Topography of the neurovascular formations of the pelvis. Formation and topography of the sacral plexus. Places where nerves and blood vessels exit the pelvic cavity.

Operation description

Robot-assisted radical prostatectomy is performed under general anesthesia. On average, the operation lasts about 2-3 hours, depending on the scope of treatment: with or without removal of lymph nodes, with preservation of the nerve bundles responsible for potency or without nerve sparing.

Robot-assisted RP is performed through 5 incisions on the anterior abdominal wall, each less than 1 cm long. Subsequently, so-called trocars, or ports, are installed through these incisions, to which are attached the “arms” of the robot, which are controlled by the surgeon. Carbon dioxide is then injected into the abdominal cavity to create a working space. Upon completion of the operation, it is removed from the abdominal cavity. For cutting and suturing tissue, coagulation (“sealing” with energy) of blood vessels, the surgeon uses special robotic instruments with greater maneuverability and a greater number of degrees of freedom than a human hand. Moreover, the stereoscopic lenses of the eyepieces, into which the surgeon looks throughout the entire operation, have access to a 3D camera with the highest resolution, that is, the doctor sees the clearest image possible, having the properties of a three-dimensional image.

The surgical assistant is usually located next to the operating table and, through a specially designated port, helps the surgeon with various instruments, mainly an aspirator (“suction”), collecting spilled blood for better visibility or pushing aside organs and tissues that may be in the field of view and surgeon's work. One of the operating team members rolls the Da Vinci system with robotic “arms” off the operating table where the patient lies, and the “arms” are attached to the previously installed ports. Then, through these ports, the assistant starts the tools for work. The surgeon is located at some distance from the operating table, behind the so-called console. It is while sitting at the console that the surgeon looks into the eyepieces and “controls” the robot.

Genital neurovascular bundle

The genital neurovascular bundle (a. et v. pudendae internae and n. pudendus) is located in the infrapiriform foramen most medially. Upon exiting the infrapiriform foramen, the genital neurovascular bundle lies on the sacrospinous ligament, lig. sacrospinal, and the spine of the ischium, forming the upper edge of the lesser sciatic foramen (see Fig. 4.11). Then the bundle passes through the lesser sciatic foramen under the sacrotuberous ligament, lig. sacrotuberale, on the inner surface of the ischial tuberosity. The latter is part of the lateral wall of the ischioanal fossa and is covered by the obturator internus muscle and its fascia. The splitting of this fascia forms the so-called Alcock canal, in which the genital neurovascular bundle passes. N. pudendus in it is located downward and medial from the vessels.

Connection of the fiber of the subgluteal space with neighboring areas. Holes of the subgluteal space. Messages from the gluteal region.

The subgluteal cellular space communicates:

1) through the supra- and infrapiriform openings - with the pelvic cavity; 2) through the lesser sciatic foramen - with the ischioanal fossa; 3) along the sciatic nerve - with the posterior region of the thigh; 4) through the gap under the proximal part of the tendon of the gluteus maximus muscle - from the lateral and anterior. Anterior weak point of the capsule of the hip joint

The anterior “weak spot” of the hip joint capsule is located between the lig. iliofemorale and lig. pubofemorale (Fig. 4.15).

The anterior weak point of the hip joint capsule is covered by the fascial sheath of the iliopsoas muscle, m. iliopsoas. Between the capsule and the muscle there is a bursa iliopectinea, which in 10% of cases communicates with the joint cavity. Streak from the anterior weak point spreads along the posterior surface of m. iliopsoas, i.e. through the muscle lacuna, further along the wing of the ilium and the lateral surface of the spine to the lumbar region proximally, to the lesser trochanter - distally. The swelling with this type of swelling has an hourglass shape - the constriction is formed by a stubborn inguinal ligament.

From under the inner edge of m. iliopsoas can spread between the pubis and pectineus muscle into the medial femoral bed. The most dangerous leak is along the femoral vessels - along the sulcus femoris anterior and further into the adductor canal.

Rice. 4.16. Posterior “weak spot” of the hip joint (according to Spalteholz, with modifications). 1 - os ilium; 2 - lig. iliofemoral; 3 - trochanter major, 4 - crista intertrochanterica; 5 - trochanter minor; 6 - posterior “weak spot” of the joint capsule; 7 - lig. ischiofemorale; 8 - tuber ischiadicum.

Posteroinferior weak point of the hip joint capsule

The posteroinferior “weak spot” of the hip joint capsule is located under the lower edge of the lig. ischiofemorale (Fig. 4.16).

Here a protrusion of the synovial membrane forms from under the lower edge of this ligament. On the posteroinferior “weak spot” lies m. obturatorius externus.

Through the posteroinferior “weak spot,” leakage from the cavity of the hip joint can spread through the fascial sheath of the obturator externus muscle into the medial fascial bed of the thigh, in which the adductor muscles are located. From here, through the obturator canal, it can penetrate into the pelvic cavity. When the swelling spreads posteriorly, it enters under the gluteus maximus muscle through the gap between the inferior gemellus and quadratus femoris muscles.

Collateral circulation in the hip joint. Collaterals of the hip joint. Collateral vessels of the hip joint.

In the area of ​​the hip joint, in the surrounding muscles, there is a wide network of anastomoses, as a result of which the disruption of blood flow through the external iliac and femoral arteries can be compensated (Fig. 4.17). Thus, an anastomosis between the lumbar artery and the deep circumflex iliac artery can compensate for the disruption of blood flow in the area from the aortic bifurcation to the distal external iliac artery.

Occlusion in the area between the internal iliac artery and the femoral artery is compensated by anastomoses between the gluteal arteries and the ascending branches of the lateral and medial circumflex femoral arteries.

Rice. 4.17. Collaterals of the hip joint 1 - aorta abdominalis; 2 - anastomosis between a. lumbalis and a. circumflexa ilium profunda; 3 - anastomosis a. glutea superior with a. circumflexa ilium profunda; 4 - a. iliaca communis; 5 - a. iliaca interna; 6 - a. glutea superior, 7 - a. circumflexa ilium profunda; 8 - a. iliaca externa; 9 - a. glutea inferior, 10 - a. obturatoria; 11 - anastomosis between a. glutea inferior and a. obturatoria; 12 - a. circumflexa femoris medialis; 13 - r. ascendens a circumflexae femoris lateralis; 14 - a. circumflexa femoris lateralis; 15 - a. profunda femoris; 16 - a femoralis.

