Violations in the natural process of urination, sometimes require emergency medical attention. Urethral catheterization is not always a panacea. In difficult situations, to drain urine from the MP, they resort to urgent (emergency) surgical intervention, using the method of intraluminal drainage.
Epicystomy is one of the many intraluminal drainage techniques used today in the practice of surgical urology.
Overview of Epicystostomy
The history of epicystomy has ancient roots. For the first time (300 years BC) it is mentioned in the annals of Erasistratus. The famous physician and philosopher Ibn Sina (1037) dealt with the problem of urine diversion, who described in detail the technique of performing the operation and the instruments necessary for it. The first operation was successfully carried out to the Roman-German monarch by the Hungarian doctor Benedict.
A more modern technique of epicystomy was described by F.I. Inozemtsev in 1836. Further research and various modernizations of this method of drainage of the MP are associated with the names of famous surgeons – H. H. Salomon, (1840), A. G. Podrez (1896). Since the beginning of the 19th century, N.V. Sklifosovsky, B.N.Kholtsov, S.P. Fedorov, and others took up the baton in the study of methods of drainage of the bladder.
Thanks to numerous studies, today, in addition to the pharmacological treatment of functional disorders of the urinary organ, intermittent (periodic) and constant drainage of the MP are used in conservative therapy. Those patients who have preserved the functions of the urinary organ, but have impaired urethral patency, know well what epicystostomy is.
Unlike urethral drainage, which can be complicated by urethritis, this system can be installed for a long time. With proper installation of the epicystostomy, observing all the rules of antisepsis and asepsis, the risk of complications is minimal.
In addition, the drainage system has a more stable structure, which prevents accidental fallout. It is convenient in terms of self-care, and when removed, it leaves no scars or scars.
Indications for the imposition of an epicystoma
Operative epicystomy is indicated for many pathologies and conditions that provoke prolonged stagnation of urine.
- in the absence of a normal tone of the urinary reservoir, provoked by chronic processes of urine retention,
- with the development of intravesical calculi and neoplasms that prevent the outflow of urine,
- in the presence of acute conditions caused by tamponade of the urinary cavity (the presence of blood clots, due to injuries, operations, etc.),
- in case of violation of the urinary-vesical walls (medical manipulations or injuries),
- in the presence of neurogenic dysfunctions (wheelchair patients),
- with different genesis of urethral obliteration (partial or complete clogging of the urethral canal sections).
Types of epicystostomy
Until recently, two types of MP epicystomy were used for urine diversion – open and trocar. Today, a new drainage method is being successfully introduced – without opening the urinary-vesical cavity.
- The open epicystomy technique involves the installation of a drainage system by means of a high section of the MP and the formation of a fistula in the suprapubic area of the peritoneum. It can be used as a temporary measure, as a preparation for the main surgical treatment, and as a permanent drainage.
- Trocar epicystomy is the formation of a suprapubic urinary-vesicular fistulous tract by puncturing the anterior abdominal wall and installing a drainage system using special instruments – a trocar or a hollow needle. It is used for short-term drainage of MP. This makes it possible to thoroughly examine the patient in the period of preoperative preparation for delayed surgical interventions and eliminates the need for permanent drainage.
- The technique of epicystomy without opening the urinary reservoir allows urine to be removed without causing unnecessary injury to the organ. It is used in patients with bladder injuries, in the presence of neurogenic dysfunction of the MP or urethral strictures.
Preparing for an operation
The algorithm for preparing a patient for an epicystomy is no different from preparing for any surgical intervention. During the planned operation, the patient undergoes a number of mandatory tests – monitoring of urine and blood, assessment of the hemostasis system, methods of instrumental examination of the pelvic organs, diagnostic assessment of the state of the body as a whole.
Previously taken drugs that can affect blood clotting are canceled. Consultation of an endocrinologist is recommended.
An exception is emergency intervention. In this situation, for a possible correction of further treatment, the necessary examination is carried out after the operation.
Technique of operating techniques
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Open access epicistomy
For epicystomy of the bladder using the open access method, local or epidural anesthesia is used. The operation is performed when the bladder cavity is filled, starting with the preparation of access to the urinary-vesical cavity. At a distance of 2 cm above the pubis, an incision is made in the center of the abdomen along the white line.
Access to the walls of the bladder is provided – flat muscles are pushed apart by a blunt method using hooks, the transverse fascia is dissected and the abdominal fold is shifted with a gauze swab, exposing the wall of the MP.
Holders made of nylon thread are attached to its upper part. A small incision is made between them. The contents of the bladder are removed with a vacuum pump, a digital revision of the organ is performed and a catheter is inserted into its cavity, which is tightly fixed to the bladder with sutures to prevent urine from flowing into the retinal space. The bladder itself is secured with two stitches to the flat abdominal muscles.
The wound is sutured in layers until the drainage tube is released, which is fixed to the skin with ligatures. An antiseptic treatment of the operating field is carried out and an aseptic bandage is applied. In parallel, a rubber outlet is installed to drain the pre-vesicle space, in order to avoid the accumulation of blood or urine that gets into this area during surgical procedures.
Trocar epicystomy technique
Installation of an epicystostomy is performed under visual control using a special set of instruments for epicystomy – a trocar with a tube and stylet. With the help of a camera or cystoscope, all manipulations are displayed on the monitor.
The operation begins with infiltration of local anesthesia, filling the bladder with a disinfectant and inserting a transmission device (camera or cystoscope) through the urethra. The area of the operating field is treated with an antiseptic. On the anterior wall of the peritoneum, a small, up to 2 cm incision is made.
The muscles and tendon plates (aponeurosis) of the peritoneum are pierced by rotating movements of a trocar with an inner tube diameter of 16–20 mm, monitoring the pressure on the urinary-vesicle walls using video surveillance. The bladder wall is perforated with helical movements.
After the trocar is inserted into the vesical cavity, the trocar stylet is removed, and a corresponding catheter with a balloon retainer is inserted into the bladder along the tube lumen. The tube is removed and the catheter is pulled until the balloon contacts the bladder wall. The end of the drain is fixed with ligatures to the skin of the peritoneum.
Epicystomy technique without opening the urinary tract
This technique allows you to provide emergency assistance to patients with signs of MP dysfunction and the presence of urethral strictures. The epicystoma is applied by forming a canal in the MP through an incision in the navel. An epicystoma is installed in it and through the umbilical ring, through the formed channel, it is carried out into the cavity of the bladder. The formed canal of the epicystoma is sealed by suturing the peritoneum around the umbilical ring. The operating wound is sutured tightly in layers and postoperative treatment is carried out.
This technique is so good that it completely excludes infection of the subcutaneous tissue and the development of postoperative complications.
MP epicystostomy care
The success of an epicystomy depends on the proper use and maintenance of the drainage system. All necessary manipulations with the epicystostomy should be carried out after thorough hand washing.
Minimizes the risk of complications:
- daily hygiene treatment of the skin adjacent to the catheter,
- regular cleaning of the outer part of the drainage system,
- proper control over the fixation of the catheter, in order to avoid its accidental loss from the bladder cavity,
- timely replacement of drainage – after 1-1,5 months.
When the operation is performed by a competent specialist and all his recommendations are followed, these epicystostomy techniques allow patients to lead a full life without constant discomfort, move freely, play sports and not limit themselves even in terms of sexual relations.