Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 679 - файл
.pdf
166
https://t.me/medicina_free
C. Tao and H. Zhou
caused by insufcient laparoscopic anastomosis, postoperative anastomotic edema, fading
urine extravasation or internal stent blockage
and displacement. Good laparoscopic anastomosis, unobstructed internal stent drainage,
and indwelling catheters to maintain bladder
low pressure drainage to prevent reux can
reduce urinary leakage. If postoperative urinary leakage persists, the possibility of ureteral blockage and stent tube displacement
should be considered. If necessary, internal
stent tube replacement or nephrostomy should
be performed, and nutrition should be
strengthened to promote wound healing.
Generally, improvement can be achieved after
1-2 weeks.
6. Anastomotic stenosis usually occurs in the
early learning curve stage of the surgeon
because the operation of suture technology is
not skilled, the principle of longitudinal and
transverse ureteral suture is not adopted, and
postoperative drainage is not smooth, resulting in repeated urinary tract infection, anastomotic edema, ischemia, and inammatory
hyperplasia. Skilled suture techniques can
avoid clamping and pulling the anastomotic
tissue during the suture process, and the principle of longitudinal and transverse suture can
ensure spacious and smooth, good blood supply and no tension anastomosis, which can
reduce the risk of anastomotic restenosis.
24.8 Comparisons with
Conventional Laparoscopic
Surgery
The Da Vinci robotic system facilitates many
complex laparoscopic operations [8]. Robotassisted laparoscopic pyeloplasty is the most
popular. It was previously reported by Binder et
al. in 2002, and there were many similar reports
later. Similar reports have been reported in infants
and young children. All these reports have fully
veried the feasibility of this technique. Its surgical indications and principles are the same as
those of conventional laparoscopic surgery, and it
has certain advantages in the accuracy, time and
postoperative recovery of anastomosis [9, 10].
The main disadvantage of robotic surgery is the
high cost, usually three times that of traditional
laparoscopic surgery [11].
24.9 Case Introduction and
Operation Video
Figures 24.1–24.3
References
1. Cao H, Zhou H, Liu K, etal. A modied technique of
paraumbilical three-port laparoscopic dismembered
pyeloplasty for infants and children. Pediatr Surg Int.
2016;32:1037–45.
2. Huang Y, Wu Y, Shan W, etal. An updated metaanalysis of laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children. Int J Clin
Exp Med. 2015;8:4922–31.
3. Boysen WR.Robot-assisted laparoscopic pyeloplasty
in the pediatric population: a review of technique, outcomes, complications, and special considerations in
infants. Pediatr Surg Int. 2017;33:925–35.
4. Liu D, Zhou H, Ma L, etal. Comparison of laparoscopic approaches for dismembered Pyeloplasty in
children with Ureteropelvic junction obstruction:
critical analysis of 11-year experiences in a single
surgeon. Urology. 2017;101:50–5.
5. Andol C, Adamic B, Oommen J. Robot-assisted
laparoscopic pyeloplasty in infants and children: is it
superior to conventional laparoscopy? World J Urol.
2020;38:1827–33.
6. Kawal T, Sahadev R, Srinivasan A, etal. Robotic surgery in infants and children: an argument for smaller
and fewer incisions. World J Urol. 2020;38:1835–40.
7. Bowen DK, Yerkes EB, Lindgren BW, etal. Delayed
presentation of Ureteropelvic junction obstruction and
loss of renal function after initially mild (SFU grade
1–2) Hydronephrosis. Urology. 2015;86:168–70.
8. Suda K, Koga H, Okawada M, etal. The effect of
preoperative urinary tract infection on postoperative
renal function in prenatally diagnosed ureteropelvic
junction obstruction: indications for the timing of
pyeloplasty. J Pediatr Surg. 2015;50:2068–70.
9. Blanc T, Kohaut J, Elie C, et al. Retroperitoneal
approach for Ureteropelvic junction obstruction:
encouraging preliminary results with robot-assisted
laparoscopic repair. Front Pediatr. 2019;7:209.
10. Yang K, Yao L, Li X, etal. A modied suture technique for Transperitoneal laparoscopic dismembered
Pyeloplasty of Pelviureteric junction obstruction.
Urology. 2015;85:263–7.
11. Sun L, Zhao D, Shen Y, et al. Laparoscopic versus
robot-assisted pyeloplasty in infants and young children. Asian J Surg. 2023;46:868–73.
