Method for predicting vesicoureteral reflux recidivation in children

FIELD: medicine.

SUBSTANCE: method involves carrying out urological examination for determining hydrodynamic resistance of ureter calculated from formula Z=8Lμ/(πR4), where Z is the hydrodynamic resistance of ureter, L is the ureter length, R is the ureter radius, μ is the urine viscosity. Angle α at which the ureter enters the urinary bladder is determined from formula cosα = 8l1μ/(ZπR4), where l1 is the perpendicular drawn from the upper edge of the ureter to the its exit projection line, μ is the urine viscosity, Z is the hydrodynamic resistance of ureter, R is the ureter radius. Vesicoureteral reflux recidivation is predicted when the angle of α+90° is less than 120°.

EFFECT: enhanced effectiveness in reducing the number of recidivation cases.

2 dwg, 1 tbl

 

The invention relates to medicine, namely to pediatric urology, and can be used for the treatment of vesicoureteral reflux in children and predict outcomes of antireflux procedures.

Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the ureter and Cup-pelvis system due to the insolvency of the switching mechanism uretero-vesiculosa fistula. This disorder endoscopy plays a leading role in the development of acute and chronic pyelonephritis, which is often nephrogenic hypertension, and when bilateral lesions of chronic renal failure. In this regard, the timely treatment of PMR is one of the urgent problems.

The main method of treatment of PMR is operational, the advantage of which lies in the rapid achievement of termination regurgitation of urine. However, despite the multiplicity of methods of antireflux operations, major complications include recurrence of reflux, the frequency of which according to the literature ranges from 3.6 to 34%, with the closest results for certain types of operations, better remote (1).

The best method of ureteral reimplantations is the method of Cohen. He is in intravesical mobilization mochito the nick for the past 4-5 cm, the creation of a submucosal tunnel and moving the mouth of the ureter on the opposite side above the contralateral. This operation in recent years, the most prevalent (2).

However, the recurrence of the PMR meet with this method, averaging according to Lopatkin N.A., Pugachev A.G. to 1.5% (3).

A prototype of the invention is selected there is a method of predicting recurrence of the PMR, including General clinical and special surveys (4).

The known method is as follows. Carry out clinical examination, ultrasound diagnostics, neprezentare (if indicated), excretory urography, voiding cystourethrography, uroflowmetry, cystometry, cystoscopy. Based on the results of the studies conclusively determine the prognosis of the disease and choose the type of treatment.

However, none of these methods used in isolation from other, may not be the determining factor in the choice of treatment and prognosis of the disease. So vesico-renal reflux even when significant decompensation uretero-vesiculosa connection may be unstable and therefore not be detected at each cytometrical study (5). The results of measuring the length of the intramural division of the ureter when performing cystoscopy very cha what then are erroneous. Only in cases of severe shortening of this Department can confidently speak about its true length, and in other cases the possible errors (6). Using the ultrasonic method can be used to diagnose PMR only significant dilatation of the ureter (7). Urodynamic research methods are optional, allowing you to set the neurogenic disorders of urination.

Only the combined use of all methods objectively, with a single pathogenetic positions to determine the indications for conservative and surgical treatment, to choose and to determine the method of operation, and subsequently to evaluate its results. However, the known method does not allow to predict the recurrence of the PMR, which are up to 1.5% (3).

The task of the invention is to improve the accuracy of predicting recurrence of the PMR.

This object is achieved in that in the known method of predicting recurrence of vesicoureteral reflux in children, including common clinical and special examination, additionally determining the magnitude of the hydrodynamic resistance of the ureter and the angle of the confluence of the ureter into the bladder αand relapse vesicoureteral reflux predict when the angle α+90° and less than 120 degrees, and hydrodynamic fight is their ureter is determined by the formula:

where Z is a value equal to the resistance of the occurrence of the PMR,

L is the length of the ureter;

R is the radius of the ureter;

μ the viscosity of urine;

and the angle of the confluence of the ureter into the bladder is determined by the formula:

where l1- the perpendicular from the top edge of the ureter to the line of projection of his mouth;

μ the viscosity of urine;

Z - hydrodynamic resistance of the ureter;

R is the radius of the ureter.

The present invention meets the criteria of “novelty” and “inventive step”, because in the process of conducting patent information research has not identified the sources prejudicial to the novelty of the present invention, as well as technical solutions with the same essential attributes.

In the literature there is information about the location of the ureter relative to the bladder.

