From Big Medical Encyclopedia

INTESTINAL PLASTICS in urology (Latin intestinum gut; grech, plastike sculpture, plastics) — operation on replacement patholologically the changed departments of uric ways (an ureter, a bladder, an urethra) pieces of intestines.

Tizzoni and Foggi (G. Tizzoni, A. Foggi) for the first time in 1888 in an experiment executed a cystoplasty the isolated loop of a small bowel. The first operations on closing of defect of a wall of a bladder with a piece of a gut at the person at an ekstrofiya (a malformation of a bubble) were made by Rutkovsky (M. Rutkowsky) and I. Mikulich in 1899. The idea of use of a small bowel for replacement of an ureter was introduced in 1894 by Fingerom (E. Finger), and its implementation in an experiment on dogs belongs to D'urso and De Fabia (G. D’Urso, And. De Fabii, 1900). In 1906 such operation with success was executed by J. Schoemaker on the patient with ulcer tuberculosis of a bladder and an ureter. The segment of a sigmoid gut is used by A. P. Frumkin (1960) for replacement of an urethra at men.

The significant contribution but to implementation of Nominative in a wedge, medicine was brought by domestic surgeons A. E. Melnikov (1912), A. V. Melnikov (1924), B. M. Garmsen (1925), A. T. Lidsky (1926), S. I. Spasokukotsky (1948), S. D. Goligorsky (1959), A. M. Gasparyan (I960), D. V. Kan (1973). It was established that the isolated segment of both a thin, and large intestine can undertake function of a bladder, an ureter.

Nominative. it is shown at irreversible patol, conditions of a bladder, an ureter, an urethra when other operative measures are impracticable: at congenital anomalies of uric ways, after a cystectomy concerning cancer of a bladder, a symptom complex of a «small» bladder as a result of tuberculosis, hron, intersticial cystitis, radiation therapy of a papillomatosis, extensive injuries of a bladder.

As the indication for replacement of an ureter serves its full functional insolvency caused by the multiple hems in its various departments which developed as a result of inflammatory process, an injury, operative measures. Ureteroileoplastika is shown at patients with bilateral defeats when any of kidneys cannot be removed. At persons of young age at the only kidney it is operation of the choice (see. Ureteroplasty ).

Replacement of an urethra with an intestinal transplant is carried out at its obliteration on a big extent when all other types of an ureteroplasty are inefficient (see. Urethroplasty ).

Are suitable for replacement of uric ways an ileal and sigmoid gut. The ileal gut is more preferable to substitution of an ureter as the constant peristaltics actively moves contents in the direction of a bladder and provides outflow of urine. The sigmoid gut is more convenient for substitution of a bladder since is closer to it is located, has the smallest rezorbtsionny ability, in normal fiziol. conditions serves as a tank for accumulation, has bigger sokratitelny ability, than thin. A sigmoid gut richly in a vaskulyarizirovan that provides good food of a transplant. The possibility of use as a tank for urine of a caecum, a wall of a stomach, and for replacement of a part of an ureter — a worm-shaped shoot is proved.

Fig. 1. Scheme of options of an intestinal cystoplasty: and — vertical; — vertical with a longitudinal section of the lower end of an intestinal transplant and its formation in the form of pads; in — U-shaped; — J-shaped; d — ring-shaped; e — in the form of a hat (the bottom of a bladder over which in the form of the cylinder the mesentery is located is formed of an intestinal transplant); — an open loop (an intestinal transplant after a longitudinal section will turn out a mucous membrane outside, over it in the form of a cone — a mesentery); 1 — a kidney; 2 — the ureter replaced in an intestinal transplant; 3 — an intestinal transplant; 4 — a bladder; 5 — a mesentery of an intestinal transplant; 6 — the ureter falling into a bladder.
Fig. 2. Rentgenotsistogramma of the patients who transferred intestinal cystoplasty: and and — after vertical cystoplasty, in — after cystoplasty as a hat; on roentgenograms well filled bladders (1) and an intestinal transplant are visible (2).

At cystoplasty one of ureters, as a rule, changes in an intestinal transplant that creates optimal conditions for functioning of an enterovesical tank. At the only kidney the ureter changes also in an intestinal loop.

Options of cystoplasty differ from each other in way of preparation of an intestinal transplant (fig. 1). The main of them are ring-shaped, vertical, J-shaped, U-shaped, «hat». After a total cystectomy use vertical or U-shaped option. At the kept vesical triangle it is more reasonable to apply hat option since at the same time wider enterovesical anastomosis is created. In need of single-step replacement of a bladder and the lower half of an ureter the J-shaped option is most reasonable. At damages of a vesical triangle, destruction of a sphincter of a bladder and a full incontience of urine one end of again formed uric tank is removed under a press of a rectum (Gershuni's operation, 1898; Frumkin's operation, 1960) or on a front abdominal wall (Brikker's operation, 1950).

