ileal bladder surgery

The basic advantages of ileal bladder surgery are: 1 ileal bladder shunt can quickly introduce urine from the kidney and ureter into the socket, because the shunt bowel is short, so that the urine is in contact with the intestine for a short time. 2 Compared with ureteral sigmoid anastomosis, electrolyte imbalance is mild, and the incidence of urinary tract infection is less. Therefore, ileal bladder shunt has become a recognized and preferred surgical procedure. Treatment of diseases: bladder valgus bladder cancer Indication 1. Bladder cancer is performed before total cystectomy or at the same time. 2. Congenital diseases. Bladder valgus or urethral fissure, there is still urinary incontinence after plastic surgery. 3. Neurogenic bladder. Children with sacral fissures and meningocele often need to be shunted (or by intermittent self-cleaning catheterization). 4. Previous surgery failures. Urinary incontinence after prostatectomy or ureteral colon anastomosis. 5. Palliative treatment, inoperable pelvic tumors with severe urinary frequency, persistent hematuria and urinary incontinence and urinary leakage. 6. Other rare indications. Contracture of the bladder, contracture of the bladder due to tuberculosis, interstitial cystitis, or fibrosis after radiation. Contraindications Patients who are unable to take care of their own urine bags, such as blind people and multiple cerebrosostosis, affect the function of the hand. Preoperative preparation 1. On the 3rd day before surgery, enter a high-calorie, high-protein, low-slag diet to strengthen nutrition; 24 hours before surgery to give a fluid diet (double). 2. Sulfonamide 1g, 4 times a day, for 3 consecutive days. Or oral streptomycin was started 36 hours before surgery, 0.5g every 6 hours. 3. A few days before surgery, 200ml saline can be enema once, so that it stays and walks down to test whether there is no incontinence. 4. For 48 and 24 hours before surgery, each serving was 15 ml of castor oil. On the 2nd day before surgery, 2000ml of warm saline was used every night. Two hours before surgery, 500 ml of 1% neomycin was used for rectal enema to remove intestinal dirt. 5. Blood potassium, sodium, chloride and co2 binding. 6. Need to pay attention to pre-operative driving. Surgical procedure 1. Position: supine position, head slightly downward. 2. Selection of the fistula site: The fistula is selected in the rectus abdominis bulge, which can make the patient satisfied for life; the exact part should be marked with methylene blue after the patient is anesthetized. Generally, it is selected on the right side, and the edge of the urine bag can be buckled in the right lower abdomen so that the upper edge reaches the umbilical level and the inner edge reaches the middle line. Also indicate the center of the sputum and the circumference of the ring. Also mark the position of the lower edge of the urine bag so that the lower abdomen transverse incision is below its lower edge. 3. Incision: for the lower abdomen transverse incision, starting from one side of the anterior superior iliac spine to the other side of the anterior superior iliac spine, convex facing down. Note that the incision must be below the predetermined fistula. Then, the layers of the abdominal wall were cut along the incision line, and the deep movements and veins under the abdominal wall were ligated to explore the abdominal cavity. The ileocecal and the peritoneum of the lateral and inferior margins of the sigmoid colon were dissected, and the right ileocecal and left sigmoid colon were isolated. 4. Cut the ureter: When the peritoneum is seen, the right ureter often sees the ureter over the iliac vessels and enters the pelvis on the inside. The peritoneum on the ureter is incised and the ureter is separated, taking care not to damage its blood supply. Its blood supply comes from the inside of the ureter at this level. Any vascular branch from the bifurcation of the abdominal aorta and the pelvic cavity can be cut off to help the separation, but the vascular branch and the parallel branch at the height must be carefully preserved. The ureter is cut at 3 to 4 cm below the edge of the pelvis, and the broken end is ligated. Short-term urinary flow blockage can make the upper ureter dilate without damage to the kidney, which is conducive to future ureteral anastomosis. The upper ureter was separated over the abdominal aortic bifurcation and was withdrawn from a 2 cm incision in the posterior peritoneum. On the left side, the sigmoid colon is moved inward until the left ureter is exposed across the iliac vessels. The left ureter is separated and severed as shown on the right side. The colon is lifted forward, and after branching of the inferior mesenteric artery, it is divided by fingers to the opening in the posterior peritoneum. Finally, a straight angle clamp is passed through the opening, and the free left ureter end is brought to the opening of the posterior peritoneum and juxtaposed with the right ureter. 