URETEROPLASTY (Greek ureter an ureter + plastike sculpture, plastics) — the operative measure on an ureter which is carried out for the purpose of recovery of outflow of urine.
Depending on localization of defeat At. it can be executed in a lokhanochno-ureteric segment or throughout an ureter in its belly and pelvic parts. As material for plastics use own tissues of the patient, napr, a rag of a pelvis, a bladder, the site of intestines, and also alloplastichesky prostheses. With the help At. recover natural uric ways or create new ways for removal of urine (through intestines, skin fistula).
• The indication for At. disturbance of passability of an ureter serves (see) at strictures, malformations, svrpets and other defeats of ureters and bodies, adjacent to them. Contraindications to At. — acute inflammatory process, general serious condition of the patient.
In preoperative preparation much attention is paid by sanitation of uric ways by means of antibacterial pharmaceuticals. For prevention of an exacerbation of pyelonephritis appoint antibiotics of a broad spectrum of activity, and in some cases make drainage of a kidney (see the Nephrostomy, the Pyelostomy) during 2 — 3 weeks. An important action before operation is preparation of intestines. For this purpose the patient appoint the high-calorific food deprived of cellulose, siphon enemas daily within a week, antibacterial drugs for suppression of intestinal microflora, and in 3 days prior to operation — opiates for weakening of a vermicular movement of intestines in the next postoperative period.
The simplest operation — a resection of an ureter with imposing of an ureteroureteroanastomoz the end in the end is made at strictures and other defects of small extent; the anastomosis the end of one ureter sideways another is carried out at a resection of the lower third of one of ureters concerning a tumor or a unilateral vesicoureteral reflux (see the Ureter, operations). At extensive anatomic defects of an ureter more difficult reconstructive operations are shown.
Plastic surgeries on a lokhanochno-ureteric segment make usually at a hydronephrosis (see). Schweitzer's operation — Foley, applied at high otkhozhde-niya of an ureter, consists in funneled expansion of its prilo-hanochny department at the expense of plastics of a pelvis. With the same purpose apply Albarran's operation in A. Likhtenberg's modification — a longitudinal section of an ureter and a pelvis in the field of narrowing and imposing of a wide ureteropiyeloanastomoz. At plastics according to Kalp Verdu for elimination of narrowing of an ureter of big extent use the rag found from a back wall of a pelvis (see the Hydronephrosis).
At the strictures of an ureter of big extent located in its upper third in combination with an intra renal arrangement of a pelvis the operation Neyvir-ta is shown (ureterokalikoanastomoz), at a cut cut the bottom of a kidney and the end of the resected ureter anastomose with the lower big renal cup (see idronefroz; Ureter, operations). In 1978 N. A. Lopatkin offered operation of imposing of a latero-lateral piyeloureterokalikoanastomoz for treatment of this pathology. The ureter is not cut from a pelvis, and cut lengthways on a stricture to the healthy site; resect the increased pelvis and the nizhnemedialny site of a kidney and impose an anastomosis, sewing walls of an ureter in an upper chastis a pelvis, in lower — with a big renal cup (fig). Before imposing of an anastomosis enter a shiniruyushchy tube into an ureter, to-ruyu then remove through a nefrostomichesky opening together with drenazhy. The tire is deleted in 2 weeks after operation, a drainage — in 3 weeks at the recovered outflow of urine on an ureter.
Plastic surgeries in the lower third of an ureter represent various options of its resection and creation of a new anastomosis with a bladder — an anastomosis a side sideways, reimplantation, substitution of defect of an ureter tissues of a bladder (see the Ureter, operations; Ureterocystoneostomy).
At a neuromuscular dysplasia (see the Ureter, malformations), the cut is the main manifestation narrowing of intramural (vesical) department of an ureter and sharp expansion of overlying departments, apply two types of operations. One of them — plastics of an ureter across Bishoff — consists in a longitudinal resection (excision) of a part of the expanded site of an ureter after its cutting off from a bladder, formation of a tube and its anastamosing from stumps of an ureter. Before this operation the plastics of an ureter offered
N. A. and L. N. Lopatkiyymi has considerable advantages. After a resection of an ureter create a dublikatura in its venter and anastomose a newly created ureter with a bladder. Feature of operation is education an anti-reflux-nogo of the roller from a lower part of an ureter in this connection the mouth of an ureter takes an ulitkopodobny form; the blind channel formed during creation of a dublikatura of an ureter performs function of the valve, to-ry blocks current of urine from a bladder to a pelvis.
Partial or full substitution of an ureter the isolated segment of a gut is shown at multiple strictures of an ureter or its obliteration on a big extent, tumors of an ureter, a huge hydronephrosis, a recurrent nephrolithiasis. A contraindication is the late stage hron. renal failure. For plastics use segments of both a thin, and large intestine, but apply a small bowel more often (see. Intestinal plastics). For total replacement of an ureter use a piece of a gut 35 — 40 cm long on a mesentery together with feed vessels (without tension of a mesentery). Passability of intestines recover by imposing of an anastomosis the end in the end or a side sideways. The piece of a gut used for plastics of an ureter have isoperistaltically. At substitution of the right ureter watch that the turn of a mesentery did not lead to disturbance of blood supply of a gut. Lokhanochno-kishechny the anastomosis and an anastomosis of a gut with a bladder have in retroperitoneal space. At not changed upper parts of an ureter substitution of its lower part can be executed by a loop of a small bowel, to-ruyu proksimalno connect to not changed part of an ureter, and distally — to a bladder. For substitution of both distal departments of ureters the loop of a small bowel is given the V-shaped form (see. Intestinal plastics). The pelvis is drained with the help a nave-ropiyelostomy and tubes brought out of a pelvis through a newly created ureter and a bladder outside through an urethra or through tsistosty. The tube from an ureter is deleted on 12 — the 14th day after check of passability of a lokhanochno-intestinal and enterovesical anastomosis by means of excretory urography, antegrade (in the presence nefro-or piyelostoma) or a retrograde piyelografiya (see). The segment of a gut provides a good passage of urine, does not create disturbances of electrolytic balance; the puzyrnomochetochnikovy reflux is observed seldom. Peritonitis, an aggravation hron can be complications of intestinal plastics of ureters. renal failure, acute pyelonephritis.
