BLADDER

From Big Medical Encyclopedia

BLADDER [vesica urinaria (PNA, JNA, BNA)] — the hollow body serving as a tank for urine of the region inflows on ureters and is periodically removed through an urethra.

EMBRYOLOGY

Fig. 1. The scheme of development of a bladder and the next or related bodies (at various stages of an embryogenesis of the person): 1 — a foul place; 2 — a back gut; 3 — a pedicle of an allantois; 4 — a mezonefralny channel; 5 — an ureter; 6 — a cloacal membrane; 7 — a tail gut; 8 — a rectum; 9 — a pelvic part of an urinogenital sine; 10 — a fallichesky part of an urinogenital sine; 11 — an urinogenital sine; 12 — a bladder.

The m of the item develops from a ventral part of a foul place, edges during an embryogenesis turns into a bladder and an urinogenital sine. Originally uric, genital tract and a back gut open at the caudal end of a body of a germ in the general cavity — the foul place representing the cul-de-sac closed from the ventral party by a thin membrane (membrana cloacalis). Further a number of consistently happening changes (fig. 1) follows: at first there is frontally located partition (septum urorectale) between the end of a back gut and ventral department of a foul place, from to-rogo L. S. and an urinogenital sine (sinus urogenitalis) develops, then L. S. stands apart from an urinogenital sine and primary ureters falling into it — channels of an average kidney.

From the middle of the 2nd month (a germ 14,5 mm long) L. S. intensively grows in length, that zone considerably increases, edges separates from each other places of a confluence of ureters and channels of an average kidney. As a result of an opening of ureters openings of channels of an average kidney — caudally move kranialno, and; at a male germ the last become openings of ejaculatory channels (ductus ejaculatorius). In process of increase in the sizes of L. S. there is its isolation from an urethra (urethra). Originally laying of L. S. and an urethra is covered by a single-layer cylindrical epithelium. To the middle of the 2nd month in the direction of L. S. the epithelium becomes 2 — 3-layer, and in an urethra remains single-layer cylindrical; in the first half of the 3rd month (a germ 45 mm long) the epithelial vystilka of L. S. becomes 4 — 5-layer; to the middle of the 3rd month (length of a germ of 55 mm) L. S. begins to be covered by a transitional epithelium.

At an early stage (a germ 10 — 24 mm long) L. S. is located highly in an abdominal cavity, it kranialno the pointed protrusion reaches a navel and connects to a pedicle of an allantois; the internal opening of an urethra is located at the level of a pubic symphysis up to the birth, however in the pre-natal period of development kranialno the directed protrusion of L. S. is reduced, turning in uric channel (see), from to-rogo in the subsequent remains connective tissue tyazh in the thickness of a median umbilical fold (plica umbilicalis mediana).

Muscles of L. S. at first (age of 51 — 52 days, length of a germ of 22,5 mm) are more developed from its back wall, forming longwise the going bunches from a top to area of openings of ureters, the germ 26 mm long under an epithelial vystilka of L. S. has a layer of ring muscles (also earlier from a dorsal surface of L. S.). Much later the germ (age of 72 — 73 days, 55 mm of length) has an inner layer of longitudinal muscles therefore ring muscles are located between two layers of longitudinal muscles.

At a germ 80 mm long the 3-layer arrangement of muscles is broken and formed a uniform muscle of the intertwining spiral-shaped bunches of smooth muscles though from top to bottom from openings of ureters there is only a layer of ring muscles. The muscle sphincter (szhimatel) of a neck of a bladder (m. sphincter vesicae urinariae) at a germ 90 mm long is developed well.

The ANATOMY

is located with L. S. in a cavity of a small pelvis, directly behind a pubic symphysis (symphisis pubica), from to-rogo is separated by a layer of friable connecting fabric, pozadilobkovy space, pl Rettsius's (spatium retropubicum) space. In L. S. distinguish a bottom (fundus vesicae), a top (apex vesicae), a body (corpus vesicae) and a neck (cervix vesicae), edges, being narrowed, passes in urethra (see).

Fig. 2. The diagrammatic representation of bodies of a men's basin on a sagittal section (the relation of a peritoneum to a bladder): 1 — the left ureter (is cut off); 2 — a pozadipuzyrny fold; 3 — rectovesical deepening; 4 — a seed bubble; 5 — a prostate; 6 — an urethra; 7 — a small egg; 8 — a spongy body of a penis; 9 — a bulb of a penis; 10 — the sciatic and cavernous muscle (is crossed); 11 — a peritoneum; 12 — the bladder covered with a peritoneum.

The sizes, form of L. S., the relation to a peritoneum change depending on a degree of admission its urine, funkts, conditions of the bodies, next to it. Stretched by L. S. a front surface prilezhit to a pubic symphysis and a front abdominal wall. Acting over a pubic symphysis, L. S. displaces up the peritoneum passing to it from a front abdominal wall therefore it is possible to make a puncture of a wall of L. S. through a layer of an abdominal wall without getting into an abdominal cavity; from a back surface of L. S. the peritoneum at the man passes to a front surface of a rectum, forming rectovesical deepening (excavatio rectovesicalis) (fig. 2), and the woman — on a front surface has uterus, forming vesicouterine deepening (excavatio vesicouterina).

When L. S. does not contain urine and is reduced, it lies entirely on an urinogenital diaphragm, slightly towering over a pubic symphysis. At the filled bladder the top acts over a pubic symphysis on 5 cm and more; especially the vertical size of L. S. when the rectum is stretched increases.

At the emptied L. S. of a wall are thick, the mucous membrane is collected in folds, except for the triangular site in the field of a bottom — a vesical (lyetodiyev) triangle (trigonum vesicae) located between openings ureters (see) and urethra, where mucous membrane always smooth. At the man behind L. S. seed bubbles, an ampoule of deferent ducts and a rectum are located, from below to a neck of L. S. the prostate prilezhit. At the woman of L. S. is directly on an urinogenital diaphragm, kzad from it the uterus with an upper part of a vagina lies.

Except a serous cover (tunica serosa) with a subserosal basis (tela subserosa), covering body partially, the wall of L. S. consists of a muscular coat (tunica muscularis), a submucosa (tela submucosa) and a mucous membrane (tunica mucosa). In a muscular coat distinguish 3 mutually intertwining layers: outside, consisting of longitudinal fibers; average — from circular and internal — from longitudinal and cross. All three layers intertwine among themselves in the uniform muscle expelling urine (m. detrusor urinae), reduction a cut leads to removal of urine outside. The most developed interlayer in the field of an internal opening of an urethra (ostium urethrae int.) forms a muscle — a sphincter of a neck of a bladder (m. sphincter vesicae urinariae); also circular fibers covering openings of ureters are strengthened.

The inner surface of L. S. is covered with a mucous membrane, it from a laying at stretching of walls of L. S. disappear. In the bottom of L. S. the internal opening of an urethra, a kzada from it — a vesical triangle is located (lyetodiyev), the top to-rogo is directed down to an internal opening of an urethra, and on corners of its basis openings of ureters open, between to-rymi the interureteric fold (plica interureterica) limiting in front a pozadimochetochnikovy pole (fossa retroureterica) is allocated. Behind an internal opening of an urethra sometimes the average share of a prostate forms protrusion — the uvula of a bubble (uvula vesicae) which was more expressed at advanced age. The mucous membrane of L. S. of pinkish color, is covered with a transitional epithelium, contains small glands of a bubble (glandulae vesicales) and limf, follicles.

At newborn L. S. has veretenoobrazno the extended form, it is located much above therefore the internal opening of an urethra is at the level of the upper edge of a pubic symphysis. After the birth of L. S. begins to fall and on the 4th month of life

Blood supply === acts over the upper edge of a pubic symphysis approximately on 1 cm ===

Fig. 1. Vessels and nerves of a bladder; anterior aspect: a part of pubic bones is cut; the front wall of a bladder and an urethra is removed; on the right nerves of a bladder are removed, absorbent vessels and nodes are removed at the left.
Fig. 2. Sagittal cut of a men's basin: 1 — a ventral aorta; 2 — an upper hypogastric texture; 3 — the general ileal artery; 4 — the general ileal vein; 5 — an ureter; 6 — a yaichkovy artery, veins and a yaichkovy texture; 7 — a rectum; 8 — the lower hypogastric texture; 9 — an internal ileal artery; 10 — a deferent duct; 11 — an umbilical artery; 12 — an outside ileal artery; 13 — an upper vesical artery; 14 — an outside ileal vein; 15 — vesical neuroplex; 16 — a bladder; 17 — a vesical triangle; 18 — a prostate; 19 — a seed hillock; 20 — a spongy part of an urethra; 21 — a locking membrane; 22 — an interureteric fold; 23 — an opening of an ureter; 24 — a texture of circulatory and absorbent vessels in a wall of a bladder; 25 — internal ileal lymph nodes; 26 — the lower vesical artery and a vein; 27 — an internal opening of an urethra; 28 — a seed bubble; 29 — a prostatic utricle; 30 — a prostatic part of an urethra; 31 — a webby part of an urethra; 32 — a navicula of an urethra; 33 — a pubic symphysis; 34 — a median umbilical sheaf; 35 — an internal ileal vein.

M.'s walls and. are supplied with blood from the top and bottom vesical arteries anastomosing among themselves (aa. vesicales sup. et inf.), the first of to-rykh depart from the right and left umbilical arteries (aa. umbilicales dext, et sin.), the second — from branches of internal ileal arteries (aa. iliacae int.). The m of the item receives a number of branches also from internal sexual, locking, average pryamokishechny arteries (aa. pudenda int., obturatoria, rectalis med.). Veins allocate for L. S. blood a part in a vesical veniplex (plexus venosus vesicalis), a part in internal ileal veins (vv. iliacae int). Veins in front anastomose L. S. with a sexual veniplex, behind — with a veniplex of a rectum (tsvetn. fig. 1, 2). Arteries and veins of L. S. form the textures having a characteristic structure for each layer of body.

A lymph drainage

Limf, vessels of L. S. originate from networks limf, capillaries, creating subserous and submucosal textures, vessels to-rykh go in internal ileal limf. nodes (nodi lymphatici iliaci int.). At men limf, vessels of L. S. anastomose with limf, vessels of seed bubbles and a prostate and through them with limf, a bed of a rectum.

An innervation

Nerves approach L. S. from upper and the lower hypogastric textures (plexus hypogastrici sup. et inf.); efferent parasympathetic preganglionic fibers begin in side horns of the II—IV sacral segments of a spinal cord from where leave as a part of ventral roots of spinal nerves. Separating in the form of pelvic splanchnic nerves (nn. splanchnici pelvini), they enter okoloorganny nodes of L. S., from to-rykh postganglionic fibers to muscles of L. S depart. These fibers cause reduction of the muscle expelling urine and sphincteri incontinence of a bladder. Efferent sympathetic fibers originate from side horns of a lumbar part of a spinal cord. They leave as a part of ventral roots and separate from them in the form of white connecting branches (rr. communicantes albi), to-rye, without being interrupted in nodes of a sympathetic trunk, reach the lower mesenteric node; from here the postganglionic fibers of the last following as a part of hypogastric nerves begin (nn. hypogastrici) to smooth muscles of L. S. Sympathetic nerves cause relaxation of a detruzor and reduction of a sphincter of a bladder.

Afferent ways from L. S. pass in structure lower mesenteric, top and bottom hypogastric textures, and also pelvic splanchnic nerves (tsvetn. fig. 1, 2).

HISTOLOGY

Fig. 202. Scheme of a structure of a mucous membrane of a bladder: 1 — a transitional epithelium: and — a cover coat — intermediate and basal layers; 2 — a basal membrane; 3 — own plate of a mucous membrane with a capillary network.

In a wall of L. S. distinguish mucous (tunica mucosa), muscular (tunica muscularis) and adventitious (tunica adventitia) of a cover; upper and a part the back surface of L. S. is covered with a serous cover (tunica serosa).

The mucous membrane of L. S. consists of a transitional epithelium, own layer and a submucosa. The transitional epithelium has the covering, intermediate and basal layers. Large cells of a finishing coat are located, as a rule, in one-two rows, contain one or several kernels, are covered with a cuticle; in places of contact of these cells the network of the closing plates is defined. Cells of a medine have irregular shape and various sizes, to-rye, as well as quantity of rows, change depending on degree of stretching of a wall of L. S. Cells of a basal layer small, as a rule, a cubic form, are located in one-two rows. Dark and single scyphoid cells occur among epithelial cells. In nek-ry cases of a cell of a transitional epithelium of L. S. can cosecrete slime. In strongly stretched L. S. of a cell of a finishing coat get the flattened form, in moderately filled and fallen down L. S. the transitional epithelium gains external looking alike a multilayer flat epithelium.

Own layer of a mucous membrane of L. S. is formed by friable connecting fabric with a large amount of elastic fibers; in it accumulations of lymphocytes meet, solitary lymphoid follicles in places are visible. In own layer the dense network of circulatory capillaries is defined. In the field of a vesical triangle own layer quite often contains small branched glands, and also the accumulations of cells of a transitional epithelium carrying the name of epithelial nests of Brunn (see. Brunna epithelial nests ).

Own layer without sharp border passes into a submucosa, edges is formed by friable connecting fabric with a large number circulatory and limf, vessels. In the field of a vesical triangle connecting fabric of a submucosa differs in bigger density, than rather smooth inner surface of this site speaks.

The muscular coat has considerable thickness and forms the ground mass of a wall of L. S.; it consists of smooth muscular tissue, between bunches a cut layers of friable connecting fabric with circulatory and limf, vessels, nerve fibrils and nervous gangliya are located. Distinguish three layers of a muscular coat unsharply delimited from each other: internal and outside — with preferential longitudinal arrangement of muscle fibers and average — with their circular arrangement. The inner layer of a muscular coat is most expressed in the field of a vesical triangle.

The extima of L. S. is presented by a layer of fibrous connecting fabric, to-ry without sharp border passes into paravesical cellulose, and in the field of upper and a part of a back surface of L. S. — into a subserosal layer of connecting fabric.

The wall of L. S. contains numerous nerve fibrils and vegetative nervous a ganglion, the greatest number of the last find in the field of mouths of ureters. Thin branches and single nerve fibrils of own layer of a mucous membrane form epithelial neuroplex; sensitive nerve fibrils lose a myelin cover and terminate between epithelial cells in kolboobrazny expansions. Nerve fibrils and cells form textures also in a submucosa of a mucous membrane and between layers of a muscular coat. In a serous cover of M. and. educations like Fater's little bodies — Pachini, in muscular and mucous covers — sensitive nerve terminations are had.

