Quite often in the practice of surgeons, it is necessary to remove the bladder for various indications. This is called a cystectomy. Bladder cancer (BC) becomes the most common indication, followed by pelvic tumors with metastases to the bladder, complications of radiation therapy (urinary fistulas, microcystis), tuberculosis and ureteral injuries, neurogenic pathologies. Usually problems are characteristic of the elderly.
When removing an organ, there is always a problem - where will the urine go and drain? In such cases, Bricker's operation becomes a lifesaver. After removal of the bladder, for most surgeons, it becomes the next step in the intervention. This happens because the manipulation is not considered difficult, gives few complications, is reliable and does not require the patient's participation in adapting to a new way of urination.
Operation Bricker - what is it?
This is the transplantation of both ureters into a segment of the small intestine, the end of which is removed and sutured to the skin of the anterior abdominal wall, and the other is connected to the ureters. The method was proposed in 1950. Brieker (Brieker) specifically for diversion of urine after bladder ectomy.
What is the essence of the Bricker operation method? In general, this is a surgical intervention with the removal of the bladder, when all its functions are taken over by an isolated loop of the ileum. Its one end is removed and sewn (implanted) to the front wall of the abdomen.
Bricker operation (ureteroileocutaneostomy) is a surgical technique in which a new outflow is created to remove urine, a stoma is created on the front wall of the abdomen. Its place is determined individually. The Bricker operation thus exposes the ureters and isolates the distal ileum and restores continuity.
What determines the choice of method?
It is due to many factors:
- age of patient;
- surgeon qualification;
- patient's wish;
- state of internal organs after radical removal of MP;
- prior radio or chemotherapy, cancer prognosis, etc.
The most popular methods of surgery in these cases are usually: the formation of an artificial bladder to divert urine (according to Studer) and the creation of a urostomy for the same purpose (Bricker operation).
Pros of the method
Benefits include:
- Not classified as a complex intervention.
- Short operation time.
- No complications or emergencies for staff.
- No need for catheterization after surgery,which makes care much easier.
Flaws
Disadvantages include:
- external unattractiveness associated with a cosmetic and physical defect;
- discomfort, primarily emotional.
Reviews of Bricker's operation speak about this psychological aspect. But when it comes to a defect and life extension, the choice should be unambiguous. Moreover, judging by the same reviews, a person gets used to and soon stops noticing his new features, continues to lead the same lifestyle.
Another inconvenience is that urine must be collected in an external storage device, which can become a source of odor or simply start to leak. And finally, urine can be thrown back into the kidneys during the excretion process, causing inflammation in the pelvis (pyelonephritis).
Bricker operation (urostomy or ileal conduit) - an artificially formed hole in the abdominal wall. How is a place chosen for it? The surgeon brings the ureteroileostomy to the surface in a place in the abdomen where folds do not occur, regardless of the patient's posture, whether it is sitting on a chair or a vertical posture. And it should not be located near the navel. This proposed stoma site is marked with a marker.
Usually, in practice, within 2 days before surgery, the patient is offered to walk with a partially filled urinal, which is fastened to the intended stoma site. This is done so that the patient gets used to it and to make sure the doctor is choosing the right one for the stoma.site. The standard is the place between the navel and the iliac spine.
Indications
Indications for Bricker's operation are as follows:
- no effect of other treatments for bladder cancer;
- metastases to the bladder from other cancer sites;
- bleeding in bladder;
- pelvic injuries and bladder deformities;
- multiple papillomas on the walls of the bladder;
- cancer relapses.
If the neoplasms of the bladder are not aggressive and do not increase in size, the organ is not completely removed, but only the affected part.
Contraindications
Contraindications for Bricker operation:
- bladder obstruction and impaired kidney function;
- kidney or liver failure;
- diseases of the gastrointestinal tract;
- injury or removal of the urethra;
- pelvic irradiation;
- blood clotting disorders;
- mental illness;
- damage to the sphincter of the bladder or anus;
- neurogenic urinary incontinence.
Relative contraindications:
- At the age of 70, surgery is in principle possible, but undesirable, because there is a weakness of the sphincter.