The obturator artery, which anastomoses with the medial circumflex femoral artery, also takes part in the development of collateral circulation

It should be noted that the deep femoral artery, from which the circumflex femoral arteries branch off, plays an extremely important role in the development of collateral blood flow in the proximal thigh .

Who is the operation indicated for?

Robotic prostatectomy is indicated for patients with clinically localized prostate cancer, and in some situations where the disease extends beyond the organ. Most patients who are good candidates for open radical prostatectomy can undergo robot-assisted surgery. Today, in most centers, preference is given to robot-assisted operations, which have a number of advantages: a more acceptable cosmetic effect, less blood loss, shorter hospitalization, a quick recovery period, and less severe pain.

Preparing for surgery

Preoperative preparation usually includes:

• general blood analysis,
• general urine test with culture,
• blood chemistry,
• coagulogram,
• blood for infections
• results of prostate biopsy with revision of glass preparations,
• MRI data of the pelvic organs with contrasting,
• ECG,
• X-ray of the lungs,
• consultation with a therapist, who can somewhat expand this list of examinations depending on whether the patient has any concomitant pathology.

Admission to the clinic occurs the day before the operation, when the attending physician will introduce you to the anesthesiologist, who will provide anesthetic support during the operation. Immediately before the operation, it is necessary to shave the hair from the inter-nipple line to the level of the upper third of the thigh, including the groin area. You should avoid eating solid food for about 6 hours before surgery. The nurse will also perform a cleansing enema immediately before surgery. You must have preoperative compression stockings with you and put them on on the day of surgery (early in the morning without getting up).

How is the operation performed?

A schematic representation shows the relative positions and relationships between the bladder, prostate, neurovascular bundles (NVBs), rectum and vas deferens with the seminal vesicles. The course of the operation involves separating the prostate with the prostatic part of the urethra running through it from the bladder and that part of the urethra that is a continuation in the small pelvis of the so-called “penile” urethra, that is, the urethra within the penis.

Preservation of neurovascular bundles to ensure erection

If it is planned to preserve the neurovascular bundles to ensure an erection and faster urinary retention (in a situation where this does not contradict the oncological viability of the operation), the robotic system allows this to be done most delicately and accurately. To accomplish this task, an experienced surgeon resorts to a number of techniques. For example, the surgeon performs separation of the SNP from the lateral surfaces of the prostate in a “cold” way, that is, without using any type of energy, in order to avoid thermal damage to the nerve fibers sensitive to this type of influence. In addition, the maneuverability of the 3D camera, the angle of inclination and the distance to the object, which are controlled by the surgeon from the console, allows him to “look” into the layer between the lateral surface of the prostate and the secreted SNS, rather than asking the assistant to “move” the nerve bundle to the side, which can lead to to now mechanical damage, tearing of the spinal cord, which, even with correctly performed dissection (separation from adjacent tissues), will not adequately transmit the nerve impulse. All these techniques allow us to hope for the earliest and most complete restoration of “male function” in the postoperative period.

If preservation of neurovascular bundles is not possible

In a situation where, due to oncological risks, preservation of the neurovascular bundles is impossible and the patient is indicated for removal of regional lymph nodes, the robotic system allows the surgeon to remove the fiber (adipose tissue) with the lymph nodes contained in it as a single block. Once the prostate is removed, it, along with the lymph nodes (if the operation involved their removal), is placed in a special container, which will later be removed from the abdominal cavity through one of the extended incisions on the anterior abdominal wall. In this case, the remaining urethral stump is sutured to the neck of the bladder. This stage is performed “on a catheter,” that is, on a catheter inserted into the bladder through the urethra, a tube that has a balloon at its inner end, which, when filled with liquid, prevents it from falling out of the bladder. On the one hand, the catheter serves as a kind of splint, with a frame around which a new connection between the bladder and urethra is created, and on the other, it ensures a constant outflow of urine from the bladder, which prevents its walls from straightening when filling and creating pressure on the newly created anastomosis.

Here there is a particular advantage of performing a vesicourethral anastomosis (suturing the urethral stump to the bladder neck) using the Da Vinci system. Indeed, it makes it possible to most accurately compare the mucous membrane of the urethral stump with the mucous membrane of the bladder neck, since the comparison of “the same” tissues (muscle with muscle, mucous with mucous) is the key to “proper healing” of the latter. Typically, the urethral catheter is in the bladder from 3-4 to 7 days. Upon completion of the operation, another tube is inserted through one of the holes on the anterior abdominal wall - an insurance drainage, which, if installed, is usually for no more than 1 day and, as the name suggests, is a kind of “insurance” in case such a complication occurs, as bleeding, since if it occurs, blood will flow out, including through the insurance drainage.

At the very last stage, the trocars are removed and the incisions on the anterior abdominal wall are sutured. Although immediately after removal of the urethral catheter, most men experience elements of stress urinary incontinence - leakage of urine during prolonged walking, changes in body position, especially when getting out of bed - in most cases these phenomena subside by 3-6 months after the operation. In some cases, the time frame for restoring retention can be calculated in weeks, in others – in months. Of great importance for the restoration of early retention is the fact of preservation of the SNP, although, unfortunately, this is not always feasible if the patient has high oncological risks, which are determined individually in each specific case.

About maintaining potency

As for the restoration of potency after surgery, it is somewhat more difficult to assess the effectiveness of preserving the SNP, since the occurrence of an erection is influenced by factors such as the patient’s age, the safety and quality of the erection at the preoperative stage, the percentage of preserved SNP (on the one hand, on both sides, interfascial dissection, intrafascial dissection - the last two techniques are also largely determined by oncological principles), a history of diabetes mellitus, arterial hypertension, excess body weight, high blood cholesterol, smoking, etc.

According to some authors, in patients with initially preserved potency, bilateral (on both sides) intrafascial preservation of the SNT, sexual intercourse with or without additional drug support is observed in 50%, 73% and 88% of patients after 3, 6 and 12 months, respectively .

