total length nephroureterectomy

The incidence of renal tuberculosis is the highest in male genitourinary tuberculosis, and its primary lesions are almost in the lungs. According to statistics at home and abroad, the incidence of 20 to 40 years old accounts for 70.9% to 83.1%. Kidney tuberculosis is a blood-borne infection, so there are many opportunities for simultaneous infection on both sides. However, during the development of the disease, one side of the lesion may be severe, while the contralateral lesion develops slowly. If the patient's body resistance is reduced, the condition develops rapidly, which may be manifested as bilateral lesions, accounting for about 10%. Most patients with mild contralateral lesions can heal themselves, and the tuberculosis seen is unilateral. The incidence on the left and right sides is almost equal. The lesion damage is more inclined to the poles of the kidney. Early tuberculosis nodules, no difference with other tissue tuberculosis lesions, cheese-like necrosis often occurs in the central part of this nodule, surrounded by tuberculous granulation tissue. 90% of the lesions are in the renal cortex, and gradually expand, fuse, and further develop, rupture at the renal papilla, and then spread to the renal pelvis and renal pelvis mucosa. It is a clinical kidney tuberculosis that spreads to the distant place through the renal pelvis and renal pelvis, or the bacteria spread to other parts of the kidney or all the kidneys through the lymphatic vessels of the kidney. During the progression of the lesion, if the patient's anti-tuberculosis immunity is strong, it is fibrotic or with calcium salt deposition. If it becomes a cheese-like change, the ulceration will leave a tuberculous cavity, which may be focal. Can also be vine and whole kidney to become tuberculous pus. Due to the pollution of tuberculosis, infiltration, ulceration and fibrosis occur in the ureter mucosa, submucosa or ureteral layer; the lesions involve the ureter, the lumen is rough, the lumen is uneven, and the ureter becomes a stiff cable. The lumen may be blocked and accelerate kidney damage. If the kidneys are completely destroyed and there is no urine secretion, no tuberculosis enters the bladder at this time. Most of the kidneys have calcified areas or are filled with cheese-like substances. This is called "home kidney removal." The lesion spreads to the bladder and initially causes mucosal congestion and edema, tuberculous nodules or ulcers. Clinically, there are obvious urinary urgency, dysuria and hematuria. If the lesion further invades the muscular layer, causing tissue fibrosis, the bladder loses its telescopic force, and the volume is reduced, forming a bladder contracture. The heavier penetrating the bladder wall forms a bladder vaginal fistula or a bladder rectal fistula. Tuberculosis of the bladder may involve the ureteral orifice of the healthy side, resulting in water accumulation in the kidney and ureter, and renal damage in the liver. Treatment of diseases: ureteral tuberculosis Indication Renal ureteral resection is suitable for tuberculous abscess, ipsilateral ureter due to lower end stenosis or atresia to expand empyema, or multiple stenosis, dilatation, and abscess formation in the whole segment, all should be treated with renal and ureteral resection. In the removal of genitourinary tuberculosis, it is conducive to postoperative treatment and prevention of sequelae. Preoperative preparation 1. After partial anti-tuberculosis treatment with regular drugs, partial nephrectomy is performed. 2. Correct anemia and improve physical fitness. 3. Prepare blood 400~800ml. 4. The indwelling catheter continues to drain the bladder. Surgical procedure 1. The incision tangential line is forward from the tip of the 11th rib to the lateral edge of the rectus abdominis, and then extends vertically downward to the pubic symphysis, resembling a "7" shaped incision (Fig. 7.2.5.5-1), the skin and subcutaneous tissue. After the incision is turned up, along the lateral edge of the rectus abdominis, the external oblique muscle and the rectus abdominis sheath are cut, and the external oblique muscle is incised obliquely along the fiber, and the latissimus dorsi and part are cut open. Lumbar fascia, up to the lower edge of the 12th rib. Directly down to the upper edge of the pubic symphysis, the rectus abdominis muscle is completely separated from the intra-abdominal and external oblique muscles, and the posterior rectus abdominis sheath is cut along the entire length of the incision line. And bluntly separate from the deep peritoneum, do not tear the peritoneum. 