Treatment megouretera

Megaureter treatment always involves an operative intervention (with the exception of vesicular-dependent variants of the disease). In cases where a megaureter is a consequence of a ureterocele, an occlusive stone of the distal ureter or some other obstruction to urinary outflow, surgical treatment of the mega -ureter should be aimed at its elimination and, if necessary, combined with correction of the ureter and antireflux plasty of the mouth.

Groups of operative treatment megaureter depending on access to the zone of the bladder-ureter sphincter:

• intravascular;
• extravesical;
• combined.

Cohen's operation (1975) found the greatest popularity among the intravesical methods of reimplantation of the ureter. Operation Barry is the most successful variant of extravesical ureterocystoanastomosis. Among the methods of uretero-cystoanastomosis from the combined access, the most active is the operation of the Politano-Lidbetter.

Modeling of the ureter

More broad coverage in this article deserves such a feature of ureterocystoanastomosis, as modeling. It is quite obvious that with a pronounced expansion of the VMP with a mega -ureater it is not enough just to restructure the evacuation of urine. In these conditions, it is necessary to reduce the diameter of the enlarged ureter, that is, to perform its "training". Among the ways of "training" the ureter, the methods of Kalitsinsky, Matisse, Hodson and Hendren, Lopatkin-Pugachev have found application. Lopatkina-Lopatkina.

After excision of the ureter from the bladder, it is emptied, which leads to a partial reduction.

Sharp and blunt way to perform a gradual expansion of the folds and the advance of the ureter towards the kidney. In most cases, the megoureter is buried with embryonic connective tissue membranes ("spikes"), which serve as a fixing mechanism of ureteral flexures. The dissection of these "adhesions" makes it possible to straighten the ureter, which, as a rule, is greatly elongated. This "undressing" does not violate its blood supply and innervation, which is confirmed by data from follow-up examinations of operated patients with normal contractile activity of the ureter (the presence of cystoids on excretory urograms).

The next stage of modeling is transverse resection of the ureter in order to provide the necessary length for proper application of ureterocysto-anastomosis. The resected tissue of the ureter wall is referred for histological examination, which is essential in determining the timing of postoperative splitting of the anastomosis and the prognosis of restoring the contractility.

At the next stage of operative treatment of megaureter perform a longitudinal oblique resection of the distal part of the ureter. Depending on the age of the patient, the length of longitudinal resection may vary, but, as a rule, it corresponds to the lower third. ON. Lopatkin produces a duplicate ureter, and not his resection for the purpose of the least trauma of the ureter and the greatest preservation of its neuromuscular elements. When performing dally, it is recommended to use nodal seams, and ureterocystoanastomosis should be applied according to the principle of "inkwell-non-spillage".

Suture of the ureter along the side wall is carried out using a resorbable suture material in a continuous manner. Enlightenment of the ureter after modeling should ensure unimpeded passage of urine in conditions of reduced evacuation function, and its diameter should correspond to the size of the antireflux tunnel of the bladder wall. The further course of operative treatment of a megaureter does not differ from that in the standard procedure of ureterocystoanastomosis. Immediately before the anastomosis is applied, the ureter is splinted by an intubating drainage tube of the required diameter (10-12 SN). Depending on the severity of sclerotic changes in the wall, which is determined by histological examination, ureteral lining is performed for 7 to 14 days.

As a rule, histological examination reveals a sharp decrease in nerve and elastic fibers. Severe sclerosis of the muscular layer with almost complete atrophy of muscle beams, fibrosis under the mucous layer. Segmentary ureteritis.

The effectiveness of ureterocystoanastomosis with a mega -ureter, depending on the method of operation, is 93-99%.

With a very pronounced decrease in the secretory capacity of the kidney (insufficiency of secretion with dynamic nephroscintigraphy more than 95%) perform nephroureterectomy.