5. Free shunt back to the intestine: shunting the ileum should quickly pass the urine and enter the urine bag under very low pressure. The shunt intestine should be short, smooth and bloody. The ileum is superior to the colon because the peristalsis is more active than the absorption capacity, and the intracavity pressure and volume are small. The shortest way to shunt the intestine is to pass through the abdominal cavity. It has a smaller chance of occlusion than the extra-abdominal shunt. The shunt is divided from the abdominal aorta bifurcation to the midline side of the fistula. Because the lateral gap is wide, it is not easy to cause intestinal obstruction. So you don't have to try to turn it off. Use the terminal ileum as a shunt intestine. The final length is about 15 cm, but a longer bowel segment (20-25 cm) can be separated at the beginning so that it can be appropriately shortened according to various tensions during the ostomy. The proximal end of the shunt intestine can be close to the bifurcation of the abdominal aorta and the root of the mesentery, while the distal end is opened through the avascular region of the mesentery and is pulled out of the abdominal wall by tension. First, starting from the distal part of the ileum, lift the terminal ileum and understand the blood vessels by illuminating. Find the avascular zone between the ileal artery and the last branch of the superior mesenteric artery, then cut the marginal blood vessels 4 to 5 cm from the ileocecal valve, and use a traction joint at the distal end of the shunted intestine to avoid shunting The direction of peristalsis is wrong; the shunt in the direction of peristalsis can cause hydronephrosis. Then, the ileum was selected as the distal cut and the upper cut was measured 20 to 25 cm as the proximal cut. Three to four terminal vascular branches were ligated at the mesenteric opening. At the selected two places, the small intestine was cut between the intestinal clamps to complete the release of the ileal shunt intestinal fistula. The continuity of the intestine was restored by end-to-end anastomosis. The mesenteric opening is largely sutured, but a hole is left in the mesenteric root for the shunt to pass through. 6. Ureteral ileal anastomosis: The first step is to connect two ureters to form a tube, gently pull the two tubes down with the same pulling force and cut off 4 to 5 cm below the posterior peritoneal opening. In the bladder cancer patients will cut the ureteral part, send pathological examination or frozen section examination to exclude unsuspected ureteral cancer or carcinoma in situ; if there is cancer, it needs to be removed at least 2cm above the upper edge of the tumor A section of the ureter, if extensively involved, is suitable for renal ureterectomy. On the opposite side of the ureteral vascular supply, the two ureters were longitudinally cut 2 cm and trimmed into a tongue-and-split plate. The posterior border of the ureter is connected upwards with the gut line from the posterior horn of the ureter. Each stitch must pass through the tough outer layer of the ureteral wall and tighten. Before reaching the upper end of the trimming section, a 10f balloon ureteral catheter was inserted into the renal pelvis as a stent. The catheter should pass smoothly, indicating no ureteral obstruction. The leading edge of the trimming portion is then continuously stitched until the two rake angles of the trimming portion. The proximal end of the shunt intestine is placed close to the connected ureter so that there is no tension. The proximal end of the intestinal fistula was anastomosed to the end of the connected ureter with a thin gut. The suture needs to pass through the entire layer of the intestinal wall and the ureteral wall. The intestinal tract and the connected ureter have different diameters, and attention should be paid to eliminating the gap when suturing. After the ureteral ileal anastomosis is completed, the posterior peritoneal opening edge should be sutured to the shunted upper wall of the anastomosis, so that the anastomosis can be located in the retroperitoneal position and the anastomotic tension can be reduced. The shunt is then passed back through the unsewed mesenteric opening, and the excess open pores are intermittently sutured. 7. Formation of fistula: the entire anterior abdominal wall of the skin is excised according to the expected ostomy, and the anterior sheath of the rectus abdominis is longitudinally cut, and the rectus abdominis muscle fibers are split along the muscle line, and the two fingers are made from the abdominal cavity. The mouth is ejector, and the posterior sheath of the rectus abdominis and the peritoneum are cut open between the two fingers so that the two fingers can pass freely. A small intestine forceps is inserted into the abdominal cavity from the opening of the abdominal wall, and the distal end of the shunt intestinal fistula is gently clamped, and pulled out through the opening of the abdominal wall, and at least 6-8 cm is pulled out, so that the appropriate length of the fistula can be pulled out. It is not necessary to fix the shunt intestines to each layer of the abdominal wall, and it is only necessary to fix the superficial fascia with a few needles. The distal end of the shunt intestinal fistula was inverted, and the subcutaneous tissue of the three-needle through the margin was divided into three parts, and the deep part of the intestine sputum muscle layer and the intermittent intestinal line of the intestinal fistula were sutured to maintain the inverted state. At this point, the fistula should protrude above the surface of the skin by 2 cm and present a healthy pink color. complication Postoperative complications The ileal urinary shunt is a complicated operation. If it is completed at the same time as total cystectomy, there are often postoperative complications, which must be closely observed and treated early. 