The PHYSIOLOGY

With fiziol, the points of view, L. S. performs two functions: accumulation and deduction of urine (reservoir function); its removal (evakuatorny function). Fiziol, the capacity of a bladder, i.e. the amount of urine causing a desire to to an urination (see), fluctuates ranging from 200 to 400 ml. Women have it slightly less, than at men. Owing to weakening of muscles the capacity of L. S. at elderly people increases. In L. S. periodically, on average in 20 — 30 sec., from ureters urine nonsynchronously arrives. The rhythm of intake of urine is subject to fluctuations depending on amount of the drunk liquid and its character, from the various mental phenomena. The desire on an urination appears with an intravesical pressure of 10 — 15 cm w.g. during the definition in horizontal position and to 30 cm w.g. — in vertical. In the mechanism of maintenance of a certain amount of urine in L. S. have the leading value mechanioreceptors (see), pressure reacting to size in L. S. and degree of stretching of its wall. In a wall of L. S. there are receptors of two types: one are irritated at fast changing of volume of a bubble, others — at slow increase in intravesical pressure. Existence of two types of mechanioreceptors has essential value in activity of a bubble thanks to special characteristics of its muscular wall. At smooth muscles of L. S. the property of a plastic tone consisting in ability to stretch to the known limit is sharply expressed almost without changing the tension. When the amount of liquid in L. S. surpasses nek-ry critical size, pressure begins to increase in his cavity sharply because of tension of a muscular wall. Not the absolute value of hydrostatic pressure, but the speed of its increase is important for activation of receptors. In this regard at bystry receipt even of a small amount of liquid in a bubble tension can increase stronger, than at slow receipt of bigger amount of liquid, respectively there can quicker come also the urination. The sphincter of L. S., the urethra which reflex is reduced at nek-rum, rather small, stretching of a wall of a bubble participate in the mechanism of deduction of urine.

Evakuatorny function of L. S. is carried out by means of three basic processes: reductions of a bubble at considerable stretching of its walls, irritations of mechanioreceptors of an urethra the urine getting into it and relaxations of muscles of an urethra at irritation of walls of a bubble.

The afferent impulsation on parasympathetic (pelvic) and sympathetic (hypogastric) nerves at a certain level of urine of L. S. reaches the spinal and nadsegmentarny centers regulating activity of L. S. Formation of a desire to an urination begins with reflex reduction of a muscle of L. S., at the same time a small amount of urine flows into a zone of an internal sphincter. At irritation of this zone the alarm system from it is transferred to bark of big hemispheres. In reply there is a reduction of the outside sphincter formed by cross-striped muscles, urine is squeezed out in a bubble again, the detruzor relaxes, there occurs M.'s adaptation and. and suppression of a desire. It should be noted that reduction of a detruzor at an urination is preceded by relaxation of muscles of a crotch and, therefore, an outside sphincter. Evakuatorny function of L. S. is promoted considerably by tension of an urinogenital diaphragm, front abdominal wall. Evacuation of urine from a bubble is carried out 4 — 6 times within a day, the frequency of an urination is influenced considerably by the food and water modes, ambient temperature, a condition of intestines, pelvic bodies.

The mesencephalon, the bridge of a brain (varoliyev the bridge) exert on the spinal centers brake impacts, and a mesencephalon and bark of big hemispheres (a paracentral segment on a medial surface of a hemisphere and a front central crinkle) — the stimulating influences. There is an opinion that efferent nerves of L. S. are presented only by parasympathetic fibers; nek-ry consider what participates in an efferent innervation and a sympathetic part of century of N of page

of L. S. participates in maintenance of constancy of internal environment of an organism, providing generally removal from an organism of metabolic products. The healthy person has the urine which is in L. S. usually does not undergo essential changes. However there are facts testimonial of participation of a wall of L. S. in regulation of exchange of ions and water under the influence of such hormones as vasopressin and bradikinin.

METHODS of the RESEARCH

begin the Research with inquiry and survey of the patient (see. Inspection of the patient, urological ). The main symptoms of a disease of L. S. — pain in the bottom of a stomach, an urodynia, disturbance of the act of an urination (see. Dysuria ) and changes from urine. Changes of urine are defined at survey of svezhevypushchenny urine or at microscopy. Color of urine changes depending on food, medicines, presence of bilious pigments, porphyrine, blood, a lymph, melanin etc. of Svezhevypushchennaya urine can be muddy from impurity of salts, bacteria, slime and pus. The reasons of opacification of urine can be established by microscopy of its deposit or easier way. So, e.g., salts are dissolved at addition acetic and salt to - t and at warming up of urine. For clarification of a source of a pyuria (see. Leukocyturia ) and hamaturia (see) apply two or trekhstakanny tests (see. Stakanny tests ).

At survey of the patient with the crowded L. S. protrusion of an abdominal wall over a pubis on the centerline is visible. At a delay of the act of an urination M.'s palpation p, allows to reveal its borders. It is possible to define palpatorno L. S. only at poorly expressed hypodermic and a pliable abdominal wall. More exact idea is given by a bimanual research of L. S. (women have per vaginam, men have per rectum), a cut allows to estimate also a condition of the next bodies and cellulose of a small pelvis. Percussion of L. S. is made on the centerline of a stomach beginning from area of a navel and going down towards a pubis from top to bottom. It is possible to determine by percussion degree of stretching of L. S. and its border. At the filled L. S. the stupid percussion sound over a pubis is defined. Defining perkutorno the upper bound of L. S. immediately after an urination, conditionally judge quantity of a residual urine.

For more exact diagnosis resort to catheterization (see. Catheterization of uric ways ), to sounding of L. S., tsistoskopiya (see), tsistografiya (see). At catheterization of L. S. apply rubber, metal and elastic catheters (see). The purpose of catheterization — scoping of a residual urine, receiving urine for crops, tsitol, researches etc. Sounding of L. S. is made by buzham (see. Bougieurage ) or metal catheter.

The majority of diseases of L. S. diagnose by means of a tsistoskopiya, to execute to-ruyu perhaps only on condition of satisfactory passability of an urethra, sufficient capacity of L. S. (not less than 50 ml) and transparency of the environment in it. Sometimes apply an endovesical biopsy to recognition of a disease or differentiation of a type of a tumor of M. of N.

At the diseases which are followed by disturbance of emptying of L. S. the tsistometriya — determination of pressure in a cavity of L. S. is shown that allows to establish reflex type of L. S., to judge a tone and sokratitelny ability of a detruzor, to estimate urethral resistance. For these purposes use the water manometer connected to a tsistostomichesky tube (a direct tsistometriya) or the catheter entered into an urethra (a retrograde tsistometriya). Filling a cavity of L. S. with indifferent sterile liquid, register the volume of the entered liquid and pressure in a bubble, at Krom for the first time there is a N then there is imperative a desire on an urination. At the healthy person the desire for the first time appears with a pressure of 10 — 15 cm w.g.; introduction of 300 — 400 ml of liquid increases pressure to 30 — 40 cm w.g. also does insistent emptying of a bubble. Hyper reflex L. S. reacts to much smaller amount of liquid while the areflektorny bladder is capable to contain bigger amount of liquid without the corresponding build-up of pressure. At a direct tsistometriya determine also intravesical pressure at the beginning of an urination and maximum in the course of an urination that allows to judge intra urethral resistance. It is possible to reveal and define quantity of a residual urine also by a radio isotope tsistometriya, that is by determination of radioactivity over area of a bladder before and after an urination.

The incontience of urine at a tension, neurogenic dysfunction of L. S. is diagnosed by means of the sfinkterometriya allowing to define funkts, a condition of sphincters of L. S. The essence of this method consists in determination of resistance of sphincters of L. S. at rest and tension. For this purpose by means of the T-shaped tube connected to the manometer enter liquid or gas into an urethra. In process of administration of liquid or gas pressure increases in an urethra and suddenly falls after overcoming resistance of a sphincter and penetration of the entered substance into L. S. Measurement is performed twice — at rest and at a natuzhivaniye of the patient. The maximal pressure noted at rest corresponds to switching ability of a smooth muscle sphincter and normal 40 mm of mercury equal. Maximal pressure at a natuzhivaniye corresponds to switching ability of a cross-striped sphincter of L. S. and normal 80 mm of mercury equal. This method of a sfinkterometriya cannot be considered physiologic, and results absolutely reliable. More reliable is definition of changes of pressure in an urethra in process of extraction from it of a catheter, on Krom liquid constantly proceeds. On the curve received at the same time double build-up of pressure is noted, the first increase reflects funkts, a condition of a smooth muscle sphincter, and the second — cross-striped. Carrying out a sfinkterometriya is accompanied by risk of infection of urinogenital ways and it is contraindicated at inflammatory diseases.

Idea of work of L. S. and passability of an urethra gives definition and graphic record of rate of volume flow of current of urine during an urination — urofloumetriya (see). According to special indications, generally at damages and tumors, the laparoscopy is applied (see Peritoneoskopiya).

Plays a large role in a research of L. S. rentgenol, inspection, a cut begin with a survey picture of the basin allowing to define pathology of a bone skeleton, to reveal stones or foreign bodys, phleboliths, calciphied fibromatous nodes or vessels.

For the purpose of studying of a configuration of L. S. and identification patol, processes in it apply contrast tsistografiya) by means of introduction to it of iodinated drugs, a suspension of fixed white, oxygen or carbon dioxide gas. The technique of a research depends on the purpose of a tsistografiya. The most physiologic is the descending tsistografiya received 20 — 30 min. later after intravenous administration of X-ray contrast agent. The ascending (retrograde) tsistografiya is carried out by introduction to L. S. of X-ray contrast liquid on an urethra or an urethral catheter or through a suprapubic drainage. For identification of vesicoureteral refluxes and obtaining the image of a neck of L. S. and a prostatic part of an urethra the picture is done at the time of an urination (a so-called miktsionny tsistografiya). The tumor of L. S. can be revealed by the «sedimentary» tsistografiya which is carried out by way of introduction to a bubble of 5 — 10% of a water suspension of fixed white and oxygen. Specification of the diagnosis of adenoma of a prostate is promoted by a so-called lacunary tsistografiya, at a cut into L. S. on a catheter enter 15 — 20 ml of liquid X-ray contrast agent, and then 150 — 200 ml of oxygen; at the same time the shadow of adenoma of a prostate is visible against the background of a small shadow zone of radiopaque substance in the form of defect of filling. For definition of a stage of cancer of L. S. resort to a politsistografiya: on a catheter enter into L. S. fractionally, several portions, radiopaque substance. After introduction every portion do a picture on the same film. About a stage of a tumor judge by degree of mobility of walls of L. S. in various sites. With the same purpose, and also for identification of tumoral infiltrates in a small basin of a tsistografiya) combine with a peritsistografiya, to-ruyu make by administration of gas (oxygen or carbon dioxide gas) in paravesical cellulose in number of 500 — 600 ml. The double contrast study allows to receive rentgenol, the image of outside contours, to define a form and thickness of walls of L. S. of Sokratitelnuyu ability of a detruzor and sphincter document by means of a tsistografiya using X-ray television (see. Television, X-ray television ) and X-ray cinematographies (see).

Definition of a stage of cancer of L. S. is helped by pelvic arteriography (see. Pelvic angiography ), to-ruyu carry out by transdermal transfemoralny aortic catherization on Seldingera. To judge extent of germination of a tumor in walls of L. S., pelvic cellulose and the next bodies, and also existence of metastasises in regional limf, nodes, apply a pelvic venografiya (see. Flebografiya ), to-ruyu make by administration of radiopaque substance in a deep dorsal vein of a penis or in spongy substance of both pubic bones.

Apply to recognition of diseases of L. S. also an ekhografiya (see. Ultrasonic diagnosis ), contours of its walls, existence of a tumor, the extent of its germination etc. allowing to reveal.

The research of L. S. by means of radioisotopes is conducted for the purpose of studying funkts, conditions of uric system (a radio isotope renotsistografiya, a radio isotope tsistorenografiya, radio isotope determination of quantity of a residual urine), and also for definition of degree of prevalence of malignant tumors of L. S. (a radio isotope lower venografiya).

Fig. 3. The radio isotope renotsistogramma is normal (and) and at a vesicoureteral reflux: I \a tsistogramma (((((((((1 — a vascular piece of a curve, 2 — «plateau» of a bladder, 3 — the site of intravesical accumulation); II \a renogramma (((((((((4 — accumulative and 5 — secretory sites of a curve); on abscissa axis time in min., on ordinate axis — the level of activity in imp / sec.; at a puzyrnomochetochnikovy reflux the level of activity on the site of intravesical accumulation decreases, and on the secretory site of a renal curve (5)) increases.

Isotope renotsistografiya (see. Renografiya radio isotope ) is modification of a renografiya. One of the collimated scintillation sensors of radiometric installation is centered on area of L. S. after intravenous administration 131 I-gippurana at the rate of 0,05 — 0,1 mkkyur on 1 kg of weight of the patient, in addition to two renal curves, is carried out record of a curve from area of L. S. The vesical curve to similarly renal curves is subdivided into 3 segments: vascular, plateau of L. S., intravesical accumulation of isotope (fig. 3, a).

Normal the vascular piece of a vesical curve has amplitude, smaller in comparison with a renal curve, due to less plentiful blood supply of L. S.; the plateau of L. S. corresponds to the site of a renografichesky curve, reflecting a phase of canalicular secretion; from the moment of hit of the first portions of marked urine in L. S. raising of the third site of a tsistogramma (intravesical accumulation of isotope) begins. Quantitative parameters of a tsistogramma are: time of emergence of isotope in L. S. (3 — 5 min.); a corner between the plateau of L. S. and a piece characterizing accumulation of drug in L. S. (98 — 110 °); time of crossing of a piece of accumulation of drug in L. S. with a secretory piece of a renogramma (6 — 7 min.).

The technique of a radio isotope renotsistografiya has the greatest value at children in diagnosis of vesicoureteral and vesical and renal refluxes. In the presence reflux (see) unilateral or bilateral rise in activity in a secretory piece of renal curves with simultaneous decrease in level of activity on a curve of L. S. is noted (fig. 3, b).

