Patent Publication Number: US-2015080920-A1

Title: Device for preparing a hole formed in a bodily wall and system for making an anastomosis between a bodily wall and conduit

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims priority under 35 USC §119 and the Paris Convention to French Patent Application No. FR 12 00731, filed on Mar. 9, 2012. 
     FIELD OF THE DISCLOSURE 
     The present invention relates to the field of surgery, and in particular to the fields of urological, visceral, vascular, and other surgeries. 
     More particularly, the invention relates to a surgical treatment system for performing an anastomosis between an organic wall having an opening and an organic hollow tube, such as the bladder and urethra of a patient. The invention may, for example, be used following a prostatectomy undergone by the patient, typically a radical prostatectomy or total vesiculo-prostatectomy, with the aim of surgically restoring communication between the bladder and the terminal opening of the urethra at the end opposite the urethral meatus. 
     BACKGROUND OF THE DISCLOSURE 
     Conventionally, anastomosis between the bladder and urethra of a patient is performed manually by surgeons using a needle to place one or more sutures. During such a procedure, the surgeons must first reconstruct the bladder neck. To do so, they deform the bladder wall at the opening created in this wall by the prostatectomy, to form a neck or tubular portion to connect to the urethra by suturing. 
     Such a treatment method offers certain advantages, including the fact that it creates an end-to-end connection of the urethra and the neck or tubular portion formed on the bladder wall. More specifically, such a method directly joins the edge of the bladder neck and the edge of the terminal end of the urethra, without having to fold either of these edges back. Direct contact is thus established between the mucosa of the respective edges, which is particularly advantageous in terms of healing and a complete and reliable restoration of communication between the patient&#39;s bladder and urethra. 
     However, this manual anastomosis technique has many disadvantages and is particularly difficult to perform. Such a technique requires a particularly long period for the surgery and a high level of dexterity in the surgeon, especially for reconstructing the bladder neck and precisely aligning the ends of the two channels to be connected, which in this case are the terminal opening of the urethra and the neck or tubular portion shaped on the bladder wall. Such a manual reconnection is made even more complex because the procedure area, located behind the pubic bone, is particularly difficult to access and contains the sphincter whose integrity must be preserved throughout the procedure by avoiding any pulling, perforation, squeezing, etc. 
     Moreover, this manual surgical method can have the disadvantage of being performed as open surgery and requiring large incisions in the body wall in order to access the procedure area, resulting in many inconveniences for the patient, particularly in terms of length of hospitalization, recovery time, and postoperative sequelae. 
     Finally, because of the manual nature of this surgical technique it is relatively tedious for surgeons, who must pay particular attention to suturing a properly tight anastomosis and establishing a consistently tight connection along the circumference of the anastomosis area. An insufficiently tight connection between the two portions of organic tubes hinders tissue healing, poses a risk of infection, and may ultimately result in separation of the connection between the two portions to be joined. Conversely, an excessively tight connection can cause tissue damage and lead to stenosis in the anastomosis area. 
     Another known technique is described in document US 2008 114385A and consists of folding the edge of the bladder neck and the edge of the terminal opening of the urethra inwards or outwards, and attaching the folded portions by a series of staples introduced from inside or outside the hollow organs to be treated. However, such a technique is not completely satisfactory because, since the edges of the openings connecting the two bodies have been folded, the connection between these two bodies is not end-to-end and their respective mucosa are not touching. This does not allow a natural consolidation of the anastomosis and requires long term fasteners, thus increasing patient recovery time, in particular bladder function, and can lead to the formation of bladder stones. Furthermore, the folding of organ portions to establish a connection creates a risk of thrombosis or stenosis at the anastomosis when these portions are folded inside the organs to be treated, and a risk of infection when these portions are folded outside the organs to be treated, where their mucosa may be exposed to a bacteria-rich environment. Moreover, one can easily see that this technique requires a significant number of staples covering a large portion of the periphery of the anastomosis area, and made of non-resorbable material to ensure longevity of the anastomosis as the tissues heal. 