- Women's manipulations are complicated by the fact that they have to remove the urethra as well. At the same time, it is difficult to create an artificial organ. If there are minor metastases, other treatments are performed first to avoid surgery.
Preparatory stage
As with all surgical interventions, a standard set of tests is required. In addition, a month before the operation, it is already necessary not to consume tea, coffee, alcohol, and not to smoke. Preoperative preparation is the same as for resection of the small intestine.
If there is an inflammatory process as a result of an infection, a course of antibacterial treatment is carried out. Anticoagulants are also excluded. 3 days before the operation, foods with fiber are also excluded.
On the eve of Bricker's operation, only drinking water is allowed. From the gastrointestinal tract, preparations are also underway - they take a tincture to inhibit the work of the intestines and do cleansing enemas for 3 days in a row.
Execution technique
For bladder cancer, the Bricker operation can be performed either immediately with the removal of the bladder or as a first stage. After laparotomy, a loop of the ileum up to 25 cm long (usually from 12 to 18 cm) is resected on the mesentery. This segment is not separated from the vessels. An end-to-end anastomosis is subsequently created for the patency of the small intestine.
The ureters are gently lowered into the abdominal cavity. They are crossed in the pelvic regions. Then connect the ureters and the intestinal segment. Catheters (polyethylene drainage tubes) are attached to the ureters to drain fluid after surgery. Their proximal ends are immersed in the segment to a depth of 10-15 cm. The free peripheral end of the segment on the right is brought to the front wall of the abdomen and sutured toskin.
In the elderly, a loop of free bowel is pulled up to the left ureter. The central end is sewn up tightly.
At the last stage, the integrity of the seams is checked. After suturing, a sterile dressing is applied to the wound. The only inconvenience is the constant need for the presence of a urinal.
Catheters are removed by the end of 3 weeks. The rubber drainage in the intestine with the outlet to the receiver remains.
Bed rest is observed for at least 12-14 days. The question may arise: why is the small intestine used and not the large intestine?
Loops from the small intestine (ileum) can be easily connected to any part of the upper urinary tract, and its distal end can be brought to the skin of the abdominal wall anywhere.
In the future, if necessary, you can easily perform a reconstructive operation - suturing a loop of the ileum together with the ureter to the formed urine reservoir. These are the benefits.
Rehabilitation period
After surgery, patients recover quickly. There is no need for a catheter. General hospitalization - about 2 weeks.
In the postoperative period of Bricker's operation, it is allowed to get up on the second day, you can walk. If there is no discharge in the urine, the catheter is removed. Parenteral nutrition in the early days, until the intestines begin to work. Further food in the usual mode. The electrolyte balance is corrected too.
Complications
Postoperative complications may be early or late. If the intestinal anastomosis has failed (rare),then it threatens with peritonitis and acute pyelonephritis, since the outflow of urine is disturbed.
Other complications during this period include:
- leakage of urine in the suture area and its penetration into the abdominal cavity;
- no urine output - 14% of cases and usually after 2 years;
- the intestines did not work for too long, and intestinal obstruction developed, but it is most often passing, dynamic.
Long-term complications occur months or years later:
- in the stoma area there is skin irritation - 56% of cases, ischemia, stoma hernia and prolapse - 31%;
- stenosis of the bowel-ureter junction;
- chronic pyelonephritis, hydroureteronephrosis, renal hypertension and CRF (chronic renal failure).
Life after surgery
Reviews of Bricker's operation suggest that it is difficult for patients to come to terms with the presence of a urostomy for quite a long time. The problem is purely psychological. Thoughts arise about their ugliness. This leads to changes in character - self-doubt and stiffness appear.
Also, according to reviews, stoma scares many, and they prefer the choice of forming an artificial bladder. And this is confirmed by the fact that after the Studer operation, the patient's quality of life is incomparably higher. But other data do not reveal such a difference. The problem is that the Studer method is not suitable for everyone. Then Bricker's operation comes to the rescue. Proper wound care after surgery is important.
Disability
The disability group is given to the patient after the operation is mandatory. To determine which particularthe VKK commission evaluates the severity of functional disorders in the body - qualitatively and quantitatively. In most cases, the 3rd group is given indefinitely.
