BOARI OPERATION (A. Boari, the ital. surgeon) — plastic surgery for recovery of passability of pelvic department of one or both ureters. Operation received the name according to the decision of the International society of urologists.
Operation is developed in an experiment by Van-Guk (W-Van-Hook, 1893), Boari (1894). In clinic for the first time executed it Nyustr (E. G. Nystrom, 1918), later applied Okkerblad (N. Ockerblad, 1936), Colan (G. Caughlan, 1942), A. P. Frumkin (1943).
make Planned operation at a stricture or an obliteration of pelvic departments of the ureters formed hl. obr. after various operative measures (obstetric, gynecologic, urological), and also at tuberculosis or an achalasia of ureters. Indications to the emergency performance of B. of the lake — an acute injury of pelvic departments of ureters on a considerable extent when the possibility of imposing ureterouretero-or an ureterotsistoanastomoza is excluded.
Contraindications to B. of the lake: cancer infiltration of pelvic cellulose, the wrinkled bladder after intersticial cystitis.
Earlier conducted course of radiation therapy is not an absolute contraindication to operation though its performance at the same time is connected with considerable technical difficulties.
Technology of operation
At a preparation for surgery is necessary careful sanitation of uric system when there are uric fistulas which are especially opening in a vagina.
Operation is made under an intratracheal anesthesia using muscle relaxants (see) and artificial ventilation of the lungs. The most convenient is Pirogov's section (see. Pirogova section ), which provides access to ureters and a bladder. At bilateral defeat of ureters more favorable conditions are created by a suprapubic arc-shaped section. However use of extra peritoneal access can be complicated by existence of commissural process. In such cases transperitoneal access which facilitates mobilization of ureters is applied. The B. lake consists of 4 main stages: 1) mobilization of an ureter; 2) excision of a rag from a bladder; 3) formation of artificial department of an ureter; 4) imposing of an ureteric and vesical anastomosis. Allocating ureters from surrounding dense cicatricial fabric, it is necessary to aim to keep an extima to avoid ischemia and a necrosis after operation. Ureters cross above the place of an obliteration, within healthy fabrics that is important for ensuring sufficient blood supply. It promotes engraftment of ureters and guarantees good passability and function of an anastomosis. Enter into the proximal end of an ureter on depth of 10 — 12 cm a polyethylene catheter.
After allocation of a bladder excise on its front side surface a rag 2 — 2,5 cm wide, 10 — 12 cm long. The basis of a rag has to be about 1/2 times wider than the distal end and to be located at a bottom of a bubble thanks to what its blood supply at the expense of branches of an upper vesical artery is provided. At a bilateral obliteration of ureters at the same time find rags: from the arch of a bubble in the form of horizontally located letter N, or two rags down, or one wide rag, about the Crimea connect both ureters.
The best conditions of food of a rag are created at a longitudinal cystotomy on the centerline. Then both half of a dissect wall take to the parties and ureters connect to them one of the next ways:
1. The Invaginatsionny method — the stump of an ureter is immersed in a vesical tube on depth of 1 — 1,5 cm (fig., 1) and fixed seams to its demukozirovanny surface. At the same time special attention is paid on that mucous membranes were precisely compared; to some extent it eliminates danger of formation of strictures of an anastomosis.
2. An anastomosis the end in the end: connect, as a rule, slantwise the cut-off ends of a vesical tube and ureters (fig., 2).
3. Implantation of stumps of ureters in the submucosal tunnel throughout 1,5 — 2 cm with the subsequent carrying out their ends in a gleam of a vesical tube.
The main conditions providing success of operation are: good blood supply of a stalk, lack of a tension in the conjunction of an ureter with a vesical tube and the sufficient diameter of an anastomosis.
The anastomosis is imposed by means of knotty catgut seams. Then close defect of a bladder, previously removing the end of a rubber drainage outside — at women through an urethra, at men — through an additional section on a front wall of a bladder; near an anastomosis establish one more rubber tube. In a bottom corner of a wound bring a bunch of thin rubber drainages. At patients with plentifully developed hypodermic fatty tissue the wound is drained through a locking opening, and then layer-by-layer taken in to a drainage.
Formation of an anastomosis is carried out on the catheter which is previously entered into a gleam of an ureter or a tube (tire). Polyethylene tubes since they are less inlaid with uric salts are the best, but diameter them shall not exceed No. 12 — 14 on Sharyera.
Tubes of such diameter do not oppress development of an epithelium and do not cause cicatricial changes in ureters and in surrounding cellulose.
Tubes delete from an ureter usually for the 10th days since their longer stay causes lymphocytic infiltration, a hypertrophy and fibrosis of a wall; vesical drainages — in 2 weeks. In the presence of a nefrostoma the drainage is taken after establishment of passability of an ureteric and vesical anastomosis.
Short-term results in most cases satisfactory. Criterion of a happy end of B. of the lake is free outflow of urine from a renal pelvis in a bladder and elimination of an infection; such outcomes are observed in 75 — 80% of cases. Fistulas in the field of an anastomosis observe approximately in 8% of cases, is preferential at patients who were exposed to radiation therapy earlier. The vesicoureteral reflux occurs approximately at 7% of patients.
A lethality directly after B. the lake makes 2 — 3%. The main reason for death — peritonitis. The main complication in the remote period is the stenosis of an anastomosis developing in 5 — 6% of cases and leading to death of renal fabric.
Bibliography: Nan D. V. Plastic surgery of ureters, M., 1973; Boari A. L’uret£ro-cysto-n£ostomie, Ann. Mai. Org. g6n. - urin., t. 17, p. 1059, 1141, 1899; Burns R. Reconstruction of the lower ureters by a tube made from bladder flaps, J. Urol. (Baltimore), v. 74, p. 348, 1955; With an u g h 1 a n G. V. Ureterovaginal fistula, repair of ureteral defect by use of bladder flap, ibid., v. 58, p. 428, 1947; Cukier J. Oryogashp of de Boari, Acta urol. belg., t. 34, p. 15, 1966; N y s t r about m G. Beitrage zur Chirurgie der Ureteren, Nord. med. Ark., Bd 51, S. 109, 1918; Ockerb lad N. F. Reimplantation of ureter into bladder by flap method, J. Urol. (Baltimore), v. 57, p. 845, 1947.
D. V. Kan.