     Finally, for an anastomosis between an organic wall having an opening and a organic hollow tube, such as the bladder and urethra of a patient, in particular after a prostatectomy, a first problem consists of forming a tubular portion on the wall at the opening, and giving this tubular portion a geometry that allows it to fit precisely against the end of the organic tube and allows establishing contact between their respective mucosa. The opening formed in the wall during the prior surgery may not necessarily have a regular geometry, and the wall may vary in thickness along the circumference of the opening: establishing a snug fit between the wall and hollow tube and mating their respective mucosa can be particularly difficult. None of the above techniques offer a satisfactory solution to this problem. 
     OBJECTS AND SUMMARY OF THE DISCLOSURE 
     According to a first object, the present invention provides a system for preparing a created opening on an organic wall, particularly in preparation for an anastomosis with a organic hollow tube, in order to form on the wall at the opening, in a reliable and reproducible manner, a tubular portion having a predetermined geometry. 
     The invention further aims to provide a mechanical system which provides surgeons with the ability to perform procedures in a minimally invasive manner, in particular via the natural passages of the patient, in order to limit operative trauma, and which allows preparing an opening in a wall of an organ or vessel in a reliable and reproducible manner, particularly in preparation for a subsequent anastomosis with a organic hollow tube or a prosthesis such a vascular prosthesis. 
     For this purpose, a first aspect of the invention relates to a system for preparing a created opening on an organic wall, remarkable in that it comprises:
         a supporting body defining a longitudinal axis and having a proximal portion and a distal portion, said distal portion being adapted for insertion through the opening;   external clamping elements deployable in an outwardly flaring arrangement relative to the supporting body while being distributed circumferentially, and able to cover, about said opening, portions of an annular surface of said organic wall; and,   biasing elements arranged to tighten and juxtapose said external clamping elements on said supporting body in order to progressively deform said annular surface so as to, on the one hand, shape on said organic wall a tubular portion extending along the longitudinal axis, and on the other hand, form an anchoring clamp consisting of said external clamping elements.       

     With these arrangements, one can reliably, accurately, and reproducibly prepare the organ wall to form a tubular portion extending from its opening, said portion having a geometry calibrated for an end-to-end or abutting connection to a hollow tube. For this purpose, the external clamping elements placed on the outside of the tubular portion of the wall in the radial direction advantageously form an anchoring clamp that can be used to reconnect the hollow tube. 
     The invention has a particularly advantageous application in the field of urology, in particular for reconstructing a patient&#39;s bladder wall and forming a tubular portion of predefined geometry on the wall at an opening created for example as a result of a prostatectomy, in preparation for an anastomosis with the patient&#39;s urethra. 
     However, it is conceivable to use the tubular portion formed by means of the system according to the invention to connect an inorganic hollow tube to the organ wall, for example a tube that is part of a prosthesis, particularly a vascular prosthesis. 
     According to the invention, the supporting body has at least one cylindrical or substantially cylindrical portion, and the biasing elements are used to move the external clamping elements towards the supporting body, said external clamping elements pulling the wall towards the supporting body by bearing on portions of an annular surface extending around the wall opening. The wall is then progressively deformed around its opening until it presses against the cylindrical portion of the supporting body and adopts a substantially tubular shape as it is sandwiched between said supporting body and the external clamping elements. 
     The external clamping elements may advantageously have at least one gripping and/or attachment hook to establish the gripping and/or attachment of said external clamping elements to the portions of the annular surface of the wall extending around the opening. 
     Advantageously, the system comprises an applicator for placing the supporting body through the opening formed in the wall and for fastening said supporting body to said wall. This applicator is adapted for removable connection to the proximal portion of the supporting body and for at least partially controlling the biasing elements, in particular from outside the patient&#39;s body. 
