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1305 afișări
2. Operation lecture with discussion of the
clinic for urology and child urology of the FSU Jena
(Advisers: Mrs. Dr. R. Fröber, PD Dr. A. conciliators Professor Dr. J. Schubert, PD Dr. T. Steiner, Professor C Terrone, M. Wolf, PD Dr. H. Wunderlich)
A minimization of the complication spectrum after a radical cystectomy with orthotopic bladder substitute is published in publications increasingly world-wide. Numerous new operation technologies, with what the partial prostate gland receipt stands in the middle point here, are described on that occasion.
 | Idea of the Jena operation strategy
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Idea of the Jena operation strategy
Implementation
(J. Schubert)
The team of the clinic for urology and child urology of the FSU Jena, under the direction of Univ. Professor Dr. J. Schubert, developed 2004 a new operation strategy for men, with a partial prostate gland receipt, who suffer at a bladder carcinoma.
”The firm bleeding tendency of the prostate gland with the conventional operation law cases should be prevented by the new law case so that a recontamination of possible tumorous cells in the blood is prevented by an autologous blood contribution to charity, that seems for that reason not appropriate anyway. We need a hour less than early for these interventions, and can give up the usage of blood transfusions completely. However, the primary goal of our new operation strategy is the continence receipt and an as high as possible number of male patients, who have postoperative to suffer no more over an erectile dysfunction”, so Professor Dr. J. Schubert in the implementation of the 2. Operation lecture with discussion.
Anatomy
(abstract with subsequent demonstration: R.Fröber)
Multiple arterial and venous blood vessels encompass of the Sacrum from dorsal comes, interwove the bladder, that drags on up to the prostate gland, with a nervous system. A jumby vein network covers the arterial tissue and the be annoying branches on that occasion and forms concretions in the vesical neck and prostate gland area. The lymphatic ways follow the vein systems on that occasion.
The nerves necessary to the erection, that should be spared during the operation, are belong to the parasymphatic nervous system, coming from the Sacrum (S2-S4), outgoing to the pelvicus plexus, of the branches to the bladder, prostate gland and Rectum releases. It turns especially into the Nervi splanchnici pelvici (Nn. erigentes), that is responsible for an erection. It looks like a flat Fascie and proceeds coming dorsal from the Sacrum to the bladder and branch into the prostate gland and seminal vesicle, in order to take finally its way through the basin muscular system above the urethra as dorsal penis nerve until into the penial spongy bodies.
 | | Graphics: Attestation at Hirschfeld |
 | | Graphics: Henry Gray (1825.1861). Anatomy of the humanely Body. 1918 |
Which spectrum of complications is evident at a radical cystectomy with orthotopic bladder substitute?
( Abstract: A. Schlichter)
Most important for the approach at a partial receipt of the prostate gland and the urethral tissue are the exact selection criterions with the anticipated patients of this operation technology.
Complications with the previous orthotopic bladder substitute:
- Continence during the day = approximately 90%,
Continence at night = approximately 70%,
from the 60. Ages after the OP become essentially worse (old-age incontinence the results).
Hyper continence from approximately 2 to 20 per cent of the cases is observed, that a catheterization and resections transurethrial (TUR) makes necessary.
In 0,5 to 5,7 per cent of the cases, it is told about an urinary calculus formation.
- Often, a metabolic acidosis originates, evoked through an excessive small bowel exclusion for the formation of an ileal bladder substitute.
- After approximately 3 years after the cystectomy with formation of an ileal bladder substitute, the status of the cyanocobalamin is to be checked and if necessary, to after-administer.
- Postoperative complications are angulation of the intestine and inflammatory intestinal diseases moreover, whose cause during and after the OP, too premature postoperative solid eating, a big field, firm bleedings and secretions as well as a bad healing of a wound can be.
Models of the reduction of side effects and complications
(Abstract: T. Steiner, H. Wunderlich )
The clinic for urology and child urology of the FSU Jena has since 2004 as the new operation law case was developed, operates over 40 patients with this method in the meantime.
Following results opposite the conventional operation technologies are evident:
- The continence during the day rose opposite the current methods by up to 10 per cent and almost reached 100 per cent.