Substitution of an ureter allopla-stichesky prostheses is made at its extensive defeats (a tumor, radiation strictures, it-romyshechnaya a dysplasia, etc.) when other ways U cannot be used. (see the Ureter, operations). Feature of operation is what uric ways do not drain. Carry obturation of a prosthesis to specific complications salts with development of insufficiency of an anastomosis.
1^ис. The diagrammatic representation of a kidney, renal vessels and ureter at a stricture of prilokhanochny department of an ureter with an intra renal arrangement of a pelvis (a) and the main stages of operation (c) a latero-lateral piyeloureterokalikoanastomoz:
— the ureter is opened with a slit through a stricture, the pelvis and the nizhnemedialny site of a kidney are resected; in — a type of a kidney and an ureter after unwinding (1 — a kidney, 2 — a pelvis, 3 — the narrowed prilokhanochny department of an ureter, 4 — a renal artery, 5 — a renal vein, 6 — a big renal cup, 7 — the lower pole of a kidney after cutting off of the nizhnemedialny site, 8 — edges of the resected pelvis, 9 — edges of a dissect ureter, 10 — the line of seams of an anastomosis).
For constant or temporary removal of urine at impossibility of use of other operational techniques because of the general serious condition of the patient or at the bad forecast of a basic disease (an obtura-iionny anury owing to tumors of female generative organs or a prostate, inoperable cancer of a bladder with obstruction of intramural departments of ureters, removal of a bladder concerning extensive tumoral process and sharp dilatation of upper uric ways), and also at a severe injury of an ureter as the first stage of operational treatment carry out implantation of ureters (as a rule, both) in skin of a stomach, is more often than ileal area (ureterocutaneostomy), or in intestines, including in a large intestine (ureterocolostomy), in a sigmoid gut (ureterosigmoideostomiya). At change of ureters in skin they are crossed over the place of obstruction, then enter into them drainage tubes to a pelvis and removed outside through openings in skin, watching that they were not bent. The end of an ureter shall be located on 1,5 — 2 cm over skin. Separate seams fix it to an aponeurosis and skin. If operation is final, create small bucket-handle grafts and implant ureters into them. It facilitates adaptation of an urinal and prevents maceration of skin. In the postoperative period the main attention is paid to control of the correct situation and functioning of drainage tubes in ureters. Carry out different types of change of ureters in intestines more often. Change of ureters in a sigmoid gut — one of the most widespread in a crust, time of ways of removal of urine, at Krom as a tank for it use a rectum. Contraindications for this operation are hron. diseases of a large intestine and dysfunction of an outside sphincter of an anus.
At change of ureters by Tikhov's method open an abdominal cavity with the lower midsection. After allocation of an ureter through a section in a back parietal peritoneum cross it between two ligatures as it is possible closer to a bladder, bring to a side surface of a sigmoid gut ekstraperitonealno and implant into a perednebokovy wall, taking in the first seam an extima of an ureter, in the second — serous and muscular covers. The wound of a leaf of a peritoneum is taken in noose sutures. The opposite ureter is replaced in a gut in the same way at distance by not less than 10 cm from the first. Enter into a rectum on 15 — 16 days a thick rubber tube for removal of urine. Mirotvor-tsev's operation differs from Tikhov's operation in the fact that the ureter is not implanted into a gleam of a gut, and anastomose with it on type the end sideways. The ureterosigmoideostomiya is most widespread on a method Goodwin - Bore - bit - Koffi - II. The gleam of a gut is opened more widely. The ureter which is carried out to it is split and sew edge to the region with a dissect mucous membrane of a gut, leaving a drainage tube in an ureter. In the postoperative period special attention is paid to functioning of the drainage tubes which are in an ureter and in a rectum. The drainage tube is in a rectum round the clock up to
14 — 16 days, and then when independent emptying of a gut is recovered, it is established only for the night within 5 — 7 days. Tubes delete from ureters on 12 —
the 14th day. Carry out intensive antibacterial care, correction of water and electrolytic balance and acid-base equilibrium. The most frequent complications of plastics of this look — peritonitis and acute pyelonephritis.
Bibliography: Kucera Yang. Surgery
of a hydronephrosis and ureterohydronephrosis, the lane from Czeches., Prague, 1963; Lopat-kin N. A. and B. M Pretzel. The long-term results of an ureterokaliko-anastomosis, At a beater. and nefrol., No. 2, page 21, 1975; Lopatkin N. A. and Shovels-to and N and L. N. About operational treatment of a neuromuscular dysplasia of an ureter, in the same place, No. 3, page 25, 1973; To ii s s R. and. With h a t e 1 an i n C. Surgery of the ureter,
V. and. lake, 1975.
H. A. Lopatkin, A. G. Martov.