METHOD FOR PERIOPERATIVE SUPERVISION OF PATIENTS IN SURGICAL TREATMENT OF STRICTURES OF PROXIMAL PART OF BULBAR AND MEMBRANOUS URETHRA BY REPLACEMENT URETHROPLASTY IN ACCORDANCE WITH CONCEPT OF ACCELERATED RECOVERY PROGRAM Russian patent published in 2024 - IPC A61B1/307 A61B5/522 A61B5/01 A61B5/107 A61B8/13 A61B17/00 A61B18/04 G01N33/48 A61K31/78 A61K31/167 A61K31/341 A61K31/545 A61K31/573 A61K31/727 A61K38/36 A61M25/01 A61P13/00 

FIELD: medicine.

SUBSTANCE: invention relates to surgery. Replacement urethroplasty is carried out in accordance with the concept of the accelerated recovery program, which includes the following actions: at the preoperative stage, the patient undergoes MSCT-urethrography or MRI-urethrography with 3D modelling and assessment of the state of the osteoarticular apparatus of the pelvis and internal organs. Patient's initial nutritional status is assessed. Trophological insufficiency is detected with its further correction; 2–3 days before the operation, the patient is switched to a diet according to Pevzner’s N4 diet. Compression of lower extremities is carried out, which is started before operation and continued during and after it, as well as low-molecular heparins are introduced. Preoperative carbohydrate food mixtures are used in amount of 200 ml. Antibiotic prophylaxis is performed 60 minutes before the operation using cephalosporin antibiotics. At the intraoperative stage: during the operation, normothermia is maintained, including heating of the introduced solutions. State of intraoperative euvolemia is maintained in the patient; nausea and vomiting are prevented using dexamethasone and ondansetron. At the postoperative stage, multimodal anaesthesia based on non-steroidal anti-inflammatory drugs is used. At the preoperative stage: the indications for surgical treatment are assessed: maximum urine flow rate less than 12 ml/second according to uroflowmetry, urethral lumen diameter less than 4 mm, presence of residual urine in bladder, presence of distraction urethra defect; multi-disciplinary examination of the patient is carried out: urologist, anaesthesiologist, ENT doctor, dentist, therapist or cardiologist, radiologist, physiotherapist; patient’s body weight index (BWI) is evaluated to assess the patient’s initial nutritional status. If the BWI is less than 18.5, the patient is exhausted and a dietitian and endocrinologist are consulted. Patient’s blood haemoglobin level is examined: if the hemoglobin level is below 130 g/l, anemia is diagnosed and corrected; dynamometry and walking test, bioimpedance measurement and anthropometry for detecting sarcopenia, if observing sarcopenia, the patient is physically active and provided with protein-containing food for a period of four weeks before the operation. Insulin resistance is assessed by hyperinsulinemic-normoglycemic clamp: for this purpose, insulin is introduced at a constant rate until reaching the level exceeding the fasting value. If observing carbohydrate tolerance disorder or diabetes mellitus, an endocrinologist is consulted. Patient is provided with the last intake of solid food during the operation in the morning hours, at 9–10 o'clock at night the previous day, during the operation in the afternoon, not later than 6 hours before the operation. Patient is given laxatives or a single micro enema is performed; preoperative premedication is carried out: celecoxib 100 mg, gabapentin 600 mg, dexamethasone 10 mg once orally 2–3 hours before the operation. Patient performs oral rinsing with an aqueous solution of chlorhexidine during the day between meals for 3–7 days before the operation, the last time, 3 hours before the operation; patient wears compression jersey from the day of hospitalization, starting before operation and for up to 21 days after operation, as well as low-molecular heparins, enoxaparin sodium 0.4 ml is administered subcutaneously once a day, or fraxiparine 0.3 ml subcutaneously once a day; the first injection is performed before the operation and the injections are continued until the patient is discharged from hospital. Patient is provided with a carbohydrate- and protein-containing liquid in amount of 200 ml 2.5 hours before the operation in the absence of contraindications: diabetes mellitus, gastric evacuation dysfunction. Antibiotic prophylaxis is performed 60 minutes before surgery with preparations of cephalosporins of 3^rd generation with sterile urine culture, once. At the intraoperative stage, the patient is placed in a modified lithotomy position on the operating table; regional anaesthesia is used, and a magnifying optical system is used. Bipolar coagulation is applied. Normothermia is maintained by heating the patient during the operation with the help of electrically heated mattresses and blankets with control of normothermia, as well as infusion solutions and inhalation gases are heated to temperature of 30 °C. Silicone urinary catheter 14 Fr is inserted into the patient, a linear perineal approach is performed, the incision is made along the midline of the perineum towards the scrotum, at least 2 cm from the anus, skin incision length is not more than 4–5 cm, the approach is performed in layers to the bulb-spongy muscle, pushing this muscle apart along the fibres and forming a window to the anterior surface of the bulbar body of