Surgery via the Bladder Approach

Surgery via the bladder route for surgical treatment of vesicoureteral reflux. The ureteral junction has a valve function. When the bladder pressure increases, the normal ureteral junction can prevent retrograde reflux of the bladder urine to the ureter. When the ureteral junction is insufficiency, different degrees of vesicoureteral reflux can occur, resulting in ureteral dilatation, and even hydronephrosis, renal parenchyma thinning, especially in the case of infection of the lower urinary tract, vesicoureteral reflux can cause acute Pyelonephritis. Recurrent episodes of hydronephrosis plus pyelonephritis often cause severe damage to renal parenchyma and kidney function. Treatment of diseases: primary vesicoureteral reflux vesicoureteral reflux in children Indication Cystic ureteral reflux causes ureteral dilatation, hydronephrosis, thinning of the renal parenchyma, and renal function can be tolerated by surgery. Preoperative preparation 1. Preoperative excretory bladder urethrography, urodynamic examination, bladder urethra microscopy, double kidney B ultrasound, etc., to understand primary or secondary vesicoureteral reflux, if the secondary should first treat the primary disease . 2. Do urine routine and urine bacterial culture, drug sensitivity test, if there is urinary tract infection, you should choose sensitive antibiotics to control infection. 3. Check blood urea nitrogen, creatinine, etc. to understand the renal function, such as severely impaired renal function, you can first indwell the catheter to continue drainage, until the kidney function is improved and then surgery. Surgical procedure 1. Incision: Take the lower pubic transverse incision so that the future incision scar is located in the pubic pubic hair. 2. Exposure: Cut the skin and subcutaneous tissue, reveal the rectus abdominis sheath, separate the rectus abdominis from the midline, push the peritoneum upwards, cut the bladder longitudinally, and pull it with a ring pull, using 3-0 or The 4-0 silk sutures the lowest position of the bladder incision and lifts it up to help reveal, prevent the incision from tearing down to the urethra and facilitating the suture closure at the lowest incision of the bladder. Check the number, position and shape of the ureteral orifice. , creeping off the situation and measuring its tunnel length. The ureter was inserted into the ureter with a thin catheter No. 3 or No. 5 and sutured. Make a circular incision around the ureteral orifice. 3. Anatomy: Carefully dissect the ureter along the annular incision around the ureteral orifice, generally starting from the lower part of the ureteral orifice, entering the level between the bladder muscle layer and the ureter, and then separating the ureter completely. Be careful not to damage the ureteral blood vessels and muscle layers when dissociating. In addition, when the ureter is free, pay attention to push the peritoneum close to the front. In men, care must be taken to prevent damage to the vas deferens. The contralateral ureter was removed in the same way. 4. Intermittent suture of the bladder wall defect: the suture should not be too tight to avoid affecting the movement of the ureter. Establish a submucosal tunnel to the contralateral ureteral orifice. First make a mucosal incision, use scissors to cut into the ureter under the mucosa. To prevent wrinkles and affect the submucosal dissection, use two tissue clamps to pull outward on the outside of the mucosal incision. The new submucosal tunnel should have a sufficient width to allow the ureter to pass loosely. The general length should exceed 2 to 3 times the diameter of the ureter to prevent backflow. 5. Gently pull the ureteral support line through the submucosal tunnel, taking care to prevent ureteral distortion. 6. Suture the ureter and bladder muscles completely with a 3-0 gut, then suture the bladder and ureteral mucosa with a 5-0 gut, and close the mucosal incision of the original ureteral orifice. 7. At the end of the ureter with obstruction or stenosis, the end of the ureter should be removed. In most cases, the degree of ureteral dilation in the upper segment will be reduced after removal of the obstruction or stenotic ureter. If the degree of expansion is not serious, it can still be carried out as described above. If the degree of expansion is severe, the ureter should be shaped according to the method of severely dilated ureter replantation before ureteral transplantation. 8. The same method was used to transplant the contralateral ureter. Some scholars used the upper submucosal tunnel for the side of the ureter with severe reflux. Some people applied the same submucosal tunnel for bilateral ureters, but the ureters may be mutually Adhesion affects peristalsis, so most authors still use a separate two submucosal tunnels to transplant bilateral ureters. 9. In infants and young children, the distance between the triangles is very short. If transplanted as described above, the submucosal tunnel in the lower position will be too short to have a strong anti-reflux effect. In this case, the submucosal tunnel should extend outward beyond the contralateral ureteral orifice. Lift the two support sutures at the lower end of the bladder incision, and lift the upper end of the incision with two tissue forceps. The bladder mucosa is sutured continuously from bottom to top with 4-0 or 5-0 chrome gut, using 2-0 or 3-0 chrome. The gut layer is sutured to the bladder muscle layer. The bilateral ureter was indwelled with a thin stent drainage tube, and the bladder was indwelled with a 12 or 14 ostomy tube. The rectus abdominis sheath, subcutaneous tissue and skin were sutured with silk suture. Place the cigarette drain strip behind the pubis. In recent years, some surgeons have not advocated indwelling ureteral stent tubes for cases in which the ureter itself has not undergone plastic surgery. complication 1. Leakage of urine. 2. Urinary fistula formation. 3. Infection.

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