- The continence at night reached more on average 5 per cent, in dependence of the age of the operated patients.
- While is gone out from approximately 42 per cent with operation technologies, which spare the nerves, over a potency conservation, the share of the patients, with which the prostate gland was gotten and doesn't report postoperative about any erectile breakdowns, is with approximately 91 per cent.
- Since a return of the bladder carcinoma is observed in the urethra up to 4,7 per cent of the cases, the diagnostic security also is for that reason pre-operative to clarify before a partial prostate gland receipt is taken into consideration.
- Clearly defined exclusion reasons in order to also exclude a risk largely prospective for the patients is drawn near. To this, all necessary diagnosis measures are applied pre-operative.
The entire seen new operation strategy of the Jena urologists includes following approaches:
1. Pre-operative backup of contraindications, that exclude a divider stop of prostate gland and prostatic urethra,
(Abstract: H. Wunderlich, M. Wolf)
- biopsy and TUR of the prostatic urethra, with histological positive results exclusion criterion,the diagnostic security over the statuses of the prostate gland through prostatic examination, by means of biopsies, Sonografie, MRT, CT, that is contraindicated with tumorous affection,
- the common occurrence of bladders and prostate gland cancer, since both tissue types have the same embryonic emergence and own genetically similar cellular tissue with it.
- An in stock local tumor or invasive tumorous results, as well as a carcinoma in situ (CIS) close to the urethra,
- Tumor in the prostatic urethra or the vesical neck,
and following contraindications at conventional cystectomy with an ilean orthotopic bladder substitute.
2. Avoidance of the firm blood loss during the operation through forward ligatures and statements this A. vesicalis superior and inferior at the short weight from it A. iliaca interna ambilateral, the arterial and venous vessels of the bladder, the prostatic blood vessels, especially the ligature of the plexus vesicoprostaticus; and this during all incisions.
3. The operative technology
( Live - OP of the Jena method: J. Schubert et.al., 2005)
- outlook of the Situs,
- cut of the peritoneum and the upper bladder columns,
- transmission of both Ureteren prevesical,
- lymphadenectomy,
- the ambilateral ligatures of the duct deferens, the A.vesicalis superior and inferior in combination ascend and descend with statement at the short weight from it A. iliaca interna,
- the incision of the endopelvic fascia and ligature of the plexus vesicoprostaticus with subsequent purse-string ligature of the ventral plain of the prostate gland under sonography,
| |  | Graphics: Clinic for urology and child urology at the FSU Jena. Prostate gland circular order of Millin and the separation of the ventral plain of the prostate gland
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- takes place 4 puncture after it - ligatures at the ventral prostate circular order (after Millin), and the separation of the ventral plain of the prostate gland,
- after the rescue of the catheter (40ml block), a constricting seam takes place at the cranial prostate gland resection plain and the separation of the dorsal prostate gland share and the lateral ligaments,
- now, the intra--operative ultrasound-pegged preparation and distance of the adenoma with the prostatic urethra takes place with subsequent temporary filling of a balloon catheter (no catheter for ilean orthotopic bladder substitute!) to tamponage,
- the tumor control after the rescue of the bladder to the sighting of a possible contraindication, that prevents another operative action with partial prostate gland receipt,
| |  | Photo: Clinic for urology and child urology at the FSU Jena. Exclusion an approximately 40 -50cm tall small bowel segments with the W - shaped reanastomizing and two short tubularing shares outside the primary operation area,
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- the distance of the appendix (appendix distance)
- after the exclusion of an approximately 40. 50cm tall ileum segments and the anti-mesenteric longitudinal division takes place its reanastomizing under receipt of two short tubularing shares, that W - shaped site-to-site- anastomizing become,
| |  | Photo: Clinic for urology and child urology at the FSU Jena. anastomizing of the caudal fringe of the intestinal plate with the prostate gland capsule
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- the anastomizing of the caudal fringe of the intestinal plate with the prostate gland capsule take place after it and the shutter of the intestinal plate to the actual ilean orthotopic bladder substitute,
- in the connection at it doesn't take place the anastomizings the ureter tail spatulierten in each case distal with the corresponding one - detubular end of the intestinal plate and after a density examination of the shaped ilean orthotopic bladder substitute and its link of the prostate gland capsule, that extra – peritonealisition of the ilean orthotopic bladder substitute, the backup of the established derivations and the wound shutter.
