficial form is 70%, and we

cervical-invasive forms of the disease - 30%. Often, patients seek help when the disease is already at a later stage.

Surgical treatment of bladder cancer

The surgical method is of leading importance in the treatment of bladder cancer. All types of radical operations for bladder cancer can be divided into organ-preserving and organ-removing. Organ-preserving operations include transurethral and open resection of the bladder. Cystectomy is a organ-removing operation, requiring the creation of conditions for artificial outflow of urine or bladder replacement.

According to many authors, the recurrence rate of a superficial bladder tumor after transurethral resection (TUR) is from 60 to 70%. This is the highest frequency among all malignant neoplasms. It should also be borne in mind that with multiple lesions of the bladder, the recurrence rate is higher.

Approximately 30% of patients with superficial bladder tumors have a high risk of disease progression to a muscle-invasive form and an increased risk of mortality. It was found that tumor recurrence within 9 months after TUR despite intravesical BCG therapy is accompanied by a 30% risk of tumor invasion, and if a tumor recurs after 3 months, 80% of such patients subsequently progress to a muscle-invasive form.

Naturally, the preservation of the bladder, for example, with partial cystectomy (resection) or TUR of the bladder, theoretically implies the presence of certain advantages regarding the volume of surgical intervention, the absence of the need for urine diversion, and the preservation of sexual function. However, at the same time, there is a decrease in survival rates and the recurrence rate reaches 70%.

The first radical cystectomy was performed by W. Bardeheuer in 1887. Prior to this, in 1852, Simon J. made the first attempt

ureterorectal anastomosis with ectopia of the bladder.

Since the 1960s, radical cystectomy has become the gold standard for the treatment of invasive bladder cancer. Over the subsequent time, the methods of performing the operation were improved in parallel with advances in the field of surgery, anesthesiology and postoperative care, which made it possible to reduce mortality after radical cystectomy from 20% to 2%. Currently, there is no doubt that radical cystectomy is the method of choice in the treatment of muscle-invasive bladder cancer in stage T2-T4 N0-x, M0. In addition, the indications for performing radical cystectomy for superficial bladder cancer have been expanded. This primarily applies to patients with an increased risk of progression, with multifocal tumors, recurrent superficial bladder cancer, refractory to intravesical immuno- and chemotherapy, concomitant carcinoma in situ. Studies have shown that in 40% of patients with stage T1 who underwent radical cystectomy, a histological examination of the removed preparation showed a higher stage of the tumor process.

Some studies have shown that 25-50% of superficial bladder tumors eventually progress to muscle-invasive forms, with 41% recurring.

When the bladder is removed, the question inevitably arises of how the urine excreted by the kidneys will be excreted from the body. At the same time, urinary diversion methods are of paramount importance and relevance, which should ensure the preservation of the function of the upper urinary tract and a satisfactory quality of life. This aspect is very important, since in 25-30% of cases, patients die due to imperfect methods of derivation.

Urine diversion options after radical cystectomy

The search for optimal options for reconstructive operations after cystectomy was undertaken at the beginning of the last century, but even today the choice of the most optimal method of urine diversion remains one of the urgent problems of urology. For the reconstruction of the lower urinary tract after cystectomy, various segments of the gastrointestinal tract are most often used, however, an ideal replacement for the natural bladder has not yet been found. This is evidenced by the fact that more than 40 different methods of urine diversion are known to date, which is an indicator that the ideal method has not yet been found.

All options available in the arsenal of urine diversion after radical cystectomy can be divided into

into continental and non-continental. Non-continental urinary diversion methods include ureterocutaneostomy, pyelostomy, transureteroureteronephrostomy, and iliac and sigmoid conduits.

Continental methods are characterized by the fact that there is a mechanism responsible for urinary retention, but there is no voluntary urination. This group includes ureterosigmoid anastomosis (Goodwin), ileal reservoir (Kock), ileocecal reservoir and reservoir from the sigmoid colon (method Gilchrist, Mansson, Mainz pouch II, LeBag, Indiana pouch).

Finally, in orthotopic cystoplasty, an artificial bladder is formed at the site of the removed bladder, and voluntary urination through the urethra is preserved. When creating an orthotopic neocystis, a detubularized segment of the ileum is used (methods of Carney I-II, Hautmann, Studer, Kock), an ileocecal segment (method of Mainz pouch I, LeBag), a section of the stomach (method of Mitchell-Hauri), a large intestine ( Reddy technique).

Of practical importance, as some authors believe, is the transplantation of the ureters into an isolated segment of the small or large intestine, using it to divert urine through an ileocolostomy. At the same time, the switched off intestinal segment functions as a urinal with a limited absorption surface, low pressure and the absence of enteroureteral reflux. Currently, there are two options for such operations. These include ureterosigmocutaneostomy (Blokhin's operation, Morra) and ureteroileocutaneostomy (Brikker's operation). A big problem that aggravates the life of patients is the presence of a weeping urino-stoma, with the development of skin maceration around it, which reduces the quality of life. The use of urinals, hermetically fixed to the skin, avoids damage to the adjacent skin.

