Quite often, in the practice of surgeons, one has to remove the bladder for various indications. This is called a cystectomy. More often, bladder cancer (RMP) becomes the indication, followed by pelvic tumors with metastases in the bladder, complications of radiation therapy (urinary fistulas, microcystis), tuberculosis and injuries of the urea, neurogenic pathologies. Typically, problems are characteristic of the elderly.
When removing an organ, a problem always arises - where will the urine go and merge? In such cases, the Bricker operation becomes the 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, it gives few complications, it is reliable, and patient participation in adapting to a new method of urination is not required.
Bricker operation - what is it?
This is a transplant 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 by Brieker specifically for urine diversion after bladder ectomy.
What is the essence of the Briker operation method? In general, this is a surgical procedure with removal of the bladder, when an isolated ileum loop takes over all its functions. Its one end is removed and sewn (implanted) to the front wall of the abdomen.
Briker's 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. Briker's operation, thus, excretes the ureters and isolates the distal ileum fragment, then its continuity is restored.
What determines the choice of method?
It is due to many factors:
- patient age;
- surgeon qualifications;
- patient desire;
- state of internal organs after radical removal of MP;
- previous 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 an urostoma for the same purpose (Briker's operation).
Pros of the method
The benefits include:
- Not included in the category of complex interventions.
- Short duration of the operation in time.
- The absence of complications and emergency situations for staff.
- There is no need for catheterization after surgery, which greatly facilitates care.
disadvantages
The disadvantages include:
- external unattractiveness associated with a cosmetic and physical defect;
- discomfort, primarily emotional.
Reviews of Briker's operation speak precisely of this psychological aspect. But when it comes to defect and life extension - the choice should be unambiguous. Moreover, judging by the same reviews, a person gets used to it and soon ceases to notice its new features, continues to lead the same way of life.
Another inconvenience - urine needs to be collected in an external drive, which can become a source of odor or just start to leak. And, finally, urine can be thrown back into the kidneys during the excretion process, causing inflammatory processes in the pelvis (pyelonephritis).
Briker surgery (urostoma or ileal conduit) is an artificial hole in the abdomen. How do you choose a place for him? The surgeon brings the ureteroileostomy to the surface in a place of the abdomen where folds do not occur regardless of the patient’s posture, whether it is sitting in a chair or an upright posture. And it should not be located next to the navel. This putative stoma site is indicated by a marker.
Usually, in practice, within 2 days before the operation, the patient is offered to walk with a partially filled urinal, which is fastened to the proposed place of the stoma. This is done so that the patient gets used to it and to make sure the doctor in the correctness of the site selected for the stoma. The place between the navel and the ilium spine is considered standard.
Indications
Indications for the Briker operation are as follows:
- lack of effect from other treatments for bladder cancer;
- bladder metastases in other cancers;
- bleeding in the bladder;
- pelvic injuries and bladder deformities;
- papillomas of a multiple nature on the walls of the bladder;
- relapse of cancer.
If neoplasms of the bladder are not aggressive and do not increase in size, they do not completely remove the organ, but only the affected part.
Contraindications
Contraindications to Briker operation:
- obstruction of the bladder and impaired kidney function;
- renal or liver failure;
- gastrointestinal diseases;
- trauma or removal of the urethra;
- pelvic irradiation;
- bleeding disorders;
- mental illness;
- damage to the sphincter of the bladder or anus;
- neurogenic urinary incontinence.
Relative contraindications:
- After the age of 70, surgery is, in principle, possible, but undesirable, because there is a weakness of the sphincter.
- In women, manipulation is complicated by the fact that they have to remove the urethra. It is difficult to create an artificial organ. If there are minor metastases, other treatments are first performed to avoid surgery.
Preparatory stage
As with all surgical interventions, a standard set of tests is needed. In addition, a month before the operation, it is already necessary not to consume tea, coffee, alcohol, or smoke. Preoperative preparation is the same as for resection of the small intestine.
If there is an inflammatory process as a result of infection, conduct a course of antibacterial treatment. Anticoagulants are also excluded. 3 days before surgery, fiber foods are also excluded.
On the eve of Briker'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 make cleansing enemas for 3 consecutive days.
Execution technique
In case of bladder cancer, Bricker surgery can be performed either immediately with removal of the bladder or as a first step. After laparotomy, a resection of the ileum loop up to 25 cm long (usually from 12 to 18 cm) on the mesentery is done. This segment is not separated from the vessels. For patency of the small intestine, an anastomosis is created end to end.
The ureters are carefully lowered into the abdominal cavity. They cross in the pelvic sections. Then connect the ureters and intestinal segment. Catheters (polyethylene drainage tubes) are attached to the ureters for the outflow of fluid after surgery. Their proximal ends are immersed in a 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 to the skin.
In the elderly, the loop of the free intestine is pulled to the left ureter. The central end is sutured tightly.
At the last stage, the integrity of the seams is checked. After suturing, a sterile dressing is applied to the wound. The inconvenience is only in the constant need for the presence of the urinal.
Catheters are removed by the end of 3 weeks. Rubber drainage in the intestines with output 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 one?
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 - hem the ileum loop with the ureter to the urine reservoir formed. These are the benefits.
Rehabilitation period
After surgery, patients recover quickly. There is no need for a catheter. General hospitalization is about 2 weeks.
In the postoperative period, Briker's surgery 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. Next, power as usual. Electrolyte balance is corrected too.
Complications
Postoperative complications can be early and late. If the intestinal anastomosis turned out to be insolvent (it is rare), then this threatens with peritonitis and acute pyelonephritis, since the outflow of urine is impaired.
Among other complications during this period:
- leakage of urine in the suture area and its penetration into the abdominal cavity;
- no urine excretion - 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 after a few months or years:
- in the stoma area there is skin irritation - 56% of cases, ischemia, stoma hernia and prolapse - 31%;
- stenosis of the intestinal-ureter;
- chronic pyelonephritis, hydroureteronephrosis, renal hypertension and chronic renal failure (chronic renal failure).
Life after surgery
Reviews of Briker's surgery suggest that it is difficult for patients for a long time to come to terms with the presence of a urostoma. The problem is purely psychological. Thoughts about your ugliness arise. This leads to changes in character - self-doubt and tightness appear.
Also, according to reviews, many stoma are scared, and they prefer the choice of forming an artificial MP. And this is confirmed by the fact that after Studer’s surgery, 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 helps out. Proper care after wound surgery is important.
Disability
A disability group is given to the patient after surgery necessarily. To determine which one, a special commission of the CWC assesses the severity of functional disorders in the body - qualitatively and quantitatively. In most cases, the 3rd group is given indefinitely.