Operations to create a bladder from the intestine. Artificial bladder and how to live with it. Patient's life after surgery

Category: Treatment methods in Germany

It is known that in 24 hours a person excretes 1.5-2 liters of urine. The bladder is a reservoir of fluid, the function of which is finely regulated by the autonomic and central nervous system. Unfortunately, the most common neoplasm of the urinary and excretory organs is bladder cancer. Thus, in Germany, this disease is diagnosed in 25,000 patients every year. It is believed that the main “culprits” of its occurrence are smoking and certain chemical compounds. " Even small amounts of blood in the urine should be taken as a warning sign", warns Professor Christian Bornhof, chief physician Urological Department of the Nuremberg Clinic. Superficial bladder tumors are easily removed using gentle endoscopic operations. But what to do if the tumor is found in an advanced stage?

In such cases, the bladder is completely removed, and the question arises of replacement surgeries, which are designed for both men and women. Over the past two decades, medicine has made significant progress in this direction. " Depending on the spread of the tumor and general condition We offer a range of replacement surgeries to patients“- say the staff of the Urological Clinic of Nuremberg. And at the Bochum Urological Clinic, much attention is paid to the cosmetic result - operations are performed either by laparoscopy or minimal surgical intervention.

NEW RESERVOIR

The most common material for creating an artificial bladder is intestine, large or small. In addition, in laboratories, scientists are trying to “grow” bladder tissue “in vitro”, so far, however, these efforts have not been successful.

Operations can be divided into two large groups: formed bladder connects to the urethra and then urination occurs physiologically, or an artificial outlet is created on the anterior abdominal wall.

For the first time, the large intestine, or rather its sigmoid section, became the material for replacing the bladder. The fluid was directed through the ureters to the sigmoid colon, where it accumulated. The ability to retain urine in this case depended on the function of the anal sphincter. Due to certain shortcomings, this method is now used only in isolated cases.

More often, a reservoir resembling a bladder is formed. This requires an area small intestine about 60 cm long. A hollow spherical organ is formed from it through plastic surgery, which will serve bladder. This structure is then sutured to the ureters and urethra.

If there are contraindications to this method, for example, when the urethra is infiltrated by a tumor, the method of choice is to create a reservoir from the intestines and connect it to the skin abdominal cavity in the navel area. In this case, the patient needs to empty the reservoir several times a day using a catheter. Another method is to anastomose (connect) the ureters to the small intestine, and then bring a loop of small intestine to the skin of the abdominal cavity, usually in the right lower quadrant of the abdomen. A collection tank is connected to the hole. Doctors at the Bochum Urological Clinic assure that skin care in the area of ​​such a reservoir is absolutely simple, and patients can not only travel, but also visit a swimming pool. If the attachment of the ureters to the small intestine is impossible, for example, after radiation therapy, then a connection with the large intestine is formed according to the same principle.

NEW OLD LIFESTYLE

During the first 14 days after surgery, even if a physiological passage of fluid is formed, urine will be collected through an opening on the anterior abdominal wall into a special reservoir; This time is required for the connections of the bladder to the ureters and urethra to heal. A few days after the operation, procedures for rinsing the new bladder with saline begin. Since the operation involves not only the bladder, but also the intestines, it is necessary to abstain from eating for several days; instead, full intravenous nutrition is given. In 2 weeks the early term ends postoperative period. Usually by this time all drainages, catheters are removed, suture material, the process of physiological nutrition and urination begins.

After surgery, special attention should be paid to the process of urination itself. It is best done in a sitting position. Now the emptying of the bladder occurs not due to contractions of the muscle fibers of the organ itself, but with the help of pressure from the anterior abdominal wall, the “press”. Therefore, during urination, it is recommended to either push or press with your hand on the anterior abdominal wall. The duration of this process is longer than the physiological one. It is also necessary to prevent excess urine retention or insufficient emptying, which can lead to infections and bladder overdistension. The natural urge to urinate disappears after surgery, so it is important to monitor your bladder emptying at regular intervals. When the bladder is overstretched, some patients feel heaviness in the lower abdomen, but it may be too late - ruptures occur and urine spills into the abdominal cavity.

In the first 3 months after surgery, you need to empty your bladder every 3-4 hours. Night time is no exception, so the patient should be prepared for the alarm clock to ring 2-3 times at night. After about 3 months, the bladder is already so stretched that the intervals can increase to 4-6 hours. However, one urination is also necessary at night.