Classical ureterosigmostomy is rarely performed at the present time, since these patients have a rather high incidence of complications, such as hyperchloremic metabolic acidosis (31-50%), ascending pyelonephritis (26-50%) due to gas or fecal reflux. This quickly leads to the progression of chronic renal failure and uremia [14, 58, 60]. Another negative side of this method of urine diversion is a high risk of developing ureteral strictures in the area of ​​anastomosis with the intestine (33-50%), malignancy of the colon mucosa (10-30%) at the site of the uretero-intestinal anastomosis [14, 58, 60]. This method is used when it is impossible to perform other types of operations and at present the frequency of its use does not exceed 3-5%.

Heterotopic plasty of the bladder with the formation of a cutaneous retaining mechanism expands the choice of the method of urinary diversion for the urologist in favor of improving the quality of life of patients,

which orthotopic forms of substitution are contraindicated.

In 1908, Verhoogen J. and DeGraeuvre A. described a reservoir that they formed from a segment of the caecum. At the same time, Verhoogen J. introduced a urine diversion technique using an ileocecal segment brought to the skin through the appendix. Other scientists Makkas M. and Lengemann R. used an isolated ileocecal segment as a reservoir and an appendix as an outlet valve. The first abdominal reservoir (conduit) from an isolated loop of the ileum was formed by Zaayer E.J. in 1911. This operation was performed in 2 patients with bladder cancer.

In 1958 Goodwin W.E. et al. published their results on the anastomosis of the original intestinal segment in the form of a bowl to the triangle of Lieutaut. The authors gave the neocystis a spherical shape by reconfiguring the detubularized segment of the ileum 20-25 cm long in the form of a double loop, called "dome-shaped" or "cup-patch" cystoplasty. This made it possible to obtain a reservoir of low internal pressure due to a larger radius, capacity and the absence of coordinated contractions of the intestinal wall.

In 1982 Kock N. et al. presented the results of their work on the formation of a continent iliac reservoir with urine diversion to the skin.

The final stage of the continental diversion of urine was the creation of an artificial bladder anastomosed with the rest of the urethra. Pioneers in this area were Carney M. and LeDuc A., to create an orthotopic artificial bladder in 1979, they used a segment of the ileum.

The conduit is a system with high intraluminal pressure, which, in combination with infected urine with the development of reflux or stricture of the uretero-reservoir anastomosis, can lead to impaired renal function.

Unlike the conduit, the orthotopic reservoir is characterized by low intraluminal pressure. Therefore, there is no need for an anti-reflux technique for ureteral transplantation, and the risk of developing a stricture of the uretero-reservoir anastomosis with impaired function of the upper urinary tract is lower.

Also, the advantages of orthotopic bladder replacement, according to many researchers, are the absence of the need to use a urinal, a positive perception by the patient himself, good social and psychological adaptation, and a low incidence of complications compared to other methods.

The round-shaped reservoir has a low intravesical pressure, a lower frequency and amplitude of spontaneous and tonic contractions, has

better evacuation function, to a greater extent prevents the development of vesicoureteral reflux than a reservoir formed from a non-detubularized segment.

The creation of an artificial bladder after radical cystectomy has now gained great popularity. According to Studer, up to 50% of patients with muscle-invasive bladder cancer are potential candidates for orthotopic cystoplasty. Other researchers consider the main task of the formation of neocystis to improve the quality of life of the patient. Currently, in the absence of contraindications, orthotopic bladder replacement after radical cystectomy is the gold standard.

Recent studies demonstrate that the long-term evolution of the choice of plastic material for bladder replacement in case of its functional or anatomical failure confirms the greatest physiological suitability for these purposes of an isolated segment of the intestine.

The creation of an aficial bladder from a detubularized segment of the ileum or sigmoid colon in most cases ensures the preservation of the urinary retention function and the absence of severe metabolic disorders.

Use of the ileum

The ileum for the formation of an artificial bladder is most often used in the following operations:

1) Operation Carney II. It is a modification of the original technique that Carney M. proposed earlier. It differs in that the intestinal segment undergoes detubularization in order to eliminate peristaltic activity. A segment of the ileum 65 cm long is opened along the antimesenteric edge along the entire length, with the exception of the area left for the subsequent formation of the ileourethral anastomosis. The detubularized segment is folded into a U shape, the medial edges are sutured with a twist suture. Then the reservoir is displaced into the pelvic cavity, where an anastomosis with the urethra is performed with 8 sutures, which are tightened after the neocystis is brought down. The capacity of such an artificial MP is on average about 400 ml, the pressure at the maximum capacity is 30 cm of water. Art. More than 75% of patients (men) held urine, waking up 2-3 times a night to empty the reservoir.