the urethra so as not to separate the muscle along the lateral surfaces of the bulb, determining a distal end of urethral narrowing by means of intraoperative urethrocystoscopy or using a urethral catheter, dissecting a spongy body and urethra in a projection of a bulbous-membranous physiological curve, but distal to urethral lumen narrowing, urethral approach length is 2–3 cm, urethral edges are separated with pre-blunted hooks of Scott retractor, through produced window lumen of proximal part of bulbar and membranous urethra is expanded, a conductor is introduced into the bladder through the narrowed part of the urethra, the narrowed part of the urethra is dissected ventrally with penetration beyond the urethra into the muscular thickness, then cicatricial-changed urethral tissues in ventral semicircle are excised within five to seven o'clock on clock face, forming platform for graft within excised cicatricial tissues of urethra so that the proximal and distal boundaries of the formed area are 10 mm within the unchanged urethral tissues. Adequacy of the urethral lumen is checked by introducing 24Ch bougie into the bladder. Oral mucosa graft is used as a substitute material, shape and size of the graft are selected in accordance with the parameters of the site formed for it; an oral graft is taken under local anaesthesia; a defect of the oral mucosa at the graft sampling site is closed. Prepared oral graft is fixed without tension in urethra bed by continuous suture with absorbable suture material 4\6–0, first, proximal part of graft with triangular apices is fixed by inlay technique, further, its through stitching is performed in the centre to the underlying structures. Suture quality is controlled by intraoperative urethroscopy. Then, a urethral Foley catheter 16-18Ch is inserted into the bladder, the balloon is inflated by 5–10 ml, and the distal portion of the graft is stitched according to the technique and fixed without tension. Thrombocyte-rich plasma is injected into submucosal layer of urethra and surrounding tissues by centrifugation in test tubes from patient’s peripheral venous blood. Urethrotomy approach is closed with a continuous suture with the submucosal base of the graft underrun with 4/6-0 monocryl. Plication of fibrin glue or biodegradable sulphacrylate is performed on urethral suture. Perineal approach is closed with a cosmetic skin suture with monocryl 4–0; an adhesive dressing is applied on the skin with biodegradable cyanoacrylate glue. Intraoperative multimodal prevention of postoperative nausea and vomiting is carried out using dexamethasone and ondansetron as follows: dexamethasone 4 mg and ondansetron 4 mg are administered intravenously once during the operation. At the postoperative stage, the patient is transferred to the intensive care unit and resuscitation unit for 2–3 hours after the operation. Multimodal analgesia is performed using non-steroidal anti-inflammatory drugs in combination with acetaminophen. Patient is provided with fluid intake in 2–3 hours after the operation, and food, 6 hours after the operation; the patient is provided with chewing gum on the first and second postoperative days, periodically throughout the day. Proton pump blockers are used: Ranitidine is taken orally 150–300 mg at night, until pain syndrome subsides and non-steroidal anti-inflammatory drugs are stopped. Patient is seated or placed vertically 6–8 hours after the operation, after the patient's condition is assessed by an anaesthesiologist. Patient observes postoperative hygiene of genitals and postoperative wounds, hygienic shower daily from the first day; blood and urine values are monitored on the first postoperative day. Preparations improving microcirculation, reparants are used: pentoxifylline 100 mg orally 2 times day for 14 days. Sessions of hyperbaric oxygenation are performed starting from the second-third postoperative day in mode of 1.0–1.5 atm., for 45 minutes, 5–10 sessions once a day with no contraindications. Pericateter urethrography is performed before removal of the urethral catheter, wherein the urethral catheter is removed no later than the seventh postoperative day. Patient is discharged from hospital 1–3 days after the operation; the discharge criteria are: possibility of patient mobilization, pain control and adequate independent nutrition. Patient returns to work two days after discharge, after removal of the urethral catheter. Patient uses Longidaza rectal suppositories 14 days after the operation according to the scheme: 1 suppository rectally 1 time in 2 days, that is suppositories are used every second day, course is 20 suppositories, the specified course of Longidaza preparation is repeated every 6 months for 2–3 years. Postoperative check-up plan is drawn up for the patient, and the patient is in daily contact with the attending physician.

EFFECT: method enables to reliably reduce the average length of hospitalization, in bed days, as well as reduce the severity of lower urinary tract symptoms according to the IPSS score, improve erectile function according to the IIEF-5 scale (IIEF-5), reduce the severity of postoperative pain syndrome according to the visual analogue scale of pain in patients, to achieve maximum urine flow rate of more than 12 ml/s, assessed by uroflowmetry.

12 cl, 2 dwg, 7 tbl, 1 ex