Robot-Assisted Ureterovesical
https://t.me/medicina_free
Replantation
GuangjieChen andHuixiaZhou
25
25.1 Introduction
With the rapid development of science and technology, surgery has entered the minimally invasive era. However, in the eld of child urinary
surgery, some more complex laparoscopic surgical reconstructions (such as ureter replantation)
have high technical requirements and long learning curves, and many doctors can not successfully navigate the learning curve and give up,
which makes laparoscopic surgery unable to
serve patients universally. Even after the learning
curve, surgeons are often in an awkward position
during these complicated operations. Many surgeons suffer from chronic repetitive strain injuries to bones and muscles. A surgeon who spent
years mastering laparoscopy soon had to scale
back or even abandon it because of bone and
muscle strain . Since robot-assisted laparoscopic
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_25.
G. Chen (*)
Department of Pediatric Urology, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: dr.chenguangjie@zju.edu.cn
H. Zhou
Department of Urology, Bayi Children’s Hospital
Afliated of the Seventh Medical Center of PLA
General Hospital, Beijing, China
surgery was proposed in the late 1990s, it has
overcome the technical defects of traditional laparoscopic surgery due to its advantages such as a
3D surgical eld, 15× magnication effect, 7
degrees of mobility, and tremor ltering, and has
been rapidly developed and applied in the surgical eld [1]. This chapter focuses on the application of robot- assisted ureterovesical replantation,
for the treatment of diseases such as vesicoureteral reux (VUR), ureterovesical junction
obstruction, ectopic ureteral opening, bladder
diverticulum. This chapter will provide an overview of robotic-assisted ureterovesical replantation for VUR treatment in children.
25.2 Indications
andContraindications
25.2.1 Indications
(1) Ureteral stenosis or occlusional obstruction
(stenosis or obstruction segment < 3 cm)
caused by various reasons below the pelvic
cavity: congenital lower ureteral stenosis,
non iatrogenic traumatic stenosis, iatrogenic
traumatic stenosis (mostly caused by pelvic
surgery in obstetrics and gynecology or
endoscopic surgery, etc.), inammatory or
tuberculous stenosis.
(2) Ectopic ureteral opening (when the renal
function of displaced ureter drainage is
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_25
167
168
https://t.me/medicina_free
G. Chen and H. Zhou
good), ureterovaginal stula, or vesicovaginal stula near the ureterovesical junction.
(3) Ureteral cysts and partial obstructive
megaureter.
(4) Lower ureteral calculi after failure of conser-
vative treatment or endoscopic treatment.
(5) High-grade VUR that failed to spontane-
ously resolve at the age of 5 years old or
recurrent febrile UTI.
(6) Symptomatic congenital paraureteral blad-
der diverticulum.
25.2.2 Contraindications
The obstruction of ureteral bladder junction
caused by lower ureteral tumor or bladder tumor
is contraindicated for this technique. Neurogenic
bladder dysfunction and urinary tract infection
must be treated before surgery. Low bladder volume caused by pelvic chemotherapy is also a
relative contraindication.
der bags will be xed in the patients with operation bed (avoid head low, moves down), neck soft
dressings paste, small tripod protect the patient's
face (avoid collision intraoperative mechanical
arm head).
Docking: An open Hassan technique is used
for placement of umbilical camera trocar, followed by two 8-mm robotic trocars and a 5-mm
assistant port placed under direct vision (the distance between operating port and pubic symphysis should be more than 10 cm, to ensure the
robot surgery have enough wide eld of vision,
and operating space), The two arm ports are
located at about 6 cm horizontally outside the
camera ports (the contralateral robotic arm port
can be appropriately outward and downward
adjustment).The assistant port was placed about
3 cm above the midpoint of the connection
between the ipsilateral surgical port and the camera port (Figs.25.1 and 25.2) [2–4].
25.3 Preoperative Preparation
Laboratory tests include routine blood and urine
tests, liver and kidney function, electrolytes,
blood glucose, and coagulation function.
Bacterial culture and drug sensitivity tests are
required for coinfected patients. Imaging examinations included abdominal ultrasound, chest
radiographs, and preoperative IVU or retrograde
pyelography to determine the location and degree
of the stenosis. Abdominal or pelvic CT or MRI
was performed to exclude external pressure
lesions. In patients with a history of pelvic surgery or chemotherapy, preoperative cystoscopy
can determine bladder volume. For patients with
vesicoureteral reux, preoperative urodynamic
examination is also feasible.