In doubtful cases resort to more exact method — a radio isotope tsistorenografiya. For performance of this research enter into L. S. 131 I-gippuran at the rate of 0,2 — 0,25 mkkyur on 1 kg of weight of the patient. Then fractionally enter solution of Furacilin. Within 15 — 20 min. register activity over area of kidneys in L. S. Normal at once after administration of isotope over area of kidneys curves decide on small rise. Sharp rise over area of L. S is at the same time noted. After administration of Furacilin the type of curves does not change, and after removal decreases to zero. Tells one about existence of a reflux - or bilateral rise in activity over area of kidneys and simultaneous decrease of the activity over area of L. S. after administration of liquid in it.

Radio isotope determination of quantity of a residual urine is carried out at patients with adenoma of a prostate, at patients with a neurogenic bladder etc. After a preliminary urination intravenously enter 10 — 15 mkkyur 131 I-gippurana; in 40 — 60 min. count quantity of impulses in 1 min. over area of L. S. After an urination carry out determination of level of radioactivity over area of L. S again. The difference of level of radioactivity over area of L. S. before and after an urination taking into account the volume of the emitted urine allows to define with a big accuracy quantity of a residual urine in L. S.

The radio isotope lower venografiya is the mediated method of definition of a stage of tumoral process in L. S. The essence of a method consists in receiving by means of the gamma camera of the image of the right and left general ileal veins and the caudal site of the lower vena cava after a simultaneous injection

1 — 3 mkkyur 99m Ts-pertekhnetata in saphenas of the back of both feet. Processing of information recorded with the videorecorder allows to reveal even insignificant disturbances of venous outflow that testifies to a prelum or germination of vessels in the specified zone. Advantages of a method are lack of complications and contraindications, an atravmatichnost, a possibility of quantitative assessment.

PATHOLOGICAL ANATOMY

Dystrophic changes in a wall of L. S. are connected with local, is long proceeding patol, processes, napr, cystitis, or nek-ry general disbolism. Fatty dystrophy is characterized by emergence of small-drop fatty inclusions in cytoplasm of cells of an epithelium of L. S. At microscopic examination in a submucosa of L. S. sometimes define the focal deposits of cholesterol surrounded with macrophages. At the same time in a cavity of L. S. quite often find cholesteric stones.

The hyalinosis of a wall of L. S. is observed sometimes at an urolithiasis in places of a bedding of urinary stones and characterized by changes of mucous and muscular covers, and also walls small circulatory and limf, vessels (see. Hyalinosis ).

At amyloidosis (see) on gistopreparata find deposits of mass of amyloid of hl. obr. in a submucosa and vessels, is more rare in a muscular coat of L. S. At an amyloidosis of L. S. the reactive inflammation, an ulceration of a mucous membrane, and also a necrosis of its wall can be observed.

Disturbances of pigmental exchange are shown by decolourizations of a mucous membrane of L. S. and are most often caused by deposits of hemosiderin as a result of hemorrhages or disturbance of blood circulation, and also at malakoplakias (see). At increase in content in blood serum of bilirubin the mucous membrane of L. S. quite often gets characteristic light yellow coloring.

Disturbances of blood circulation in a wall of L. S. most often arise in the conditions of a venous plethora, but can be caused by various reasons, in particular as a result of changes of intravesical pressure. At the same time macroscopically mucous membrane of L. S. at a venous plethora has bluish-red color with the acting expanded venous vessels. The long venous plethora can be followed by a varicosity and a vein thrombosis of a wall of L. S. with development of inflammatory and necrotic changes, and also bleeding in a cavity of L. S.

At a pathoanatomical research quite often find hemorrhages in a mucous membrane of L. S., to-rye most often are located in the field of its top and mouths of ureters. In the same sites hemorrhagic erosion sometimes meet. At microscopic examination of hemorrhage, sometimes surrounded with lymphocytic infiltrates, find hl. obr. in a mucous membrane and a submucosa.

At disturbance of a lymphokinesis there comes hypostasis of a wall of L. S.: macroscopically his mucous membrane and a submucosa look bulked up, with the reinforced folds turning with places into subauriculate protrusions (at a violent form of hypostasis), and sometimes taking a form of polyps.

Inflammatory changes of a wall of L. S. most often have character cystitis (see). Less often in L. S. displays of tuberculosis, syphilis and fungus diseases can be observed.

At tuberculosis (see. Tuberculosis of urinogenital bodies ) on a mucous membrane of L. S. single tubercular granulomas appear, to-rye further as a result of a necrosis can turn into small tubercular ulcers. At their merge the extensive fields of ulcerations occupying sometimes all inner surface of L. S are formed. So-called caseous cystitis is in rare instances observed, at Krom of mass of a caseous necrosis cover all inner surface of L. S. In some cases hypostasis of a mucous membrane, formation of papillomatous outgrowths of an epithelium and adjournment in ulcerated sites of salts uric to - you is noted. In the outcome of a disease the sclerosis of a wall of L. S. and paravesical cellulose can develop, unions with nearby bodies are formed, fistulas and cold abscesses develop.

In the secondary period syphilis (see) defeat of L. S. the hl is characterized. obr. papular rash, papillomatous growths, small ulcerations of a mucous membrane; in the tertiary period at morfol, a research in L. S. typical gummas and gummous infiltrates can be found.

At actinomycosis (see) defeat of L. S. is most often secondary and develops as a result of transition of process from the struck paravesical cellulose. In these cases in gistol, drugs among accumulations of purulent exudate, growths of specific granulyatsionny and fibrous fabric Druzes an actinomyce are visible.

Atrophic changes are expressed in thinning of a wall of L. S., flattening and smoothing of his mucous membrane with reduction of thickness of epithelial layer.

The obstacle to emptying of L. S., napr, at a prelum of an urethra the increased prostate, leads to development of hypertrophic changes of a wall of L. S. Macroscopically at the same time find sharp (to 4 cm) a thickening of a muscular coat. In the subsequent there occurs expansion of L. S., dystrophic changes in its intramural nervous device develop, focal thinnings and protrusions of a wall of a bubble — so-called false diverticulums appear. They are located usually between moderator bands, deeply pressing in a wall of L. S. The rupture of a wall of a false diverticulum of L. S is in rare instances possible.

Postmortem changes in L. S. come early and consist in swelling of cytoplasm of epithelial cells, in loss of ability of their kernels to perceive dyes, in a loosening and exfoliating of an epithelium. Cadaveric emphysema of L. S. with the advent of vials of gas in a submucosa and a muscular coat can be caused by putrefactive changes. The muscular coat of L. S. is exposed to cadaveric changes later — muscle fibers at microscopic examination look unstructured, lose ability to coloring in gistol, drug.

PATHOLOGY

Malformations

Inborn lack of a bladder (agenesia) — extremely rare malformation; 3/4 children with this defect are born the dead. Also lack of an urethra is characteristic of an agenesia of L. S. Ureters, separately or merging, fall into an entrance of the vagina or into a rectum. External genitals look normally, but the vagina is usually underdeveloped also a uterus — two-horned. At girls this defect is combined with doubling of kidneys, an ureterohydronephrosis, soon after the birth pyelonephritis develops.

In view of a full incontience of urine and bystry development of the ascending uric infection treatment consists in creation of the isolated L. S. from a segment of a large intestine (see. Intestinal plastics ) or removal of ureters on skin.

Fig. 4. The diagrammatic representation of a bladder at some defects of its development: and — full doubling of a bladder (1 — mouths of ureters, 2 — the partition which is completely dividing a bladder, presented by a double wall of a bladder); — incomplete doubling of a bladder (1 — mouths of ureters, 2 — the partition which is partially dividing a gleam of a bladder); in — a full sagittal partition of a bladder (1 — the cavity of a bladder which is emptied on an urethra, 2 — not changed right ureter, 3 — the closed cavity of a bladder, 4 — an expanded left ureter, 5 — the partition which is completely dividing a bladder); — an incomplete sagittal partition of a bladder (1 — mouths of ureters, 2 — the partition which is partially dividing a gleam of a bladder); d — a full frontal partition of a bladder (1 — a front cavity of a bladder, 2 — not changed ureter, 3 — an expanded ureter, 4 — the mouth of an ureter, 5 — the closed (back) cavity of a bladder, 6 — a partition, 7 — the mouth of an ureter); e — an incomplete frontal partition of a bladder (1 — ureters, 2 — a partition).

Doubling of L. S. — a malformation, the second for a rarity. Disturbance of an embryogenesis happens between the 5 and 7 weeks. Meets identical frequency at persons men's and female. At full doubling of L. S. it is presented by two isolated cavities, each of to-rykh accepts urine from one ureter and is drained by a separate urethra (fig. 4, a). At the same time there is a difaliya (doubling of a penis) or both urethras pass on the ventral surface of a penis nearby. At girls bifurcation of a clitoris, a longitudinal partition of a vagina is noted. More than a half of patients has duplikatsionny cysts went. - kish. a path, doubling of caudal department of a backbone is possible. The diagnosis is made on the basis of survey, given to a tsistouretrografiya also by tsistoskopiya. Treatment usually consists in correction of genitalias and elimination of duplikatsionny cysts of intestines.

Incomplete doubling (fig. 4, b) is characterized by partial division of L. S. in the form of two cameras which are reported in a neck and drained the general urethra. Anomaly comes to light accidentally at a tsistografiya or a tsistoskopiya and correction does not demand.

A two-chamber bladder — rare defect, for to-rogo existence in L. S. of a longitudinal or cross partition formed doubled mucous, and sometimes and muscular by covers is characteristic. The partition can be full and incomplete.

In the presence of a full sagittal partition (fig. 4, c) L. S. is divided thus that one its half is not emptied and, stretching, closes an internal opening of an urethra, causing an ischuria, and then uraemia. After deflation of urine a catheter the protrusion which is available over a pubis remains. The diagnosis is made by means of the tsistografiya revealing the shift and big defect of filling of L. S. At excretory Urografinum the shadow of one kidney does not come to light because of irreversible changes. Treatment consists a kidney and an expanded ureter, full excision of a partition of L. S at a distance.

The incomplete sagittal partition (fig. 4, d) can clinically not be shown if an opening in it wide. Otherwise cystitis, pyelonephritis develop over time that demands excision of a partition.

The full frontal partition (fig. 4, e) slantwise divides L. S. into two cavities, at the same time the lobby is reported to a thicket with an urethra, and back is closed. The ureter falling into the closed cavity is sharply expanded, the kidney anatomically and is functionally defective. A wedge, manifestations and treatment same, as at a full sagittal partition.

An incomplete frontal partition (fig. 4, e) usually has defect in a neck of L. S., but in nek-ry cases it proceeds from top to bottom, simulating the valve of a back urethra. At considerable disturbance of evacuation of urine the atony of upper uric ways and pyelonephritis quickly enough develop. After establishment of the topical diagnosis by means of a miktsionny tsistografiya and a tsistouretroskopiya make excision of a partition.

An inborn diverticulum of a bladder — sacculate protrusion of its wall — see. Diverticulum .

Contracture of a neck of a bladder. In 1933 Marion (N. of Marion) reported about the child with an ureterohydronephrosis who developed because of cicatricial obstruction of a neck of L. S. Since then the disease received the name of a sclerosis of a neck of L. S. or Marion's disease. The disease is carried to inborn; there is it preferential at boys. However changes in a type of a hypertrophy of an internal sphincter, an inflammatory sclerosis, characteristic of it, are observed also at other forms of obstruction, including at valves of an urethra.

The wedge, a picture includes a dysuria and an incontience of urine at the complicated urination. In an initial stage the disease proceeds is latent, with approach of a decompensation of a detruzor the volume of a residual urine increases that promotes development of an uric infection. By means of a tsistografiya reveal flattening of a neck, in late stages — roughness of contours of L. S., a vesicoureteral reflux and a large number of a residual urine. At a tsistoskopiya note resistance at the time of carrying out the cystoscope through a neck, the trabekulyarnost of walls of L. S. and the phenomenon much expressed hron, cystitis. According to an urofloumetriya and a tsistomanometriya judge degree of a decompensation of a detruzor.

Fig. 5. The diagrammatic representation of Y — V-shaped plastics of a neck of a bladder at its contracture: and — a Y-shaped section of a front wall of a neck of a bladder; — podshivany tops of an educated triangular rag in a bottom corner of a section; in — the section of a bladder is taken in, the line of seams in the form of a letter V.

Treatment is directed to expansion of outlet opening of L. S. by means of Y — V-shaped plastics (fig. 5) or an electroresection of a neck of L. S.

A crevice of a bladder — the inborn lack of a front wall of L. S. and the site of a front abdominal wall which is combined with an epispadiya and an underdevelopment of pubic bones (see. Ectopia of a bladder ).

Damages

Damages of L. S. happen closed and opened. The damage rate of L. S. can be various: a bruise, the incomplete (not getting) or full (getting) damage of a wall of L. S., a separation of an urethra. Among the closed damages (gaps) of L. S. distinguish: simple (extra peritoneal or intraperitoneal); mixed (a combination inside - and an extra peritoneal gap); combined (combined with changes of pelvic bones or with damages of other bodies); complicated (shock, peritonitis, uric infiltration of fabrics of a basin, osteomyelitis, an urosepsis, pyelonephritis, etc.).

The closed damage of L. S. mostly results from an injury. The contributing condition is overflow of L. S. urine.

The extra peritoneal rupture of L. S. most often arises at a change of pelvic bones as a result of a tension of vesical and pelvic sheaves or injury of bones by fragments. The intraperitoneal rupture of L. S. is caused at the crowded L. S. by a bruise, pressure upon a front abdominal wall. Damage of L. S. can be and iatrogenic, connected with tool manipulations (a tsistoskopiya, a cystolithotripsy, catheterization of L. S. a metal catheter, electrothermic coagulation), with an operative measure (a laparotomy, herniotomy, a hysterectomy). The spontaneous rupture of L. S. is in most cases observed at patol, change of a vesical wall as a result of inflammatory, tumoral, syphilitic, tubercular and other processes or at trophic change of a neurogenic origin.

The extra peritoneal rupture of L. S. at a change of pelvic bones is followed by considerable bleeding in cellulose of a basin from a prostatic veniplex, and also from top and bottom vesical arteries and veins. Not less serious effect is uric infiltration of cellulose of a basin, hips, buttocks and a scrotum with development of phlegmon of a basin, fistulas and an urosepsis (see. Sepsis ). In these conditions easily there is osteomyelitis of pelvic bones. At intraperitoneal ruptures of the bladder develops peritonitis (see).