Even Vnesheconom drew attention to the oblique arrangement of the ureter as it passes through the bladder wall, which among other things prevents reflux (8).

According to the literature, the absence of reflux in the norm due to 5 factors: the length of the submucosal area of the ureter, diameter, elasticity, corner of mouth in the bladder and finally intravesical pressure (9).

Congenital factor is m, determining the occurrence of the PMR, is a direct passage of the ureter through the bladder wall (10).

The angle of connection juxtapositioning and intramural departments of the ureter with the child's age changes. In younger children and infants, this angle is close to vertical, whereas in older children and adults vesicoureteral segment is located at an oblique angle (11).

Various methods of antireflux operations aimed at lengthening submucosal tunnel, i.e. the increase in the intravesical portion of the ureter and change the angle of entry of the ureter into the bladder.

According to Javad zadeh PPM (12), only antireflux technique by Cohen changes the angle of entry of the ureter. Submucosal tunnel is formed in the transverse direction, thereby forming an obtuse angle, which enhances the reliability of the switching antireflux mechanism gallbladder-uretralnogo segment.

However, none of the message is not specified the value of the hydrodynamic resistance of the ureter and the angle of the confluence of the ureter into the bladder, necessary for predicting recurrence of the PMR.

1 schematically depicts the angle of the confluence of the ureter into the bladder α.

Figure 2 shows the trigonometric dependence of the hydrodynamic resistance on the value of ug is a α .

Figure 1 shows: 1 - kidney, 2 - bladder, 3 - the mouth of the ureter, L is the length of the ureter,

l1- the perpendicular from the top edge of the ureter to the line of projection of his mouth, α - the angle of the confluence of the ureter into the bladder, α+90° - the angle of the confluence of the ureter into the bladder + 90°.

The method is as follows.

On admission the patient hold the overall clinical and special (ultrasound of the kidneys and bladder, voiding cystourethrography, intravenous urography, cystoscopy, uroflowmetry, cystometry) survey. According to x-ray (intravenous urography) measure the distance l1- the perpendicular from the top edge of the ureter to the line of projection of his mouth. Additionally, determining the magnitude of the hydrodynamic resistance of the ureter by the formula:

where Z is the hydrodynamic resistance of the ureter;

L is the length of the ureter;

R is the radius of the ureter;

μ the viscosity of urine.

Then the patient calculate the angle of the confluence of the ureter into the bladder by the formula:

where l1- the perpendicular from the top edge of the ureter to the line of projection of his mouth,

μ - viscosity urine,

Z - hydrodynamic resistance of the ureter,

R is the radius of mocejon the ka.

The angle α define table Wmiprvse.

As a rule, patients with PMR angle α less than 30°and the angle α+90° (measured from the horizontal line) is less than 120°.

Count, how many degrees should increase the angle of inclination of the ureter to the bladder to prevent recurrence of the PMR.

Perform standard antireflux surgery Cohen. This artifactual mouth formed so that the angle between juxtapositioned intravesical departments of the ureter was not less than 120°.

The method was tested in 15 patients. Surgical treatment was performed by the standard technique of Cohen. Thus was formed a submucosal tunnel so that was observed calculated the angle between intravesical and vaposyrup departments of the ureter. When the control cystography (6 months - 1 year) the positive effect in the form of disappearance of reflux. Recurrence of the PMR is not marked.

We present a mathematical model of the TMR equations for the wall of the ureter and to the flow of urine.

The hydrodynamic part of the model is reduced to the law of Poiseuille flow

where Z is the hydrodynamic resistance;

L is the length of the ureter;

R is the radius of the ureter;

μ the viscosity of urine is close to the viscosity of the water and Rav is th 1

The angle of junction of the ureter into the bladder reflects the following relationship:

where l1- the perpendicular from the top edge of the ureter to the line of projection of the estuary (figure 1).

Therefore,

The dependence of the hydrodynamic resistance from the angle reflects the trigonometric function (figure 2).

Therefore, the greater the angle, the higher hydrodynamic resistance.

We have determined the magnitude of the hydrodynamic resistance necessary to prevent MTCT.

The ureters newborns have a length of 5-7 cm and a lumen - 3 mm (radius - 1.5 mm) (13).

Therefore, the hydrodynamic resistance is:

The length of the ureter at the age of 1 year is 9-10 cm in 2 years 12-14 cm, 5 years 15-17 cm, 12-15 years 18-20 cm (14). The average diameter of intravesical Department of the ureter is 3, 9 mm (15).