During the first time after surgery, problems such as urinary retention or incontinence may occur. Urinary retention can be a consequence of the formation of scars or adhesions, and may also appear against the background of the development of an infectious process. If urinary retention occurs, an urgent consultation with a urologist is required! Urinary incontinence often occurs due to weakness of the urethral sphincter. To prevent this problem, training is recommended, which is useful to start immediately after surgery. The training involves trying to “squeeze” the urinary catheter several times a day. Most patients experience significant improvement after training in the first weeks. After a year, more than 90% of patients do not suffer from urinary incontinence. However, about 50% of patients still need to set an alarm to prevent involuntary urination at night.

Since the intestines from which the bladder is formed continues to perform its natural function, namely the secretion of mucus, the urine becomes cloudy, patients note the presence of flakes. The biggest danger here is “clogging” of the urinary tract with mucus clots. Against increased mucus formation German doctors They recommend an extremely simple remedy - lingonberry juice, one glass twice a day.

Due to the natural secretory function of the intestinal wall, the amount of fluid released usually increases. If patients forget about this, dehydration may occur. Therefore, the daily amount of fluid consumed by adults should increase to 2-3 liters.

Diarrhea occurs in 10-20% of patients, but it can be stopped quite simply - with the help of drugs that bind bile acids or slowing down intestinal motility.

In general, doctors assure that significant lifestyle changes are not required after surgery to reconstruct an artificial bladder. All you need is punctual control of urination and regular examination by a doctor.

Dr. Sophia Rothaermel

MORE ON THE TOPIC:

In some cases, when treating bladder cancer, this organ must be removed in an operation called cystectomy. As a rule, such an operation is performed by Top Assuta surgeons using a gentle laparoscopic method, often using. It is completely safe and very effective. If there are no contraindications, after removing the cancer-affected bladder, Top Assuta surgeons resort to its reconstruction, which allows you to completely restore the process of urination.

Oncourologists at our clinic perform bladder reconstruction (Neobladder operation) with exquisite craftsmanship - replacing the removed organ with a completely artificial bladder.

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patients with a reconstructed bladder do not experience any problems with urination

Bladder removal surgeries are performed at Top Assuta using the Da Vinci robot

hour-long support in Russian

Bladder reconstruction in Israel: Neobladder operation

This involves creating a new bladder from a section of the patient's small or large intestine (or both) and connecting it to the urethra (urethra). Such an organ is capable of fully performing all the natural functions of the bladder. Reconstructed bladder allows urine to be drained naturally and thus significantly improves the patient's quality of life after a cystectomy by eliminating the need to carry an external urine reservoir (as in the case of a urostomy).

Despite all its advantages, bladder reconstruction is not indicated for every patient who has undergone a cystectomy. This is especially true for patients with intestinal pathologies or cancer diseases history of pelvic organs, as well as those whose cancer has spread to the urethra.

The reconstruction operation itself is performed using several techniques. Most often used reconstruction according to Studer ( Studer), in which a 40-60 cm long section of intestine is used to form the tissues of a new bladder. The ureters (ducts connecting the bladder and kidneys) are connected to a container formed from intestinal tissue that will perform the functions of the bladder. A catheter is inserted into the new bladder through the urethra and used to drain urine for about 4 weeks while the patient recovers from surgery. The catheter is then removed.

If the patient refuses reconstruction surgery or it is contraindicated for him, to ensure normal urine drainage, a urostomy is performed - the creation of an external reservoir in which urine accumulates and is discharged through an opening in the abdominal wall. This operation is usually performed in parallel with a cystectomy. After urostomy, the patient needs to adapt to new conditions.

Another type of urostomy involves placing the reservoir not outside the patient's body, but in his abdominal cavity. This eliminates some of the inconveniences associated with a urostomy: for example, it eliminates the need to carry an external reservoir; the patient only needs to empty the internal abdominal reservoir through a catheter several times a day.

Cost of bladder reconstruction at Top Assuta center

The price of bladder reconstruction is determined by several factors - the complexity of the chosen reconstruction technique, the patient’s condition at the time of surgery, etc. Therefore, the doctor can give an exact figure only after carefully planning all stages of the bladder restoration procedure.

Anyway surgical operations(including reconstruction of distant organs), which are carried out in Israeli clinics, are 30-40% cheaper than interventions carried out in medical centers of the European Union and the USA.

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Advantages of operations at the Top Assuta clinic

• Surgeons with many years of clinical experience, each of whom has more than a dozen successfully performed bladder reconstruction operations.
• Operating rooms equipped in accordance with today's requirements - modern intraoperative tomographs, robotic surgical units, computer control.
• Individual attitude to each patient - maximum comfort, attentive and respectful attitude of the staff, personal curator-translator.