     In an advantageous arrangement of the invention, the biasing elements comprise connecting elements, each connecting element being adapted to connect an external clamping element to the supporting body, and a device for exerting traction on the connecting elements, said connecting elements each having a first end connected to said traction device and a second end adapted to be retained on an associated external clamping element, and actuation of said traction device tightening and juxtaposing said external clamping elements on said supporting body. The connecting elements are used to connect the external clamping elements and the supporting body by passing through the wall. These connecting elements are preferably flexible. They can advantageously be in the form of thread, for example of a bioresorbable material. 
     The traction device can advantageously be housed inside the supporting body and controlled from the applicator which places and stabilizes the supporting body. Alternatively, the traction device can be carried and controlled by the applicator. 
     Advantageously, it is possible for the traction device to be provided with a force-limiting system to limit the squeezing of the wall against the supporting body by the external clamping elements. This minimizes the risk of injury to organ tissue due to excessive tightening of the connecting elements. 
     Preferably, a return prevention device can be provided between the connecting elements and the supporting body, said device being adapted to prevent the external clamping elements from loosening on the supporting body when actuation of the traction device ceases. 
     According to another advantageous arrangement of the invention, the system further comprises a feedthrough and anchoring device adapted to move the second end of each connecting element between a retracted configuration where said second end is located at a radial distance from the longitudinal axis that is less than the radius of the opening, and an anchored configuration where said second end is retained on an associated external clamping element after passing through the wall. Thus, the second ends of the connecting elements in the retracted configuration can be inserted through the opening, and then moved to the anchored configuration such that they pass through the wall and are anchored in the external clamping elements placed on the other side of the wall. 
     Preferably, the feedthrough and anchoring device comprises support members for releasably supporting the second ends of the connecting elements. 
     Advantageously, the second ends of the connecting elements are provided with an anchoring element adapted to engage with a corresponding anchoring portion provided on the external clamping elements in order to retain said second ends on said external clamping elements when they are in the anchored configuration after passing through the wall. 
     The support members of the feedthrough and anchoring device and/or the anchoring elements equipping the second ends of the connecting elements may advantageously have a tip able to pierce the wall when said second ends move from their retracted configuration to their anchored configuration. 
     Preferably, in the retracted configuration, the second end of each connecting element is located at a radial distance from the longitudinal axis that is less than or substantially equal to the outer radius of the supporting body. 
     Advantageously, the feedthrough and anchoring device is integrated into the supporting body, and extends into the distal portion of said body intended for introduction through the wall opening. 
     Thus, in the retracted configuration, the connecting elements and the feedthrough and anchoring device can be accommodated inside the supporting body, which minimizes the risk of its catching on and damaging the tissue or affecting the function of the system according to the invention when it is inserted into the patient&#39;s body. 
     According to a preferred embodiment of the invention, this feedthrough and anchoring device can be controlled by the applicator, for example by means of a cable or a coupling rod. 
     According to a particular embodiment of the invention, the system further comprises a deployment mechanism adapted to move said external clamping elements at least between a retracted configuration where they are folded in the direction of the longitudinal axis, and a deployed configuration where they are away from the longitudinal axis and flare outwards substantially perpendicularly to it, and the deployment mechanism comprises support members on which the external clamping elements are releasably supported. 
     The deployment mechanism is adapted to move the external clamping elements between the deployed configuration and a collapsed configuration either simultaneously or sequentially. In the case of a sequential deployment of the external clamping elements by the deployment mechanism, the external clamping elements can be moved individually, one after the other, in a predetermined sequence, for example one after the other circumferentially or in a more dispersed manner. It is also conceivable to have sequential deployment in subsets of external clamping elements, the external clamping elements that are part of each subset being regularly distributed circumferentially. Thus, in the case of six external clamping elements, it is possible for example to provide two successive deployment sequences, namely a first deployment sequence in which three clamping elements spaced 120° apart circumferentially are deployed, followed by a second deployment sequence in which three clamping elements spaced 120° apart circumferentially and located between the external clamping elements deployed in the first sequence, are deployed. Again in the case of six external clamping elements, three successive deployment sequences could be provided for example, by pairs of diametrically opposed external clamping elements. 