1. Anuria and leaking urine: On the day after surgery, the urologist should first know if the urine passes through the fistula. If there is no urine in the intestinal fistula, there may be several reasons: 1 renal or prerenal anuria; 2 obstruction; 3 leak urine. It is difficult to diagnose renal or pre-renal anuria after shunting, and only the obstruction and urine leakage can be determined. The central venous pressure should be checked and 100 to 200 ml of 20% mannitol shock therapy should be administered intravenously to see if there is an increase in urine. If a ureteral stent is not used, a catheter can be inserted into the fistula, and sometimes the urine can be retained in the shunt and misdiagnosed as anuria. Obstruction is rare as a cause of anuria, especially in patients with a ureter with a stent. Obstruction is often seen only in patients with lonely kidneys. The ureter of the solitary kidney can be blocked across the sigmoid mesenteric membrane so that the urine cannot enter the shunt bowel. Leakage of urine into the abdominal cavity often manifests as a large amount of exudate leaking from the drainage site or wound. To determine if it is urine, determine if the urea content of the drainage fluid is higher than the blood. Sometimes there is no urine to lead out and the signs are sepsis or intestinal paralysis; if the blood urea (but not creatinine) value is increased, urine leakage should be suspected, that is, need to be confirmed by shunt intestinal angiography, urine extravasation can be seen. Non-surgical treatments that use rainbow to attract flow can sometimes cure urine leaks, but it is best to have a surgical exploration, especially if the urine leak has lasted for more than 72 hours. Often the urine leak is from the ureteral ileum anastomosis and should be repaired on the ureteral stent. 2. Ostomy or shunting necrosis: The second thing the urologist wants to know on the day after surgery is whether the sputum is healthy. If it is pink, it means good blood flow, such as dark gray indicating ischemia. If this color deteriorates further, it is necessary to probe the patient to see if it is affected by the fistula wall or the entire shunt bowel. If the entire shunt ischemic, it must be removed, the connected ureter is closed and bilateral nephrostomy is performed, and after 3 months, a new shunt is performed. If it is just a necrosis of the intestinal wall, it can be removed and a new flat fistula made from the original shunt. 3. Intestinal obstruction: If the cecum is not fully separated, the distal ileum can be obstructed in the trans-intestinal hernia. The adhesion of the medial malleolus and the omentum to the mesenteric margin can cause small bowel obstruction. Once the diagnosis is confirmed, and the non-surgical treatment does not work, it should be immediately surgically explored and relieved. [late complications] The most important late complication is urinary tract obstruction, which is associated with infection and often leads to progressive renal failure. 1. Stenosis of the fistula: stenosis of the fistula often causes ischemia. Measuring its diameter can confirm its decrease. Healthy shunt intestinal fistula shows active intestinal peristalsis, and a urine is discharged every 2 to 5 minutes; if the interval is prolonged, it indicates that the fistula is narrow and the diverticulum is dilated. A catheter can be inserted into the shunt, and residual urine (10 ml or more) and intra-intestinal pressure (more than 1.96 kPa (20 cmh 2o)) can be measured to confirm this diagnosis; intravenous urography or shunt angiography It can show dilated shunt intestines. In this case, a sputum reconstruction is required. 2. Ureteral ileal anastomotic stenosis: This complication is often caused by the formation of scar after partial anastomotic rupture, and should be suspected when the patient complains of recurrent low back pain and fever. Intravenous pyelography will show dilatation of the kidney and ureter, but the shunt intestine will not expand, and the pressure in the shunt can be less than 20cmh 2o. The patient should be surgically explored and the anastomosis reconstructed. 3. Stone formation: Intrarenal stones are often infectious, caused by Proteus, and can be treated like other kidney stones. After all stones have been removed, the infection must be completely treated. The stones in the shunt intestines are almost always combined with a fistula stenosis, which should be removed when the stoma is reconstructed. 4. The fistula of the fistula is dissected: the distal end of the shunt intestine is released from the anterior abdominal wall, the excess is removed, and the fistula is rebuilt. 5. The formation of sputum next to the fistula: the patient is required to wear a proper belt. 6. Diverted bowel torsion: often occurs when the shunt bowel is too long and there is excess. In addition to relieving bowel torsion, the excess should be removed to avoid recurrence. 7. The formation of internal hemorrhoids around the diverticulum: occasionally the small intestine can reach the right side of the shunt. The sputum should be returned and the gap between the lateral abdominal wall, the cecum, and the shunt mesentery should be closed with the peritoneum.