RU2763252C1 - Method for conducting endovideosurgical adenomectomy with extraperitoneal access using a morcellator - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology. After retropubic access to the prostate by introducing an optical trocar and two working trocars into the retropubic space and insufflation of carbon dioxide into the retropubic space, the anterior surface of the prostate is isolated, while the pelvic fascia is not opened. A transverse section of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal to the puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and the adenomatous tissue of the right and left lobes of the prostate. Then, bluntly and using the THUNDERBEAT apparatus, the adenomatous nodes are cut off. The prostatic urethra is cut off. Then small vessels are coagulated by bipolar coagulation, a trocar with a diameter of 10 mm is replaced by 12 mm, and an Olympus morcellator is brought to the adenomatous nodes. After removal of the adenomatous tissues, the posterior wall of the bladder with the urethra is fixed by 1 cm proximal to the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long, the posterior wall of the bladder is "trigonized" followed by a needle puncture on the anterior surface of the upper leaf of the capsule prostate gland. Next, suturing is performed along the right semicircle of the prostate capsule with the capture of the bladder wall along the lateral, with the transition to the anterior surface, symmetrically suturing the tissues on the left side. Control the tightness of the anastomosis; then the adenomatous tissue is immersed in the container and removed. A tubular drainage is installed in the retropubic space. Sutures are applied to the skin, iodine treatment and an aseptic bandage are applied.

EFFECT: method allows to reduce trauma with subsequent shortening of the rehabilitation period, to reduce the likelihood of postoperative sclerosis of the bladder neck, to preserve the muscular frame and to provide accelerated rehabilitation of the patient after surgery with a simultaneous increase in his quality of life.

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Description

The invention relates to medicine, in particular to urology, and can be used in urology.

To date, there are a significant number of different methods of surgical treatment of prostatic hyperplasia: (Transurethral Needle Ablation - transurethral needle ablation, Transurethral Microwave Therapy - transurethral microwave therapy, UroLift, laser and electric vaporization) [EAU Guidelines on Treatment of Non-neurogenic Male LUTS. EA Guidelines. / S. Gravas (Chair) J. N. C., M. J. Drake, M. Gacci, C. Gratzke, T.R.W. Herrmann, S. Madersbacher, C. Mamoulakis, K.A.O. Tikkinen, Guidelines Associates: M. Karavitakis I. K., S. Malde, V. Sakkalis, R. Umbach - Arnhem, The Netherlands: EAU Guidelines Office, 2018. EAU Guidelines]. However, monopolar transurethral resection of the prostate (M-TUR) or bipolar transurethral resection of the prostate (B-TUR) and open adenomectomy are still the main methods for removing small and large adenomas [EAU Guidelines on Treatment of Non-neurogenic Male LUTS. EA Guidelines. / S. Gravas (Chair) J. N. C., M. J. Drake, M. Gacci, C. Gratzke, T.R.W. Herrmann, S. Madersbacher, C. Mamoulakis, K.A.O. Tikkinen, Guidelines Associates: M. Karavitakis I. K., S. Malde, V. Sakkalis, R. Umbach - Arnhem, The Netherlands: EAU Guidelines Office, 2018. EAU Guidelines. Today, endovideosurgical adenomectomy is an alternative to open adenomectomy, as it is less invasive, but loses this advantage over endoscopic techniques.

A known method for endosurgical removal of prostate adenoma, including access to prostate adenoma and removal of adenoma, (see RF patent RU2647147C1 according to IPC A61B 17/00 dated March 14, 2018 - prototype).

The disadvantage of this method is:

- access to adenomatous tissue, their isolation and resection is carried out in the area of the bladder neck, which causes technical difficulties and increases the trauma of the bladder neck;

- formation of sclerosis of the bladder neck in the late postoperative period;

- the adenoma bed is poorly visualized, and as a result, unstable hemostasis and non-radical removal of adenomatous nodes are achieved;

- for the evacuation of removed adenomatous nodes, it is necessary to increase the incision of the tissues of the anterior abdominal wall, which increases the invasiveness of the operation and the patient's rehabilitation period.

