vesicosigmoid anastomosis

Gil-Vernet et al (1957) was successfully used for clinical use for the first time in the bladder sigmoid anastomosis. The basic procedure is to take a segment of the sigmoid colon with a mesentery, close the proximal end, and the distal end is anastomosed to the bladder to expand the bladder capacity and maintain a normal urinary route. If there is ureteral stricture or reflux, additional ureter-sigmoid anastomosis is needed. The main advantages of this operation are: 1 The sigmoid colon is located in the pelvic cavity, adjacent to the bladder, and easily fits with the bladder, thus reducing the chance of abdominal cavity contamination. 2 The lumen of the sigmoid colon is larger than the ileum, the muscle wall of the wall is thick, the postoperative emptying ability is strong, and the residual urine volume is less. 3 Compared with ileal bladder angioplasty, the mucus secreted by the sigmoid colon mucosa is less than that of the ileum mucosa. Postoperative urination is not easy to block, and the incidence of stone formation and urinary tract infection is low. 4 The innervation of the sigmoid colon is the same as the innervation of the urination organ, so the neurological reflex of postoperative urination is close to normal. The main disadvantage is that residual urine and its ureteral reflux and urinary tract infections may occur after surgery. Although the ability of the sigmoid colon to selectively absorb electrolytes is weak, preoperative renal dysfunction may still have high blood chlorine acidosis. 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. Generally speaking, this procedure is mainly used for cases of tuberculous bladder contracture. 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. Preoperative preparation 1. Routine barium enema or colonoscopy, pay attention to the sigmoid colon with lesions, adhesions and fixation, especially in the history of colitis. Stools routinely tested for intestinal mites should be treated with sputum. 2. X-ray cystography and/or cystoscopy. 3. Tuberculous bladder contracture, although the symptoms of urinary tuberculosis have disappeared and the urine test is normal, two or three anti-tuberculosis drugs should be used in combination for more than 2 weeks before surgery. 4. Intestinal preparation must ensure colon emptying and sterilization (the same method as rectal bladder surgery). 5. Prepare blood 600~900ml. Surgical procedure 1. Exploring the abdominal cavity Make a midline incision and enter the abdominal cavity. Explore the abdominal organs, pay attention to the presence or absence of lesions such as abdominal tuberculosis and whether the sigmoid colon and its mesentery are normal. Appendectomy was performed. Women of childbearing age underwent bilateral tubal ligation. 2. Reveal the bladder Temporary sutures were used to close the peritoneal incision for bladder separation outside the peritoneum. If the bladder is too small, a metal urethral probe can be inserted into the bladder through the urethra to facilitate identification of the bladder and separation of adhesions around it. Cut the upper part of the bladder and remove the contracted bladder tissue as much as possible (removing 1/2 of the entire bladder) to make the remaining bladder dish-shaped. At the edge of the bladder incision, 6 to 8 traction lines are sewn. Finally, gauze is used to fill and cover the bladder area. There is ureteral ureteral reflux or ureteral stricture, which should be cut at the ureter near the bladder wall; the ureteral stump is inserted into the F8 catheter to reach the renal pelvis, temporarily draining urine. If the ureteral stump left after tuberculosis nephrectomy is found to be thickened and hardened, it should be removed. If there is thickening or ridge-like bulging in the bladder neck or ureter, wedge-shaped resection should be performed. 3. Free sigmoid colon Remove the peritoneal incision suture, select the appropriate sigmoid colon, and separate the sigmoid colon with a mesangium length of about 15 cm, taking care to retain enough blood supply. The intestinal fistula was cut, and the intestinal lumen was repeatedly washed with isotonic saline and 1% neomycin solution, and the contents were drained. Colonic end-to-end anastomosis is performed below or above the free sigmoid colon to restore continuity of the intestine. 4. Sigmoid colon-bladder anastomosis The free sigmoid colon was pulled down so that the distal stump approached the disc-shaped incision without tension. At the distal stump, the intestine wall was cut longitudinally at the edge of the mesentery, so that the diameter of the colon was comparable to the size of the disc-shaped incision of the bladder. First anastomosis of the posterior wall, followed by anastomosis of the anterior wall The outer layer of the posterior wall of the anastomosis was sutured intermittently with a thin wire, and the inner layer (ie, the bladder mucosa and colonic mucosa) was sutured intermittently (or continuously) with a 3-0 absorbable line; the posterior wall was anastomosed, and a three-chamber balloon was inserted through the urethra. The urethra reached the sigmoid colon; 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. 5. Ureteral sigmoid colon anastomosis The anastomosis method is the same as the rectal bladder and colon abdominal wall ostomy. If there is no upper urinary tract, it is not necessary to have a ureter-sigmoid anastomosis. 6. Close the proximal stump of the sigmoid colon First, the 2-0 absorbable line was used for continuous inversion suture to close the stump, and then the suture was sutured with a thin thread. Inject the isotonic saline 150-200ml from the balloon catheter, and observe whether there is water leakage in the suture of the stump and the sigmoid colon-bladder anastomosis. If necessary, add sutures. 7. Close the peritoneum The free sigmoid colon wall and the adjacent posterior peritoneum were sutured with a thin wire to fix it to the posterior abdominal wall. When the pelvic incision margin was sutured, the sigmoid colon-bladder anastomosis, ureter-sigmoid anastomosis and proximal sigmoid stump closure were placed in the peritoneum. Suture the sigmoid mesenteric space and defects. 8. Place drainage The posterior pubic space is left with a rubber tube drainage strip or a double lumen drainage tube. 9. 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 the sigmoid bladder urine to empty, 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 Sigmoid-bladder anastomotic stenosis occurred after surgery. In a few cases, bladder tuberculosis was not controlled during surgery, 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: sigmoid colon-bladder anastomosis should be surgically explored, that is, the sigmoid colon is cut open, and the anastomosis is wedge-shaped. In order to prevent postoperative sigmoid-bladder anastomotic stenosis, some authors advocate cutting the free sigmoid colon 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 sigmoid colon-bladder anastomosis, sigmoid bladder abdominal wall stoma). 3. Ureteral reflux Postoperative sigmoid cyst angiography found 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 sigmoid colon-bladder anastomosis, bladder neck and posterior urethral stricture, the same treatment as before. 4. Water and electrolyte disorders The ability of the sigmoid colon to selectively resorb electrolytes is weak, and there are fewer electrolyte disturbances and acid-base imbalances after surgery. Patients with high blood chlorine acidosis are mainly seen in patients with chronic renal insufficiency before surgery and postoperative sigmoid-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 sigmoid colon 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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