The closed damage of L. S. can be followed shock (see), internal bleeding (see). Symptoms of damage of L. S. are pain over a pubis, disturbance of the act of an urination, a hamaturia (see) and signs of flowing of urine in paravesical and pelvic cellulose or in an abdominal cavity — uric became numb (see), peritonitis. At the late address of the patient with an extra peritoneal rupture of L. S. that happens at the kept urination, on a front abdominal wall in the field of a symphysis, in inguinal areas, on an inner surface of hips can appear redness and puffiness as a result of development of uric zatek and inflammatory process. In case of an intraperitoneal rupture of L. S. desires on an urination can be absent for a long time or to be not intensive. The patient is forced to be in a sitting or semi-sitting position as in horizontal position sharp strengthening of abdominal pains is observed. Penetration of urine into an abdominal cavity even without damage of bodies leads to peritonitis. During the first hours urine in an abdominal cavity can be not infected and peritonitis proceeds atypically that sometimes leads to late diagnosis and dangerous complications.

In diagnosis of the closed damage of L. S. data of the anamnesis (an injury of a basin, blow in a stomach matter at the crowded L. S.) and objective inspection (a palpation, percussion, a rectal and vaginal research, catheterization of L. S., a tsistoskopiya, a tsistografiya and a laparoscopy). Tsistoskopiya is feasible only at incomplete or very small damages when it is possible to fill L. S. for its survey. The excretory urography and the descending tsistografiya are not always possible because of traumatic shock and often do not allow to distinguish damage. The main role in diagnosis of the closed damages of L. S. is played by the ascending tsistografiya with liquid radiopaque substance, a cut enter into L. S. in number of 250 ml: pictures do in direct and slanting projections, having established a beam tube at an angle 45 °. If necessary pictures are repeated 20 — 30 min. later after administration of contrast medium in L. S. (the delayed tsistografiya) and after its evacuation from L. S.

Fig. 6. Tsistogramma at an extra peritoneal rupture of the bladder: shooters specified the roughness of contours of a shadow of a bladder formed as a result of an effluence of it a contrast agent in pelvic cellulose.

At an extra peritoneal rupture of L. S. it is palpatorno possible to define morbidity and a muscle tension in lower parts of a stomach, infiltrate in ileal area, sometimes a thickening of seed cords. Find Perkutorno over a pubis the dullness without clear boundary which is not displaced at a postural change of a body and not disappearing after emptying of L. S. At a research through a rectum or a vagina reveal pastosity of paravesical and pelvic cellulose owing to infiltration by its urine. At catheterization urine from L. S. is not emitted or follows a weak stream and contains impurity of blood. The diagnosis is confirmed by the ascending tsistografiya, at a cut note flowing of a contrast agent out of limits of L. S. in pelvic cellulose (fig. 6).

Fig. 7. Tsistogramma at an intraperitoneal rupture of the bladder: 1 — the contrast agent which flowed out in an abdominal cavity, 2 — a bladder.

Suspicion on an intraperitoneal rupture of L. S. arises if at percussion at the patient, it is long not urinating, over a bosom do not define characteristic dullness. At the same time most often 12 — 24 hours later and more it is perkutorno possible to define free liquid in an abdominal cavity. At a manual rectal research (see) define the overhang of a front wall of a rectum caused skopley wet in rectovesical deepening. For this type of damages Zeldovich's symptom is pathognomonic: allocation on a catheter of a large amount of the muddy, bloody liquid (urine, blood, exudate from an abdominal cavity) containing a lot of protein (Yu / 00 above). Sometimes observe a symptom of resuming of release of urine on a catheter if to put the patient on legs. The diagnosis of an intraperitoneal rupture of L. S. is confirmed by the ascending tsistografiya, at a cut flowing of contrast liquid in an abdominal cavity (fig. 7), and laparoscopies is defined (see. Peritoneoskopiya ), added with introduction to L. S. of solution of indigo carmine. In cases, difficult for diagnosis, of the closed damage of L. S. an operative measure is recommended.

At an incomplete extra peritoneal rupture of L. S. perhaps conservative treatment: antishock actions, a high bed rest, cold on a stomach, hemostatics, a constant catheter in L. S. At a complete separation of a bladder operational treatment is obligatory.

At an extra peritoneal gap are shown audit of L. S. from suprapubic access and sewing up of the point of fracture of a bubble. Nek-ry surgeons at an arrangement of a wound of L. S. in the inaccessible place (napr, in the field of a vesical triangle, a neck of a bubble) recommend to abstain from suture and to be limited to an epicystostomy (see. Vesicotomy ). Drainage of L. S. (see. Drainage ) carry out by cystostomy, at women in nek-ry cases establishment of a constant catheter is admissible. Drainage of a basin is made through a locking opening across Buyalsky — Mac-Uortera, through an ischiorectal pole and a suprapubic wound.

At the closed intraperitoneal damage of L. S. urgent is shown laparotomy (see) with audit of an abdominal cavity, sewing up of a wound of L. S. and epicystostomy. In the presence of purulent peritonitis leave a drainage in an abdominal cavity for introduction of antibiotics. At the combined damage of L. S. and abdominal organs carry out operation on bodies of a stomach in the beginning.

Open damages of L. S. arise owing to falling on the acute, pricking objects (a knife, a bough of a tree and so forth), to-rye get into a bubble through a front abdominal wall, a crotch, a rectum or a vagina. Wound of L. S. fire or cold weapon in peace time meets seldom. In wartime these damages make 0,05 — 0,3% of all wounds, in relation to the getting wounds of a stomach of 2,3 — 5,7%, at wounds of a basin meet in 21 — 55,2% of cases.

Open damages of L. S. can be out of - and intraperitoneal. Wounds of L. S., especially fire, often happen combined and are followed by damage of other bodies. On character of a hurting shell open damages of L. S. happen cut, chipped and fire. The last can be divided on through, blind (getting or not getting), tangent, indirect, or secondary, caused not by a hurting shell, but splinters of a bone.

The wound at patients with open damage of L. S. is quickly infected, there is an uric infiltration, edges extends to surrounding fabrics and bodies with formation of uric phlegmon, an urosepsis, osteomyelitis of pelvic bones. In addition to the symptoms characteristic of the closed injury of a bladder, at open damage emergence of urine in a wound is observed.

The principles of diagnosis of open damages the same L. S., as at the closed damages. The colourful tests (intake methylene blue, intravenous administration of indigo carmine, injection of the painted sterile liquid in a bladder) confirming release of urine from a wound are important.

At open extra peritoneal damages of L. S. the immediate surgery — primary surgical treatment of a wound, sewing up of a wound of L. S., an epicystostomy, drainage of a small pelvis is shown. At damage of pelvic bones removal of fragments of bones is shown, at wound of a rectum — colostomy (see).

At open intraperitoneal wound of L. S. after removal of the patient from shock or along with it make the emergency laparotomy, audit of abdominal organs, sewing up of a wound L. S. and an epicystostomy.

A lethality at damages of L. S. high.

Stage treatment

In the battlefield and in the center of mass defeat is performed most and mutual assistance, and also the help by junior medical staff. It comes down to imposing on a wound of a protective sterile bandage, to administration of anesthetics from an unit-dose syringe, immediate evacuation in battalion or directly in a regimental first-aid post, and in the conditions of civil protection — in OPM.

In the IFV if necessary correct earlier applied bandage, enter cordial and anesthetics. Victims are evacuated on PMP, and at an opportunity directly in MSB.

First medical assistance (see) on PMP includes medical sorting of persons with damages of L. S.; at the same time they are divided into two groups. Carry patients with moderately severe damages to the first, correct the Crimea or replace bandages, enter antitetanic serum, tetanic anatoxin, analgetics and antibiotics and first of all evacuate on a stage of the qualified help. The second group includes victims in heavy and critical condition when, except the events held in the first group antishock actions are required (hemotransfusion, blood substitutes, introduction of cardiovascular means, novocainic blockade), after implementation to-rykh make evacuation in MSB. At an ischuria with to lay down. the purpose make catheterization of a bladder a rubber catheter. The victim with the expiration of urine in a wound before evacuation (in warm season) the area of a basin is hardly bandaged, the wound is widely closed a bandage. In the winter wet bandages can freeze therefore it is necessary to apply means against cooling (warm bags, chemical hot-water bottles). In the absence of the combined damage of pelvic bones and long tubular bones of extremities of L. S. which were injured with the open wounds located on a front wall of a stomach it is possible to evacuate on the subsequent stage in situation on a stomach.

the Qualified medical care (see), carried out to MSB and OMO, begins with medical sorting of victims. Distinguish victims with the proceeding bleeding from veniplexes from them, paravesical and a pararectal fat, spongy substance of a bone, to-rykh first of all send to the operating room. The victim who is in state of shock without symptoms of internal bleeding carries out intensive antishock care. If in the next 2 — 3 hours after an initiation of treatment it is possible to achieve improvement of the general condition of victims, to lift the ABP to 80 mm of mercury. above, they are sent to the operating room for performance of necessary interventions. Victims with insignificant (like bruises) damages of L. S. are evacuated in hospital for lightly wounded (see) or all-surgical hospital for performing generally conservative therapy.

At the opened and closed intraperitoneal damages of L. S. the median laparotomy, audit of abdominal organs and L. S is carried out. Ruptures of a bubble take in two-row noose catgut sutures.

Operations on L. S. in all cases finish with imposing of suprapubic vesical fistula. The rubber drainage tube, a bulbous catheter (Pezzera, Maleko) or a catheter with a razduvny cylinder are established at a depth of 5 — 7 cm and fixed at a top of L. S. The catheter with a razduvny cylinder to a vesical wall is not fixed. It keeps in a bubble at the expense of a cylinder.

At extra peritoneal ruptures of L. S. bare a section on the centerline over a pubis, carry out audit of a cavity of a bubble and removal of foreign bodys, take in wounds of a lobby and sidewalls two-storeyed catgut seams. Hardly accessible wounds in the field of a bottom, do not take in a vesical triangle and a neck of L. S. Outside bring rubber drainages to the sewn-up wounds. The extensive bleeding ruptures of any localization take in. Removal of urine is carried out through suprapubic vesical fistula.

In the presence of uric zatek make their opening and drainage of paravesical and pelvic cellulose through a suprapubic wound, a crotch (across Kupriyanov), a locking opening (across Buyalsky — Mac-Uortera) or through an ischiorectal pole.

At the combined damages of L. S. and pelvic bones surgical treatment of bones, removal of impractical fragments, mending of wounds of L. S., imposing of suprapubic vesical fistula is shown.

Drainage of L. S. needs to be combined with active suction of urine by means of a siphon drainage, a rubber bulb, a water-suction pump, etc.

After operations on L. S. in combination with a laparotomy victims remain nontransportable during 8 — 10 days.

Their evacuation on the following stage can be carried out in earlier terms, in 4 — 5 days if the sparing types of transport evacuation are available.

In the conditions of GO give help similar to the help on PMP in OPM, at severe defeats by the nontransportable patient — similar to the help in MSB.

Spetsializirvanny medical care (see) it appears in hospitals of GB of the front, in the conditions of GO — in pro-thinned out-tsakh hospital base. At this stage carry out operative measures on elimination of uric zatek, osteomyelites, reconstructive operations, closing of fistulas, carry out medical aid in full by that victim, to-rye arrived passing the previous stages of medical evacuation or for various reasons could not receive it earlier.

Diseases

the Neurogenic bladder — the syndrome combining the frustration of an urination arising at defeat of the nerve pathways and the centers, the innervating L. S. and providing function of any urination.

Fig. 8. Roentgenograms of lumbosacral department of a backbone (a direct projection) at its inborn defects leading to development of a neurogenic bladder: and — not fusion of a handle of the V lumbar vertebra (it is specified by an arrow); — not fusion of handles I, II and III sacral vertebrae (it is specified by an arrow); in — defect of the I lumbar and all sacral vertebrae; spinal hernia (it is specified by an arrow).

Etiological factors: inborn defects of terminal department of a backbone and spinal cord with not fusion of handles of vertebrae, spinal hernias (fig. 8), an agenesia and a dysgenesis of a sacrum and tailbone, an inborn underdevelopment of muscles of L. S. and its intramural gangliyev; a spine injury and a spinal cord, damage of peripheral nerves during operations on pelvic bodies and at patol, childbirth; inflammatory and degenerative diseases of a head and spinal cord (meningomyelitis, myelosyringosis, multiple sclerosis, back tabes); benign and malignant tumors of a backbone, spinal cord and its covers; defeat intramural gangliyev L. S. at obstructive uropathies; diabetic, alcoholic, post-diphtheric polyneurites with preferential damage of pelvic visceral nerves; discogenic radiculitises.

At an inborn underdevelopment or damage of the cortical, spinal centers or peripheral gangliyev and the conduction paths responsible for an innervation of L. S., its hierarchy with the spinal or cortical centers is broken, a part or all links of a reflex chain of the act of an urination drops out. Level and volume of damage is decisive factor. The most various processes on character at the identical level and volume lead to identical displays of a disease. The basic in a pathogeny is denervation and funkts, dissociation of L. S. with the cortical and spinal centers, disturbance of its reservoir and emptying function. At preferential defeat of the centers and ways of a sympathetic innervation reservoir function suffers, that is shown by disorder of adaptation and an incontience of urine; at defeat of a parasympathetic part of an innervation the emptying function is broken that is expressed by an ischuria. Cross damage of a spinal cord is higher than lumbar segments leaves intact the spinal centers. Communication with the cortical centers at the same time is absent, however reflex function of emptying remains. Damage of the cortical centers leads to disturbance of their brake influences on the subcrustal, spinal and peripheral centers, adaptation and oporozhnitelny function are carried out in the conditions of the weakened control of the cortical centers.

In a pathogeny of a syndrome of neurogenic L. S. the secondary changes in kidneys caused hron, an ischuria (vesical ureteric lokhanochny a reflux, pyelonephritis, hron, a renal failure), in a bubble (intersticial cystitis, wrinkling of a bubble and an atony of sphincters of a bubble), parallel dysfunctions of a large intestine (locks, an incontience a calla), and also nervnodistrofichesky changes in a zone of an innervation of the struck segments of a spinal cord or conduction paths (decubituses, trophic ulcers and the septic state connected with it) are of great importance.