     It can thus advantageously be arranged so that, when the second ends of the connecting elements and the external clamping elements are in the retracted configuration, one can insert from outside the patient&#39;s body, particularly by means of the applicator, the assembly consisting of the supporting body, the deployment mechanism with said external clamping elements, and the biasing elements at least partially housed inside the supporting body, through a through-hole formed in a trocar placed on an external body wall of the patient, for example the abdominal wall. 
     Advantageously, the deployment mechanism is provided on the end of a distal portion of the applicator, adapted for connection to the supporting body, said mechanism preferably being controlled by means of said applicator. 
     According to a particularly advantageous arrangement, the applicator, and in particular the deployment mechanism arranged on the distal end of said applicator, comprises a stop member adapted to cooperate with the wall to limit the insertion of the supporting body through the opening. Alternatively, the stop member could be provided directly on the supporting body. 
     In a first embodiment, the feedthrough and anchoring device is adapted to move the second end of each connecting element between the retracted configuration and the anchored configuration when the external clamping elements are in the deployed configuration. 
     In a second embodiment, the deployment mechanism is further adapted to move the external clamping elements between the deployed configuration and a collapsed configuration where said external clamping elements are folded in the direction of the longitudinal axis on the distal end side of the supporting body, and said deployment mechanism is part of the biasing elements. 
     In this embodiment, the external clamping elements in the deployed configuration can be moved to a collapsed configuration by pulling and progressively deforming the wall so that it is pressed against the supporting body and adopts a substantially tubular shape as it is sandwiched between said supporting body and the external clamping elements. 
     Similarly to the movement between the retracted configuration and the deployed configuration of the external clamping elements, the deployment mechanism is adapted to move the external clamping elements either simultaneously or sequentially between the deployed configuration and the collapsed configuration. 
     In this second embodiment, the feedthrough and anchoring device is adapted to move the second end of each connecting element between the retracted configuration and the anchored configuration when the external clamping elements are in the collapsed configuration. 
     According to a particularly advantageous arrangement of the present invention, the supporting body releasably supports internal clamping elements angularly aligned circumferentially with the external clamping elements, and the biasing elements are arranged to tighten and juxtapose said external clamping elements on said internal clamping elements. These internal clamping elements, when they are retained on the supporting body, define a substantially cylindrical portion therewith, which the wall is pressed against via the biasing elements, causing it to adopt a substantially tubular shape. When the internal clamping elements are separated from the supporting body, the wall is sandwiched between the external and internal clamping elements, and the supporting body can be withdrawn from the opening and removed from the patient&#39;s body, particularly by means of the applicator. 
     Advantageously, the system further comprises an ejection device adapted to move the internal clamping elements between a retracted configuration where they are at least partially housed inside the supporting body, and an ejected configuration where they are removed from said supporting body. Preferably, the ejection device is integrated with the supporting body. It may be controlled by means of the applicator. 
     Preferably, each connecting element comprises a portion associated with a respective internal clamping element, the system further comprising a cutting device adapted for cutting the connecting elements between the internal clamping elements and the first ends of said connecting elements. Preferably, the cutting device is integrated with the supporting body. It may be controlled by means of the applicator. 
     The internal clamping elements may advantageously be sized so that, after removal of the supporting body, they are held together in a circular configuration by their mutual contact with each other. 
     Additionally or alternatively, a retaining element may be provided that is able to retain the internal clamping elements and/or external clamping elements in a circular configuration after removal of the supporting body. 
     Through these arrangements, the hole created in the wall can be prepared so as to form a tubular portion on the wall which can be connected to an organic or inorganic hollow tube. 
     Still according to this first aspect, the invention also relates to a method for preparing a created opening on an organic wall, wherein:
         a supporting body defining a longitudinal axis and having a proximal portion and a distal portion is provided;   external clamping elements are also provided;   the distal portion of the supporting body is introduced through the opening;   the external clamping elements are deployed so as to flare outward relative to the supporting body, said external clamping elements being distributed circumferentially and covering, around said opening, portions of an annular surface of said organic wall;   the external clamping elements are urged so as to tighten and juxtapose said external clamping elements on said supporting body in order to progressively deform said annular surface so as to, on the one hand, shape on said organic wall a tubular portion extending along the longitudinal axis, and on the other hand, form an anchoring clamp consisting of external clamping elements.       