After surgical removal bladder (due to its severe disorders, especially oncological ones), the question arises of prosthetics of the urinary system. An artificial bladder, the restoration technique of which is well developed in urological and surgical clinics in Germany, provides a good solution to the problem, allowing patients to independently overcome the everyday physiological stages of self-cleaning of the body and not depend on a catheter or an external reservoir for collecting urine. An artificial bladder also allows you to maintain optimal kidney function.

The most anatomically adapted techniques allow the artificial bladder to be connected to the natural excretory channel. This is possible in patients of both sexes. If the area of ​​the constipating muscle that regulates urinary excretion has undergone pathological changes (for example, tumor), then an alternative excretory channel is surgically installed, which also allows patients to do without an external reservoir of secreted fluid.

Neoblase technology - orthotopic artificial bladder

The Neoblase technique is a bladder replacement using orthotopic transplantation. Orthotopic transplantation is the transplantation within the body of one organ or its fragment in place of another, with the corresponding transfer of organ functions.

A small fragment of tissue from which the walls of the small intestine are formed is transplanted into the place of the removed bladder. This selected fragment is given the shape of a ball, reproducing the contour of the bladder. The plastically formed bladder is connected (over the constipation muscle) to the urethra, so that after healing everything begins to function as before.

The operation to replace the bladder with an artificial one is performed microsurgically. An innovative technique (Studer operation) allows the installation of an artificial bladder without frame devices (splints) guiding its formation. The frameless technique guarantees faster healing and accelerated rehabilitation of the patient. In this case, the stay in the surgical hospital is limited to only two weeks.

The course of postoperative rehabilitation carried out in a hospital includes “continence training”. This is learning to use a new bladder. The patient learns to confidently manage the excretory system so that annoying incontinence does not occur. In principle, upon discharge, he treats his new bladder (Neoblase) in the same way as he did with the old one when it was healthy. If necessary, to normalize the activity of the constipating muscles, the patient receives special medications.

According to experts in the field of surgery and urology, Neoblase with Studer installation is the ideal bladder replacement option, allowing patients to return to a normal quality of life.

Catheter stoma

If, during bladder prosthetics using the Neoblase method, it is not possible to connect an artificial organ to the urethra, then a bypass excretory tract with an external stoma is installed. Stoma is, in surgeons' language, an artificially formed external opening.

In this case, the stoma is formed in the navel (Indiana-Pouch technique). Like the natural urethra, it is equipped with a constipation muscle. This muscle is formed plastically and implanted from the inside into the navel funnel (from the outside, this anatomical “addition” remains invisible). An artificial bladder, formed from a fragment of the small intestine, is connected to the umbilical stoma through a shut-off valve, which is also made from a small fragment of tissue from the intestinal wall. The constipation muscle and valve prevent the spontaneous release of urine. To empty the bladder, the patient periodically inserts a special cleansing catheter into the stoma. From a hygienic and cosmetic point of view, this is an ideal solution if a person can no longer use the normal urethra.

Unification of the urinary system and intestines

Implantation using the Sigma-Rektum Pouch method aims to use the constipating muscles at the end of the intestines to control the release of both “your own” secretions and urine. Historically, this is the oldest technique for installing urinary bypass, the foundations of which were laid back in the 19th century. Subsequently, it was modernized several times. Currently, operations to install the “intestinal bladder” are carried out in surgical and urological clinics in Germany to the highest standards, using innovative technology and achieving a completely comfortable result for patients.

Strictly speaking, in this case, it is not a bladder prosthesis that is performed, but a direct drainage of urine into the large intestine. The ureters, which are normal conditions connect the kidneys to the bladder, reconnect to the final segment of the intestine. Before the operation, the functions of the constipation muscles of the anus are tested. She should be fine, because after the operation she will have to retain fluid in her rectum, along with the usual secretions.

Diversion of urine into the intestines is an alternative to the Neoblase method (artificial bladder). An alternative solution is taken if the natural urethra does not function (tumor or other pathological disorders). Under such circumstances, a bladder replacement would be ineffective. Therefore, a “simplified” scheme is used - urine drainage without a bladder. By the way, from a technical point of view, reconnecting the ureters to the intestines is really much simpler than forming a new bladder.

Conduit and urethrocutaneostomy

The word "conduit", familiar to us from a children's book, in medicine refers to an artificial tubular cavity formed in the body for certain physiological needs.