Therefore, the hydrodynamic resistance of the child 1 year is:

in 2 years

in 5 years

in 12-15 years

Thus, the dependence of the hydrodynamic resistance to the child's age next (table 1):

table width="90%" border="1" cellpadding="0" cellspacing="0" frams="all"> Table 1 



AgeZNewborn305,71 year286.62 years254,85 years254,712-15 years302,5

Knowing hydrodynamic resistance and measuring the x-ray l1you can calculate the angle of the ureter:

The child 1 year cos α is 0,88; α=28°;

2 years - cos α=0,84; α=32°;

5 years - cos α=0,87; α=29°;

12-15 years - cos α=0,89; α=27°.

Thus, the angle β between juxtapositioned intravesical departments of the ureter in the norm should not be less than: 1 year 118°(28+90); in 2 years - 122°(32+90); 5 years - 119°(29+90); 12-15 years 117°(27+90).

Therefore, when performing antireflux procedures should seek to create angle of ureter α+90° at least 120° to prevent recurrence of the PMR.

Examples of specific performance are given in the form of extracts from the records.

Example 1. Patient K., age 12 (no history of the disease - 14221). Operated on for TMR 3 degrees to the right in 2000. Before the operation, the necessary angle of inclination of the ureter in 117°value is vtorogo observed on the operation, performed by the method of Cohen. At step control in 2001, 2002, at cystogram TMR no. At cystoscopy right mouth is above mioclonica folds over the left mouth.

Example 2 Patient Year, 1 year and 8 months. (no medical history - 11090). Operated on for TMR 3 degrees to the right in 1999 prior To surgery the necessary angle of inclination of the ureter 120°, which is formed on the operations performed by the method of Cohen. When the control cystography in a year, 2 years, the PMR is not defined.

References:

1. Javad zadeh PPM Comparative characteristics of antireflux operations, the reasons for the recurrence vesicoureteral reflux in children // Urology and Nephrology. - 1998. No. 6. - p.17.

2. Lopatkin N.A. vesicoureteral reflux. M.: Medicine, 1990. - P.124.

3. Lopatkin N.A. vesicoureteral reflux. M.: Medicine, 1990. - c.l92.

4. Lopatkin N.A. vesicoureteral reflux. M.: Medicine, 1990. - 74.

5. Isakov Û.F. Clinic and diagnostics of vesico-renal reflux // VI all-Union Symposium pediatric surgeons: Abstracts.-M., 1973. - p.19.

6. Lopatkin N.A. vesicoureteral reflux. - M.: Medicine, 1990. - p.69-70.

7. Lopatkin N.A. vesicoureteral reflux. - M.: Medicine, 1990. - p.53.

8. Tereshchenko A.V. Ureteric reflux. - Kiev: Health, 1986. - p.6.

9. Murvanidze SHOSTAKOVICH About etiology and pathogen is E. ureteric reflux // VI all-Union Symposium pediatric surgeons: Abstracts, - M., 1973. - p.14.

10. Tereshchenko A.V. Ureteric reflux. - Kiev: Health, 1986. - c.13.

11. Lopatkin N.A. vesicoureteral reflux. - M.: Medicine, 1990. - c.7-8.

12. Javad zadeh PPM Comparative characteristics of antireflux operations, the reasons for the recurrence vesicoureteral reflux in children // Urology and Nephrology. - 1998. No. 6. - p.18.

13. Operative surgery with topographic anatomy of childhood: the Textbook / under the editorship Ufficale, Humopehy. - M.: Medicine, 1989. - s.

14. Salov percentage POINTS of the Pelvic floor muscles and dysfunction of the pelvic organs. - Novosibirsk, 1998. - c.74.

15. Salov percentage POINTS of the Pelvic floor muscles and dysfunction of the pelvic organs. - Novosibirsk, 1998. - c.85.

A method for predicting the recurrence of vesicoureteral reflux in children, including urological examination, characterized in that determining the magnitude of the hydrodynamic resistance of the ureter by the formula:

where Z is the hydrodynamic resistance of the ureter;

L is the length of the ureter;

R is the radius of the ureter;

μ the viscosity of urine;

and determine the angle of junction of the ureter into the bladder α by the formula

where l1 is perpendicular from the top edge of the ureter to the line of projection of his mouth,

μ - in scost urine,

Z - hydrodynamic resistance of the ureter,

R is the radius of the ureter;

and relapse vesicoureteral reflux predict when the angle α+90° less than 120°.



 

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