Field of technology to which the invention relates

The invention relates to medicine, in particular to human anatomy and the anatomical method for studying somatometry, and can be used to determine the projection of the internal genital neurovascular bundle (NPB) on the body. The method can be used for performing manual therapy with an impact on the components of the genital neuropathy, determining the projection of the surgical incision for access to the genital neuropathy, for the purpose of blocking the internal pudendal nerve, for diagnosing patients with neuropathy, neuroma of the internal genital nerve, as well as pathologies of the vessels of the internal genital nerve . The invention makes it possible for practicing students to determine the projection without special equipment, thereby reducing the likelihood of errors in the treatment of patients with pathology of the internal genital SNP.

State of the art

A modern method for diagnosing the internal pudendal neurovascular bundle is known, which consists in identifying the course of the internal pudendal artery using an ultrasound machine, determining the location and suggesting the course of the internal pudendal nerve accompanying this artery [Fernanda Rafael Tobar Roa, etc. Regional anesthesia guided by ultrasound in the pudendal nerve territory // Colombian Journal of Anesthesiology. — 2021. — Vol. 45, No. 3, P. 200-209].

The disadvantage of this method is the large number of arteries of similar caliber passing in this area layer by layer, as well as the absence in a number of medical institutions, or in a number of private practices, for example, chiropractors, of both trained specialists and ultrasound machines.

The closest to the proposed invention is the method for determining internal sexual SNP, described by Corning [G.K. Corning, Topographic Anatomy - 1931, - P. 701]. The method consists in determining by palpation the superior posterior iliac spine, the ischial tuberosity and the apex of the greater trochanter. A line is drawn from the superior posterior iliac spine to the apex of the greater trochanter; it crosses the greater sciatic notch at the origin of the inferior gluteal artery. This artery enters the gluteal region slightly downward from the middle of the above line, and medial to it is the internal pudendal artery with the nerve of the same name. The internal genital SNP emerges medially from the infrapiriform foramen.

However, when using this method, it is difficult to determine the entire projection of the fascicle (border) in the patient, since of the above anatomical elements and landmarks, only the ischial tuberosity can be palpated. This method relies on the projection of the inferior gluteal artery and only indirectly informs about the possible location of the internal pudendal artery in a narrow section of the area under study.

Disclosure of the Invention

The objective of the present invention is to develop a method that makes it possible to accurately determine the position of the internal genital SNP in the gluteal region.

The technical result consists in increasing the accuracy of determining the boundaries of the projection of the internal genital neurovascular bundle (INB) on the surface of the patient's body in the gluteal region.

A method for determining the projection of the internal genital neurovascular bundle (INB) on the surface of the patient’s body in the gluteal region using external landmarks, which are the ischial tuberosity, the greater trochanter, according to which the points of the mentioned external landmarks are marked on the patient’s body in the gluteal region, as well as the midline of the body and the lines defining the minimum distance from the specified points of external landmarks to the midline of the body; then mark a line corresponding to the projection of the lower edge of the piriformis muscle, located at an angle of 15° (with a permissible error of up to 20%) to the line characterizing the minimum distance from the point of the greater trochanter to the midline; then, on the surface of the patient’s body, the projection boundaries of the area where the genital SNP is located are determined, in the form of a rectangular trapezoid,

in this case, the lower border of the SNP, which is the lower base of the trapezium, is determined from the point of the ischial tuberosity to a point located at a distance of 3 cm along the line characterizing the minimum distance to the midline of the body towards the midline of the body;

the lateral border of the SNP, located closer to the midline of the body, is determined from the above-mentioned point, located at a distance of 3 cm from the ischial tuberosity to the point that is the intersection of a line drawn through the mentioned point parallel to the midline of the body, with a line corresponding to the projection of the lower edge of the piriformis muscle ,

the upper border of the SNP, which is the upper base of the trapezoid, is determined from the specified intersection point to a point 1 cm away from it away from the midline of the body (along a line perpendicular to the midline of the body OR parallel to the lower border),

the lateral border of the SNP, located closer to the lateral line of the body, is determined from the last point to the point of the ischial tuberosity;

after which the projection of the midline of the genital SNP is determined along a line drawn through the midpoints of the bases of the trapezoid.

External landmarks in the gluteal region - the most prominent points of the ischial tuberosity of the ischium, the greater trochanter of the femur, are determined by palpation.

During the topographic-anatomical study of the gluteal region, the necessary data were obtained to determine the boundaries of the projection of the desired area of ​​​​the location of the SNP. It was determined that the projection figure is a rectangular trapezoid, whose parallel sides (bases of the trapezoid) define the upper and lower boundaries of the area where the SNP is located, the lateral side of the trapezoid, located at right angles to the base, defines the boundary of the SNP area closer to the midline of the body, the opposite side the trapezoid side defines the border of the SNP closer to the lateral surface of the body. The trapezoid line passing through the middle of the bases determines the projection of the midline of the internal genital SNP.

To determine the boundaries of the desired area of ​​the SNP, the position of external landmarks in the gluteal region and their most protruding points, such as the ischial tuberosity of the ischium, the greater trochanter of the femur, are detected by palpation. In addition, the midline of the body is determined. Measure the distance from these points to the midline in the horizontal plane. The projection line of the lower edge of the piriformis muscle is determined. This is a line drawn from the projection of the point of attachment of the piriformis muscle to the greater trochanter, going at an angle upward towards the midline of the body with its fixation to the sacrum. The line has an elevation angle of 15°. Thus, the angle between the line drawn through the point of the greater trochanter to the midline of the body and the line that is the projection of the lower edge of the piriformis muscle is 15° (Fig. 1).

This angle value, which characterizes the angle of elevation of the piriformis muscle, was determined based on the results of a topographic-anatomical study of the gluteal region, as well as data obtained as a result of morphometry based on external landmarks, individual for each person. In addition, based on the results of the research, it was determined that the area on the body that characterizes the projection of the SNP can be represented in the form of a trapezoid.