With immediate threat to the life of the patient due to renal failure or purulent-septic complications with a mega -ureter, a "saving" ureterocutaneoneostomy (hanging, T-shaped, terminal) is performed, which allows the patient to be withdrawn from a severe condition. Later, after eliminating the main reason for the development of the megaureter, the ureterocutaneostomy is closed.

An alternative way to derive urine from VMP is percutaneous puncture nephrostomy, which is considered less traumatic than ureterocutaneostomy. In the future, you do not need to perform a re-operative treatment of a megaureter to close the ureterocutaneumostomy.

Treatment megouradera: minimally invasive methods

Recently, more and more actively introducing various minimally invasive methods of treatment megaureters:

• endoscopic dissection; 
• bougie; 
• balloon dilatation; 
• stenting PMS in obstructive megaureter;
• endoscopic introduction of volume-forming substances in the ureteral cavity with a refractive megaureter.

However, the lack of data on the long-term consequences of minimally invasive megourarea treatment methods determines the limited application of these methods. The main application of minimally invasive methods is in weakened patients; in the presence of severe concomitant disease and with other contraindications to the generally accepted open methods of operative treatment of a megaureter.

Thus, operative treatment of a megaureter in neuro-muscular dysplasia of the ureter is aimed at restoring passage of the urine of the mZ pelvis along the ureter into the bladder, reducing the length and diameter without disturbing the integrity of its neuromuscular apparatus and eliminating PMR. More than 200 correction methods for its dysplasia have been proposed. The choice of the method and method of surgical intervention is determined by the nature and degree of clinical manifestation of the disease, the presence of complications, the general condition of the patient.

Conservative treatment megaureter is unpromising. It can be used in the preoperative period, since with the most careful selection of antibacterial agents it is possible to achieve remission of pyelonephritis for several weeks and very rarely for several months.

However, when establishing the normal function of the kidney (radioisotope methods of research), it is advisable to temporarily abandon the operative treatment of the megaureter, since differential diagnosis between neuromuscular dysplasia of the ureter, functional obstruction, disproportion of its growth in infants is extremely difficult.

When ascertaining the loss of kidney function, operative treatment of the megaureter is shown.

Palliative surgery (nephro-, pyelo-, uretero- and epicystostomy) is ineffective. Radical methods of treatment of neuromuscular dysplasia of ureters are shown. The best results are obtained in patients operated in the 1 st and 2 nd stages of the disease. The majority of patients are referred to the clinic for urological examination and treatment in the III or II stage of the disease. In the third stage, indications for surgery are relative, since at this time the process in the kidney and ureter is practically irreversible. Consequently, the effectiveness of treatment with a megalocera- tor can be increased, primarily by improving the diagnosis of this developmental defect, that is, the wider introduction of uro-radiological methods of examination into the practice of somatic children's hospitals and polyclinics.

Operative treatment megaureter is shown at any age after diagnosis and preoperative preparation for general requirements. The waiting tactics for this disease are unjustified. Plastic operations give the best result, the earlier they were produced.

Nephroureterectomy is used only for irreversible destructive changes in the kidney, a sharp decrease in its function and the presence of a healthy contralateral kidney.

AND I. Pytel, A.G. Pugachev (1977) believe that the main tasks of reconstructive and plastic surgery for neuromuscular dysplasia of the ureter are excision of the site that creates an obstacle, modeling the diameter to normal caliber, neoimplantation into the bladder, and antireflux surgery.

Experience shows that with a simple reimplantation of the ureter, it is not possible to create a satisfactorily functioning opening, since with the resection of the distal part, the entire complex antiphluxe mechanism is damaged. Operative treatment megaureter should be aimed at normalization of urodynamics and elimination of MTCT. Direct or indirect ureterocystoneostomy without antireflux correction in most patients is complicated by TMR, which promotes the profession of irreversible destructive processes in the renal parenchyma. Antireflux surgery can be successful provided a long submucosal canal is created. The diameter of the re-implanted ureter should be close to normal. Therefore, when reconstructing the ureter, it is not enough to resect an excess length along the length.