Fig. 9. The diagrammatic representation of a nervous system, kidneys and a bladder at various shapes of a neurogenic bladder: (the struck centers, nodes or nerves are blackened and shown by shooters): and — not slowed down cortical neurogenic bladder (the cerebral cortex is affected); — a reflex spinal bladder (the spinal cord above the spinal centers of a bladder is injured); in — not adapted spinal bladder (spinal sympathetic segments of a spinal cord are struck); — not adapted ganglionic bladder (nodes of a sympathetic trunk, a hypogastric nerve and a nizhnebryzheechny texture are struck); d — an areflektorny spinal bladder (sacral parasympathetic segments of a spinal cord are struck); e — an areflektorny ganglionic bladder (parasympathetic prevesical nodes and nerves are struck); — an areflektorny intramural bladder (intramural vesical textures are struck); z — the mixed neadaptirovanno-ganglionic bladder (the lower lumbar and upper sacral segments of a spinal cord are struck).

H. E. Savchenko and V. A. Mokhort distinguish 8 pathogenetic of reasonable forms of neurogenic L. S. (fig. 9).

Not slowed down cortical neurogenic by L. S. (fig. 9, a) arises at defeat of the cortical centers. Owing to weakening of the braking influences of bark desires on an urination have imperative, uncontrollable character and develops incontience of urine (see).

Reflex spinal neurogenic L. S. (fig. 9, b) is result of damage of a spinal cord above the spinal centers, in to-rykh and the reflex on an urination becomes isolated. Owing to lack of desires the urination has reflex, uncontrolled character and arises in response to threshold filling of a bubble or on an inadequate irritant.

Not adapted spinal neurogenic by L. S. (fig. 9, c) and not adapted ganglionic neurogenic by L. S. (fig. 9, d) arise at defeat of the sympathetic centers of an innervation. At the same time adaptation of a bubble to the arriving urine is broken and the incontience of urine develops.

Areflektorny spinal neurogenic L. S. (fig. 9, e), areflektorny ganglionic neurogenic L. S. (fig. 9, e), areflektorny intramural neurogenic L. S. (fig. 9, g) arise at defeat of the relevant switching parasympathetic centers or the peripheral perceiving mechanisms owing to what the reflex on an urination is absent, the desire is weakened or disappears completely. In view of impossibility of any urination arises hron, an ischuria, stretching of a bubble, and in final stages of a disease — stretching of sphincters of a bubble and a secondary incontience of urine.

Mixed neadaptirovanno-ganglionic neurogenic by L. S. (fig. 9, h) arises at defeat of both parts of an innervation (parasympathetic and sympathetic). At the same time both functions of a bubble are broken: there is both an ischuria (residual urine), and its incontience. At uncomplicated forms of neurogenic L. S. of the complaint generally come down to easing or total disappearance of feeling of a desire to an urination and various disturbances of the act of an urination.

Range of changes of a desire is wide — from sharply strengthened uncontrollable at not slowed down cortical neurogenic M. and. before total disappearance at all forms of the areflektorny and deadapted neurogenic L. S. In the latter case the desire can be caused by the forced stretching of a bubble liquid. At incomplete damage of innervatsionny systems the equivalent of a desire in the form of weight in the field of L. S can be recovered. The following forms of frustration of an urination are possible: an incontience of urine in combination with a strong desire — at not slowed down neurogenic L. S., an uncontrolled urination in the absence of a desire — at patients with spinal reflex neurogenic L. S.; the ischuria forcing to squeeze out it or to resort to catheterization — at all forms of areflektorny neurogenic L. S.; primary incontience of urine (the continuous expiration) — at the deadapted forms of neurogenic L. S.; secondary incontience of urine as outcome hron, delays (paradoxical incontience). The ischuria happens chronic, however at an injury of a spinal cord and acute meningomyelites it can have acuity and unlike obstructive uropathies to be followed by loss of feeling of a desire. Crowded L. S. acts as tumorous education over a bosom, and for its emptying by the patient it is necessary to natuzhivatsya or squeeze a stomach. Disturbances of a motive and sensitive innervation of the lower half of a body, against the background of to-rykh usually there is neurogenic L. S., are shown by decrease in all types of sensitivity, decubituses, trophic ulcers, easily arising burns, duck gait, deformation of shins and feet, disturbance of defecation. During the developing of pyelonephritis and hron, a renal failure the corresponding symptoms join.

The diagnosis is based on data of the anamnesis and an objective research. In the anamnesis it is necessary to reveal the injuries which were available earlier and diseases of a nervous system, the undergone backbone operations and bodies of a basin, change from an urination and defecation. Careful nevrol, the research allows to establish the level and prevalence of defeat of a nervous system. Crucial importance has tool and rentgenol, inspection for the purpose of detection of pathology of a backbone, a back urethra. An isotope renografiya and excretory urography (see) functions of kidneys allow to estimate a condition. Tsistoskopiya and the ascending ureteropiyelografiya will be seen off carefully. For assessment funkts, conditions of L. S. apply a tsistosfinkterometriya, an urofloumetriya, X-ray cinematography, record of biocurrents of sphincters and a detruzor.

Treatment conservative and operational. The majority of methods of conservative treatment is directed to elimination of a residual urine, fight against an infection and ensuring control of emptying of L. S. At hron, an ischuria and an areflektornost of L. S. appoint parasimpatiko-mimetichesky drugs for the purpose of strengthening of a tone of a detruzor. Anticholinergic and Ganglioblokiruyushchy means interfere with momentum transfer in peripheral synapses and eliminate reflex spasms of sphincters of L. S. Sacral, presakralny and other types of novocainic blockade, an ionogalvanization with atropine or Pilocarpinum in some cases allow to achieve feeling of a desire to an urination, improvements of a tone of a detruzor and sphincters.

In system of complex treatment of neurogenic L. S., especially at an incontience of urine, LFK pursuing the aim of strengthening of muscles of a pelvic bottom has importance. It is long apply tidal system across Monro (see. Drainage ), what promotes formation of reflex L. S. At an incontience of urine and decrease in a tone of sphincters of L. S. apply rectal electrostimulation of L. S. At the neurogenic L. S. which developed because of an injury of a spinal cord apply the developed A. A. Vishnevsky and A. V. Livshits a method of implantation of the radio-frequency stimulating device that allows to recover the natural act of an urination in nek-ry cases.

Fig. 10. Diagrammatic representation of stages of operation of an ileovezikopeksiya: and — mobilization of a segment of an ileal gut (1 — a mesentery of an ileal gut; 2 — an ileal gut; 3 — the mobilized segment of a gut pressed since both ends by clips (are specified by shooters); 4 — an ileocecal corner); — a longitudinal section of a serous muscular layer (1) of the mobilized segment of a gut, allocation of the cylinder of a mucous membrane (2); in — the mobilized segment (1) is dissected away from an ileal gut and will develop on a leg of a mesentery (2); — recovery of a continuity of an ileal gut the enteroenteroanastomozy (1) end in the end; d — a wrapping (the direction is specified by an arrow) a serous and muscular segment of a gut (1) around a bladder (2); e — a serous and muscular segment of a gut (1) is hemmed by noose sutures (2) to a wall of a bubble.
Fig. 11. Diagrammatic representation of stages of operation of strengthening of a neck of a bladder: and — suture (1) on a neck (2) bubbles; — seams (1) are tied, the gleam of a neck (2) is narrowed.
Fig. 12. Diagrammatic representation of stages of operation of an autotsistodublikatura: and — a semi-circular section of a wall of a bladder; — the formed upper rag of a wall of a bubble (1) is delayed up; in — sewing together iod a rag (1) of both walls of a bubble at the level of a section (2) (the arrow specified the direction of the subsequent podshivaniye of a rag to a wall of a bubble); — the rag of a wall of a bubble (1) is hemmed by noose sutures (2) to its front surface
Fig. 13. Diagrammatic representation of stages of operation of a remuskulyarization of a bladder: and — cutting out of two muscular rags (1) from direct muscles (2) stomachs; — a podshivaniye of muscular rags (1) to a wall of a bladder (3).

Among operational methods the most reasonable is the pathogenetic method of treatment of neurogenic L. S. — reinnervation of L. S. in the way of an ileovezikopeksiya (fig. 10) developed by H. E. Savchenko and B. A. Mokhort (1970). After a deperitonization of L. S. open an abdominal cavity, will mobilize at distance 30 — 35 cm from an ileocecal corner a segment of an ileal gut 20 cm long on a mesentery. A continuity of a gut recover an anastomosis the end in the end. The switched-off segment is demukozirut, the mesentery of a segment is fixed to a back leaf of a peritoneum, the segment is zabryushinno brought to a bubble and sewn to it a catgut. Wedge. observations confirmed funkts, full value of new nerve pathways after such operation. At most of patients the desire and any urination is recovered. Among the St. 350 patients operated thus at 70% the positive take is received. At the accompanying contracture of a neck of a bubble or sharp hypotonia of an internal sphincter it is reasonable to combine an ileovezikopeksiya with a section or strengthening of a neck of L. S. on V. M. Derzhavina (fig. 11). At defeat of the intramural nervous device and a secondary atony of a detruzor it is shown an autotsistodublikatur (fig. 12) — doubling of own wall of a bubble, and at easier forms — a remuskulyarization by direct muscles of a stomach (fig. 13).

The amyloidosis of a bladder meets very seldom, being one of manifestations of primary amyloidosis of urinogenital bodies (see. Amyloidosis ).

Circulatory disturbances. 3 types of a circulatory disturbance of L. S. are observed: arterial hyperemia, ischemia and venous (congestive) hyperemia of a wall of L. S. Circulatory disturbances most often have focal character and are localized usually in a neck of L. S. and a vesical triangle, but can have total character. The arterial hyperemia of L. S. arises generally at inflammatory diseases and malignant tumors of female generative organs, and also at pregnancy. At an arterial hyperemia of L. S. frustration of an urination at absence in urine is possible patol, elements. At tsistoskopiya (see) the focal hyperemia and hypostasis of a mucous membrane of L. S is noted. Ischemia of walls of L. S. is often observed at weakness of patrimonial activity, discrepancy between a head of a fruit and capacity of a small pelvis, long childbirth, imposing of obstetric nippers or vacuum extraction of a fruit. In these cases of L. S. it is long it is restrained or squeezed between pelvic bones and a head of a fruit. Ischemia of walls of L. S. arises also owing to long spasms of L. S., radiation therapy and an injury of L. S. The venous hyperemia of L. S. can be caused by the general (e.g., owing to a circulatory unefficiency) or the local reasons (pregnancy, diseases of internal female generative organs, adenoma of a prostate, a delay of an urination, a vein thrombosis of a basin and so forth). At a venous hyperemia of L. S. the mucous membrane, especially in a neck and a vesical triangle, has cyanotic-red color, varicose veins, to-rye sometimes are a bleeding point.

At a circulatory disturbance of L. S. to lay down. actions shall be directed to improvement of blood circulation in a cavity of a small pelvis. At bleeding from L. S. use of hemostatics, hemotransfusion and blood substitutes is shown. At the menacing bleedings the high section of L. S. with the subsequent stop of bleeding and drainage of L. S is shown.

Gangrene of a bladder. Understand an inflammatory necrosis of a wall of L. S as gangrene of L. S. Gangrene generally is result of disturbance of blood circulation of L. S. Its development is promoted by disturbances of outflow of urine, sometimes accidental introduction to a cavity of L. S. of the concentrated solutions of chemical substances, and also inf. diseases. Gangrene of L. S. can arise also in cases of organic diseases of c. N of page, at a diabetes mellitus etc.

Benign gangrene of L. S. (pseudomembranous cystitis) is characterized by leukocytic infiltration and adjournment on a mucosal surface of a cover of films of fibrin of more or less considerable thickness, sometimes disintegration of surface layers of a mucous membrane. More severe form of gangrene of L. S. (hymenoid cystitis) is characterized by the necrosis of a mucous membrane extending to a muscular layer of L. S. and taking sometimes all thickness of its wall.

Gangrene of L. S. in most cases proceeds very hard with sharp disturbance of the general condition of the patient, high temperature, a fever, vomiting, an abdominal pain. Urine muddy, alkali reaction, has a putrefactive, fetid smell, contains a significant amount of blood and fibrin, scraps of a devitalized mucous membrane. At a tsistoskopiya the mucous membrane of L. S. looks edematous, is covered with fibrinous films of gryaznosery or brown color; the affected area is surrounded with a line of demarcation, on a cut the devitalized mucous membrane is torn away.

The disease can be complicated by perforation of L. S., phlegmon of paravesical cellulose and purulent peritonitis. A frequent complication of gangrene of L. S. is ascending pyelonephritis (see) and urosepsis.

Treatment: imposing of suprapubic fistula, use of antibacterial agents, washings of L. S. antiseptic solutions. At a favorable outcome depending on depth of defeat of a wall of L. S. comes or a complete recovery of a mucous membrane and function of L. S., or its wrinkling.

The ulcer of a bladder is observed quite often. Except specific inflammatory and parasitic diseases, and also new growths of L. S., the circulatory disturbance and an inflammation of L. S. of nonspecific character can be an origin of an ulcer. Distinguish 3 types of ulcers of L. S. of nonspecific character: a simple ulcer, an ulcer at intersticial cystitis and a trophic ulcer.

Fig. 14. A cystoscopic picture at the patient with an ulcer of a bladder: and — a simple ulcer; — a trophic ulcer.

The simple ulcer of L. S. — a rare disease, is observed preferential at female persons at young and middle age. The ulcer is caused by disturbance of blood circulation of a wall of L. S. owing to an embolism of a large vessel, septic thrombosis, a prelum of vessels inflammatory infiltrate. Usually simple ulcer of L. S. of an odinochn. Several stages of its development — from superficial exfoliating of a mucous membrane before destruction of all layers of a wall of L. S are observed. The simple ulcer is followed by an urodynia and a hamaturia. The urination is usually not speeded up since the capacity of L. S. does not change. At a tsistoskopiya find roundish defect of a mucous membrane, diameter to-rogo usually does not exceed 2 cm. The ulcer has smooth, accurate edges and a brilliant bottom (fig. 14, a). Mucous membrane around an ulcer, except for a thin corbel of a hyperemia, normal. Most often the ulcer is localized on a top of L. S., is more rare on a sidewall, is extremely rare in the field of a vesical triangle. The slightest hiting at to an ulcer the tool causes sharp pain and bleeding.

The ulcer of L. S. at intersticial cystitis results from defeat first of all of subepithelial fabric, and then a mucous membrane and other layers. There is an ulceration of a mucous membrane, often linear form, wrinkling of L. S. to reduction of its capacity and the expressed dysuria.

