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12CHARACTERISTICS OF MEGAURETER RECONSTRUCTIVE-
PLASTIC OPERATIONS IN CHILDREN Ahmedov Yu.M.1, Yusupov Sh.A.2, Akhmedov I.Yu.3, Sadikov Z.Yu.4
1Ahmedov Yusufjon Mahmudovich - Professor;
2Yusupov Shukhrat Abdurasulovich - Head of the Department;
3Akhmedov Islomjon Yusufjonovich - Master of Pediatric Surgery, DEPARTMENT OF PEDIATRIC SURGERY, SAMARKAND STATE MEDICAL INSTITUTE;
4Sadikov Zafar Yusufovich - Surgeon, SAMARKAND DISTRICT MEDICAL ASSOCIATION, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: megaureter is a severe pathology of the urinary system. According to different authors, it makes up from 22% to 40% of all malformations. An increase in the number of early diagnosis of this disease, the use of various diagnostic methods, the presence of a large number of surgical treatment methods, and a high percentage of unsatisfactory results make this disease a topical issue in pediatric surgery. The study presents the results of surgical operations of 62 patients with a refluxing and obstructive megaureter at the base of the Department of Pediatric Surgery of Samarkand State Medical Institute for the period from 2010 to 2019.
Keywords: megaureter, uretero-vesical segment, urodynamics, reconstructive plastic surgery.
Relevance. Surgery to normalize urodynamics is an indispensable component of complex treatment and prevention of complications of congenital megaureter. Megaureter in children is subject to mandatory surgical treatment, following the diagnosis, regardless of the patient's age.
Purpose of the study. Determine the effectiveness of reconstructive plastic surgery in children.
Material and methods. Reconstructive plastic surgery with megaureter was performed in 62 patients. In connection with the exacerbation of chronic obstructive pyelonephritis, the presence of chronic renal failure, malnutrition and anemia in 25 children, surgical treatment was delayed until the condition stabilized.
The results of the study. When choosing the type of operation, they relied on the functional state of the kidney and the degree of preservation of the dynamic activity of the ureter. A contraindication to reconstructive plastic surgery was considered the loss of kidney function due to irreversible destructive changes in the parenchyma. In connection with the complete loss of kidney function, 8 patients underwent primary nephrureterectomy. Taking into account the ability of the ureter to sharply stretch under the influence of retention of urine and not less dramatic reduction after elimination of obstruction, which is a feature of the ureter in children of predominantly young children, neoimplantation of the ureter without stenosis was performed if its diameter did not exceed 1 cm. If the ureter had a diameter of 2 or more cm, then it narrowed for 3-5 cm to a size of 1-1.5 cm in diameter and was neo-implanted into the bladder with the passage in the submucous layer of no more than 2-2.5 cm i.e. the ratio between the diameter and the length of the submucosal ureter was observed as 1 to 2 or 1 to 2.5 cm. Synthetic absorbable sutures on an atraumatic needle of the type Vycril Plus 4/0 -5/0, Monocryl 4/0 -5 / were used as suture material. 0, as well as Catgut 4-5 / 0.
Regardless of whether the refluxing or obstructive type of megaureter, surgical tactics consisted in resection of the ureterovesical segment of the ureter and subsequent neoimplantation into the bladder with antireflux protection.
When choosing the type of surgical treatment of the megaureter, the condition of the contralateral kidney, the frequency of exacerbation of obstructive pyelonephritis, the safety
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of the renal parenchyma, and the degree of ureteral dysplasia were taken into account. When determining surgical tactics, the stage of megaureter degree, functional state of the kidney (determination of intraoperative urine specific gravity), the presence of complications and their nature were taken into account. Types of reconstructive plastic surgery are shown in the table 1.
Table 1. The number of operations depending on the cause of MU
Type of operation Reason MU TOTAL
Obstructive Reflux
Politano-Leadbetter 8(8ureter) 5 (5ureter) 13(13ureter)
Cohen 6 (6ureter) 6 (6ureter) 12(12ureter)
Cohen in the modification of the clinic 6 (12ureter) 8 (16ureter) 14(28ureter)
Extravesical ureterocystoanastomosis 8(10 ureter) 7(10 ureter) 15(20 ureter)
Nephrureterectomy 5 3 8
TOTAL 33 (36 ureter.) 29 (37 ureter.) 62 (73 ureter.)
As can be seen from the table, the Politano-Leadbetter operation was performed in 13 children with MU (13 ureters). Cohen's operation - in 12 (12 ureters). Cohen's operation in the modification of the clinic was performed on 14 patients (28 ureters). Extravesical ureterocystoanastomosis was performed in 15 children (20 ureters). In patients with exacerbation of CVD, antibiotic therapy in combination with uroseptics was included in the complex of preoperative preparation. Antibiotics were selected individually, according to the sensitivity of the microflora of urine. Good results were obtained from the use of antibiotics in combination with ceftriaxone with metride, gentamicin with amoxicillin or amoxiclav + nitrofuran series drugs. Antibacterial treatment was carried out in combination with vitamin therapy, as indicated by blood and plasma transfusions. The criterion of readiness for surgery was considered to be the good general condition of the child, the absence of inflammatory changes in blood tests. In children with bilateral lesions, preoperative preparation was aimed at reducing azotemia and restoring acid-base balance.