Operations with megureter

Operation by Bischoff

Mobilize the corresponding half of the bladder and the pelvic part of the ureter. The ureter is dissected, keeping the pelvic part of the department. The enlarged part of the distal part is resected. The remainder of the tube is formed and stitched together with the remaining section of the intra-wall section of the ureter. In the case of bilateral anomalies, surgical treatment of the megaureter is performed on both sides.

J. Williams, after resection of the megalocerera, implants the ureter into the wall of the bladder in an oblique direction, creating a "cuff" from the wall.

Operation by V. Gregor

Conduct the lower pararectal incision. Peritoneal bag bluntly exfoliate and divert in the opposite direction. The ureter is exposed and isolated extraperitoneally from the opening in the bladder. Then the posterior wall of the bladder is separated and dissected to the mucous membrane from the place of the ureteral confluence towards the apex at a distance of 3 cm. The ureter is placed in the wound, and the knotted sutures are sewn over the wall of the bladder. The wound is sewed tight.

V. Politano, V. Lidbetter reimplanted ureter first for 1-2 cm is carried out under the mucous membrane of the bladder and only then removed to the surface and fixed.

Some authors exclude narrowing of the ureter's orifice and its end is sutured in the formed opening of the wall of the bladder.

Operation on NA. Lopatkin-A.Yu. Svidleru

After the formation of the urine by the method of M. Bishov, he is immersed under the serous membrane of the descending part of the large intestine, that is, they perform ureteroenteropexy. According to the authors, the ureter is well "implanted" in the surrounding tissue, and between the intestine and the ureter forms a vascular network that provides additional blood supply. The disadvantage of this treatment megaureter is the ability to perform it only on the left side. On the right, the immersion can only be anti-peristaltic, which violates the passage of urine. In addition, this operation does not allow to eliminate the expansion of the lower cystoid ureter. A significant drawback of this method is the need for complete mobilization of the lower cystoid, which leads to complete avascularization and denervation.

Given these shortcomings, N.A. Lopatkin, L.N. Lopatkina (1978) developed a new technique for surgical treatment of a megaureter, consisting in the formation of an intramural valve while maintaining vascularization and innervation of the ureter, its muscular layer, and in narrowing the enlightenment of the enlarged part to the slit-like through duplication.

Operation on. Lopatkin-LN. Lopatkina

Conduct an arcuate incision in the inguinal region. The upper angle of the cut can reach the edge arch. Mobilize the enlarged part of the ureter. A special feature of this stage is an extremely careful attitude towards the vessels of the ureter. The most affected area, which has lost its contractility (usually the lower cystoid), is not resected along the boundary of the interstitial narrowing, but is receding 1 cm, i.e., along the lower cystoid. Form the duplicate ureter during the remaining expanded cystoids (with full preservation of its vessels) on the tire with a continuous seam chrome catgut, starting from intercystoid narrowing. The seams should be close together. A feature of ureterocystoanastomosis is the formation of an antireflux roller from the flap of the lower cystoid (in front of its opening).

The opening resembles a snail-like formation. Thus, duplication of the ureter narrows the ectopic lumen, and the formed blind channel serves as an anatomical valve: at the time of urination or with increasing intravesical pressure, the urine stream rushes to the ureter and fills both channels. Blind canal, overflowing with urine, with its walls comes into contact with the through and covers the current of urine from the bladder to the pelvis.

Operative treatment megaureter, proposed by NA. Lopatkin and LN Lopatkina (1978), qualitatively differs from the interventions based on resection of the ureter across the width. The authors achieve narrowing of the lumen of the ureter not by cutting out strips of this or that width from it, but by creating a duplicate. This technique has several advantages. Resection by width over a considerable length disrupts the blood supply to the abnormal ureter. When scarring a long wound surface, the ureter turns into a rigid tube with severely impaired contractility. The formation of the duplication does not disturb its blood supply, and due to the "doubling" of the wall the peristaltic activity of the ureter is slightly increased. With neoimplantation, the "doubled" wall, forming a roller around the artificial hole, prevents reflux.