The trophic ulcer of L. S. develops hl. obr. after radiation therapy of diseases of female generative organs, a rectum, etc. Such ulcer has the flat or subdug edges, to-rye become dense and sclerosed eventually; the bottom is usually covered with a necrotic plaque (fig. 14, b). The ulcer badly heals and can lead to burrowing. Capacity of L. S. decreases, the dysuria and a terminal hamaturia is observed.

The differential diagnosis is carried out with tuberculosis, syphilis, a schistosomatosis and a tumor of L. S. The endovesical biopsy has major importance.

Conservative treatment of ulcers of L. S. consists in use of fortifying means, fabric drugs, vitamins, novocainic blockade, instillations in L. S. of 5% of solution of novocaine, fish oil, an emulsion with antibiotics, methyluracil, injections of glucocorticoids in affected areas of L. S. At unsuccessfulness of conservative treatment resort to a resection of L. S., supplementing it if necessary with intestinal plastics of L. S., change of ureters in a sigmoid colon or on skin. In case of perforation of an ulcer the urgent laparotomy, a resection of L. S. with the subsequent cystostomy and drainage of paravesical cellulose is shown.

Inflammatory diseases

Most often meets cystitis (see), to-ry can proceed in an acute or chronic form.

Tuberculosis of a bladder is always the secondary process arising most often owing to a nephrophthisis; much more rare as a result of spread of an infection from primary centers of tuberculosis in generative organs (see Tuberculosis of urinogenital bodies). At a nephrophthisis process in L. S. begins with a focal hyperemia in the field of the mouth of an ureter, a rash of tubercular hillocks, their ulceration with formation of deep ulcers and hems. Walls of L. S. are thickened, replaced with cicatricial fabric, there is a wrinkling of L. S., the switching mechanism of mouths of an ureter with emergence of a vesicoureteral reflux is broken.

The main symptom of tuberculosis of L. S. is the dysuria. Frequency of an urination constantly increases, it becomes painful, is followed by a pyuria and a terminal hamaturia. Capacity of L. S. gradually decreases.

Fig. 15. A cystoscopic picture at the patient with tuberculosis of a bladder: and — tubercular hillocks (1); — ulcers (2) in a bladder.

Crucial importance for diagnosis of tuberculosis of L. S. have detection in urine of tubercular mycobacteria, specific changes at a tsistoskopiya and a X-ray analysis of kidneys and uric ways. At the urinogenny descending distribution of process at a tsistoskopiya find a hyperemia and puffiness of a mucous membrane in the field of the mouth of an ureter of the affected kidney, typical small tubercular hillocks of yellowish color, with a nimbus of a hyperemia (fig. 15, a), ulcers with the uneven, subdug edges, the bottom to-rykh is covered with a grayish-yellow gnoynofibrinozny plaque (fig. 15,6). Sometimes find the tubercular granuloma simulating a tumor of L. S. Detection on excretory Urogramums or retrograde piyelogramma in kidneys and upper uric ways of kidneys of changes, characteristic of tuberculosis, allows to diagnose tuberculosis of L. S with bigger persuasiveness. On tsistogramma at tuberculosis of L. S. deformation of contours of L. S., a skoshennost of one of its walls, reduction of volume, a vesicoureteral reflux is observed.

Treatment consists in use of antitubercular drugs, vitamin therapy, fortifying and a dignity. - hens. treatments. At sharply expressed dysuria in addition apply topical treatment: instillations in L. S. of sterile fish oil, 20 — 30 ml of 5% of solution of Saluzidum, 5% of PASK solution (50 ml), an electrophoresis of Dicainum on area of L. S. At cicatricial wrinkling of L. S. resort to its plastics.

Syphilis of a bladder meets seldom. The wedge, picture it has no clearly expressed specific features. The disease proceeds as usual cystitis with the speeded-up and painful desires to an urination, at this or that degree of a pyuria. More often than at other forms of cystitis, the hamaturia appears; constancy and its firmness can serve as the directing symptom to a certain extent. It is not always easy to find in urine existence of a pale spirochete. At a tsistoskopiya in primary period of changes from L. S. practically do not find; in secondary there is a picture of ulcer cystitis almost different from other forms of similar defeats, in particular tubercular ulcers, but in the absence of hillocks, characteristic of tuberculosis. During the gummous period at a tsistoskopiya of L. S. reminds a picture of changes it at tumors. Speak well for the diagnosis of syphilis of L. S. the long and persistent course of the disease which is not giving in to usual methods of treatment, anamnestic data or existence of lyuetichesky defeats of other bodies and systems; positive Wassermann reaction has crucial importance (see. Wasserman reaction ), etc., and also bystry and almost always positive effect from specific treatment.

Parasitic diseases

the Schistosomatosis (bilgartsioz) of a bladder, the caused Schistosoma haematobium, is shown by a hamaturia, edges are more often than terminal character, and in case of accession of an infection — the speeded-up urodynia. At a tsistoskopiya signs hron, courses of a disease are pale, a little vaskulyarizovanny mucous membrane with sites of calcification in the form of grains of sand, deformation of mouths of ureters. At an aggravation of process find shistosomatozny hillocks, ulcers, infiltrates and papillomas (see. Shistosomatoza ). On the survey roentgenogram of uric ways calcification of walls of L. S. and the lower third of ureters comes to light. Complications: narrowing of terminal department of an ureter with development of an ureterohydronephrosis, hron, pyelonephritis, a lithogenesis, wrinkling of L. S., cancer transformation. The diagnosis is established on the basis of detection in urine of eggs shistosy, given to a tsistoskopiya, rentgenol, by inspections. At the erased forms the endovesical biopsy is important. Treatment: drugs of trivalent antimony (potassium antimonyl tartrat, fuadin, astiban), tioksantonovy connections (nilodin, etrenol), niridazol (ambilgar). At complications operational treatment after the previous chemotherapy is shown. Make usually an ureterocystoneostomy, at the wrinkled L. S. — a sigmotsistoplastika or an ureterosigmostomy.

Filariasis of a bladder. A characteristic symptom of the disease caused by Wuchereria bancrofli and Brugia malayi helminths (see Filariases), is defeat limf, systems with the discoloration of urine reminding the milk diluted with water. Staz of a lymph leads to expansion and a rupture of the changed vessels with emptying of contents in uric ways (see. Chyluria ). Vessels in a zone of pyelocaliceal system are broken off limf, is more rare in other departments of an uric path. The emulsified neutral fats which are contained in a lymph give to urine whitish color, intensity to-rogo changes depending on character of food of the patient. Sometimes at the expense of impurity of blood urine has cream or even brown color (gematokhiluriya). Except fat, erythrocytes and leukocytes, urine contains a lot of protein, including and fibrinogen that causes formation of the clots breaking outflow of urine from a pelvis and causing thereby emergence of pains or even renal colic, and at formation of clots in L. S. — the complicated urination or an ischuria. At a tsistoskopiya the expiration from the mouth of an ureter at its reduction of urine of lactescence is visible. The diagnosis is established on the basis of detection of microfilarias in blood and urine. Localization of an anastomosis between lymphatic and uric systems is defined with the help limfografiya (see). Symptomatic treatment; the diet with restriction of fats is recommended. Reception of a dietilkarbamazin (ditrazin) is reasonable. In cases of a persistent chyluria operational treatment, including transurethral electrothermic coagulation of lymphatic fistulas, a segmented resection of L. S is shown.

An echinococcosis of a bladder develops extremely slowly. The parasitic cyst of a small pelvis or paravesical cellulose squeezes L. S. or sprouts its wall, being emptied sometimes in its gleam. The wedge, symptomatology depends on localization of a cyst. Complaints of patients to frustration of an urination or defecation are combined with objective data — emergence of tumorous education over a pubis or in perirectal cellulose, a pyuria and a hamaturia at break of a cyst in L. S. The delay of an urination is possible. The diagnosis is made on the basis of simultaneous defeat echinococcosis (see) others of the bodies given to a palpation, a rectal research, a tsistoskopiya (the protrusion of a wall of a bubble of rounded shape covered with not changed or hyperemic mucous membrane), tsistografiya (deformation of contours), a lab. researches (eosinophilia, positive immunol, reactions, existence in urine of affiliated echinococcal cysts). Treatment operational — removal of cysts with paravesical cellulose and a resection of an affected area of a wall of L. S.

A trichomoniasis of a bladder — a complication of a mecotic urethritis. Develops in the ascending urigenous way. Meets more often at women. Trichomonas vaginalis activator. The arising cystitis in most cases is caused not only a trichomoniasis (see), but also the accompanying bacterial flora. The main wedge, symptoms: speeded up and an urodynia, a pyuria, a hamaturia. The cystoscopic picture is not characteristic. The diagnosis is established on the basis of detection of trichomonads in the second portion of urine; in case of their absence investigate a discharge from an urethra and a vagina. Complex treatment includes antibiotics of a broad spectrum of activity, Trichopolum, flagyl, washing of L. S. solutions of oxymercurous cyanide, Furacilin, caustic silver, injection in L. S. of solution of Osarsolum with levomycetinum. Treatment is successful only during the performing prevention of reinfection by sanitation of the centers in generative organs and simultaneous treatment of the spouse.

Stones of a bladder. In addition to the general reasons of a lithogenesis, to-rye are found out not completely, promotes emergence of stones in L. S. staz urine. Stones of L. S. occur most often at boys owing to relative narrowness of an urethra and a phymosis, and also at elderly men at adenoma of a prostate. Thanks to the smaller length and bigger diameter of an urethra stones of L. S. occur at women much less often.

The stones formed in L. S. can be primary, however more often they are formed in kidneys in the beginning and then depart in L. S., increasing owing to stratification of uric salts (secondary stones).

Distinguish the free and fixed stones. Free stones are initially formed in L. S. or depart from kidneys, fixed develop in a diverticulum of L. S. or on a ligature, foreign bodys.

Promote formation of stones of L. S. of a tumor of a prostate, hron, cystitis, a contracture of a neck, diverticulums of L. S., neurogenic L. S., strictures of an urethra. Besides, foreign bodys of L. S., egg shistosy can be a kernel for formation of stones. A surface, color, a consistence and chemical structure of stones of L. S. same, as well as at stones of a renal origin. The structure them is defined chemically, crystallographic or a physiographic method (see. Urinary stones ).

Symptoms: pain, frustration of an urination and change of character of urine. Pain often develops during the walking or jolty driving. It has characteristic irradiation — to the area of a crotch, a small egg or a balanus. Pain amplifies in the presence of aculeiform stones (oxalates) or at often found accompanying cystitis and is caused by movement of a stone and irritation of a mucous membrane, especially necks of L. S. as most prolific receptor zone.

Frustration of an urination are shown by hl. obr. increase of desires, their strengthening at the movement (in a quiet state they become more rare, and during sleep stop). L. S., typical at stones, is the sudden termination of a stream of urine during an urination (a symptom of «jamming») and resuming of an urination at change of position of a body of the patient therefore the put stone is rolled away from a neck of L. S. Small stones can be restrained in a back urethra and cause an acute ischuria. Quite often patients have an incontience of urine when the stone is located with one part in L. S., and another is in a back urethra. In these cases full short circuit of a sphincter of L. S. is impossible that defines involuntary release of urine. Long finding of a stone in a neck of L. S. and a back urethra leads to their sclerosis therefore the incontience of urine can remain also after removal of a stone.

Changes of character of urine at stones of L. S. are characterized by a micro and gross hematuria that is explained by an injury of a mucous membrane of a bubble. Emergence of leukocytes and microflora in urine indicates an inflammation of L. S. Depending on structure of a stone in urine the corresponding salts are found.

Stones of L. S. can be found at introduction of a metal catheter (buzh) to a bubble: friction is felt, and at dense concrements — oxalates, urates — knock of the tool about a stone. This procedure is made at the filled L. S. More exact diagnostic method is the survey X-ray analysis, on the basis the cut can be judged quantity and the size of stones. In case of X-ray negative stones (tsistinovy, proteinaceous) they can be found in military by a pnevmotsistografiya or a tsistografiya with solution of a contrast agent. In these cases defects of filling indicate existence of a stone. The final diagnosis is established on the basis of a tsistoskopiya. Tsistoskopiya it is not always possible to find the stone located in a diverticulum of L. S.

The standard methods of treatment are lithotripsy (see) and lithotomy (see).

A leukoplakia of a bladder — keratinization of a vesical epithelium, most often in a neck and a triangle. The keratosic sites of usually irregular shape with accurately outlined edges adjoining with not changed or slightly inflamed mucous membrane. Centers leukoplakias (see) tower over a mucous membrane. It is most often observed at women at the age of 30 — 40 years. Patients complain on speeded up, an urodynia day and night, the hamaturia is sometimes observed. In analyses of urine a large number of cells of the keratosic epithelium, leukocytes and erythrocytes. Diagnosis is based on a characteristic cystoscopic picture.

The disease is a consequence of chronic inflammatory process of urinogenital bodies. Treatment antiinflammatory using locally hydrocortisone or electrothermic coagulation of the keratosic sites.

A malakoplakia of a bladder — the soft plaque most of which often is localized in the field of a triangle and on a back wall of a neck of L. S. Etiology malakoplakias (see) it is not found out, women are ill more often. A characteristic symptom is long cystitis. At a tsistoskopiya white-yellow educations decide on the equal contours towering over not changed mucous membrane. The quantity of plaques can be big, quite often they merge among themselves, occupying mouths of ureters.

The diagnosis is established on the basis of an endovesical or operational biopsy or at operation for a tumor of L. S. Symptomatic treatment; electrothermic coagulation of plaques of a malakoplakia is possible.

Endometriosis of a bladder — existence in a submucosa of a wall of L. S. of the tumorous education morphologically similar to an endometria. Defeat of L. S. makes 2% of all cases endometriosis (see). The etiology of a disease is not found out, however there is an assumption of development in a submucosa of the cells of an endometria which got lost in the embryonal period. As the reasons of development of a disease it is possible to consider abortions, a metrosalpingografiya, use of contraceptives.

Characteristic symptoms of a disease are unpleasant feelings in suprapubic area, to-rye amplify in the period of periods. During this period the dysuria, a micro or gross hematuria appear. Intensity of pain and a dysuria depends on localization patol, process. Symptoms in cases when the endometriozny node is located in the field of a vesical triangle and a neck, during the involvement in process of mouths of ureters are most expressed. Diagnosis of endometriosis is based only on the tsistoskopiya which is carried out to various periods of a menstrual cycle. At a tsistoskopiya during the intermenstrual period find the education acting in a gleam of L. S. with not changed mucous membrane or cysts of cyanotic color: around a node the dense network of vessels is defined. During periods the node of endometriosis increases, appears hypostasis and a hyperemia, vessels around an endometriozny node become more injected.