The author's methods of forming ureterocystoanastomosis according to Politano-Leadbetter, Cohen, Lich-Gregoir are widely introduced into surgical practice, however, these methods are not without drawbacks, which was the reason for their improvement. In particular, when using the Cohen operation in the classic version in children, due to the small size of the bladder, the creation of two parallel submucosal tunnels is difficult and unnecessarily traumatic. In this regard, for the treatment of 14 children with a bilateral megaureter, a modified ureterocystoanastomosis technique was used. The bottom line is to create a single submucosal tunnel for neoimplantation of the ureters into the bladder. This method allows you to avoid excessive trauma to the mucous membrane of the bladder. The technique of the operation is as follows: A skin incision according to Pfannenstiel upward from the incision 3-5 cm separates the skin with subcutaneous tissue. Long abdominal muscles are dilated along the white line of the abdomen in a blunt way, then the peritoneum is retracted to the top, the bladder is exposed and taken to the holders. Dissection of the anterior wall of the bladder is performed over a length of 4-6 cm to approach the area of application of the vesicoureteral anastomosis. The ureters are taken on the holders, the intramural part is secreted. When the terminal section is narrowed, they are resected within healthy tissues.
After this, a single submucosal tunnel is created in which the ureters are neoimplanted parallel to each other, the ratio between the diameter and length of the submucosal ureter as 1 to 2 or 1 to 2.5 is observed. The ureters are intubated. A Foley urethral catheter is inserted into the bladder. The bladder is sutured with a two-row suture, the wound is sutured in layers tightly.
All methods, ultimately, are based on the principle of creating an intramural ureter by implanting it into the tunnel between the detrusor and the bladder mucosa, they suggest a transvesical overlay of ureterocystoanastomosis. The main disadvantage is that when creating an antireflux mechanism in the area of implantation of the ureter into the bladder, it is necessary to dissect the detrusor and then suturing it over the ureter, and this creates the conditions for the formation of a scar in the anastomotic zone. In connection with these, during surgical treatment of MU, we decided to use the extravesical ureterocystoanastomosis technique without wide opening of the bladder, which do not have the abovementioned disadvantages.
The essence of the operation was as follows. The oblique skin incision in the iliac region according to McBurney, the extra third of the ureter, is extravasally blunt and sharp, is released. Next, the ureter is taken on a holder and with constant traction it is secreted to the place of its flow into the bladder. The ureter is stitched and cut off in the intramural section. A Z-stitch is placed on the ureteral stump. In the lateral-cranial direction, with a reciprocating motion, Mayo or Satinsky scissors run a submucous tunnel with a length of 25-30 mm. The scissors are removed from the tunnel and the Schnidt clamp is inserted into the last. The clamp is held to the end of the tunnel and without opening the mucous membrane in this zone, the muscle and adventitious layer of the bladder is perforated. The perforation extends extravasally to the diameter corresponding to the outer diameter of the ureter. With the same Schnidt clamp, after expanding the perforation and removing the intubating drainage from the ureter, the latter is captured and implanted into the submucous tunnel.
The ureter is intubated with polyvinyl chloride drainage with side openings. Four catgut chromic sutures N 0/4 are extravesically placed between the adventitious ureter and the bladder. Intravesical with four to six catgut sutures N 0/4 forms the mouth of the ureter. Intubating drainage is fixed to the bladder wall with a catgut ligature and is discharged from the bladder through the contraperture in the front wall of the bladder. The latter is sutured with a two-row catgut seam. Bladder drainage is performed in boys with cystostomy drainage, and in girls with a urethral catheter.
In the absence of secretions for insurance drainage, urine and other pathological fluids, the latter was removed for 2-3 days. The endotracheal tube was removed 4-5 days after removal of the swelling of the suture line. Urinary tract instillation was performed using basic drainages with antiseptic solutions in an amount of 3 to 5 ml for 3-5 days after surgery.
Conclusions. The results of the survey revealed that, with obstruction of the ureter-gallbladder segment, the first signs of the disease appeared at the age of 2.12 + 0.34 years, surgical correction in this group of children was performed at the age of 5.60 + 0.43 years and due to the complete loss of function renal nephrureterectomy was performed at 6.90 +
0.90.years. In case of dysfunction of the closure function of the ureter-gallbladder segment, the first clinical signs appeared at the age of 2.83 + 0.30 years, surgical correction in children with this pathology in this group was performed at the age of 6.80 + 0.33 years. In connection with the progression of the pathological process, CVD and loss of kidney function, a nephrureterectomy was performed in children from this group, whose average age was 8.9 years.
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