Method for surgical treatment of recurrent strictures of pyeloureteral junction

Abstract

FIELD: medicine.SUBSTANCE: invention relates to operative urology, namely to surgical treatment of recurrent strictures of the pyeloureteral junction (PUJ) affecting the PUJ and ureter, when resection of the narrowed PUJ segment and performing an anastomosis of the renal pelvis with the ureter is impossible. The scarred narrowed segment of the ureterocalycopyeloanastomosis is isolated. Resection of the altered part of the ureter and the kidney parenchyma above the dilated lower calyx is performed. The posterior edges of the ureter and the lower calyx are connected with three interrupted sutures without tension, a stent is placed antegradely. A buccal mucosal graft is placed on the anterior part of the anastomosis.EFFECT: possibility to perform resection of the narrowed part of the ureter and restore patency of the upper urinary tract, form a wide lumen of the anastomosis between the lower calyx and the ureter by augmenting it with a buccal graft, which provides optimal urine outflow from the kidney, minimise the percentage of recurrence.1 cl, 3 dwg, 1 ex

Description

[0001] The invention relates to the field of medicine, in particular to urology, namely the surgical treatment of recurrent strictures of the pyeloureteral segment (hereinafter PUS), affecting the PUS and the ureter, when it is impossible to resect the narrowed section of the PUS and perform anastomosis of the renal pelvis with the ureter.

[0002] A method for surgical treatment of short strictures of the UUS is known, where retrograde endoureterotomy and endopyelotomy are performed for stenosis of the ureter and UUS [Martov A.G., Kornienko S.I. Minimally invasive method for treating strictures of the upper urinary tract. / / Kuban Scientific Medical Bulletin. 2020. Vol. 122, No. 8. Pp. 126-133].

[0003] A disadvantage of this method is that retrograde and antegrade endopyelotomy make it impossible to control the location of the inferior polar renal vessels, which increases the risk of injury. Furthermore, in cases of extensive stenosis or obliteration of the ureteral ureteral junction, endoscopic surgery is not possible. Also, in rare cases, resection of an extended ureteral stricture and the creation of a repeat pyeloureteral anastomosis are impossible. In such cases, anastomosis between the ureter and the inferior calyx may be the treatment of choice.

[0004] Plastic methods are known that use various sections of the gastrointestinal tract during the intervention (plastic surgery with the small and large intestines, appendix), synthetic and allogenic materials [Komyakov B.K., Guliev B.G. Surgery of extended ureteral stenosis. - St. Petersburg: Dialect Publishing House, 2005. - 256.: ill.].

[0005] Small bowel segment plasty requires bowel resection and ureteral anastomosis, which can lead to anastomotic leakage, intestinal obstruction, and mucus formation. Furthermore, it is difficult to restore patency to a short, smaller-diameter ureter with a wide-diameter intestinal tube. An appendix is ​​not always present due to its absence due to a previous appendectomy, and with strictures of the left ureter, it cannot be straightened. Synthetic materials are poorly accepted, and obstruction due to stone formation is possible.

[0006] The closest to the claimed method is the surgical treatment of recurrent strictures of the lower ureteral calyx, when the ureter is cut off from the obliterated lower ureteral calyx, a resection of a portion of the parenchyma above the expanded lower calyx is performed, and an anastomosis is performed between the ureter and the lower calyx using interrupted sutures [NEU WIRT K. Implantation of the ureter into the lower calyx of the lower pelvis. UrolCutaneousRev. 1948 Jun; 52(6): 351].

[0007] The disadvantages of the method chosen as a prototype are as follows: In case of recurrent strictures of the PUS, due to the pronounced cicatricial process, the mobilization of this narrowed area is sharply hindered, which leads to an even greater deterioration of the vascularization of the ureter and an increased risk of anastomotic failure with the lower calyx and subsequent recurrence of the stricture.

[0008] Due to the pronounced cicatricial process in the area of ​​the stricture of the UUS and around the kidney, the length of the narrowing, it is not always possible to perform a hermetic anastomosis of the ureter with the lower calyx without tension.

[0009] The objective of the invention is to increase the efficiency of the operation.

[0010] The technical result of the stated task is achieved by the fact that in the method of surgical treatment of recurrent strictures of the PUS, which consists in isolating the cicatricially altered narrowed section of the ureterocalicopyeloanastomosis, resecting the altered part of the ureter and the renal parenchyma above the expanded lower calyx, connecting the posterior edges of the ureter and the lower calyx with three interrupted sutures without tension, installing a stent antegradely, and applying a graft from the buccal mucosa to the anterior part of the anastomosis.