Treatment is operational, consisting in full excision of an affected area. Nek-ry clinical physicians recommend a roentgenotherapy, the edge, however, is not a radical method of treatment.

Fig. 16. Tsistogramma at the patient with a true diverticulum of a bladder (it is specified by an arrow).

Diverticulum of a bladder — sacculate protrusion of a wall of L. S. — quite often found pathology of the inborn or acquired character. A true (inborn) diverticulum — result of the wrong formation of a wall of L. S. in the field of a vesical triangle. Educated small protrusion in the form of a sack (sacculus) under the influence of inside vesical pressure gradually increases, displacing the mouth of an ureter. Loss by an ureter of a muscular support leads to emergence of a vesicoureteral reflux. Sacculus occurs preferential at girls of 3 — 10 years and can be revealed at a tsistografiya. With age its frequency decreases that is connected with «ripening» of an ureterovezikalny anastomosis. The true diverticulum of L. S. is more often single and is located on a posterolateral surface of a bubble (fig. 16). The false (acquired) diverticulum represents protrusion of a mucous membrane between bunches of the hypertrophied, trabekulyarno changed detruzor. Infravezikalny obstruction (tumors of a prostate, a contracture of a neck of L. S., valves and strictures of an urethra), and also neurogenic leads L. S to formation of a false diverticulum. False diverticulums more often happen multiple, small. They can be located in all departments of L. S., except a vesical triangle. The diverticulum long time can proceed asymptomatically. At its big sizes there is a symptom of an urination in two steps, and also the complicated urination, up to its full delay. Sometimes in suprapubic area the swelling disappearing after catheterization of L. S is palpated. At a big diverticulum in L. S. there is always a residual urine, edges is easily infected, causing in the subsequent emergence of such complications as a diverticulitis, ulcer and hemorrhagic cystitis, and in the presence of a vesicoureteral reflux and pyelonephritis. In a diverticulum also formation of stones or tumors is possible that is followed, as a rule, by a pyuria and a hamaturia.

In recognition of a diverticulum of L. S. the tsistoskopiya has essential value, at a cut find an entrance to a diverticulum. At a true diverticulum the mucous membrane in the field of an entrance to a diverticulum has radiarny folds. The acquired diverticulums usually happen multiple, superficial, inlet opening has no characteristic skladchatost. Sometimes it is possible to consider stones or a tumor in a diverticulum. Tsistografiya executed in direct and side projections reveals the additional cavity which is reported with L. S. It is sometimes reasonable to execute tsistografiya) during an urination, at the moment to-rogo there is a pelting of X-ray contrast liquid in a cavity of a diverticulum. At excretory Urografinum is established by changes in upper uric ways at falling of an ureter into a diverticulum or a prelum of an ureter by a diverticulum. At the descending tsistografiya it is also possible to find diverticulums of L. S. and to define existence and quantity of a residual urine. Sacculus and small diverticulums with a wide neck which are not followed by a vesicoureteral reflux, as a rule, of treatment do not demand. The big sizes the true diverticulum is recommended to be excised. If at the same time the ureter opens in a diverticulum, then make ureterocystoneostomy (see). Treatment of a false diverticulum is connected with elimination infravezikalyyuy obstructions and recovery of a normal passage of urine; big diverticulums delete.

The forecast after timely made operational treatment favorable.

Cystoceles — loss of its wall through hernial gate. More often happen inguinal and femoral, seldom sciatic, locking, hernias of the white line and perineal.

Distinguish intraperitoneal, extra peritoneal and okolobryushinny hernias of L. S., at to-rykh hernial protrusion on a bigger or smaller extent (but not completely) it is covered with a peritoneum. Hernias of L. S. subdivide also on true and false. False arise during operation of herniotomy as a result of extraction in an operational wound of a wall of L. S.

In an etiology of hernia of L. S. weakness of a front abdominal wall, its aponeuroses, abnormal width of natural foramens and cracks, obstacles to emptying of L. S matter. On the mechanism of herniation of L. S. are sliding.

In a wedge, a picture it is characteristic: existence of the hernial protrusion changing the sizes depending on a degree of admission of L. S., an urination in two steps, an ischuria, increase of an urination. Sometimes the patient to urinate, shall squeeze hernial protrusion. At accession of an infection the pyuria is observed.

Quite often hernias of L. S. diagnose during operation, after damage of a wall of L. S., and sometimes only in the early postoperative period on release of urine from a wound when damage of a wall of L. S. remained during operation unnoticed. Diagnosis of hernia of L. S. is based on data of a tsistoskopiya and tsistografiya, to-rye allow to specify existence, size and a form of hernia.

Complications of hernia of L. S. — an inflammation, stones, tumors of L. S., infringement, damage of a wall of L. S. during operation.

Treatment operational: mobilization of L. S., its separation from a peritoneal hernial bag, at hernias of big size — a resection of the dropped-out part of a vesical wall, audit of a cavity of L. S. and plastic of the hernial channel. During the opening of a gleam of L. S. it is drained through suprapubic fistula or by means of a constant catheter.

Tumors

Tumours of L. S. occur in 1,3 — 3,2% of cases among all new growths. They are observed preferential aged from 50 up to 70 years, is more often at men.

Classification

Exists histologic and clinical classifications of tumors of L. S.

Gistol, classification is created at the initiative of WHO in 1973 by I. Epithelial tumors. Transitional cell papilloma; the inverted type of transitional cell papilloma; planocellular papilloma; Schmincke's tumor and its options: with a planocellular metaplasia, with a ferruterous metaplasia, with a planocellular and ferruterous metaplasia; planocellular cancer; adenocarcinoma; undifferentiated cancer. II. Not epithelial tumors: high-quality; malignant; rhabdomyosarcoma. III. The mixed group of tumors: pheochromocytoma; lymphoma; carcinosarcoma; malignant melanoma, etc. IV. Secondary tumors. V. Not classified tumors. VI. Not tumoral changes of an epithelium: papillary «cystitis»; Brunn's nests; cystous «cystitis»; ferruterous metaplasia; «nephrogenic adenoma»; planocellular metaplasia. VII. Opukholepodobny changes: follicular cystitis; malakoplakia; amyloidosis; fibrous (fibroepitelialny) polyp; endometriosis; gamartoma; cysts.

Klien, classification of epithelial tumors of L. S. is offered in 1963. International anticarcinogenic union. In it primary tumor is designated by a letter T, regional limf, nodes — N and the remote metastasises — M; additional designations at these letters testify to extent of distribution of process: T — primary tumor; TIS — preinvazivny cancer (carcinoma in situ); T1 — a tumor infiltrirut subepithelial connecting fabric, without extending to a muscular coat; T2 — a tumor infiltrirut an outside longitudinal muscular layer; The T3 — a tumor infiltrirut an inner longitudinal muscular layer; T4 — a tumor infiltrirut paravesical cellulose or sprouts the next bodies; N — regional limf, nodes; Nx — a state limf, nodes it is impossible to estimate; after gistol, researches limf, nodes the Nx symbol can be added: Nx_ — metastasises are not found, Nx + — metastasises are found; Nx — metastasises are defined radiological or tracer techniques; M — the remote metastasises; M0 — metastasises are not found; M1 — metastasises in the remote bodies and (or) in limf, the nodes located above bifurcation of the general ileal arteries are available.

Fig. 17. A cystoscopic picture at the patient with papilloma of a bladder: a new growth (it is specified by an arrow) with gentle freely floating fibers.

Benign tumors in L. S. meet seldom. The ground mass (98%) is made by tumors of the epithelial nature. There are several theories of an origin of epithelial tumors of L. S.: chemical, inflammatory, virus, polyetiological. Among these tumors the special place belongs to papillomas (10 — 30%), to-rye by outward and a microscopic structure are high-quality, however clinically behave as malignant. So, 24% of cancer of L. S. arise from initially benign papillomas. The main symptom of papillomas is the gross hematuria, edges can be total or terminal; the last is characteristic at localization of papillomas in a neck of L. S. Diagnosis comes easy, there is usually enough tsistoskopiya. Visually papillomas have an appearance of the single or multiple freely floating nezhnovorsinchaty growths on a thin leg (fig. 17). Treatment consists in endo-and transvesical electrothermic coagulation, a transurethral electroresection and a cystectomy (at a diffusion papillomatosis). Apply intravesical introduction of TIOTEFA, adriamycin to prevention of a recurrence of a disease.

Cancer of a bladder

In the USSR at men takes the 5th place and at women — the 16th. Favourite localization are the area of a vesical triangle, the mouth of ureters and a neck of L. S. From the factors promoting development of cancer of L. S. it is possible to call the following: smoking; hron, an ischuria at adenoma of a prostate, a diverticulum, a contracture of a neck of a bladder, a stricture of an urethra; schistosomatosis or bilgartsioz; chronic inflammatory processes. Very seldom cancer of L. S occurs at workers of aniline, rubber and oil industry professional, or aniline.

It is proved that aniline has low carcinogenic activity, and its derivatives matter (betanaftalamin, benzidine, 4 aminodiphenyl).

Fig. 18. A cystoscopic picture at the patient with fleecy cancer of a bladder: a massive grubostrukturny tumor in the form of a cauliflower (it is specified by an arrow).
Fig. 19. A cystoscopic picture at the patient with solid cancer of a bladder: the dense tumor (1) occupying area of the mouth of an ureter a part of a tumor is covered with salts of phosphates (2).

Most often the Schmincke's tumor and its options meets. Papillary growth and a large number of fleecy growths with sites of a necrosis (fig. 18 and 19) is characteristic of it. Very much rapid growth and early innidiation are inherent to a Schmincke's tumor with a planocellular metaplasia. Much less often planocellular cancer meets, to-ry differs in endophytic growth, has the fungoid or saucer-shaped form, is frequent with an ulceration; opinions on his tendency to innidiation are contradictory. The third place on frequency is taken by an adenocarcinoma, edges most often has the nodal form, but sometimes and papillary. Metastasizes late.

Cancer of L. S. extends on lymphatic or to blood vessels or by direct growth. Metastasises are found in regional limf, nodes, a liver, bones.

Most often cancer of L. S. is shown by a gross hematuria, and also leukocyturia (see), arising owing to the accompanying inflammation, and dysuria (see), more characteristic of infiltriruyushchy tumors. Clinically cancer of L. S. differs relatively in drift; long time process remains local. Due to the frequent localization in the field of a vesical triangle and mouths of ureters in a wedge, a picture on the first place changes from upper uric ways in the form of the attacks of pyelonephritis can act, hron, a renal failure etc. The main diagnostic method is the tsistoskopiya. The conjoined manipulation made under anesthetic quite often helps to define a stage of process. Such methods as tsitol, the research of urine, the excretory urography descending and a retrograde tsistografiya, a peritsistografiya, a sedimentary tsistografiya, a lacunary tsistografiya, a direct limfografiya, a limfoskanirovaniye, an ekhografiya, a computer tomography, pelvic arteriography, a flebografiya, have auxiliary value.

Cancer therapy of L. S. generally operational; apply endo-and transvesical electrothermic coagulation, a cryolysis, a transurethral electroresection, a resection of L. S., a simple and expanded cystectomy. The first three ways apply seldom, preferential at the I stage at patients with considerably the expressed associated diseases, for to-rykh radical operational treatment represents big risk. Carry a resection of L. S. with an ureterocystoneostomy to radical methods of operational treatment or without it, simple total or radical total cystectomy (see). The total cystectomy is applied at localization of a tumor in a neck, a vesical triangle, at widespread defeat of a bubble. At impossibility of radical operation palliative interventions are shown: cystostomy, piyelonefrostomiya, ureterocutaneostomy.

The chemotherapy of cancer of L. S. is carried out with the medical and preventive purpose, applying one or at the same time several drugs; enter their peroral, intravesical, intravenous or intra arterial in the ways. The most effective drugs are adriamycin, diiodbenzotephum, 5-ftoruratsit, a methotrexate, Bleomycinum, mitomitsin Page.

Radiation therapy has the greatest value in late stages of a disease when surgical treatment in view of neglect does not yield satisfactory results. Use static or mobile gamma therapies (see), and also a bremsstrahlung of betatrons and linear accelerators expands indications and increases its efficiency. The long-term results improve at use of radiation therapy before or after operation. Preirradiation is shown at cancer of the I—II, the III stages of a disease are more rare, and also at a possibility of organ-preserving operation (a resection or a resection with change of ureters). Preirradiation creates conditions of an ablastika for the subsequent operation, and also can transfer a tumor to a resectable state. Postoperative radiation therapy is shown at insufficiently radical or doubtful operation on radicalism.

Independent radical radiation therapy is shown at the I—III stages of a disease when because of the general contraindications or failure of the patient operation is not applied, and also at a recurrent tumor after operation.

The indication for palliative radiation therapy is the IV stage of a disease complicated by dysfunction of uric ways, pyelonephritis.

Contraindications — a cachexia, an urosepsis, big tumors with disintegration and danger of developing of fistulas, beam damages.

The philosophy of radiation is local impact directly on a tumor and on the way of a regional lymph drainage at the maximum shchazheniye of healthy fabrics and surrounding bodies.

For remote radiation therapy gamma and therapeutic installations, and also linear accelerators and betatrons, and are applied to intracavitary radiation — the hose device «Agate — V-5». At a rhythm of radiation 5 weekly a single focal dose 180 — 200 I am glad, the total focal dose shall not exceed 6500 is glad. Exceeding of a dose does not improve the long-term results and increases risk of emergence of complications. Apply «the split course» to the prevention of reaction and complications — with a break in treatment to 2 — 3 weeks on a dose 3000 — 4000 I am glad. At postoperative radiation therapy total focal doses shall not lower than 5000 be glad.

In the course of radiation and after it there can be beam reactions and complications (see. Beam damages ). Extent of manifestation and duration of their current depend on localization and a stage of a tumor, a condition of the patient, a rhythm of radiation, a single and total dose, and also the sizes of fields of radiation. The forecast at cancer of L. S. depends on a stage of process and methods of treatment. After radical operation 5 and more years live from 20 to 60% of patients.