The technical problem to be solved is:

- reduction of trauma with a subsequent shortening of the rehabilitation period, a decrease in the likelihood of the formation of postoperative sclerosis of the bladder neck.

The solution of this problem is ensured by the fact that in the method of performing endovideosurgical adenomectomy by extraperitoneal access using a morcellator, after performing a retropubic access to the prostate, by inserting an optical trocar and two working trocars into the retropubic space and insufflating carbon dioxide into the retropubic space, the anterior surface of the prostate gland is isolated, while the pelvic the fascia is not opened; a transverse incision of the anterior surface of the prostate capsule is made 1.5 - 2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and the adenomatous tissue of the right and left lobes of the prostate gland; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off; then, small vessels are coagulated by bipolar coagulation, the trocar with a diameter of 10 mm is replaced by 12 mm, and the Olympus morcellator is brought to the adenomatous nodes; after removal of adenomatous tissues, the posterior wall of the bladder is fixed with the urethra proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long, the posterior wall of the bladder is “trigonized”, followed by the removal of the needle on the anterior surface of the upper leaf of the capsule of the prostate gland and then suturing along the right semicircle of the prostate capsule with the capture of the bladder wall along the side, with the transition to the front surface, symmetrically suturing the tissues on the left side; control the tightness of the anastomosis; then the adenomatous tissue is immersed in a container and removed; tubular drainage is installed in the retropubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.

The achieved technical result is to increase the efficiency of removal of adenomatous tissues of the prostate, to reduce the volume of surgical blood loss of the patient, as well as to reduce postoperative complications and reduce the length of the patient's stay in the hospital. In addition, the technical result is the preservation of the muscular frame and the provision of accelerated rehabilitation of the patient after surgery while improving the quality of his life.

The advantages of this method are:

- high efficiency; maximum removal of adenomatous tissues with high accuracy is achieved;

- reduction in bleeding volume due to clear visual control of bleeding vessels;

- high security; reduced both intra- and postoperative complications;

- reduction of trauma; achieved due to minimal traumatization of the muscular frame and vessels of the anterior abdominal wall; integrity of the pelvic fascia, bladder neck;

- acceleration of terms of rehabilitation of the patient;

- Improving the quality of life of the patient.

Currently, the proposed method has no analogues.

The invention is illustrated in FIG. 1 and FIG. 2 showing fragments of morcellated adenomatous tissue, FIG. 3, which shows the weighing of morcellated adenomatous tissue (weight corresponds to tissue volume ~ 492 cm ³ ), FIG. 4, which shows the use of a morcellator with forceps to extract adenomatous tissue to the outside.

The method is carried out as follows:

After the retropubic access to the prostate has been made by introducing an optical trocar and two working trocars into the retropubic space, carbon dioxide is insufflated into the retropubic space. The anterior surface of the prostate gland is exposed, the pelvic fascia is not opened; a transverse incision of the anterior surface of the prostate capsule is made 1.5 - 2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off. Small vessels are coagulated by bipolar coagulation. The 10 mm trocar is replaced with a 12 mm trocar, and the Olympus morcellator is brought to the adenomatous nodes. The knife built into the tip of the instrument allows you to cut out the target area of tissue without hindrance, without clogging the channel. The smoke removal system of the morcellator provides a clear view of the instrument itself, the target area and surrounding tissues. After the removal of adenomatous tissues, the posterior wall of the bladder is fixed with the urethra proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long, the posterior wall of the bladder is “trigonized”, followed by the removal of the needle on the anterior surface of the upper leaf capsule of the prostate gland and suturing is performed along the right semicircle of the capsule of the prostate gland with the capture of the wall of the bladder along the side, with the transition to the front surface, suturing the tissues on the left side is symmetrically performed; control the tightness of the anastomosis; this allows the taper of the bladder neck and eliminates the formation of the so-called "prebladder"; then the adenomatous tissue is immersed in a container and removed; tubular drainage is installed in the back of the pubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.