A.V. Lyulko (1981) performs this operation as follows. With a key-shaped incision, the ureter is exposed extraperitoneally and mobilizes it throughout the enlarged part. Then, retreating 2 cm from the wall of the bladder, the lower cystoid is resected and the distal end of it through the opening is invaginated into the bladder. During the remaining expanded cystoids of the central segment of the ureter with preservation of its mesentery and vessels form a duplication by imposing on the tire a continuous catgut suture. After that, the central end with a specially created clamp is carried into the bladder through the invaginated distal end. Both ends are sewn with knotty catgut sutures. If the distal end of the invaginated ureter is very narrow and an end is not possible, it is dissected along the length and additionally with separate catgut sutures fixed to the duplication.

A.V. Lyulko, Т.А. Chernenko (1981) carried out experimental studies. Which showed that the formed "papilla" does not atrophy, but flattenes and becomes covered with the epithelium of the bladder. Even with the creation of a high intravesical pressure, the formed anastomosis in most cases prevents the onset of MTCT.

It is extremely difficult to draw up a treatment plan for patients with bilateral neuromuscular dysplasia of the ureter in stage III of the disease with symptoms of CRF. In such patients, surgical treatment can be performed in two stages. Initially impose nephrostomy. And subsequently perform a radical surgery on the distal departments. In recent years, such tactics have been abandoned. First, intensive detoxication therapy, antibacterial treatment, a regime of forced frequent urination.

After some improvement in the condition, a decrease in the activity of the symptoms of pyelonephritis is followed by a radical operation followed by a longer drainage of the operated ureter and bladder. In these patients, one-step operation is effective from two sides, since in the postoperative period the risk of exacerbation of pyelonephritis or development of purulent forms in the kidney drained by the unoperated ureter is very high. In those cases when the patient's condition does not allow performing a corrective operation at the same time from both sides, a nephrostomy is applied on the second side.

Surgery for neuromuscular dysplasia of ureters should be considered as one stage in complex therapy. Before and after surgery, patients should be prescribed anti-inflammatory drugs strictly under the control of antibioticograms. To children of younger age (up to 3 years) and older with clinical manifestations of chronic renal failure in the immediate postoperative period, in addition to intensive antibacterial treatment, infusion therapy is indicated for 5-7 days. Control and correction of electrolyte composition of blood plasma, normalization of acid-base state are necessary. Showing blood transfusion fractional doses depending on the age of the child with an interval of 2-3 days, vitamin therapy. For the purpose of faster sanitation of the hospital, it is necessary to wash the drainage tubes inserted into the ureters and the bladder, a solution of dimethylsulfoxide or other antiseptics.

After discharge from the hospital, patients should be under the supervision of a urologist, and patients of child age - under the supervision of a pediatrician. Every 10-14 days continuously for 10-12 months, it is necessary to perform antibacterial treatment with a change of drugs, preferably based on the data of bacteriological analysis of urine and antibioticograms. It is advisable to combine oral administration of antibacterial agents with their local application by iontophoresis (iontophoresis of antiseptics, potassium iodide, neostigmine methylsulfate, strychnine, inductotherm, electrostimulation). The appointment of hyaluronidase, pyrimidine bases, aloe and other biogenic stimulants in the postoperative period helps to improve the blood supply of the operated ureter, reduce sclerosis and enhance the repair processes in the urinary tract wall and surrounding tissues.

Further management

Clinical follow-up of patients who have undergone surgical treatment of a mega -ureter should be performed by a urologist and a nephrologist, and pediatric patients for pediatric patients. The good passability of PMS and the absence of exacerbations of pyelonephritis for 5 years allow the child to be taken into account.

Forecast

The postoperative prognosis for a mega -ureter largely depends on the preservation of kidney function.