If damage of a bladder is followed by a stenosis of pelvic department of an ureter or vesical ureteric lokhanochnym the reflux supporting hron, pyelonephritis, then the ureterointestinalny anastomosis is shown. Ways of its performance are various. Techniques of two - and three-moment substitution of a bladder are offered by an intestinal transplant, but the general recognition was gained by single-step operation as simpler intervention. Technology of operation and the sequence of performance of its stages vary. Access to a bladder can be extra belly and chrezbryushny; the last allows to estimate in one step topografoanatomichesky ratios between a bladder and intestines, to choose a transplant and option of plastics depending on length and mobility of a mesentery, the sizes and an arrangement of a bladder. Length of a transplant from a small bowel shall not exceed 20 cm, and from sigmoid — 10 — 12 cm. Use of longer transplants leads to stagnation of urine, slime, formation of fistulas, an atony of an artificial uric tank.

Main stages of operation: 1) before operation enter a rubber catheter into a bladder or buzh which serves as a reference point during operation and the conductor for removal of drainages at its end; 2) nizhnesredinny laparotomy (see) — the choice of a transplant, bowel resection and recovery of its integrity; processing of a transplant of 3% solution of potassium permanganate and antibiotics (Kanamycinum, Monomycinum, levomycetinum, gentamycin); 3) change of operational linen, tools, processing of hands of the surgeon; 4) a cross section of a peritoneum over a bladder, its peeling, capture of a detruzor of a bladder on handles, the resection of a bubble, the sizes a cut are defined by character and prevalence patol, process, thickness and rigidity of a wall of a bladder; 5) a podshivaniye of a transplant to a stump of a bladder a one-row catgut suture with nodes out of a cavity of a tank; 6) peritonization of an anastomosis; 7) in need of performance of change of an ureter in an intestinal transplant — opening over it a back leaf of a peritoneum, removal of an ureter in an abdominal cavity, its allocation to a bladder and crossing; the vesical end of an ureter is tied, and renal drained to a pelvis; 8) the mochetochnikovokishechny anastomosis is carried out usually tunnelizatsiy under a mucous membrane of an intestinal transplant; 9) drainage of an uric tank but an urethra or by cystostomy. At operations for cancer drainage of pelvic cellulose according to Mack Uorteru — to Buyalsky is necessary (see. Bladder ).

Success of operation is provided with tightness of an anastomosis, a careful ekstraperitonization, good drainage. Direct postoperative complications in the first 15 days (paresis of intestines and peritonitis, impassability, insolvency of an intestinal anastomosis or enterovesical anastomosis) make apprx. 9% of total number of operations. Immediate relaparotomy — the only opportunity to save the patient; the delay with performance of this operation conducts by the failure. In the postoperative period control rentgenol, the research reveals extent of recovery of capacity of an uric tank (fig. 2) and function of the imposed anastomosis.

Late complications are observed in 30% of operations. The lithogenesis, stenoses of an enterovesical or ureteric and intestinal anastomosis, a recurrence of a vesicoureteral reflux concern to them. They arise in the remote terms — 5 years and more.

Bibliography Voyno-Yasenetsky A. M. Enterotsistoplastika after a cystectomy with recovery of a natural way of an urination, Urol, and nefrol., No. 1, page 60, 1975, bibliogr.; Gasparyan A. M. and Colours E. P. Cystoplasty pieces of a small bowel, Yaroslavl, 1960, bibliogr.; To and D. V N. Plastic surgery of ureters, M., 1973, bibliogr.; Urine of fishing of T. P. Tuberculosis of uric ways, Tashkent, 1976; Frumkin A. P. Our experience of intestinal plastics in urology, Urology, No. 3, page 10, 1960, bibliogr.; With i-b e of t J. L’enterocystoplastie dans le traitement de la cystite chronique tuber-culeuse, J. Urol. Nephrol., t. 71, p. 373, 1965; With o u y e 1 an i r e R. La „petite ves-sie“ des tuberculeux genito-urinaires, es-sai de classification, place et variantes des cysto-intestino-plasties, ibid., t. 56, p. 381, 1950; F a x e n A., K o with k N. G. a. S u n d i n T. Long term functional results after ileocystoplasty, Scand. J. Urol. Nephrol., v. 7, p. 127, 1973; Schmidt J. D. a. o. Complications, results and problems of ileal conduit diversions, J. Urol. (Baltimore), v. 109, p. 210, 1973.

T. P. Mochalova.