     According to an advantageous arrangement, in the method for preparing a created opening on an organic wall according to the invention, with the supporting body releasably supporting internal clamping elements angularly aligned circumferentially with the external clamping elements, the external clamping elements are urged so as to tighten and juxtapose said external clamping elements on said internal clamping elements. 
     Preferably, in the method for preparing a created opening on an organic wall according to the invention, the internal clamping elements are moved between a retracted configuration where they are at least partially housed inside the supporting body, and an ejected configuration where they are withdrawn from said supporting body. 
     Again preferably, in the method for preparing a created opening on an organic wall according to the invention, with each connecting element comprising a portion associated with an associated internal clamping element, the connecting elements are cut between the internal clamping elements and the first ends of said connecting elements. 
     Another aim of the invention is to propose a system for performing anastomosis which provides a reliably reproducible and minimally invasive end-to-end connection of a tubular portion, formed by means of the system described above at an opening created in an organic wall, and an organic hollow tube. 
     Thus, according to a second aspect of the invention, a system is provided for performing an anastomosis between an organic wall having an opening and an organic hollow tube, said system comprising:
         a system for preparing the opening as described above, and   a device for connecting said tube and the tubular portion shaped on the wall, said device being arranged at least partially within a proximal portion of the supporting body adapted for insertion into the tube and comprising:
           suture elements adapted for connecting the internal and external clamping elements and each having a first end connected to a tightening device and a second end adapted to be retained on an associated external clamping element; and,   a suturing device adapted for moving the second end of each suture element between a retracted configuration where said second end is positioned at a radial distance from the longitudinal axis that is less than the inside radius of said tube, and an anchored configuration where said second end is retained on an associated external clamping element after passing through the tube from the inside to the outside.   
               

     With these arrangements, an end-to-end connection is created between the organic hollow tube and the tubular portion formed on the organic wall, so as to establish direct contact between their respective mucosa, which is particularly advantageous in terms of healing and complete and reliable restoration of the communication between the two organs, particularly between the patient&#39;s bladder and urethra. 
     The suture elements connect the external clamping elements and the supporting body by passing through the tube. These suture elements are preferably flexible. They can advantageously be in the form of thread, made for example of a bioresorbable material. 
     Advantageously, the system further comprises a control probe for the device for connecting the organic hollow tube and the tubular portion formed on the wall. This probe is adapted to be introduced into the hollow tube, and to be removably connected to the proximal portion of the supporting body in order to at least partially control said device, especially from outside the patient&#39;s body. 
     The tightening device can advantageously be housed inside the supporting body and controlled from the control probe. Alternatively, the tightening device can be carried and controlled by the probe. 
     Advantageously, it can be arranged so that the tightening device is provided with a force-limiting system to limit the clamping force of the anastomosis. This minimizes the risk of injury to body tissues due to excessive tightening of the suture elements which can lead to stenosis in the anastomosis area. 
     Preferably, a return prevention device can be provided between the suture elements and the internal clamping elements, said device being adapted to prevent the suture elements from loosening when actuation of the tightening device ceases. 