25.4 Position andDocking
Position: After general anesthesia, a urethral
catheter in the sterile eld the patient with supine
position with low head and high feet, the shoul-
Fig. 25.1 Take the umbilicus as camera port (C) and the
two arm ports are located at about 6 cm horizontally outside the camera ports, the assistant port (A) was placed
about 3 cm above the midpoint of the connection between
the ipsilateral surgical port and the camera port
ab
cd
25 Robot-Assisted Ureterovesical Replantation
https://t.me/medicina_free
169
Fig. 25.2 (a) Dissection of the ureter to the uretero-
vesical junction (the peritoneum opened between the
uterine artery and the lateral wall of the bladder). (b)
The course of the ureter along the posterior wall of the
25.5 Surgical Procedures
bladder is identied and marked for a distance of 3–5
cm. (c) The submucosal tunnel is complete. (d) The
detrusor reapproximated using interrupted 3-0 absorbable suture
wall. The tunnel length, which depends on
ureter size, is generally 3-5 cm. In the pro-
(1) Open the lateral peritoneum at the location of
the external iliac artery, nd the ureter and
dissect as far as possible downward along the
ureter until the ureterovesical junction. For
girl, the peritoneum should be opened
between the uterine artery and the lateral
wall of the bladder, and then the ureter should
be dissected to the ureterovesical junction.
For boys, the peritoneum should be opened
between the Vas deferens and the lateral wall
of the bladder.
(2) The tunnel route was marked on the surface
of the posterior wall of the bladder along the
ureter end toward the anterior abdominal
cess of building the bladder tunnel, attention
should be given to properly lling the bladder and maintain proper tension. Scissors
were used to cut the detrusor muscle deep
into the bladder mucosa. During this process,
attention should be paid to cutting the detrusor muscle ber bundle along a line to completely separate the detrusor muscle from the
mucosa, while minimizing the damage to the
detrusor muscle and its nerve bers. The
width of the tunnel is determined by the
diameter of the ureter, which is generally
1.2–1.5cm. During the incision of the detrusor of the bladder, attention should be given
170
https://t.me/medicina_free
G. Chen and H. Zhou
to the distribution of blood vessels. If the
blood vessels cannot be avoided, bipolar cautery is recommended for hemostasis. When
the detrusor bundle is completely separated,
the bladder mucosa can be seen to protrude
evenly and form a dome, without residual
detrusor bers on the mucosal surface, indicating that the established tunnel is up to
standard. Tunneling is best done proximal to
distal. Damage to the bladder mucosa can be
avoided in the process of tunnel construction
unless the bladder wall is hypertrophic and
accompanied by signicant trabecular
growth. If the mucosa is damaged inadvertently, the damaged area can be repaired with
gure-of-eight suture.
(3) After the tunnel is well established, the blad-
der pressure should be reduced to facilitate
the detrusor suturing. The ureter should be
sutured in a tension-free state. The detrusor
can be sutured using 3-0 absorbable discontinuous sutures. Suturing usually begins at
the beginning of the ureter, and a small ureteral membrane can be sutured during suturing to make the tunnel more stable [4–7].
25.6 Technical Points andSkills
The key step in ureteral bladder reimplantation
involves establishing a long and wide submuscular tunnel to embed the ureter and ensure that the
ureter is anastomosed to the bladder without torsion or an angle. When establishing the tunnel
under the detrusor, the detrusor should be cut into
the mucosal layer as far as possible, and the tunnel should be sufciently long and wide. When
suturing the detrusor, it is recommended to use
interrupted sutures, and at the same time, the
detrusor can be sutured with the ureter adventitia
to prevent ureter retraction and torsion.
25.7 Postoperative Complications
25.7.1 Early Complications
25.7.1.1 Persistent Reux
In patients with severe reux before surgery, persistent reux is more common after surgery, but
the grade of reux tends to be low. Most postoperative low-grade reux will spontaneously subside, which may be related to the improvement of
inammation and function in the bladder during
the early stage after surgery.