4.
The operative sighting of the Nervi splanchnici pelvici (Nn. Erigentes), that be annoying network of the Sacrum (S2 - S4) as the parasympathic nervous system. , from also to the bladder and prostate gland in branched nerves systems proceeds, is spared at the necessary incisions in the dorsal prostatic area in order to get the neurale supply of the pelvic floor muscular system, penial and neurale, that prevents a postoperative erectile dysfunction, and the urine continence should get.
The postoperative outlook of the patient on a cautious solid food, in order to prevent intestinal complications.
A training, that comprises the control of the function of the abdomen and basin muscular system, takes place fully about on the one hand the ilean orthotopic bladder substitute to can and to attain as fast as possible the urine continence, causes through postoperative traumatic realities, again on the other hand empties.
Not to forget, the postoperative help of the acquisition of the erection ability, possibly at first by means of auxiliary means, about irreversible damages of the penial spongy bodies, by which the idleness is threatened at a longer phase to prevent. |
Summary
Following advantages over the previous operation technologies at the radical cystectomy with orthotopic bladder substitute offers itself with the Jena operation strategies:
1. The pre-operative backup of contraindications, that exclude a divider stop of the prostate gland with prostatic urethra.
2. The avoidance of the firm blood loss during the operation, even if no partial prostate gland receipt is possible through the pre-operative or operative diagnostics.
3. The avoidance or decrease of the postoperative residual urine formation of the orthotopic bladder substitute of the prostate gland capsule and interrelated with it the decrease of the urinary calculus formation.
4. The avoidance or diminution of the postoperative incontinence of urine, day - and by night, through the divider stop of the prostate gland tissue and the urethra in the entire area of the pelvic floor muscular system.
5. The avoidance or decrease of cases of erectile dysfunctions of receipt of the Nn. erigentes in the dorsal prostate gland area and the postoperative adjuvant and heal approach of the follow-up treatment.
6. The diminution of a metabolic acidosis of exclusion of only 40 -50cm small bowels to the formation of the orthotopic bladder substitute.
7. The diminution of a hyper continence, that would make a catheterization and possible re-operations (TUR) necessary, of direct link of the turned off small bowel segment of the later orthotopic bladder substitute with that of prostatic gotten tissues.
8. The diminution of complications, as shutter of the intestine or inflammatory intestinal diseases through a small abdomen opening, through the exclusion of more inferior intestinal segments and the essentially more inferior bleedings and secretion accumulations during and after the operation phase, that is moreover essentially shorter, as 3,5 to 5 h. of operation time in normally - abdomen opening - with conventional operation technologies and shutdown included.
| Outlooks:
In cooperation with the urological clinic of the university Tübingen, also possible new operation strategies of the cystectomy can become discuss with women from next year with orthotopic bladder substitute. Wide operation lectures with discussion about the new operation technology will follow.
Advisers of the 2. Operation lecture with discussion:
OÄ Dr. Rosemarie Fröber
Prosektorin of the institute for anatomy
the Friedrich Schiller university Jena
PD Dr. Andreas Schlichter
OA of the clinic for urology and child urology
the Friedrich Schiller university Jena
Professor Dr. Jörg Schubert
Director of the clinic for urology and child urology
the Friedrich Schiller university Jena
PD Dr. Thomas Steiner
OA of the clinic for urology and child urology
the Friedrich Schiller university Jena
Professor Dr. Carlo Teronne
Clinica Urologica dell ` Universitatá of di Torino
Azienda Ospedaliera S. Luigi
M. Wolf
Assistant physician of the clinic for urology and child urology
the Friedrich Schiller university Jena
PD Dr. Heiko Wunderlich
OA of the clinic for urology and child urology
the Friedrich Schiller university Jena
Scientific direction of the operation lecture with discussion, with the friendly authorization to the published work:
Univ.- Professor Dr. J. Schubert, PD Dr. H. Wunderlich, et al., 2005
Author: Detlef Höwing, Selbsthilfe Harnblasenkrebs e.V., Germany
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Federation of bladder cancer Patients - FbcP