Brief description of drawings

The invention is illustrated in Fig. 1, which shows a diagram of the construction of a projection of the genital SNP on the patient’s body.

Carrying out the invention

Below is a detailed description of the proposed method.

During the topographic-anatomical study of the gluteal region, the data necessary to solve the problem of determining the location of the internal genital SNP in the gluteal region were obtained and confirmed.

To determine the projection of the SNP on the surface of the gluteal region, the patient is placed on his stomach. Using palpation, find the position of external landmarks in the gluteal region - the most prominent points of the ischial tuberosity of the ischium (point D), the greater trochanter of the femur (point G), and also determine the midline of the body, see Fig. 1.

A line is drawn through point D directed towards the midline of the body (at a right angle). At the intersection of these two lines, mark point A and measure the length of segment AD. Through point G, draw a straight line to the midline of the body at a right angle, at the intersection of these lines oG. Next, draw a straight line upward from point D. At the intersection with the horizontal line from the greater trochanter - G to the midline of the body o. The measured values ​​of the segments can be used in the future to accurately determine the location of the genital SNP when performing operational access.

Next, determine the line of the angle of deviation of the piriformis muscle from the line drawn through the place of attachment of the greater trochanter to the midline of the body. It was determined that the average value of the angle between the projection line of the lower edge of the piriformis muscle and the A'G line with its apex at point G is 15°. Based on this condition, a line is marked on the patient’s body corresponding to the projection of the lower edge of the piriformis muscle, located at an angle of 15° to the line characterizing the minimum distance from the point of the greater trochanter to the midline.

From normal human anatomy it is known that the lower border of the area of ​​​​the internal genital SNP runs along the line AD towards the midline of the body. Using a topographic-anatomical study, it was established that the point of the lower segment of the desired projection is at a maximum distance of 3 cm from point D towards the midline of the body. On a horizontal line from point D, passing to the midline of the body, this point is marked with the letter C. The segment CD is obtained.

Next, draw a vertical line from point C and at the intersection with the lines from point G o'. The length of the segment CC' is equal to the segment DD'. To determine the desired projection, determine the length of the segment C'C", where C" is the point of intersection of the projection of the lower edge of the piriformis muscle with the continuation of the vertical line CC'. The length of the segment C'C", which is a leg of the right triangle C'C"G, is determined by the formula: Tg(15°)=C'C/C'G, where C'G=(A'C-AD+3) .Hence, C'C"=0.2679×(A'G-AD+3), SS"=CC'+C'C".

Using a topographic-anatomical study, it was established that the upper limit of the area where the SNP is located has a length of 1 cm. To determine the projection of the upper limit of the location of the SNP on the patient’s body, 1 cm is retreated from point C” away from the midline of the body (point D”). By connecting this point with point D, a projection of the upper boundary of the desired area is obtained. In this case, the rectangular trapezoid C-C"-D"-D characterizes the area where the SNP is located on the patient's body, in which the parallel sides C"-D" and CD define the upper and lower boundaries of the area where the SNP is located. And the lateral side of the trapezium, located at right angles to the base C-C, defines the border of the SNP region closer to the midline of the body, the opposite side of the trapezoid DD defines the border of the SNP closer to the lateral surface of the body. After determining the upper and lower boundaries of the area of ​​the SNP, which are the bases of the trapezoid, a line is drawn through their middle, which determines the projection of the midline of the internal genital SNP.

The accuracy of the location of the fascicle (internal genital SNP) has been confirmed experimentally and clinically.

Below is a description of an experimental example performed on a biomanikin.

To determine the projection of the internal genital SNP using the proposed method, a biomanikin was placed on the stomach, the ischial tuberosity (point D) was determined by palpation and a horizontal line was drawn through it directed to the midline of the body. At the intersection of these two lines, point A was marked, then the shortest distance from the ischial tuberosity (point D) to the midline of the body, point A, was measured horizontally. Length of segment AD=8.5 cm.

Then, using palpation, the greater trochanter (point G) was determined and a straight line was drawn through it to the midline of the body, at the intersection of these lines o, located on the midline of the body (A-A'-A") along a horizontal line. Length of segment A'G=14.6 cm.

Then a vertical straight line was drawn upward from point D. At the intersection with the horizontal line (A'G) from the greater trochanter G to the midline of the body about = 5 cm.

At a distance of 3 cm along a horizontal line from point D, passing to the midline of the body, point C was marked. A segment CD equal to 3 cm was obtained.

Draw a vertical line upward from point C and at the intersection with the horizontal line (A'G) from point G o is equal to the segment DD', then CC'=3 cm.

To determine the desired projection, the length of the segment C'C" was determined using the formula: C'C"=0.2679 × (A'G-AD+3). Therefore, С'С"=0.2679 × (A'G-AD+3)=0.2679×(14.6-8.5+3)=2.44 cm. The length of the segment СС" was СС'+СС"=7 .44 cm.

We measured 7.44 cm vertically upward from point C to C", then 1 cm to the right from point C" along a horizontal line, o'-D"-D, located in the gluteal region. A line was drawn through the centers of segments CD and C'D, defining the projection of the midline of the internal genital SNP.

During the subsequent topographic-anatomical study using the method of layer-by-layer tissue preparation with morphometry and photography, the calculations of the projection of the genital SNP were confirmed.

Clinical example

Extract from medical history 22488. Patient N., 39 years old. Diagnosis: Osteochondrosis of the lumbar spine, disc herniation L5-S1. Sciatica. Pudendal neuropathy.

The location of the internal genital neurovascular bundle in the gluteal region was diagnosed using the claimed method, the boundaries of the area where the SNP was located were determined on the patient’s body, the following parameters were obtained: segment length AD=8.5 cm, segment A'G=14.6 cm, segment DD' =5 cm, CD=3 cm, segment СС'=DD'=5 cm, С'С"=0.2679×(A'G-AD+3)=0.2679×(14.6-8.5+3)= 2.44 cm, SS"=SS'+C'S"=7.44 cm.

We measured 7.44 cm vertically upward from point C to C", then 1 cm to the right from point C" along a horizontal line, o'-D"-D.