2) Orthotopic reservoir according to the VIP method (Vesica ile-ale Padovaria). This method of cystoplasty has much in common with the Carney II operation. This operation was developed by a group of researchers from Padua (Italy) (Pagano, 1990). The length of the taken intestinal segment is about 60 cm. The main difference is

in the configuration of a detubularized segment of the intestine: in the VIP operation, it twists around its axis like a snail. This creates a back base, which is then closed at the front with seams. Completely retain urine 80% of patients, enuresis is noted in 7% of cases. The capacity of neocystis is from 400 to 650 ml, intraluminal pressure reaches 30 cm of water. Art. at maximum capacity.

3) Orthotopic Hemi-Kock reservoir. This method was developed in 1987 by Ghoneim M.A. and Kock N.G. At the same time, protection against reservoir-ureteral reflux consists in the creation of a nipple valve, which requires the use of a stapler and staples. As a result, such a reservoir is characterized by an increased risk of stone formation. The neocystis is directly formed from a folded, detubularized segment of the ileum with proximal invagination to prevent reflux; a hole is left in the back for an anastomosis with the urethra. The authors reported 100% daytime continence, and bedwetting occurred in 12 of the first 16 patients operated on with this method. The average capacity of neocystis one year after the operation was 750 ml, intraluminal pressure to a maximum capacity of less than 20 cm of water column. In 64.7% of patients there is a good daytime continence, in 22.2% - at night.

4) Iliac artificial bladder. This operation, developed at the University of Ulm in 1988 (Hautmann, 1988) in Germany, has become popular all over the world and is currently performed in many clinics. It is based on the principles of Carney and Goodwin cystoplasty. A segment of the ileum 70 cm long is opened along the anti-mesenteric edge, except for the area for subsequent anastomosis with the urethra. Then the opened segment is folded in the form of the letter M or W and all 4 edges are sewn together with a blanket seam, thus forming a wide area, which is then closed. The capacity of such a tank is on average 755 ml, the pressure at maximum filling is 26 cm of water. Art. 77% of patients were fully continent during the day and night, and 12% had enuresis or mild daytime stress incontinence.

5) Artifical low pressure bladder (Studer operation). One of the options for the Hemi-Kock operation is the method of orthotopic cystoplasty, which was described in 1984 by the urologist Studer U.E. (Switzerland). This operation is somewhat simpler, since there is no need to invaginate the proximal knee of the intestinal reservoir.

This method is used in both men and women.

with equally good results.

Use of the colon or ileocecal segment

The use of the ileocecal segment to create the bladder was first made in 1956 by Gil - Vemet, and then later - in 1965. Since then, the ileocecal segment has been used to reconstruct the bladder in various modifications. The most common methods are the orthotopic Mainz pouch and the ileocolic reservoir Le bag.

The orthotopic Mainz pouch is an orthotopic variant of the cutaneous urinary diversion introduced by Thuroff et al. in 1988. The ileocecal segment is used, including 12 cm of the caecum and ascending colon and 30 cm of the ileum. Appendectomy is routinely performed. Detubularization is performed along the antimesenteric edge, and the segment is connected in the form of an incomplete letter W. This neocystis has a sufficiently large volume.

The ileocolic reservoir Le bag is formed from 20 cm of the caecum and ascending colon, and the corresponding length of the terminal ileum. The free edges of the caecum and ileum are sutured together and the reservoir is made according to the Kock method.

Other methods for the formation of an artificial MP from the tubular segments of the colon were also presented. However, high-amplitude peristaltic contractions are noted in the tubular reservoir, which inevitably leads to urinary incontinence.

Mansson and Colleen used detubularization of the right side of the colon to reduce intraluminal pressure. Reddy and Lange presented the results of using non-detubularized U-shaped colonic segments to create an orthotopic reservoir, which they rated as unsatisfactory. Partial detubularization, which was subsequently performed, improved functional and urodynamic characteristics.

The quality of life

The basis for the rehabilitation of patients after cystectomy and their return to their previous social status is the creation of a functioning intestinal bladder.

The problem of urinary incontinence after radical cystectomy with the formation of neocystis can be solved with the use of pads, while urinary leakage in case of impaired conduit function is difficult to hide. Quality of life assessment shows that patients feel better in the presence of neocystis compared with conduit. The upper urinary tract in an artificial MP is in a more protected state; than in the conduit, in the formation of which the frequency of renal dysfunction due to reflux is 13-41%.