     In preferred embodiments of the invention, one or more of the following arrangements may be used:
         each suture element comprises a portion associated with a respective internal clamping element, the system further comprising a cutting device adapted for cutting the suture elements between the internal clamping elements and the first ends of said suture elements. Advantageously, this cutting device is the same as the cutting device described above in relation to the preparation system which cuts the connecting elements;   the suturing device is further adapted to move the second end of the suture elements between the retracted configuration and the anchored configuration by passing through an intermediate deployed configuration where said second end is located opposite a corresponding anchoring portion provided on the associated external clamping element;   the suturing device comprises resiliently flexible elements, angularly aligned circumferentially with the internal and external clamping elements and axially movable within the supporting body, releasably supporting the second end of an associated suture element and adapted to cooperate with associated ramps provided in the supporting body so as to move said second end between the retracted configuration and the anchored configuration;   the second ends of the suture elements are provided with an anchoring element adapted to engage with a corresponding anchoring portion provided on the external clamping elements in order to retain said second ends on said external clamping elements when they are in the anchored configuration, after passing through the tube;   the flexible elements and/or anchoring elements equipping the second ends of the suture elements have a tip adapted to pierce the tube when said second ends move from their retracted configuration to their anchored configuration;   the ramps are movable axially inside the supporting body between first and second axial positions, the transition of said ramps from the first axial position to the second axial position causing the second end of the suture elements to move from the intermediate configuration to the anchored configuration due to elastic return of the flexible elements.       

     Still according to this second aspect, the invention also relates to a method for performing an anastomosis between an organic wall having an opening and an organic hollow tube, wherein:
         the opening created on the wall is prepared in accordance with the method according to the first aspect of the invention;   the proximal portion of the supporting body is introduced at least partially into the tube;   suture elements are provided, adapted for connecting the internal and external clamping elements and each having a first end connected to a tightening device and a second end adapted to be retained on an associated external clamping element; and,   the second end of each suture element is moved between a retracted configuration where said second end is located at a radial distance from the longitudinal axis that is less than the inside radius of said tube, and an anchored configuration where said second end is retained on an associated external clamping element after passing through the associated tube from the inside to the outside.       

     In an advantageous arrangement, in the method for performing an anastomosis between an organic wall having an opening and an organic hollow tube according to the invention, each suture element comprising a portion associated with a respective internal clamping element, the suture elements are cut between the internal clamping elements and the first ends of said suture elements. 
     With these arrangements, the anastomosis performed using the system according to the invention is maintained, after withdrawal of the supporting body, by means of suture elements connecting the internal clamping elements to the external clamping elements by passing through the organic hollow tube from the inside to the outside in the radial direction and straddling the anastomosis area, said internal and external clamping elements being held together on the wall by means of connecting elements passing through the wall, in order to define a tubular portion thereon. In this manner, the respective edges of the organic hollow tube and the tubular portion formed on the organic wall are rendered contiguous, as tubular extensions of one another, forming an interface with direct contact between their respective mucosa. 
     It is particularly advantageous if the external clamping elements, the internal clamping elements, the connecting elements, and/or the suture elements are made of a bioresorbable material, meaning a material which can be resorbed by the physico-chemical activity of living tissue in contact with the material. For example, the component material of these elements can be a bioresorbable polymer such as polylactic acid (PLA, PLLA), polyglycolic acid (PGA), or polydioxanone (PDO). 
     Thus, the elements left within the patient&#39;s body after preparation of the created opening on the organic wall, using the system according to the first aspect of the invention, or after anastomosis between said wall and the organic hollow tube performed by means of the system according to the second aspect of the invention, will be resorbed through contact with the body tissue and the surrounding fluids, and it will not be necessary to schedule a subsequent procedure to remove these elements. 
     Finally, the invention also provides for the case where a tubular portion is formed on the organic wall by a means other than the preparation system described above. 
     A second object of the invention therefore relates to a system for performing an anastomosis between an organic wall having an opening and an organic hollow tube, said system comprising:
         a supporting body defining a longitudinal axis and adapted for insertion inside the tube and through the opening;   at least one external clamping element defining with said body a tubular portion on the wall and forming an anchoring clamp;   a device for connecting said tube and said tubular portion defined on said wall, said device comprising:
           at least one suture element adapted for connecting the external clamping element to the supporting body and having a first end connected to a tightening device and a second end, said second end being adapted to be retained on the external clamping element; and   a suturing device adapted for moving the second end of the suture element between a retracted configuration where said second end is located at a radial distance from the longitudinal axis that is less than the inside radius of said tube, and an anchored configuration where said second end is retained on the external clamping element after passing through the tube from the inside to the outside.   