The obtained results of the projection of the internal genital SNP were confirmed by the results of ultrasound diagnostics, which was performed on a Toshiba Aplio 500 device with a linear sensor of 5-12 MHz.

The data obtained were used during conservative treatment, which included the use of non-steroidal anti-inflammatory drugs, traction, exercise therapy, massage, and the functional effect of PIR (post-immobilization muscle relaxation), including on the area of ​​projection of the spinal cord. The patient was discharged from the hospital in satisfactory condition. Notes a good effect from the treatment. Was examined after 2 years. No complaints. There were no symptoms of pudendal neuropathy.

Thus, the inventive method for determining the projection of the internal genital neurovascular bundle in the gluteal region makes it possible to calculate the boundaries of the projection of the internal genital neurovascular bundle in the gluteal region. This method is an alternative to ultrasound diagnostics; it allows practitioners and students to accurately determine the projection of the internal genital SNP, thereby reducing the likelihood of improper treatment of patients with pathology of the internal genital SNP.

A total of 27 patients were studied using the claimed method. Long-term observational results indicate the high reliability of the proposed method. The method is completely safe for patients.

Intra- and postoperative period: possible complications and recovery

As with any “major” operation, some complications are possible, although infrequent, with robot-assisted surgery. Potential risks are minimal, but still exist.

Bleeding: blood loss during robot-assisted prostatectomy rarely exceeds 100 ml; the need for blood transfusion for more significant blood loss is less than 2%.

Infection: with intravenous antibiotics, the risk of infectious complications is extremely small, however, if in the postoperative period you find signs of a developing infection (fever, redness of the skin around postoperative wounds, frequent painful urination), immediately inform your doctor.

Postoperative hernia: due to the fact that the size of the incisions on the anterior abdominal wall is small, the risk of the formation of postoperative hernias at the site of these openings tends to zero. In addition, the larger incision (through which the prostate is removed) is carefully sutured. However, in the literature there are descriptions of postoperative hernias even in the area of ​​8 mm robotic ports with severe weakness of the connective tissue.

Trauma to adjacent organs and tissues: Because robotic surgery is performed under improved visualization conditions, this complication is rare. However, the colon, small intestine, bladder, urethra, and main blood vessels are in intimate proximity to the area of ​​surgical intervention, which, in addition to everything, is performed in a “tight” space – the pelvis. The consequence of placing the patient on the operating table, even with the use of specially provided “pillows” in the pressure points, may be painful sensations in the muscles of the shoulder girdle and lower extremities. In the vast majority of cases, these unpleasant sensations resolve on their own over time.

Conversion of robotic surgery to laparoscopic or open: this option for the course of the intraoperative period represents a transition to another type of surgical approach due to complications that have arisen. Conversion to open surgery means that the postoperative wound will be larger than with any other method of accessing the pelvic cavity. Conversion occurs in less than 1% of situations.

Incontinence: is the incontinence of urine after removal of the urethral catheter. As noted earlier, this variant of the course of the postoperative period is normal, observed in most patients and relieved over time. Kegel exercises may be helpful in restoring continence and should be performed several months after surgery, not earlier.

Erectile dysfunction: this is nothing more than a decrease in the quality of erection in the postoperative period and directly depends on whether a nerve-saving technique was performed. As noted earlier, restoration of erection is a process that depends on many factors. The attending physician will explain in detail how “rehabilitation” of sexual function can be carried out in the postoperative period, starting from drug therapy, ending with the use of vacuum devices, intracavernosal injections (injecting medication into the penis). These treatments are aimed at maintaining blood flow to the penis while erectile function is restored.

Failure of the vesicourethral anastomosis: before removing the catheter, a study called retrograde cystography is performed, the essence of which is that an X-ray contrast agent is injected into the bladder, which, provided that the anastomosis has healed, will “color” only the bladder in X-ray “light” . If the anastomosis does not heal properly, the contrast agent may enter the tissue adjacent to the bladder, which will also be visible on the x-ray. In such a situation, the catheter is not removed, and its presence in the bladder is extended for 1-2 weeks (depending on the degree of “stiffness”).

About the diet

As for nutrition, immediately after surgery (usually for 2-3 days) it is not recommended to eat food that promotes gas formation and prevents rapid bowel movement from feces. Obviously, these products include bread (especially black bread), fresh fruits, vegetables, legumes (beans, peas, lentils), rice.

For those patients who do not tolerate milk protein well, they should avoid consuming dairy products. With the appearance of regular bowel movements, in most cases the patient returns to the diet of a healthy person.

Often in the postoperative period, bloating and constipation may be observed as consequences of anesthesia. In such situations, it is possible to prescribe mild laxatives both for use internally and in the anus. In general, drinking a teaspoon of unrefined sunflower and olive oil helps combat constipation.

We have long abandoned the use of narcotic painkillers due to constipation as a side effect of their use. Currently, for adequate management of pain, there are drugs from other groups (most often, NSAIDs).

About hygiene

You can shower immediately upon discharge from the hospital. Immediately after the hygienic procedure with baby soap (you should not rub postoperative wounds particularly hard), it is recommended to wipe the skin dry with a clean towel and treat the wounds with an aqueous solution of an antiseptic (iodopyrone, chlorhexidine).

If you are not going to work, then you do not need to cover the wounds with a band-aid. For 4-6 weeks after surgery, you should avoid washing in the bathroom, since limp skin in the area of ​​the postoperative wound can lead to the development of a wound infection.

About physical activity

Regarding physical activity, it must be said that moderate exercise is a good prevention of constipation, pneumonia and deep vein thrombosis of the lower extremities. Walking on a flat surface up to 6 times a day (about 4 km) is encouraged. Once you no longer need to use painkillers and you feel sufficient strength in your arms and legs, you can return to driving.

For the first few months, it is wise to refrain from lifting heavy objects (more than 5 kg). Some weakness and drowsiness may be observed for some time after the operation, which usually resolve on their own.

To prevent pulmonary complications, including pneumonia, you should at least walk more and lie down less. This simple and affordable method of prevention is at the same time a good way to combat sluggish intestinal motility and constipation as its manifestation. As for the prevention of pneumonia, breathing exercises (exercises on a spigometer, inflating balloons, etc.), based on deep inhalation and equally deep exhalation (must be performed in the presence of medical staff to prevent dizziness and loss of consciousness), play an important role here.