OPERATIONS

the Most frequent operations on L. S. are a suprapubic puncture, out of - and the intraperitoneal section, a diverticulectomy, sewing up of a wall of L. S. at its damages, drainage paravesical) spaces, plastic surgeries concerning urinogenital fistulas, plastic of a neck of L. S. at its contracture, the open and transurethral electrothermic coagulation, electroscission and a cryolysis applied generally at small tumors of L. S. At the considerable sizes of a tumor apply a resection of L. S., a simple and radical cystectomy with partial or full substitution of a bubble a segment of a gut. Similar operation make also at wrinkled, or small, L. S. In some cases carry out plastic surgeries on L. S. in connection with a vesicoureteral reflux and for the purpose of substitution of the lower third of an ureter.

Nek-ry operations on L. S. (a suprapubic puncture, cystostomy) can be made under local anesthesia. More difficult surgeries, as a rule, carry out under inhalation anesthesia (see).

Operational approaches to L. S. carry out through a front abdominal wall, is rare through a crotch and a vagina. A slit on the centerline of a stomach, cross, arc-shaped nadlonny and pararectal cuts are the most widespread (see. Laparotomy ).

Fig. 20. The diagrammatic representation (a sagittal section) of a bladder at a transdermal puncture of a bladder: 1 — a kosha; 2 — a cavity of a bladder; 3 — a pubic bone; 4 — the needle with mandrin entered into a cavity of a bladder.

Suprapubic transdermal puncture of a bladder it is shown at an acute ischuria when catheterization of L. S. is impossible and there are no conditions for performance of cystostomy or when there are contraindications to catheterization, napr, acute cystitis. The puncture of L. S. is made more often at the ischuria caused by adenoma of a prostate at an injury of an urethra, injury of a spinal cord (a neurogenic bladder) when frequent catheterization is required. The suprapubic puncture of L. S. is carried out or by a so-called capillary puncture, or a puncture a trocar. The capillary puncture is applied also for the purpose of receiving urine to a special research, and also to an antegrade tsistografiya. For this purpose on the centerline of a stomach by a thick needle 1,5 — 2 cm higher than a pubis do in a stake perpendicularly to a longitudinal axis of a body of the patient. The termination of resistance to introduction of a needle indicates finding of its tip in a bubble (fig. 20). On a needle urine begins to follow a stream. Further the syringe suck away as much as possible urine from a bubble and subjects prevent the subsequent outpouring it in surrounding fabrics. If necessary the capillary puncture is repeated. The trocar puncture of L. S. is made for the purpose of long drainage of a bubble. Under local anesthesia on the centerline of a stomach 1,5 — 2 cm higher than a pubis stick perpendicularly an edge of a trocar in the direction of L. S. After penetration of the end of a trocar into a free cavity extract mandrin and on a cannula of a trocar produce urine. Through a gleam of mandrin enter a rubber catheter into L. S. Holding a catheter, take a cannula of a trocar. The free end of a catheter is fixed to skin an adhesive plaster. After extraction of a catheter fistula usually heals within several days.

Diverticulectomy. Under the general anesthesia by midsection of an abdominal wall over a pubic symphysis bare L. S. After crossing of a fold of an uric channel will mobilize the corresponding half of L. S. on a big extent and gradually allocate a diverticulum from unions, watching to wounding an ureter. It is more reasonable to open at the same time L. S., to enter a finger into a diverticulum or to fill it with a gauze tampon and thanks to it to stick out a diverticulum as much as possible of a knaruzha. Such reception allows to allocate a diverticulum from commissures up to his neck. Then the diverticulum is cut and on the formed defect puts 2 rows of noose sutures. If one of ureters opens in a diverticulum, then the ureter is crossed and make an ureterocystoneostomy. The wound of a front wall of L. S. is sewn up tightly, and paravesical cellulose is drained. Enter into a bubble on an urethra a constant catheter for 5 — 7 days. If the bag of a diverticulum is not soldered to surrounding fabrics, then enter a packer into a bubble, capture by him a bottom of a diverticulum and turn out as a stocking, in a cavity of L. S. The turned-out diverticulum at a neck is cut. The formed defect is sewn up tightly with two-row noose sutures.

Operations at injuries of a bladder. Serve as indications out of - and intraperitoneal ruptures of L. S. At an extra peritoneal rupture of L. S. make longitudinal or cross nadlonny abdominal section. Allocate and open a front wall of L. S. Evacuate from paravesical checkered the streamed urine and blood. Find the point of fracture of L. S. and take in defect two-row catgut seams. Impose to tsistosty. After introduction to paravesical cellulose of rubber drainages the operational wound is sewn up. In case of an intraperitoneal rupture of L. S. open an abdominal cavity, drain it from urine and blood. Find and sew up the place of damage of L. S., taking an adjacent leaf of a peritoneum in seams. Then put a deaf stitch on a peritoneum. Create tsistosty, enter drainages into paravesical cellulose, to-rye delete on 5 — the 6th days, and a tsistostomichesky tube — for the 10th days.

Drainage of a small pelvis across Buyalsky — Mac-Uortera is applied to treatment or the prevention of uric zatek and abscesses of a cavity of a small pelvis at extra peritoneal ruptures of L. S., a back urethra, after a resection of L. S. and other operations on it.

A hip on the party of defeat take aside. 2 — 3 cm below than an inguinal fold on an inner surface of a hip cut skin and hypodermic cellulose throughout 1 — 2 cm. Adductors of a hip displace, stupidly stratify an outside locking muscle directly at nizhnemedialny edge of a locking opening. After that in the stupid way make the tunnel through a locking opening on border of the descending branch of pubic and sciatic bones and enter on it a rubber tube with several openings, avoiding damage of the locking vessels passing in a verkhnelateralny part of a locking opening. Duration of drainage depends on the nature of defeat or operation and on average 3 — 4 weeks equal.

Plastics of a neck of a bladder. As the indication serves the sclerous stenosis of a neck of L. S., a so-called disease of Marion. Under the general anesthesia open L. S. and, having convinced available a stenosis, cut longwise the sclerosed neck throughout about 1,5 cm. Then find a rag for what from an upper corner of a wound slantwise up carry out two additional side sections. The wound in the form of a letter Y is as a result formed. The top of the created rag is reduced and hemmed to a bottom corner of a section, and then put stitches on all line of a section. As a result instead of earlier Y-shaped the wound in the form of a letter Y turns out. Operation is finished with cystostomy (fig. 5). Such operation provides expansion of a neck of L. S. and normalizes a passage of urine.

Operational methods at new growths: 1) transurethral endovesical electrothermic coagulation or excision of a tumor or combination of excision and electrothermic coagulation; 2) suprapubic transvesical excision and electrothermic coagulation of a tumor; 3) a resection of a bubble with an ureterocystoneostomy or without it; 4) a cystectomy with an ureterosigmostomy or an ureterocutaneostomy, or with other methods of removal of urine (an ureteroileostomy on Brikkera, a kolotsistoplastik, etc.).

Transurethral endovesical electrothermic coagulation is carried out by means of devices for a diathermy (see. Diathermocoagulation ). After introduction to a bubble of the cystoscope find a tumor, bring to it closely the end of an active electrode and carry out coagulation. If the tumor has a long leg, then the end of an electrode is brought directly to a leg, carrying out, thus, all operation for one session. In case a leg of a tumor short and wide, it is necessary to coagulate a tumor in parts, sometimes in several sessions.

Electrothermic coagulation of a tumor on the opened bladder begin it with high section. The wound of a bubble is expanded by means of special mirrors or hooks. The tumor is carefully taken entirely at the basis special spoons and raise it. An electroknife make around the basis of a tumor an oval or roundish section through mucous and muscular covers otstupya from edge of a tumor not less than 2,5 cm. On the defect formed in a wall of a bubble put stitches. The vesical wound is closed tightly.

Fig. 21. Diagrammatic representation of stages of operation of a cystectomy for a malignant tumor: and — the abdominal cavity is opened, the bladder on a front wall is exempted from cellulose, the peritoneum (1) in the splice with a bottom of a bubble is excised on a front transitional fold; — the ekstraperitonization of a bladder (1) with excision of the site of a peritoneum (2) which is densely spliced with a bladder is made; defect of a peritoneum is taken in a continuous suture (3); in — the bladder (1) is widely opened, the wall of a bubble affected with a tumor (2) is excised.

The cystectomy is made most often concerning a tumor. Since it needs to be removed within healthy fabrics, the bubble is resected through all layers of a wall with the respective site of paravesical cellulose. The abdominal wall is opened with a nizhnesredinny or cross arc-shaped section over a bosom. Allocate a wall of L. S. and start its ekstraperitonization that is necessary for mobilization of body. The peritoneal cover, rykhlo soldered in anterosuperior, side and back departments with a wall of a bubble, easily separates in the stupid way. In the field of a top the peritoneum is soldered to a wall of a bubble more closely and opening of an abdominal cavity is required. For this purpose cross a median umbilical fold, impose a clip on its distal end and tighten a bubble of a kpereda. On a transitional fold open an abdominal cavity and continue the arc-shaped cuts of a leaf of a peritoneum in both parties (fig. 21, a). Having displaced several bubble of a kpereda, make from an abdominal cavity the second same section on a posterosuperior wall of a bubble; both sections connect together so on a top of a bubble there is an oval form a piece of a peritoneum. The wound in a peritoneum is sewn up with continuous sutures (fig. 21,6). For the purpose of a hemostasis tie up upper, and sometimes and lower vesical arteries and veins. After mobilization of a bubble it is widely opened with longitudinal or cross section. Then make excision of a bigger or smaller segment of a wall of a bubble where the tumor is located (fig. 21, c). It is necessary to carry out a section otstupya from edge of a tumor not less than on 2,5 cm. The formed defect of a wall of a bubble is taken in two-row knotty seams, imposed to tsistosty.

During the involvement in tumoral infiltrate of the mouth of an ureter or in case of an arrangement of a tumor near it make in addition an ureterocystoneostomy. For this purpose allocate a pelvic part of an ureter and cross it otstupya 3 cm from the place of falling into a bubble. Then replace an ureter in the rest of a bubble.

Boari's operation rather often finds application for the purpose of replacement of a distal part of an ureter with the rag found from a perednebokovy wall of L. S. This operation is usually made concerning an injury, by obliterations or strictures of the lower third of an ureter when the straight line cannot carry out ureterotsistoanastomoz (see. Boari operation ).

Tsistosigmostomiya (Maydl's operation and in Ternovsky and Michelson's modifications) is made at an ekstrofiya of L. S. After a laparotomy and mobilization of L. S. in a wound remove a segment of a sigmoid colon, longwise cut its front wall and connect edges of ekstrofirovanny L. S. and a gut a two-row seam.

Fig. 22. The diagrammatic representation of stages of operation on the Lexer — to Grégoire (back view): and — a section (it is specified by an arrow) a muscular layer of a wall of a bladder (1) over the place of a confluence of an ureter (2); — the ureter (2) is shipped in a section under a mucous membrane of a bubble (I), the section of a muscular layer is taken in by knotty seams.

Operation of the Lexer Grégoire is made concerning a vesicoureteral reflux (fig. 22). After an extra peritoneal exposure of L. S. allocate the terminal site of an ureter. Parallel to its course cut a muscular coat of a wall of a bubble up to a mucous membrane then to the created canal stack an ureter. The wound of a muscular coat is taken in over an ureter. Thus it is possible to extend considerably the submucosal course of an ureter that interferes with emergence of a reflux.

Along with operation of the Lexer — Grégoire at a vesicoureteral reflux Lidbetter's operation — Poly-tano finds broad application (see. Ureter ).

Endovesical (intravesical) operations carry out by means of the operating cystoscopes supplied with the special adaptation allowing to enter various tools into L. S. Treat endovesical operations: catheterization of ureters and extraction from them of a concrement, electrothermic coagulation of a tumor and ulcer, a section of the ureteric mouth at the ureterotsel and infringement of a stone in it (see. Ureter, malformations ), removal of a foreign body, a biopsy, a lithotripsy and an electrohydraulic lithotripsy (see. Lithotripsy ), a transurethral electroresection of a neck of L. S. concerning a tumor and adenoma of a prostate. Here the cryosurgery of new growths of L. S. belongs (see. the Cryosurgery, in urology ) and transurethral therapy laser (see).

The transurethral electroresection is made the resectoscope, the vesical end to-rogo has a mobile cutting loop. High-frequency current the loop is heated and progress carry out excision in parts of a new growth. By means of the electroresectoscope make also partial oncotomy of a prostate (see. Adenoma of a prostate ), and also the sclerosed fabric in a neck of a bubble.

The cryosurgery of new growths is carried out the special tool. It is entered on an urethra or through tsistosty into L. S. and make destruction of a tumor by means of low temperature. Operation is carried out under endoscopic control thanks to what it is possible to define precisely the place and depth of freezing of fabric. Duration of cryoinfluence shall not exceed 4 min. The bubble is previously filled with helium, and on the special cystoscope bring liquid nitrogen, nitrous oxide or liquid carbonic acid to a new growth. Operation of a cryolysis of L. S. can be executed also under control of the cystoscope trocar entered into a bubble by a puncture. At the same time as the cryoagent use the liquid nitrogen arriving to a tumor through a special urethral catheter. Cryosurgical treatment of new growths of L. S. and prostate is very perspective.

Cystectomy. On cystectomy (see) it is necessary apprx. 10% of all operative measures undertaken concerning cancer of L. S. There are several types of this operation. At a simple cystectomy at men delete L. S., a prostate and seed bubbles without excision regional limf, nodes, paravesical cellulose and an adjacent peritoneum; at women — L. S. and an urethra without excision of paravesical cellulose, an adjacent peritoneum, pelvic limf, nodes and genitalias.

At a radical cystectomy at men delete L. S., a prostate, seed bubbles with an adjacent peritoneum and paravesical cellulose, exsect pelvic regional limf, nodes (proksimalno, the middle of the general ileal arteries are not lower), excision continue to the periphery, including limf, nodes along internal and outside ileal vessels, and also nodes in the field of locking openings of a basin. At women, in addition to removal of L. S., an urethra, an adjacent peritoneum, paravesical cellulose and pelvic limf, nodes, operation includes a bilateral salpingooforektomiya, a total hysterectomy and removal of at least front wall of a vagina.



Bibliography:

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A. Ya. Pytel, B. A. Mokhort, B. S. Ryabin-sky, H. E. Savchenko; E. G. Aslamazov (paraz.), A. P. Yerokhin (malformations), M. N. Lantsman (gist., stalemate. An.), S. A. Osipovsky (physical.), I. A. Pereslegin (I am glad.), B. S. Revazov (An.), I. P. Shevtsov (soldier.), V. I. Shipilov (PMC.).

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