Methods for assessing the functional state of the urinary tract are divided into subjective and objective. Subjective includes the patient's well-being, including daytime and nighttime retention of urine, as well as the usefulness of his life, psychological and social adaptation. Objective methods are the results of general clinical blood and urine tests, advanced biochemical and other laboratory studies, functional methods for assessing urodynamics (ultrasound, X-ray and radioisotope diagnostics, cystometry, uroflowmetry). These methods characterize the anatomical and functional state of the studied intestinal reservoir and upper urinary tract (Komyakov, 2006).

Orthotopic bladder replacement, based on the results of many comparative studies, is reasonably considered the best to date. This method not only has a lower complication rate and good functional results, but also provides patients with the best quality of life, which is considered from the standpoint of social and sexual activity, psychological adaptation and self-esteem.

Conclusion

Thus, the choice of the part of the intestine used for the reconstruction of the bladder is extremely important and determines the functional results of the surgical intervention. The existence of a large number of different methods of urine diversion indicates that the search for an optimal reservoir continues and is far from complete. Each of the listed methods has its own complications, morphofunctional advantages and disadvantages, and ultimately leads to a different level of quality of life in operated patients. It is important to know that a unified approach to surgical tactics is initially not possible due to the characteristics of cancer, functional changes in the urinary tract, age, and the presence of intercurrent diseases. Currently, there are no clear recommendations for choosing one or another segment of the intestine in each case. Although the definition of the optimal section of the gastrointestinal tract capable of replacing the bladder and performing its reservoir, barrier and evacuation function is quite possible.

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59. Taweemonkongsap T., Leewansangtong S., Tantiwong A., Soontrapa S.

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CONTACT INFORMATION

105203, Moscow, st. Nizhnyaya Pervomaiskaya, 70 e-mail: [email protected]

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If the bladder tumor extends into the urethra well distal to the bladder neck, or if the sphincter mechanism cannot be maintained after distal urethral transection, bladder replacement should be abandoned and another method of urine diversion should be considered. To rule out cancer in situ of the paraurethral glands, a biopsy of the posterior urethra is performed before surgery. It is necessary to make sure that the patient has no serious concomitant diseases and that he is psychologically prepared for the possible consequences of the operation.

Prepare the intestines. In the pre- and postoperative periods, antibiotics are prescribed for prophylactic purposes.
Incision. Produce median laparotomy. The urethra is exposed.

URINARY BLADDER from DETUBULARI30BANN0G0 U-SHAPED P0DV3D0SHN0-INTESTINAL0G0 SEGMENT (Cameo operation)

Fig.1. Partially transect the membranous urethra and apply 8 sutures for anastomosis

A. Partially cross the membranous urethra and apply 8 sutures for anastomosis with the ileo-intestinal segment. One should not deviate from the principles of ablastics out of a desire to prevent impotence in men.
B. As the posterior wall of the urethra is crossed, sutures continue to be applied to it. In men, the urethra is crossed just below the apex of the prostate gland, in women - at the level of the vesicourethral segment. Take material for urgent histological examination. Ileocystoplasty is started only if the bleeding is stopped and the membranous urethra is preserved throughout. If tumor cells are detected at the resection border, uretrectomy is performed.

A segment of the terminal ileum with a length of 60-65 cm is selected, and the middle of the segment should reach the urethra without tension, otherwise another method of bladder replacement is chosen. If the length of the mesentery allows the intestinal segment to be brought down to the urethra, then the ileum is dissected at the ends of the marked segment and intestinal continuity is restored.

Fig.2. The ileum is dissected along the anti-abdominal edge, while the incision line on the anterior wall of the intestine should be displaced

Fig.3. Method of uretero-intestinal anastomosis according to Cameo-Le Luc

A. Stepping back 1.5 cm from the edge of the intestinal flap, cut the mucous membrane along its back wall in the longitudinal direction for 3-3.5 cm and up to the muscle membrane. At the beginning of the incision through the intestinal wall from the inside to the outside, a curved clamp is carried out so that the ureter can be freely passed.
B. The ureter is brought out through the hole for 3 cm, then the edges of the adventitia of the ureter with the serous membrane of the intestine are sutured with 3 sutures with a synthetic absorbable thread 4-0.
B. The ureter is cut obliquely and 3 sutures with a synthetic absorbable thread 3-0 fix the end to the mucous and muscular layers of the intestine at the opposite end of the incision of the mucous membrane. The formation of the anastomosis is completed by suturing between the adventitia of the ureter and the edges of the incision of the intestinal mucosa. Inflection of the ureter at its entry into the intestinal wall should be avoided. The ureter should protrude above the ileal mucosa. Similarly, another ureter is implanted at the opposite end of the ileo-intestinal flap.

Fig.3. Extra side holes cut in 8F PVC tubing

The ileo-intestinal flap is folded lengthwise and its edges are hermetically sutured with a continuous 2-0 synthetic absorbable suture. The ends of the reservoir are fixed to the walls of the small pelvis. The wound is sutured, drains are removed through additional contra-openings. Three catheters, brought out along the urethra, are fixed with adhesive tape or sutures to the penis or labia.