As soon as the doctor receives the results of a histological examination of the removed prostate and/or regional lymph nodes, he will contact you and invite you to a consultation to discuss options for further observation and/or treatment tactics.

Correction of penile abnormalities in epispadias and bladder exstrophy (literature review)

Rudin Yu.E., Marukhnenko D.V., Aliev D.K.

The exstrophy-epispadias complex represents a spectrum of urogenital malformations ranging in severity from epispadias to classic bladder exstrophy and cloacal exstrophy. The exstrophy-epispadias complex is characterized by a visible defect of the lower abdominal wall, combined with either an evaginated bladder wall (classic bladder exstrophy) or a cleft urethra (epispadias). This disease occurs on average in 1 in 100,000 newborns. In the domestic literature, epispadias and exstrophy are considered as separate nosological units, however, in world practice - only as a single complex. Anatomical changes in the penis with epispadias are expressed: 1) The urethra is split right up to the external opening of the urethra, which, depending on the shape of the epispadias, can be located on the head with the capitate form, the middle and proximal part of the shaft - with the trunk and in the peno-pubical angle - with the total form of epispadias. 2) The head of the penis is flattened, the foreskin covers only its ventral surface. 3) Due to the divergence of the pubic bones and hypoplasia of the tunica albuginea along the dorsal surface, the penis is shortened and has dorsal deformation of varying degrees. In addition, most boys with total epispadias have urinary incontinence. Thus, the main goals of correcting abnormalities of the penis in the epispadias-exstrophy complex are to achieve urinary continence, create the urethra, straighten and elongate the penis to a size sufficient for normal sexual intercourse.

This paper analyzes various methods for correcting urinary incontinence and penile anomalies in the ectrophy-epispadias complex.

DEFINITION

Exstrophy-epispadias complex (EEC) is the most serious form of anterior abdominal wall malformation. With CEE, there are characteristic defects of the urinary system, musculoskeletal system, pelvis, pelvic floor, abdominal wall, genitals, and sometimes even the spine and anus [1]. There are many theories of the embryogenesis of exstrophy, however, the most significant reason for the development of bladder exstrophy (EMB) is the pressure of the tail of the embryo on the area of ​​the urogenital diaphragm (the place where the buds of the bladder, urethra and penis are connected) during the formation of organs at 3-4 weeks intrauterine development FD Stephens, JM Hutson [2].

CEE can have varying levels of severity, ranging from a mild form of epispadias (E), with inferior and superior clefting, to the full picture of classical EMS (CEM), and cloacal exstrophy (EC) - this anomaly also occurs as part of the OEIS complex (omphalocele, exstrophy cloaca, anal atresia, sacral malformations). CEE can be subdivided into “classical” or “typical” forms of CEA (E, CEMP, and EC) and “atypical” forms of CEE (exstrophy of the accessory bladder, covered exstrophy, and pseudo-exstrophy).

STORY

The first mention of bladder exstrophy dates back to 2000 BC, and can be found on Assyrian cuneiform tablets. At that time, congenital anomalies in humans and animals were carefully recorded on tablets due to their importance as omens and were used by soothsayers for fortune telling. M. Feneley and JP Gearhart examined Assyro-Babylonian descriptions of congenital anomalies from cuneiform texts in the British Museum in London. Although references to abnormalities of the external genitalia were common (eg, hermaphroditism, absence of external genitalia, unilateral and bilateral cryptorchidism), information about abnormalities of the kidneys and bladder was sparse and difficult to interpret medically. Duplication and laterality of anomalies were described in detail due to their distinct severity, but associated malformations were not described. Based on these studies conducted with a prominent Assyriologist, the presence of an accurate description of bladder or cloacal exstrophy has not been confirmed [1].

The first recorded case of epispadias is attributed to the Byzantine Emperor Heraclius (610,641 AD). The first detailed description of exstrophy as a congenital defect by J. Schenck von Grafenberg was dated in 1595 (M. Feneley, JP Gearhart, 2000) [1]. The term “exstrophy” itself was first used by F. Chaussier in 1780 [3]. Since then, surgeons have worked to improve the results of treatment of this malformation, but progress began to emerge only from the end of the 19th century.

C. Triersch in 1869 described the closure of the exposed bladder with lateral flaps, which made it possible to achieve a bladder capacity of about 100 ml. In 1894, K. Maydl described a more successful method of urinary diversion with transplantation of Lieto's triangle into the rectum. RC Coffey, RM Nesbit and WF Leadbetter improved the technique to prevent reflux from the sigmoid colon into the ureter [4, 5, 7]. F.von Trendelenburg in 1906 reported performing a bilateral sacroiliac osteotomy and using a pelvic loop to protect the closed anterior wall of the bladder [6]. In 1942, N.N. Young reported the first case of urinary retention after closure of bladder ectrophy. In 1948, L. Michon published a case of successful treatment of a patient who underwent complete reconstruction. H. Lepor and R. D. Jeffs in 1983, H-G. Mesrobian, PP Kelalis and SA Kramer in 1988, and PGRansley in 1991. 75-80% of patients achieved urinary continence after staged reconstruction with improvements in urethroplasty and bladder augmentation [8-15].

The first successful urethroplasty for epispadias was performed by FVCantwell in 1895: complete mobilization of the urethral platform was performed, a tubularized urethra was created, which was moved under the cavernous bodies, previously rotated in the dorsal direction and connected in the middle third of the urethra [16].

EPIDEMIOLOGY

Various data have been published on the incidence of CEE, especially in relation to different subtypes, in different ethnic groups, and also regarding gender ratios. In total, when combined, the incidence of all CEA can be estimated at 1 in 10,000 births. The incidence in the ratio of male to female sex, according to various authors, varies from 1.5:1 to 6.0:1 [17-20].