In this case, we mean the function of urine excretion, if it needs to be maintained without a bladder. As in the case of the Sigma-Rektum Pouch, an artificial drainage channel is installed, only the urine does not flow into the intestines, but into a compact portable container glued to the skin on the abdomen. To do this, the ureters are connected to the small intestine and urine is directed through an additional tube (conduit) 10-15 centimeters long to the intestine to the excretory opening (stoma). Urine is released freely through the skin and accumulates in an external container, which must be emptied from time to time. The establishment of such an excretory canal is called urethrocutaneostomy. This technique with lightweight surgical intervention Especially indicated for older patients or people with general physical weakness.

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Scientists have managed to grow an artificial bladder from tissue samples from patients.

American scientists announced successful tests new technology, which makes it possible to grow internal organs in laboratory conditions from small fragments of the patient’s own tissues. A report of seven successful artificial bladder transplants was published Monday in The Lancet.

Artificially created organs functioned successfully for a long time: several years have passed since the first operations performed using the new technology.

According to research project coordinator Dr. Anthony Atala, the new technique will help doctors solve the problem of donor organ shortages. In addition, when transplanting organs created from their own cells, there is no risk of rejection and patients do not need to take immunosuppressants, which saves them from a large number of serious illnesses. side effects.

To create an artificial bladder, Dr. Atala's team used precursor cells that, when differentiated, produce the muscle cells that line the organ's outer lining and the epithelial cells that line its inner surface.

Scientists managed to develop a technique for isolating progenitor cells and then growing from them separate layers, in which either muscle or epithelial cells predominated. Then the individual layers were combined. According to Anthony Atala, it was like making a layer cake.

The artificial organs produced in this way were intended for several patients aged 4 to 19 years who suffered from bladder dysfunction caused by hereditary disease. Impaired urination in these patients could lead to severe damage to other internal organs, especially the kidneys.

The artificially grown implant was attached to the patients' bladders. Over the course of several years after the operations, doctors observed a gradual improvement in the patients' condition.

Anthony Atwla's group is currently working on creating in vitro other complex organs: blood vessels, nerves, kidneys, liver, heart and pancreas.

In cases where the bladder cannot perform its functions, it is replaced with an artificial one. Sometimes an artificial bladder is formed by connecting the urinary tract to the intestine. The bladder itself is replaced with a piece of the colon, sigmoid, rectum or ileum. In the latter case, a reservoir is formed that looks like a real bladder. This method is still being developed. Usually preference is given to those methods that are based on the use of the body's natural sphincters - the sphincter of the urethra and anus.

How is the operation performed?

The simplest method is to expose both ureters to the skin. The ureters are sewn into the anterior abdominal wall, and urine is discharged through an opening in the wall. Urine collects in plastic bag attached to the skin of the abdomen. However, this method has one drawback - over time, narrowing of the ureters may occur.

A more complex surgical method is to replace the bladder with a piece of the ileum, colon or sigmoid colon. In this case, during surgery, the ureters are implanted into the intestinal loop. Urine moves through the intestinal loop and is discharged out through an opening in the abdominal wall. The most commonly used segment is the ileum.

Reservoir from the rectum

The ureters are sewn into the rectum, where urine collects. This process is controlled by the patient and is carried out with the participation of the rectal sphincter. This method has one drawback - bacterial flora from the rectum, entering the urinary tract, can cause inflammation.

Ileal reservoir

The ileal reservoir is ideal for bladder replacement. To form it, a segment of the ileum is used, the ends of which are sutured. The formed reservoir is connected to the ureters and urethra. The urea is replaced by a sac-like reservoir formed from small intestine, which collects urine. Urine is then released through the urethra.

A reservoir even from a segment of the ileum cannot completely replace natural urea. A patient with an artificial bladder does not have the urge to urinate. The process of urine excretion is controlled by consciousness and is carried out due to the tension of the abdominal muscles. To solve this problem, the umbilical opening is used. From a reservoir formed from a segment of the ileum, urine is discharged not through the urethra, but through the umbilical opening, to which a plastic tube is attached. Before the operation, the patient is examined and his condition is assessed. The study of kidney activity is of great importance. After surgery, you must follow a diet, eat food additives. Sometimes during the postoperative period, wounds open in the intestines, adhesions and hernias occur. Pyelonephritis is also a common complication.

Indications for surgery

Indications for this operation are: malignant tumors of the bladder, trauma, severe congenital anomalies, paralysis, and a sharp decrease in the size of the bladder.

Substances that can cause serious metabolic disorders can be resorbed from urine through the mucous membrane of the small intestine. Exchange processes such patients should be examined monthly. If violations occur, prescribe drug treatment. In addition, the risk of developing a urinary tract infection increases.

Every 4 hours, urine must be removed from the small intestine, from which the bladder is formed. it may become overstretched.