2. Separate the peritoneum from the abdominal wall muscles along the entire length of the incision, and push it to the opposite side with the abdominal organs. The gauze pad is used to wrap the deep retractor, so that the retroperitoneal space of the entire side is completely exposed. come out. 3. Push the retroperitoneal fat and peritoneum forward, cut the Gai's fascia as close as possible to the posterolateral side, and extend upwards and downwards to enlarge the lumbar fascia incision and push the perirenal fat. At this point, the kidney and the middle and upper ureters are exposed in the field of vision. 4. Before freeing the kidney, the ureter with lesions is usually released first, and then tied with a cloth band and tied to prevent the pus from being squeezed into the bladder. Then the fingers are bluntly separated from each side of the kidney, and the inner side of the kidney is peeled off. After the peritoneum is separated, the renal blood vessels and renal pelvis are exposed to the field of view and are more clearly exposed than the lumbar incision. Separate the back of the kidney pedicle with your fingers, first splicing through the 7-0 silk thread, and then cutting the forceps. After suturing the distal end of the renal blood vessel, the kidney is freed, and the ureter can be separated from the incision, and the ureter is separated downwards. When the vascular plane is reached, several pelvic vessels are encountered, and the ligature is cut one by one. Lift the ureter upwards, see the bladder, clamp it, cut it, and sew it, and completely remove the kidney and ureter. 5. The upper and lower parts of the surgical department are placed with rubber tube drainage, and the abdominal incision is sutured. complication 1. Ureteral stump syndrome After tuberculosis is removed, if the residual ureter has tuberculosis, the patient often feels lower abdominal pain, frequent urination, and dysuria. Red blood cells, pus cells and Mycobacterium tuberculosis occur repeatedly in urine tests. This may be due to the narrowing of the lower end of the ureter and the accumulation of pus in the ureteral stump. Cystoscopy revealed congestion, edema, dilation around the ureteral orifice and pus into the bladder. Even in the late cavity, stones or tumors are formed. In order to further confirm the diagnosis, the ureteral catheter can be inserted and injected into the contrast medium to understand the nature of the lesion. Once the diagnosis is confirmed, the stump ureterectomy is feasible. 2. Intestinal fistula occurred after the intestinal wall was accidentally injured, and the intestinal contents flowed into the wound within a few days after surgery, causing local infection and intestinal fistula. The colonic sputum can be self-healing. If the sputum is not cured for a long time, the temporary colostomy can be performed at the proximal end, and the lumbar incision is enlarged at the same time to make the local sputum flow smoothly, and the sputum can often heal itself. If you still do not heal, you need to have intestinal fistula and intestinal anastomosis. Duodenal fistula should be regarded as a serious complication. Nutritional deficiency and imbalance of water and electrolyte balance may occur due to large loss of intestinal fluid. Tissue necrosis and secondary infection may also occur due to intestinal tissue stimulation. If found early, surgery can be used to repair the pupil. If it is too long, local inflammation is significant, should be fasted, the implementation of intravenous high nutrition. A porous rubber drain tube is inserted from the wound for negative pressure drainage. Use zinc oxide ointment to protect the surrounding skin and gradually heal the mouth. For long-term unhealed mouthwash, jejunostomy can be used at the same time to ensure adequate nutrition, maintain water and electrolyte balance, enhance body resistance and promote wound healing. 3. Wound sinus due to infection around the residual kidney pedicle, necrotic tissue and silk foreign body retention, hematoma in the wound, kidney or renal pelvis tissue fragments, can cause wound infection to form a sinus. After removing the kidney, remove the diseased perirenal adipose tissue as much as possible. Stop the bleeding carefully and place a rubber tube for drainage if necessary. If a chronic sinus has been formed, if it does not heal for a long time, if necessary, sinus fistula and sinus surgery or sinus resection should be performed. 4. Renal venous and venous fistula often occur in patients with severe adhesions around the renal pedicle and large clamps. If the pupil is small and does not affect cardiovascular dynamics, clinical observation can be continued. Otherwise, the pupil should be closed again.

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