Alternative way. Ureteric catheters are passed through the wall of the ileo-intestinal reservoir distal to the ureteroileoanastomosis zone and brought out through the anterior abdominal wall. Then the wall of the reservoir is fixed to the tissues of the retroperitoneal space around the exit site of the catheters.

After surgery, sufficient diuresis must be ensured to prevent mucus accumulation and blockage of the ureteral catheters with a mucus plug. To evacuate mucus, the ileo-intestinal reservoir is washed through the urethral catheter 4-5 times (every 6 hours) with 30 ml of saline. Parenteral nutrition is carried out for a long time, even after the restoration of intestinal motility. Drainages are removed immediately after a decrease in discharge through them, but no later than the 12th day after the operation. At the same time, ureteral catheters are removed, having previously performed urine culture and cystography. In the presence of contrast agent streaks, ureteral stents are left for another 1 week. The urethral catheter is removed 2 days later.

Reconstruction of the ileo-intestinal bladder formed according to Cameo. Urinary incontinence often occurs after replacement of the bladder with a tubular reservoir, which may require reconstruction of the bladder by creating a reservoir with a low pressure (Carini et al., 1994). To do this, resort to detubularization, dissecting the intestinal loop along the antimesenteric edge for 2/3 of its length so as to leave the area of ​​ureteroileoanastomoses intact. Sewing together the medial edges and forming the posterior wall of the new reservoir, it is folded anteriorly in the form of a cap and sutured to the free anterior edge of the intestinal loop.

Commentary by M. Camey

Before proceeding with the formation of a new bladder, it is necessary to carefully check hemostasis in the pelvis after cystoprostatectomy. Blood and lymph flowing from non-coagulated or non-ligated vessels accumulate in the lowest place, i.e. in the area of ​​urethroileoanastomosis, which can lead to the formation of a fistula.
When forming a ureteroileoanastomosis according to the antireflux technique and fixing the ends of the ileo-intestinal reservoir, care should be taken not to allow the ureters to bend in the area of ​​the anastomosis.
It is necessary to flush the reservoir of mucus every 4 hours (4-5 times a day) with 30 ml of saline; mucus buildup can cause pressure buildup in the reservoir and leaking sutures.

The ureteral catheter can be withdrawn through the wall of the ileum (7-8 cm below the ureteroileoanastomosis zone), and then through the anterior abdominal wall if the diameter of the catheter is no more than 8F. In this case, the wall of the ileo-intestinal reservoir is fixed to the tissues of the retroperitoneal space with 2 sutures near the exit site of the ureteral catheter.

Our 30-year experience, since 1958, has shown the effectiveness of replacement cystoplasty with a U-shaped tubular segment fixed to the walls of the small pelvis (Kamei I operation). In 1987-1991 110 surgeries were performed for replacement cystoplasty with a detubularized U-shaped segment. Of the 109 patients who survived after these operations, 101 (92.6%) recovered the function of continence during the day, and 81 (74.3%) patients did not experience incontinence at night. These patients noted the need to urinate 1-2 times at night. We advise such patients to urinate at least once at night to prevent bladder overflow and residual urine.

Fig.4. Sutures-holders mark 4 sections of the ileum

The selected segment of the ileum is isolated and the continuity of the intestine is restored. With the help of Babcock clamps, the segment is folded in the form of the letter W or M (depending on the position in which the knee of the segment reaches the urethra more easily). The intestinal segment is washed from mucus and opened along the protivomesenteric edge. The adjacent edges of the 3 bowel folds are sutured with a continuous 3-0 absorbable suture to form an intestinal flap, which is then folded into a large reservoir.

A small hole is formed at the suture-holder applied at the site of the proposed anastomosis with the urethra. A 22F three-way catheter is installed. An anastomosis is formed between the intestinal flap and the urethra. The inner ends of the threads of previously applied sutures are carried out on a needle through a hole in the intestinal flap, and the outer end through the intestinal flap, 5-7 mm away from the edge of the hole; both ends of the threads are tied from the side of the mucous membrane of the intestinal flap. If the intestinal flap does not reach the urethra, then the retractors are removed and the operating table is straightened. If these measures are not enough, the hole in the flap is sutured and a new one is chosen - closer to its lowest point. The anterior wall of the new bladder is partially sutured with a continuous 3-0 synthetic absorbable suture.

The ureters are implanted into the ileo-intestinal flap, the right ureter is passed through the wall of the right lateral knee of the intestinal flap, and the left ureter through the mesentery of the colon, then through the wall of the left lateral knee. The ureters are implanted along the Cameo, as described in paragraph 3, and at the point of entry into the wall of the reservoir being formed, they are fixed to the adventitia. Stents are placed in the ureters, the reservoir is drained with a cystostomy tube. The intestinal flap is folded and closed with a continuous 3-0 synthetic absorbable suture.