The International Birth Defects Monitoring Clearinghouse estimates the average incidence of epispadias to be 2.4 per 100,000 [18]. Among the 148 cases included, only four were female patients [18]. However, it is likely that a proportion of women with urinary incontinence with epispadias remain undiagnosed [17]. Taking this into account, it has recently been reported that the male to female ratio of epispadias incidence is 1.4:1. In Europe, the incidence range of epispadias is from 0.6 per 100,000 in France to 4.7 per 100,000 in Denmark. The highest incidence of epispadias, 8.1 per 100,000 births, was observed among American Indians, while the incidence among Asian Americans was 1 per 100,000 [19].

The reported incidence of CEMP varies from 2.1 to 4.0 per 100,000 live births [17,18]. It appears that CEMP is more common among white infants, and the incidence varies depending on geographic location and socioeconomic status [20]. Although C. P. Nelson et al. [20] found an almost equal ratio of men to women in ECMP; a summary of information from numerous studies shows the gender ratio as 2.4:1 [18, 20]. Reports of high male to female incidence ratios, such as 5:1 or 6:1, are very rare. The incidence of EC ranges from 0.5 to 1 per 200,000 births [17,18,20]. In general, girls are more likely to suffer from EC. According to L. Gambhir et al. the sex ratio is 2.0:1 [19].

CLINICAL MANIFESTATIONS

All components of CEE manifest themselves specifically and are determined during examination immediately after birth by pediatricians and obstetricians. With epispadias, the anatomical changes of the penis are pronounced: the urethra is split up to the external opening of the urethra, which, depending on the shape of the urethra, can be located on the head (Fig. 1), the middle and proximal part of the shaft of the penis (Fig. 2), in the peno-pubical corner (Fig. 3).

Rice. 1. Capitate form of epispadias

Fig.2. Stem form of epispadias

Rice. 3. Total epispadias

With total epispadias, the anterior wall of the urethra is absent along its entire length. The head of the penis is flattened, the foreskin covers only its ventral surface. Both cavernous bodies are located under the urethral platform. A careful examination allows you to identify the seminal tubercle and seminal ducts. Due to the divergence of the pubic bones and rectus abdominis muscles, the penis is shortened and has a dorsal deformation. The majority of male patients (about 70%) have total epispadias with urinary incontinence [21].

Classic exstrophy, in addition to manifestations of total epispadias, is characterized by the absence of part of the anterior abdominal wall and bladder, with the posterior wall of the bladder replacing the missing part of the anterior abdominal wall (Fig. 4). The visible lining of the bladder appears reddish at birth, and there may be mucous polyps on the surface. The navel is located lower than usual, below it there is a divergence of the rectus abdominis muscles and umbilical hernias that can be detected by palpation. The pubic bones can be felt on both sides of the evaginated bladder wall. The testicles are usually of normal size and located in the scrotum.

Often the developmental defects that make up CEE are combined with other malformations.

Rice. 4. 3-year-old boy with bladder exstrophy

Abnormalities associated with epispadias are usually limited to deformities of the external genitalia, diastasis of the pubic symphysis, and insufficiency of the bladder continence mechanism. In a review published by S. Arap et al. in 1988, described one case of renal agenesis and one case of renal ectopia in a group of 38 patients [21]. The function of the ureterovesical anastomosis in total epispadias is often insufficient; various studies describe from 30% to 40% of the incidence of vesicoureteral reflux [11, 22].

On average, one third of all patients with EMT, especially those with cloacal exstrophy, have urological abnormalities such as ureteropelvic obstruction, pelvic ectopia of the kidney, horseshoe kidney, renal hypoor agenesis, megaureter, ectopic ureter, ureterocele and duplication of the pyelocaliceal systems [1]. However, 100% of children with EMT have bilateral vesicoureteral reflux (VUR) due to impaired development of the vesicoureteral junction. In a review published by J. Ben-Chaim et al. Among boys with total epispadias, VUR is less common than in patients with EMT (82% versus 100%, respectively) [23].

TREATMENT METHODS

The goal of total epispadias correction is to achieve urinary continence while preserving the upper urinary tract and reconstruction of a cosmetically acceptable penis. Surgical treatment of urinary incontinence is almost identical to that performed for closure of bladder exstrophy.

The role of osteotomy in reconstructive operations in patients with exstrophy is reduced to bringing the bones of the symphysis closer together, which ensures a decrease in muscle tension and reliable closure of the abdominal wall, as well as moving the closed bladder deeper into the pelvis. These measures have a direct impact on improving urinary continence and reducing the risk of recurrent EMF. From the point of view of reconstruction of the penis, the reduction of the pubic bones ensures its lengthening [1]. Due to the divergence of the symphysis, the pedicles of the corpora cavernosa are stretched, which is one of the factors behind the shortening of the penis in patients with EMP up to 50% [24].

Currently, various forms of osteotomy are used in world practice. The most commonly used are posterior sagittal iliac osteotomy, transverse iliac osteotomy, diagonal mid-iliac osteotomy, combined vertical and horizontal pelvic osteotomy, and anterior pubic osteotomy (ramotomy).

HH Young reported the first effective treatment for urinary incontinence in a male patient with total epispadias in 1922 [3]. Since this time, the results of treatment of total epispadias have gradually improved [11, 21, 25, 26].

In patients with total epispadias and a large bladder capacity, reconstruction of the epispadias and bladder neck can be performed simultaneously. However, the results of treating small bladder with exstrophy and small bladder with epispadias have led to the practice of performing urethroplasty and penile lengthening before bladder neck reconstruction [22, 26].

A small, incontinent bladder in the presence of VUR is hardly an ideal case for bladder neck reconstruction and ureteral reimplantation

Initial bladder capacity is the most dominant predictor of urinary continence. In a study by S. Arap et al. There was a much higher rate of urinary continence in those patients who had adequate bladder capacity before bladder neck reconstruction than in patients with inadequate bladder capacity (71% versus 20%, respectively) [21]. Young-Dees-Leadbetter bladder neck repair, Marshall-Marchetti-Krantz urethropexy, and ureteral reimplantation are performed when bladder capacity reaches approximately 80-85 ml, which usually corresponds to the age of 4-5 years.

