vesicoileal anastomosis

As early as 1941, Scheele succeeded in using the ileum to enlarge the bladder, but it was not until 1953 when Cibert reported a case of bladder ileal anastomosis. The basic method of this procedure is to take a section of the mesenteric free ileal fistula to the bladder to expand the bladder capacity and maintain a normal urinary route. There are many types of anastomosis, such as cat tail, L shape, U shape, ring shape and hat shape (Fig.7.10.8-1). The main advantage of this procedure is to preserve the bladder triangle and normal urination pathways, avoiding complications and inconvenience caused by urinary diversion. In addition, compared with sigmoid colon embolization, the ileal blood supply is rich, the postoperative anastomotic healing is better; the ileal mesangial activity is larger, the scope of surgery is large, easy to anastomosis; intracavitary sterilization of the ileum is easier , preoperative bowel preparation is relatively simple. The main disadvantages are: the ileal wall is thinner, the muscle layer is not as developed as the colon, that is, the emptying ability is poor, postoperative prone to tension-free expansion, prone to a large amount of residual urine, causing or aggravating urinary tract infection and renal dysfunction; ileal mucosa More mucus secretion, postoperative urinary occlusion and stone formation; postoperative abdominal complications are also higher than sigmoid cystostomy. Due to these characteristics, the operation has been rarely used. Even some of the authors who initially used this procedure have switched to sigmoid cystoplasty. Treatment of diseases: tuberculous bladder contracture interstitial cystitis Indication 1. Tuberculous bladder contracture (ie, scarring of bladder tuberculosis). But it must be: tuberculosis has been resected and regular anti-tuberculosis treatment for more than half a year, systemic tuberculosis has been controlled, non-inflammatory urinary frequency (ie, urine without pus cells, tuberculosis urinary tract, cystoscopy no tuberculosis nodules) And ulcers), bladder capacity <100ml, no dysuria, good urinary sphincter function, no urethral stricture and basic renal function. 2. Interstitial cystitis, radiation cystitis caused by severe shrinkage of the bladder. 3. Adverse reactions occurred after ureteral colon anastomosis, but the bladder and urethral lesions have returned to normal. 4. The volume of bladder tumor after partial resection of the bladder was too small, but the bladder triangle was normal and no tumor recurrence was observed after long-term observation. Contraindications 1. Pediatric tuberculous bladder contracture. Because of tuberculosis and nephrectomy, if there is no contralateral hydronephrosis, the bladder capacity can be gradually increased with age over six months after anti-tuberculosis treatment, so it is not suitable for bladder angioplasty. 2. Urethral stricture or bladder neck obstruction has not been cured or can not be cured. 3. Urethral sphincter dysfunction. 4. Colonic tuberculosis, inflammation, diverticulum, polyps and other diseases. 5. The whole body (such as the peritoneum, mesenteric lymph nodes, intestine, liver, lung and pleura) or genitourinary tuberculosis lesions have not been stabilized. 6. The postoperative observation time of bladder tumor is too short. 7. Renal function is severely impaired. It is estimated that the postoperative kidney is difficult to bear waste excretion and maintain water and electrolyte balance. 8. If the ureteral stenosis or regurgitation, if the lower end of the ureter is cut off and then collateralized with the ileum, the anti-reflux effect of any type of ureteral ileal anastomosis is unsatisfactory, and the postoperative reflux may inevitably cause or aggravate the urine. Road infection and kidney damage. Therefore, in the presence of ureteral stricture or reflux, sigmoid cystplasty should be used. Preoperative preparation It is the same as sigmoid cystoplasty, but does not require barium enema and/or colonoscopy. It is also necessary to attach great importance to controlling urinary tract infections, improving renal function, and stabilizing tuberculosis of the systemic and genitourinary system. Surgical procedure 1. Exploring the abdominal cavity Take the midline incision under the umbilicus and enter the abdominal cavity. Explore the presence or absence of tuberculosis in the abdominal cavity, especially the ileocecal area, the terminal ileum and its mesentery. Cut the appendix as usual. Female patients of childbearing age should undergo bilateral tubal ligation to avoid adverse consequences of bladder ileum after enlarged uterine compression. 2. Reveal the bladder Temporary sutures were used to close the peritoneal incision for bladder separation outside the peritoneum. Excision of the scar contracture of the bladder detrusor, so that the remaining bladder is dished. 3. Free ileum At a distance of about 10 cm from the ileocecal valve at the end of the ileum, a free ileal fistula of about 15 cm in length was taken to form the bladder. First, the mesentery of this segment of the ileum is fan-shaped, and more than two arcuate vessels are reserved to maintain a good blood supply to the intestine. The bleeding point of the mesangial separation edge was ligated with a thin wire. The contents of the intestinal cavity were flushed with isotonic saline, and then washed with 1% neomycin solution for 2 to 3 times, and 1% neomycin solution was temporarily retained in the intestinal lumen. 4. Restore ileum continuity On the anterior superior part of the free ileal fistula, the proximal and distal end of the severed ileum are anastomosed, that is, the continuity of the intestinal tract is restored. 