This method can be used for cystoplasty. The affected part of the bladder is resected. The caudal edge of the W-shaped segment is not sutured, but connected to the rest of the bladder.

FORMATION OF THE URINARY BLADDER FROM W-SHAPED ILE-INTESTINAL SEGMENT BY MECHANICAL SUTURE (Monti operation)

Fig.5. Allocate the ileo-intestinal segment 50 cm long

SEMI RESERVOIR COCK FOR BLADDER REPLACEMENT

Fig.6. The opened intestinal segment is folded and sutured with a continuous suture

The free edge of the opened part is folded, forming the ventral wall of the reservoir, and hermetically sutured in an oblique direction. The corners of the reservoir are pushed down between the sheets of the mesentery, while the back surface of the reservoir is moved forward. The base of the reservoir is sutured to the urethra as described on p. 792. A new bladder is fixed on both sides to the muscles that lift the anus. A Foley catheter is passed through the urethra and sutured to the skin along with ureteral stents.

ILE-INTESTINAL S-SHAPED RESERVOIR (Zingg operation)

Rice. 7. A segment of the ileum 60 cm long is isolated and dissected along the distal 36 cm

URINARY BLADDER FROM THE TRANSVERSELY FOLDED ILE-INTESTINAL SEGMENT (Studer's operation)

Fig.8. 15 cm away from the ileocecal valve, the end of the isolated intestinal segment is sutured with continuous serous-muscular sutures

Before suturing the free edges of the opened segment, ureteral catheters are installed in the adductor ileum, the ends of which are led out through the reservoir wall. The most caudal part of the reservoir is determined by palpation and a hole is made in this place, to which the urethra is sutured with 6 sutures with a synthetic absorbable thread 2-0. The sutures are tied after passing the 18F catheter through the urethra. The reservoir is drained with a 12F cystostomy tube, which is withdrawn along with the ureteral stents through the reservoir wall.

With the reservoir in place, an isoperistaltic afferent knee is formed to prevent reflux of urine from the reservoir into the ureters. The ileum is dissected at the level of the pre-cut ureters - 18-20 cm above the ileo-intestinal reservoir. The ureters are cut obliquely, dissected along and anastomose end to side with the proximal unopened part of the ileo-intestinal segment. Stents located inside the segment are passed into the ureters. Restore intestinal continuity. The stents are removed through the anterior abdominal wall, and vacuum drains are placed in the small pelvis. Stents are removed after 7-10 days, cystostomy drainage - after 10-12 days, if there are no contrast agent streaks on radiography of the reservoir. The urethral catheter is removed on the 14th day after the operation.

URINARY BLADDER FROM W-SHAPED ILE-INTESTINAL SEGMENT (Goney operation)

Fig.9. A segment of the ileum 40 cm long is isolated, it is opened along the anti-breech edge

REPEATED IMPLEMENTATION OF THE URETRORESERVOIR ANASTOMOUS WITH ITS STRICTURE

If a retropubic anastomosis is not possible, the stricture area is exposed by a perineal approach to expose the end of the urethra for a sufficient length. Due to the high likelihood of postoperative urinary incontinence, an artificial sphincter is implanted.

POSTOPERATIVE COMPLICATIONS

With stenosis of the urethroileoanastomosis, bougienage is indicated. A fistula at the urethral anastomosis with a urethral catheter may close spontaneously, but sometimes surgical correction is required.

With wound infection and abscesses of the small pelvis, it may be necessary to drain the abscess. Bacteremia, septicemia, and septic shock are usually due to displacement of the ureteral catheters - in these cases, percutaneous puncture nephrostomy is indicated. Urinary incontinence is more likely with damage to the neurovascular bundles during cystectomy and is especially pronounced against the background of increased intestinal peristalsis. Urinary retention is a more common complication than urinary incontinence and occurs in approximately 70% of patients. It can occur late after surgery - in such cases, lifelong bladder catheterization is indicated.

Use of an isolated segment of the intestine to replace the bladder or increase its capacity. The experience of recent years allows us to speak in favor of colonic plasty (sigmoplasty). The large intestine, according to its anatomical and functional features, is more suitable as a reservoir for urine than the small intestine.

Indications. Need complete bladder replacement with, an increase in its capacity with a wrinkled bladder, most often on the basis of a tuberculous lesion.

Contraindications. Significant dilatation of the upper urinary tract, active pyelonephritis, late stages (III and IV) of chronic renal failure.

Preoperative preparation consists in bowel preparation (within 1 week diet with limited fiber, siphon enemas, enteroseptol 0.5 g 3-4 times a day, chloramphenicol 0.5 g 4 times a day), antibiotic therapy for urinary infection.