Clinical example:

Patient K., 63 years old, sought medical help with complaints of difficulty urinating, "sluggish" urine stream, a feeling of incomplete emptying of the bladder after urination, discomfort in the perineum.

According to clinical and laboratory data, there were no clinically significant deviations from the norms in blood and urine tests. Attention is drawn to the increase in the level of PSA _total. to 11.2 ng/ml, for which the patient underwent a multifocal prostate biopsy. The conclusion of histopathological examination: adenomatous-stromal prostatic hyperplasia, chronic prostatitis.

According to the instrumental methods of examination, a pronounced increase in the size of the prostate gland 145x86x76 mm attracts attention. Residual urine 110 ml.

The patient was offered and performed surgical treatment in the following scope: Endovideosurgical adenomectomy using a morcellator. The time of the operative benefit was: 1 hour 15 minutes, which is certainly associated with the use of the morcellator during the extraction of adenomatous tissue; the volume of blood loss was 100 ml. Below are shown in Fig. 1-4 intra- and postoperative photos.

It should be noted that the length of the maximum incision for inserting a laparoscope and the one through which at the end of the operation (as part of routine practice) the macropreparation is removed is at least 4-5 cm, although it is reasonable to assume that without the use of a morcellator its length would be at least 10- 11 cm, taking into account the size of prostate hyperplasia according to ultrasound (145x86x76 mm).

Thus, the effective use of a laparoscopic device provides a number of advantages to the previously patented method of endovideosurgical treatment of large prostate adenomas:

сокращение времени оперативного вмешательства;

reduction of the time of surgical intervention;

сохранения шейки мочевого пузыря;

preservation of the neck of the bladder;

косметический эффект (отсутствие необходимости продлевать центральный разрез для извлечения макропрепарата);

cosmetic effect (no need to extend the central incision to extract the macropreparation);

снижение послеоперационного болевого синдрома в области послеоперационных раз за счет их минимального размера.

reduction of postoperative pain syndrome in the area of postoperative times due to their minimum size.

Claims (1)

A method for performing endovideosurgical adenomectomy by extraperitoneal access using a morcellator, characterized in that after performing a retropubic access to the prostate, by inserting an optical trocar and two working trocars into the retropubic space and insufflating carbon dioxide into the retropubic space, the anterior surface of the prostate gland is isolated, while the pelvic fascia is not opened ; a transverse incision of the anterior surface of the prostate capsule is made 1.5-2 cm below the proximal puboprostatic ligaments, 5-7 cm long, a layer is isolated between the capsule and adenomatous tissue of the right and left lobes of the prostate gland; then, in a blunt way and with the help of the THUNDERBEAT device, adenomatous nodes are cut off; the prostatic part of the urethra is cut off; then, small vessels are coagulated by bipolar coagulation, the trocar with a diameter of 10 mm is replaced by 12 mm, and the Olympus morcellator is brought to the adenomatous nodes; after removal of adenomatous tissues, the posterior wall of the bladder is fixed with the urethra proximal to 1 cm of the vas deferens with a continuous V-Loc thread with a 5/8 needle 15 cm long, the posterior wall of the bladder is “trigonized”, followed by the removal of the needle on the anterior surface of the upper leaf of the capsule of the prostate gland and then suturing along the right semicircle of the prostate capsule with the capture of the bladder wall along the side, with the transition to the front surface, symmetrically suturing the tissues on the left side; control the tightness of the anastomosis; then the adenomatous tissue is immersed in a container and removed; tubular drainage is installed in the retropubic space; sutures are applied to the skin, treated with iodine and an aseptic dressing is applied.

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