5. Ileum-bladder anastomosis After the U-shaped and annular anastomosis, part of the urine often accumulates in the intestine along the direction of peristalsis, causing the ileum to gradually enlarge and elongate, resulting in increased residual urine and urinary retention. Therefore, hat-shaped and L-shaped ileum-bladder anastomosis are often used clinically. Now introduced by the hat-shaped anastomosis method. First, the free ileal sputum is cut into the whole layer of the mesenteric wall of the mesentery to make it into a sheet. Then the ileal sacral margin is matched with the disc-shaped margin of the bladder. First anastomosis of the posterior wall, followed by anastomosis of the anterior wall That is, the outer layer of the posterior wall of the anastomosis was sutured with a thin wire, and the inner layer (the bladder mucosa and the ileal mucosa) was sutured intermittently with a 3-0 absorbable line; the posterior wall was anastomosed, and a three-chamber balloon catheter was inserted through the urethra. (F18 or F20) arrives in the ileum of the shaped bladder. Above the pubis, a ostomy tube is placed in the ileal fistula of the shaped bladder for postoperative irrigation. The inner layer of the anterior wall of the anastomosis was sutured with a 3-0 absorbable line, and the outer layer of the anterior wall of the anastomosis was sutured with a thin wire. The ileal-bladder anastomosis should be >4cm to avoid anastomotic stenosis and its complications. 6. Close the peritoneum The ileum-bladder anastomosis was covered with a posterior pelvic posterior peritoneum, so that the free ileal fistula, bladder and ileum-bladder anastomosis were placed extraperitoneally, ensuring no tension, compression and distortion. Intermittent peritoneal incision space and mesenteric defect were sutured with thin wire suture to prevent postoperative internal hemorrhoids. 7. Place drainage A rubber drainage strip or a double lumen drainage tube is placed behind the pubis. 8. Suture incision Conventional suture of the abdominal wall incision. complication If the effect is satisfactory, the patient can get good urination function after operation, such as urinary frequency improvement, each time the urine output is >300ml, and the residual urine is <30ml. After the antibiotics were stopped, the urine was also sterile; intravenous urography confirmed that the upper urinary tract was significantly reduced or not aggravated, and blood biochemistry and renal function were normal. However, some cases still have some complications. Urinary tract infection More common in women. There was no significant improvement in postoperative urinary frequency, residual urine >100ml, more routine pus cells, positive urine culture, and clinical manifestations such as acute or recurrent pyelonephritis. The reason may be related to the failure of empty urine in the ileal bladder, especially in patients with chronic pyelonephritis before surgery. Treatment: effective antibiotics should be used after surgery. If necessary, long-term, alternating, combined medication should be used; timely urination; when urinating, press the lower abdomen by hand or strengthen the abdominal muscles to reduce residual urine; The catheter should be indwelled regularly, and the cause should be identified in time; pay attention to the genital area clean, female patients should urinate in time after sex. 2. Anastomotic, bladder neck and posterior urethral stricture The ileal-bladder anastomotic stenosis occurred after operation. In a few cases, the bladder tuberculosis lesions were not controlled during operation, resulting in the development of postoperative scar tissue. However, the more common reason is that the intravesical tuberculosis lesions are not enough, so that the postoperative anastomosis is narrow. It is characterized by persistent dull pain and mass in the lower abdomen, secondary urination, increased residual urine, symptoms of urinary tract infection and high blood chlorine acidosis. Bladder neck and posterior urethral stricture, the main manifestation of dysuria. Treatment: ileal-bladder anastomotic stricture should be surgically explored, that is, the ileum is cut open, and the anastomosis is wedge-shaped. In order to prevent postoperative ileal-bladder anastomotic stenosis, some authors advocate that the free ileal fistula is cut along the mesentery colon to form a flaky shape, which is then anastomosed to the bladder incision. Postoperative bladder neck and posterior urethral stricture are the results of postoperative urethral and prostate tuberculous scar hyperplasia. The symptoms are as above. Treatment: patients with mild symptoms, regular urethral dilatation; if the symptoms are severe, urinary diversion should be performed (usually the ileum-bladder anastomosis, ileum bladder abdominal wall stoma). 3. Ureteral reflux Postoperative ileal cystography revealed that the vast majority of cases had ureteral reflux during urination, with the most prominent standing position. But it is asymptomatic and does not need to be treated. Symptoms, mainly seen in the ileum-bladder anastomosis, bladder neck and posterior urethral stricture, the same as before. 4. Water and electrolyte disorders The ileum has a weak ability to selectively resorb electrolytes, and there are fewer electrolyte disturbances and acid-base imbalances. Patients with high blood chlorine acidosis are mainly seen in patients with chronic renal insufficiency before surgery and postoperative ileal-bladder anastomosis, bladder neck and posterior urethral stricture. 5. Urinary stones Bladder stones are common, followed by kidney stones. Causes of stone formation: intestinal mucus secreted by the colon, alkaline urine, residual residual urine and urinary tract infection. Therefore, patients should be encouraged to drink more water and take drugs such as money grass after surgery. If there is no urinary tract obstruction, the formation of stones will decrease after the mucosal atrophy of the ileum and its secretion capacity are weakened. Treatment should be based on the cause, location, size and complications of the formation of the stone, and appropriate treatment.

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