25.7.1.2 Contralateral Reux
For contralateral reux after surgery, the relevant
literature indicates that there is no signicant difference between different surgical techniques,
but the grade of ipsilateral corrected reux is a
risk factor for contralateral reux. The higher the
grade of ipsilateral corrected reux, the higher
the grade of contralateral reux. Management of
contralateral reux: most patients without obvious clinical symptoms can be closely observed,
and a few patients need intervention and control
of pyelonephritis. For asymptomatic children
under 4–5 years of age, contralateral reux can
be treated with prophylactic antibiotics. If the
child remains asymptomatic and infection-free,
repeat VCUG testing is not necessary because
contralateral reux will resolve spontaneously in
most patients.
25.7.1.3 Obstruction
Early after reux surgery, transient terminal ureteral obstruction is often present, with mild
hydronephrosis and ureteral dilatation on ultrasound. The problem will ease over time. Acute
postoperative ureteral terminal obstruction may
be associated with compression caused by submucosal hematoma or edema at the suture site, or
may be associated with distortion or kinking of
25 Robot-Assisted Ureterovesical Replantation
https://t.me/medicina_free
171
the ureter in the new tunnel. Most patients have
no clinical symptoms, and some patients present
with acute abdominal pain, nausea, and vomiting.
Postoperative urinary tract infections are rare, but
when they do occur they are often accompanied
by severe terminal ureteral obstruction. If the end
of the ureter is obstructed after surgery, it can be
resolved by retrograde insertion of a double “J”
stent or percutaneous nephrostomy. Most cases
do not require further surgery.
25.7.2 Long-Term Complications
25.7.2.1 Obstruction
Progressive ureter dilatation and hydronephrosis
after vesicoureteral replantation can be caused by
a variety of factors and can be classied according to the site of obstruction。
Hiatus
The obstruction point is located at the hiatus
where the ureter enters the bladder. Most commonly, the hiatus is located too close to the
abdominal wall due to a small bladder capacity or
a long tunnel, so that when the bladder is full, the
ureter pulls toward the abdominal wall, resulting
in a phenomenon called “high ureteral reinstallation.” When the bladder is not full, the ureter
empties well, and most of this situation resolves
on its own.
Tunnel
Inadequate submucosal tunnel establishment
may compress the ureter in the tunnel, leading to
ureteral obstruction. When detrusor muscle
hypertrophy and trabecular hyperplasia are evident, establishing a smooth, wide submucosal
tunnel can be quite challenging. Ischemia of the
ureteral and submucosal tunnels is another
important factor leading to ureteral obstruction.
Persistent Reux
For patients with low-grade vesicoureteral reux,
the success rate of anti-reux surgery is very
high, and surgical failure is very rare. Most operations fail because severe vesicoureteral reux
persists after surgery. A short tunnel or large ureteral diameter without ureteral cutting is an
important factor for surgical failure. Another
important factor in the persistence of postoperative reux is the failure to identify secondary
reux before surgery, such as vesicoureteral
reux associated with neurogenic bladder. In
these patients, reux is secondary to bladder dysfunction, and these problems need to be addressed
before surgery. In most cases, improved bladder
function results in spontaneous resolution of
residual postoperative reux [6, 8–14].
25.8 Comparisons
withConventional
Laparoscopic Surgery
Traditional laparoscopic Lich-Gregoir cystourethral reimplantation has been limited in its wide
application in recent decades due to its high
requirements for dissection, suturing, and knotting techniques. The introduction of robotic surgical systems has made ureter dissection and
suture techniques simple and feasible, greatly
shortening the learning curve and enabling urologists in most hospitals with robotic surgical systems to perform this procedure [8–10, 12, 14].
1. Compared with the traditional laparoscope,
the three-dimensional magnied eld of
vision of the robot system is clearer and has
higher resolution. It can maintain lens clarity
for a long time without being affected by
smoke, which guarantees a smooth surgical
process.
172
https://t.me/medicina_free
G. Chen and H. Zhou
2. The highly exible robotic arm system can
complete difcult operations such as grasping, holding, hemostasis, suturing, and ligation in a narrow space, which cannot be
achieved by laparoscopic instruments and
human hands. Moreover, the robot system can
lter the shaking of human hands, reduce the
fatigue of surgeons, and reduce misoperation.
3. The learning curve of the robot system for difcult surgery is signicantly lower than that
of traditional laparoscopy, and doctors with
certain experience in laparoscopic surgery can
quickly adapt to surgical operations.