[0011] Resection of an extended ureteral stricture and renal parenchyma above the lower calyx, connection of the healthy posterior edges of the ureter and the lower calyx, followed by closure of the anastomotic defect along the anterior surface with a graft from the buccal mucosa ensures adequate patency of urine from the kidney.

[0012] Only by connecting the posterior healthy edges of the ureter and the lower cup and closing the anterior defect with a buccal graft can a wide anastomosis be created and the patency of the ureter be restored.

[0013] The posterior edges of the ureter and the inferior calyx are connected with three interrupted sutures—this is sufficient to securely connect the posterior edges of the inferior calyx and the ureter. Interrupted sutures are less traumatic and less disruptive to the blood supply in the anastomotic area than continuous sutures. Furthermore, continuous sutures are uneven and corrugate the anastomotic wall.

[0014] The proximal end of the ureter is mobilized to allow for a tension-free anastomosis. Parenchyma must be resected above the inferior calyx to expose and isolate the inferior calyx wall, which will subsequently be anastomosed to the ureter. Otherwise, anastomosis to the inferior calyx is impossible, as it is located within the parenchyma.

[0015] The stent is placed antegrade (i.e., from top to bottom) before suturing the buccal graft, as this allows for secure and safe placement and adequate drainage of the upper urinary tract. Inserting the stent from below can lead to perforation in the anastomosis and stent displacement in the perirenal area.

[0016] The method is performed as follows. Laparoscopy is performed under general anesthesia, the colon is mobilized and retracted medially. Next, the scarred, narrowed portion of the ureterocalicopyeloanastomosis is isolated from the scar tissue (Fig. 1), the affected portion of the ureter and renal parenchyma above the dilated inferior calyx are resected, the posterior edges of the ureter and inferior calyx are connected with three interrupted tension-free sutures (Fig. 2), a stent is placed antegradely, and a buccal mucosa graft is applied to the anterior portion of the anastomosis (Fig. 3).

[0017] Example. Patient K., 54 years old, was admitted to the Mariinsky Hospital in St. Petersburg on April 12, 2023, complaining of pain in the left side and a nephrostomy drainage on the left. The patient's medical history reveals a history of repeated left kidney surgeries for stones, which resulted in obliteration of the left pyeloureteral segment. A ureterocalycostomosis was performed to restore upper urinary tract patency; however, it subsequently became obliterated. Due to obstructive pyelonephritis, a nephrostomy drainage was inserted percutaneously. Diagnosis upon admission: Recurrent extended stricture of the left ureterocalycostomosis. Left hydronephrosis. Nephrostomy inserted in 2023. Chronic pyelonephritis, latent phase.

[0018] On April 13, 2023, the surgery was performed using the proposed method. There were no early postoperative complications. The patient was discharged for outpatient treatment on the 7th day. Two months later, the ureteral stent was removed, and a diagnostic left ureteroscopy was performed, which revealed good patency of the entire ureter, including the area of ​​ureterocalicostomy augmentation with a buccal graft. A left retrograde ureteropyelography was performed; the anastomoses are competent and there is no contrast leakage. Postoperatively, the nephrostomy drain was clamped for several days and then removed due to the absence of pain and fever, and dilation of the left renal pelvis-calyceal system according to ultrasound data. The patient has had no complaints for two years. Follow-up ultrasound of the kidneys and MSCT of the urinary system with contrast revealed no signs of stricture or hydronephrosis.

[0019] Advantages of the invention:

[0020] 1. Possibility of resection of the narrowed part of the ureter and restoration of patency of the upper urinary tract.

[0021] 2. Wide lumen of the anastomosis between the lower calyx and the ureter due to its augmentation with a buccal graft, which ensures optimal urine outflow from the kidney.

[0022] 3. Minimal relapse rate.

[0023] 4. High efficiency with minimal surgical trauma.

Claims

A method for surgical treatment of recurrent strictures of the pyeloureteral segment, which consists of isolating the cicatricially altered narrowed section of the ureterocalicopyeloanastomosis, resecting the altered portion of the ureter and renal parenchyma above the expanded lower calyx, characterized in that the posterior edges of the ureter and lower calyx are connected with three interrupted tension-free sutures, a stent is installed antegradely, and a graft of the buccal mucosa is applied to the anterior part of the anastomosis.

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