Execution technique. With partial replacement of the bladder, various options are used. intestinal plasty depending on its goals, the size of the remaining part of the bladder and the individual experience of the surgeon (annular, U-shaped, vertical, planar, open loop, "cap", etc.). Under endotracheal anesthesia, the abdominal cavity is opened. The loop of the sigmoid colon to be resected should be sufficiently mobile, and the length of its mesentery should ensure free movement of the loop into the small pelvis. According to the generally accepted technique, a bowel loop about 8-12 cm long is resected, depending on the size of the alleged bladder defect. Too long grafts are poorly emptied and require further surgical correction. Intestinal patency is restored in the usual way. The intestinal lumen before its closure is abundantly irrigated with vaseline oil, which prevents coprostasis in the postoperative period. The transplant lumen is treated with a weak disinfectant solution and dried. With a shrunken bladder and vesicoureteral reflux, a prerequisite for a successful outcome of the operation is transplantation of the ureter into an intestinal graft, which helps to eliminate reflux. The ureters, after isolation and transection in the pelvic region, are transplanted into the intestinal graft using the antireflux technique (see). The bladder after extraperitonization is opened over a previously introduced metal bougie and resected, depending on the indications. The rest of the bladder is taken on holders, which help to properly adapt the intestinal graft to it. Anastomosis of the intestine with the bladder is performed with catgut or chrome-catgut sutures with knots tied outside the bladder lumen. Drainage tubes from the ureter and bladder are removed with the help of a bougie through the urethra to the outside. The anastomosis site is covered with the parietal peritoneum. The abdominal cavity is washed with a solution of antibiotics and sutured tightly. With complete replacement of the bladder with an intestinal graft, the abdominal cavity is then opened, a segment of the intestine is resected (most appropriately, the sigmoid colon 20-25 cm long). The central end of the intestinal segment is sutured tightly, and the peripheral end (after implantation of the ureters into the intestinal reservoir) is connected to the urethra. Drainage tubes from the ureters and from the artificial bladder are brought out through the urethra.

In the postoperative period, the condition of the drainage tubes, which are systematically washed with an antibiotic solution, and the activity of the intestines are carefully monitored. Drainage tubes from the ureter are removed on the 12th day, from the bladder - on the 12-14th day. The bladder after the operation is systematically washed with alkaline solutions to remove mucus, which is initially released in copious amounts. In the future, as the intestinal graft adapts to a new function, the amount of mucus decreases significantly.

Complications. Peritonitis, intestinal obstruction, electrolyte imbalance, acute pyelonephritis. Their frequency depends on the correct determination of indications and contraindications, the experience of the surgeon in performing such operations and the thoroughness of postoperative management.

Bladder plastic. This term refers to plastic surgery performed with various anomalies of its development. For example, partial or complete replacement of an organ with a segment of the large or small intestine.

Bladder plastic surgery

How is bladder plastic surgery performed?

Particularly often, plastic surgery is performed with exstrophy of the bladder - a very serious disease that combines a number of defects in the bladder, urethra, abdominal wall and genital organs. The anterior wall of the bladder and the corresponding part of the abdominal cavity are practically absent, which is why the bladder is actually outside.

Plastic surgery for exstrophy is carried out as early as possible - 3-5 days after the birth of the child. Depending on the case, it includes a number of operations, such as:

• primary plasty - elimination of a defect in the anterior wall of the bladder, its placement inside the pelvis and modeling;
• elimination of abdominal wall defect;
• reduction of the pubic bones, which improves urinary retention;
• the formation of the neck of the bladder and sphincter to achieve control over urination;
• ureteral transplant to prevent reflux of urine into the kidneys.

Fortunately, such a disease as exstrophy of the bladder is quite rare.

Bladder plastic surgery for cancer

How is an artificial bladder created with the help of plastic surgery?

Another case of bladder plastic surgery is reconstruction after cystectomy (removal of the bladder). The main reason for this operation is cancer. When removing the bladder and adjacent tissues, through plastic surgery, they achieve different ways of diverting urine. We list some of them:

From a small section of the small intestine, a tube is formed that connects the ureter to the surface of the skin of the abdominal wall. A special urinal is attached near the hole.

From various parts of the gastrointestinal tract (small and large intestines, stomach, rectum) a reservoir is formed for the accumulation of urine, connected to an opening in the anterior abdominal wall. The patient empties the reservoir on his own, i.e. he has the ability to control urination (autocatheterization)

Creation of an artificial bladder in plastic surgery. A section of the small intestine is connected to the ureters and urethra, which is possible only if they have not been damaged and removed. The method allows you to make the act of urination as natural as possible.

Thus, plastic surgery performed on the bladder plays an important role in improving the quality of life of the patient. Its goal is to facilitate and take control of the process of urination as much as possible, thereby giving the patient the opportunity to live a full life.

Bladder plastic surgery is a forced surgical intervention, during which either the whole organ or part of it is completely replaced.