4. Similar to the traditional laparoscopic system,
all operations of the robot system rely on the
eld of vision provided by the primary lens. If
the eld of vision is polluted or massive
bleeding cannot expose the operating eld,
the robot system cannot replace open
surgery.
5. The robotic arm of the robot system will
occupy a certain space, and the selection and
operation space of the assistant hole will be
more limited than that of the traditional
laparoscope.
References
1. Li Z, Song HC. Robotic-assisted procedures in pediatric urology. Chin J Pediatr Surg. 2021;8:764−9.
2. Passoni N, Peters CA. Robotic Ureteral
Reimplantation. J Endourol. 2020;34:S31−4.
3. Cannon GM, Ost MC. Robot-Assisted Laparoscopic
Extravesical Ureteral Reimplantation for Primary
Vesicoureteral Reux in Children. J Urol.
2017;197:1379−81.
4. Zhu W, Zhou H, Li P et al. Comparison of clinical
efcacy of robot-assisted laparoscopic Lich-Gregoir
procedure and gas-bladder laparoscopic Cohen ureteral reimplantation for primary vesicoureteral reux.
J Clinic Pediatr Surg. 2022;5:437−44.
5. Zhu W, Zhou H, Cao H, et al. Modied technique for
robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter. J Pediatr Surg.
2022;57:1011−7.
6. Gerber JA, Koh CJ. Robot-assisted laparoscopic ureteral reimplantation in children: a valuable alternative
to open surgery. World J Urol. 2020;38:1849−54.
7. Koehne E, Desai S, Lindgren B, et al. Robot-assisted
laparoscopic diverticulectomy with ureteral reimplantation. J Pediatr Urol. 2020;16:508−09.
8. Deng T, Liu B, Luo L, et al. Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reux: a systematic review and
meta-analysis. World J Urol. 2018;36:819−28.
9. Carbonara U, Branche B, Cisu T, et al. RobotAssisted Ureteral Reimplantation: A Single-Center
Comparative Study. J Endourol. 2021;35:1504−11.
10. Fan G, Li K, Wang Y. Efcacy and safety of robotassisted laparoscopic, laparoscopic and open surgery
in ureteral reimplantation: a network meta-analysis
and systematic review. Updates Surg 2022;74:1491–9.
11. Smith RP, Oliver JL, Peters CA. Pediatric robotic
extravesical ureteral reimplantation: comparison with
open surgery. J Urol. 2011;185:1876–81.
12. Chalmers D, Herbst K, Kim C.Robotic-assisted laparoscopic extravesical ureteral reimplantation: an initial experience. J Pediatr Urol. 2012;8:268–71.
13. Akhavan A, Avery D, Lendvay TS. Robot-assisted
extravesical ureteral reimplantation: Outcomes
and conclusions from 78 ureters. J Pediatr Urol.
2014;10:864–8.
14. Grimsby G, Dwyer M, Jacobs M, et al. Multiinstitutional review of outcomes of robotic assisted
extravesical ureteral reimplantation. J Urol.
2015;193:1791–5.
Robotic-Assisted Prostatic
https://t.me/medicina_free
Cystectomy andSeminal
Reconstruction for Prostatic
Utricle Cyst
26
26.1 Introduction
Prostatic utricle cyst is a complication of severe
hypospadias, and it has been reported that the
incidence of perineal and scrotal hypospadias is
10–15% [1, 2]. Prostatic utricle cyst may be the
consequence of paramesonephrosis or hypomasculinization of the urinary sinus. It opens in the
posterior wall of the prostatic urethra and may
cause infection, orchiepididymitis, stones, etc.
[3] and may also affect ureteral catheterization.
VCUG can be detected, and ultrasound and CT
can provide a clear location [4]. Treatment cannot be given for lack of symptoms. If recurrent
urogenital tract infection is present, surgery
should be performed [5]. The surgical methods
can be divided into open resection and laparoscopic or robot-assisted laparoscopic resection,
but the previous surgery often required simultaneous amputation of both vas deferens [6, 7]. The
extensive development of robotic surgery, espe-
cially pelvic surgery, which has great advantages.
Surgeons have begun to try to perform seminal
reconstruction at the same time as prostatic utricle cyst resection [8].
26.2 Indications
andContraindications
Asymptomatic prostatic utricle cyst may not
need surgical intervention, but if repeated urinary
tract infections, recurrent orchiepididymitis, or
compression symptoms of large cysts are present,
surgery may be considered.