Achievement of urinary continence after correction of epispadias according to various authors is shown in Table 1 [11, 21, 23, 25]. Most of these patients underwent Young-Dees-Leadbetter bladder neck repair. Urinary continence was obtained in 82% of male patients (Ben-Chaim et al.) [23]. Correction of epispadias, performed before reconstruction of the bladder neck, helps to increase resistance to urine flow at the outlet of the bladder, and a possible increase in bladder capacity. Although patients with both E and EMP achieve slightly greater bladder capacity after epispadias correction, greater increases in bladder capacity are observed more often in patients with total epispadias. Increased bladder capacity may contribute to improved urinary continence in this group compared with the group of patients with classic EMF. Clinically, bladders with total epispadias are more flexible, they are easier to mobilize and reconstruct the bladder neck than with EMT.

Reconstructive operations on the penis for epispadias and exstrophy are the same.

The main objectives of penile reconstruction are:

• correction of the curvature of the cavernous bodies, their straightening;
• formation of the urethra;
• head reconstruction;
• closing a defect in the skin of the penis.

Many different methods of urethral reconstruction for total epispadias have been proposed. G. Monfort proposed using a transversely displaced flap [27]. Many authors suggested placing the reconstructed urethra between and under the corpora cavernosa (FV Cantwell; PG Ransley et al.; J.P. Gearhart et al.) [22, 31, 32]. MI Mitchell and DJ Bagley proposed a technique for complete disassembly of the penis [28]. Later, other authors reported multicenter experience with this technique - 17 patients from four institutions (M. Zaontz et al.)[29].

Table 1. Percentage of achieving urinary continence after correction of epispadias in boys

The curvature of the penis was corrected, while erectile function was preserved, and the external urethral opening was ultimately located on the glans penis. At the same time, patients were satisfied with the cosmetic results of this operation. A characteristic feature of the Mitchell operation is the complete division of the cavernous bodies and dissection of the head into two separate halves, with dissection of the urethral platform from the cavernous bodies (Fig. 5). The authors believed that complete dissection of the corpora cavernosa and head into two separate halves was necessary to facilitate medial rotation of the corpora cavernosa, with careful ventralization of the tubularized urethral platform [28]. Rotation of the corpora cavernosa leads to satisfactory correction of the dorsal curvature. However, 77% of patients subsequently require additional operations to correct hypospadias, since during “disassembly of the penis” and straightening of the corpora cavernosa, the length of the urethral platform is not enough to reach the apex of the glans penis (AT Hafez et al.) [30].

In a larger study performed by PG Ransley and I. Surer et al., positive results of treatment using the modified Cantwell Ransley technique were obtained [31,32]. To straighten a curved penis with epispadias, P. Ransley introduced the concept of excision of the dorsal chord and preservation of the dorsomedial anastomosis of the cavernous bodies above the urethra [33]. This technique involves mobilizing the urethral platform from the underlying tissues, separating the corpora cavernosa from each other. The distal part of the urethral platform, cavernous bodies and the head remain unexcised to ensure good blood supply and prevent shortening of the developing urethra (Fig. 6). The urethral platform is tubularized and placed ventrally under the corpora cavernosa. The mobilized cavernous bodies are rotated medially and fixed by applying a cavernous-cavernosostomy, ensuring effective straightening of the cavernous bodies (Fig. 7). However, in the postoperative period, in pubertal patients with severe dysplasia of the tunica albuginea along the dorsal surface of the corpora cavernosa, its significant shortening is observed in comparison with the length of the tunica albuginea on the ventral surface. In such cases, rotation and cavernous-cavernous anastomosis may not be sufficient. S-shaped curvatures of the distal part of the corpora cavernosa (cobra-type) may be observed.

The advantages of the Cantwell-Ransley and Mitchell-Bagley techniques are anatomically correct reconstruction with only a slight degree of residual deviation of the corpora cavernosa, and a low level of fistula formation due to the covering of the neourethra by the corpora cavernosa throughout its entire length. If the mobilization of the urethral platform from the cavernous bodies is sufficiently radical, then the cavernous bodies can most likely be connected without tension, without the need to perform corporotomy and complete mobilization of the neurovascular bundles. However, scarring and shortening of the neurovascular bundles can subsequently lead to serious, often irreparable curvature of the penis. One of the main requirements for these operations is the careful and thorough mobilization of the neurovascular bundle (using microsurgical optics), which helps maintain sufficient blood supply and innervation, maintain an erection and, most importantly, prevent ischemia of the glans penis.

Rice. 5. Stages of urethroplasty according to the Mitchell-Bagley method: a) isolation of the cavernous bodies; b) mobilization of the urethral platform; c) dissection of the head and separation of the cavernous bodies; d) the stage of formation of the urethra and suturing of the cavernous bodies

Rice. 6. Scheme of urethroplasty according to the Cantwell-Ransley method: a) stage of mobilization of the pedicles of the cavernous bodies; b) mobilization of the urethral platform; c) the stage of isolating neurovascular bundles

Rice. 7. Scheme of urethroplasty according to the Cantwell-Ransley method: a) stage of formation of the urethra; b) the stage of rotation and suturing of the corpora cavernosa above the urethra

CONCLUSION

The exstrophy-epispadias complex is one of the most severe diseases in the clinical practice of pediatric urologists. Every year the number of newborns with this pathology increases. The proportion of boys among such patients is 1.5-6 times higher

Despite the fact that the description and study of exstrophy and epispadias began in the 7th century. AD successful results ensuring optimal quality of life were achieved only at the beginning of the twentieth century.

Currently, the improvement of methods for surgical treatment of urinary incontinence and reconstruction of the penis for epispadias and exstrophy continues. This is a complex problem that requires the active participation of various specialists: pediatric urologists-andrologists, surgeons, traumatologists and neonatologists. Unfortunately, there are no precise guidelines for the management of such patients, and each treatment method has its positive and negative sides. The method of choice for the treatment of urinary incontinence in patients with CEA abnormalities is bladder neck plastic surgery in combination with osteotomy. The gold standard for reconstruction of the penis, in our opinion, can be considered urethroplasty with disassembly of the penis into its components, excision of the chord, mobilization of the cavernous bodies and their straightening, as well as the formation of the urethra and its immersion under the cavernous bodies. In this case, the choice of surgical technique remains with the surgeon.

LITERATURE

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