Such an operation is performed only for special indications, when anomalies of the bladder do not allow the organ to perform all the necessary functions.

The bladder is a muscular hollow organ whose functions are to collect, store and excrete urine through the urinary ducts.

The organs of the urinary system

It is located in the small pelvis. The configuration of the bladder is completely different, depending on the degree of its filling with urine, as well as on the adjacent internal organs.

It consists of the top, body, bottom and neck, which gradually narrows and smoothly passes into the urethra.

The upper part is covered with peritoneum, which forms a kind of notch: in males it is rectal-vesical, and in females it is vesico-uterine.

In the absence of urine in the body, the mucous membrane is collected in a kind of folds.

The sphincter of the bladder provides control of urinary retention, it is located at the junction of the bladder and the urethra.

The bladder in a healthy person allows you to collect from 200 to 400 ml of urinary fluid.

The temperature of the external environment and its humidity can affect the amount of urine excreted.

The excretion of accumulated urine occurs when the bladder contracts.

However, when pathologies occur, the mechanism for performing the basic functions of the bladder is seriously impaired. This forces doctors to decide on plastic surgery.

The reasons

The need for plastic surgery of the bladder arises in cases where the organ has ceased to perform the functions intended for it by nature, and medicine is powerless to restore them.

Most often, such anomalies affect the mucous membrane of the bladder, its walls, as well as the neck of the urethra.

There are several diseases that can cause such pathologies, among which the most common are bladder cancer and exstrophy.

The main cause of cancerous organ damage is bad habits, as well as some chemical compounds.

Pathology of the bladder

The detected tumors, which are small in size, allow sparing operations to truncate them.

Unfortunately, large tumors do not allow you to leave the bladder, doctors have to decide on its complete removal.

Accordingly, after such a procedure, it is important to perform a replacement bladder plastic surgery, which makes it possible to ensure the functioning of the urinary system in the future.

Exstrophy is detected in the newborn immediately.

Such a pathology is not subject to treatment at all, the only possibility for the baby is to undergo a surgical intervention involving plastic surgery, during which the surgeon forms an artificial bladder capable of performing its intended functions without obstacles.

Technique

Exstrophy, which is a serious pathology that simultaneously combines anomalies in the development of the bladder, urethra, abdominal wall and genital organs, is subject to immediate plastic surgery.

Newborn treatment

This is also explained by the fact that most of the urinary organ has not formed, is missing.

A newborn undergoes bladder plastic surgery approximately 3-5 days after birth, because a child simply cannot live with such an anomaly.

Such a surgical intervention involves a phased plastic surgery. Initially, the bladder is placed inside the pelvis, then it is modeled, eliminating anomalies of the anterior and abdominal walls.

To ensure further normal retention of urine, the pubic bones are surgically reduced. They form the neck of the bladder and the sphincter, thanks to which it is possible to directly control the process of urination.

In conclusion, a ureteral transplant is mandatory to prevent reflux, when urine is thrown back into the kidneys. The operation is quite complicated, the only consolation is that the pathology belongs to the category of rare ones.

Bladder plastic surgery

Plastic surgery is also necessary in the case when the patient underwent a cystectomy upon detection of a cancerous disease. After complete removal of the bladder, a replacement organ can be created from part of the small intestine.

An artificial reservoir for collecting urine can be formed not only from the intestine, but in a complex from the stomach, rectum, small and large intestines.

As a result of such plastics, the patient has the opportunity to control urination independently.

Also, plastic surgery allows to ensure the most natural process of urination, during which a section of the small intestine is brought to the ureter and urethra, successfully connecting them.

Postoperative Recovery

For several days, the patient is forbidden to eat to ensure a good flushing (disinfection) of all urinary organs.

Postoperative recovery

To maintain physical strength, intravenous nutrition is carried out. The postoperative period after plastic surgery lasts about two weeks, after which the drains, installed catheters are removed, and the sutures are removed.

It is from this moment that it is allowed to return to natural nutrition and physiological urination.

Unfortunately, the urination process itself is somewhat different from the physiological one. In a healthy bladder, the output of urine to the outside is carried out by muscle contractions of the bladder.

After plastic surgery, the patient will have to push and press on the abdominal part of the abdomen, under the influence of which urine will be released, and the artificial reservoir will be emptied.

To prevent infection of the urinary system, it is important to empty every three hours immediately after plastic surgery, and after six months - every 4-6 hours.

There are no natural urges, therefore, if such requirements are not observed, excessive accumulation of urine can occur, leading in many cases to rupture.

Urine after plastic surgery becomes cloudy because the intestines from which the reservoir was created continue to secrete mucus.

The blockage of the urinary ducts with this mucus can become a danger, so the patient is recommended to take lingonberry juice twice a day. Another important recommendation is to drink plenty of water.