There are generally no obvious contraindications to surgery unless vital signs are unstable.
Relative contraindications include a history of
pelvic surgery and underweight (<5 kg), or
younger than 6 months. Prostatic utricle cysts
that are too small (long diameter of <2.5 cm),
will increase the difculty of reconstruction, and
can also be considered as a relative
contraindication.
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_26.
C. Tao (*) · Z. Xu
Department of Pediatric Urology, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: dr.taoc777@zju.edu.cn;
dr.xuzheming@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_26
26.3 Preoperative Preparation
If there was a urinary tract infection, the infection
was controlled for 2weeks before surgery.
Laboratory tests included routine hematuria,
coagulation function, liver and kidney function,
etc. Imaging tests include abdominal and urinary
B-ultrasound, VCUG, CT, etc. No operation con-
traindications were found after anesthesia
https://t.me/medicina_free
consultation.
Bowel preparation included cleansing enema
24 h before surgery, fasting for 8h, and being
water-free for 2h before surgery.
Preoperative antibiotics should be administered intravenously 30min before surgery.
Depending on the half-life of the selected antibiotics and the length of surgery, the drugs can be
administered intraoperatively to ensure that the
effective concentration of drugs covers the entire
procedure.
26.4 Position andDocking
Position: after general anesthesia, a urethral catheter
was placed in the sterile eld. The patient was in the
supine position with a low head and high feet, and
the shoulder bags were xed in the patient’s operation bed (avoid head being low and downward
movement); neck soft dressing paste and small tripod to protect the patient’s face (avoid collision
with the intraoperative mechanical arm head).
Docking: an open Hasson technique is used for
transperitoneal placement of an 8 mm umbilical
camera trocar (Fig.26.1, point C), followed by two
8mm robotic trocars (Fig.26.1, point 1, 2) and a
5 mm assistant port placed under direct vision
(Fig. 26.1). The distance between the operating
port and pubic symphysis should be more than
6cm to ensure that the robot surgery has a sufciently wide eld of vision and operating space.
The assistant port was placed about 3cm above the
midpoint of the connection between the ipsilateral
surgical port and the camera port.
Fig. 26.1 Layout of the trocar for robotic-assisted laparoscopic prostatic cystectomy and seminal reconstruction
26.5 Surgical Steps
1. Position and docking (see Position and
Docking section for details).
2. The urethra is examined by cystoscopy at a
lithotomy position, and, if possible, the position and size of the prostatic utricle cyst are
determined and an indwelling catheter is
placed under cystoscopy guidance.
3. Supine position with low head and high feet,
with needle and thread through the anterior
abdominal wall, and then through the anterior
wall of the bladder and out of the abdominal
https://t.me/medicina_free
wall on the other side (Fig.26.2a), pulling the
bladder, exposing the surgical area behind the
bladder (Fig.26.2b).
4. The pelvic oor peritoneum was opened, and
prostatic utricle cyst along the bilateral vas
deferens was identied. The anterior and posterior walls of the prostatic utricle cyst were
mobilized and exposed, and the rectum and
ureter were avoided (Fig.26.2c).
5. Dissociate the lateral wall of the prostatic utricle cyst and separate the vas deferens from the
prostatic utricle cyst. When the prostatic utricle cyst and vas deferens are clearly exposed
(Fig.26.2d), the anterior wall was cut to clarify the position of the vas deferens in the prostatic utricle cyst.
6. The top of the prostatic utricle cyst is separated, and the opening of the vas deferens is
retained (Fig. 26.2e). The main body off
the prostatic utricle cyst was fully dissociated (Fig.26.2f); the neck of the prostatic
utricle cyst was cut off near the urethra; the
proximal stump was retained at about
0.5cm, and the center section was removed
(Fig.26.2g).
7. The proximal stump and the distal stump connected with the vas deferens can be sutured
continuously with 6-0 Biosyn (Fig. 26.2h).
The rst stitch located at 6 o’clock is continuously sutured to the left half circle, and the
second stitch located at 6 o’clock is continuously sutured to the right half circle
(Fig.26.2i). The knot can be tied at 12 o’clock
(Fig. 26.2j). After ushing the wound and
achieving hemostasis, a drainage tube is
placed on the wound, and then the broken
peritoneum was closed (Fig.26.2k).
Соседние файлы в папке @xirurgi_2025