               

     With these arrangements, an end-to-end connection is created between the organic hollow tube and the tubular portion defined on the organic wall, establishing direct contact between their respective mucosa, which is particularly advantageous in terms of healing and the complete and reliable restoration of communication between the two organs, particularly between the patient&#39;s bladder and urethra. 
     The suture element connects the external clamping element and the supporting body by passing through the tube. This suture element is preferably flexible. It may advantageously be in the form of thread, made for example of a bioresorbable material. 
     In preferred embodiments of the invention, one or more of the following arrangements may be used:
         the suturing device is further adapted for moving the second end of the suture elements between the retracted configuration and the anchored configuration by passing through an intermediate deployed configuration where said second end is positioned facing a corresponding anchoring portion provided on the associated external clamping element;   the suturing device comprises at least one resiliently flexible element that is movable axially within the supporting body, releasably supporting the second end of the suture element and adapted to cooperate with a ramp provided in the supporting body so as to move said second end between the retracted configuration and the anchored configuration;   the ramp is movable axially within the supporting body between first and second axial positions, the transition of said ramp from the first axial position to the second axial position causing the second end of the suture elements to move from the intermediate configuration to the anchored configuration by elastic return of the flexible element;   the supporting body releasably supports at least one internal clamping element, and the suture element is adapted for connecting the external clamping element and said internal clamping element.   the system further comprises an ejection device adapted for moving the internal clamping element between a retracted configuration where it is at least partially housed inside the supporting body, and an ejected configuration where it is removed from said supporting body.   each suture element comprises a portion associated with a respective internal clamping element, the system further comprising a cutting device adapted for cutting the suture elements between the internal clamping elements and the first ends of said suture elements;   the system further comprises at least one connecting element adapted for connecting the external clamping element to the supporting body to form the anchoring clamp;   the system further comprises a device for exerting traction on the connecting element, and said connecting element has a first end connected to the traction device and a second end adapted to be retained on an external clamping element;   the system further comprises a feedthrough and anchoring device adapted for moving the second end of the connecting element between a retracted configuration where said second end is positioned at a radial distance from the longitudinal axis that is less than the radius of the opening and an anchored configuration where said second end is retained on an associated external clamping element after having passed through the wall.       

     Advantageously, this system may comprise a single control element adapted for controlling the various devices during a single operative phase of anastomosis. This control element consolidates, for example, all control functions of the applicator and probe which are carried out as part of the first object of the invention. 
     Still according to this second object, the invention also relates to a method for performing an anastomosis between an organic wall having an opening and an organic hollow tube, wherein:
         a supporting body defining a longitudinal axis is provided;   at least one external clamping element is also provided, defining with said body a tubular portion on the wall and forming an anchoring clamp;   the supporting body is inserted into the tube and through the opening;   at least one suture element is provided, adapted for connecting the external clamping element to the supporting body and having a first end connected to a tightening device and a second end, said second end being adapted to be retained on the external clamping element; and   the second end of the suture element is moved between a retracted configuration where said second end is positioned at a radial distance from the longitudinal axis that is less than the inside radius of said tube, and an anchored configuration where said second end is retained on the external clamping element after having passed through the tube from the inside to the outside.       

     Other features and advantages of the invention will be apparent from the following description of one of its embodiments, given by way of non-limiting example, with reference to the accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       In the drawings: 
         FIG. 1  represents a schematic sectional view of an organic wall having an opening, in this case the bladder wall of a patient who has undergone a prostatectomy, and an organic hollow tube, in this case the patient&#39;s urethra, between which an anastomosis is to be performed; 
         FIG. 2  is a schematic sectional view of the bladder wall on which a tubular portion has been formed near the opening in preparation for an end-to-end anastomosis with the patient&#39;s urethra; 
         FIG. 3  is a perspective view of a complete anastomosis system comprising a system for preparing the opening in the bladder wall according to a first embodiment of the invention; 
         FIG. 4  represents an exploded perspective view of the supporting body according to the first embodiment of the invention; 
         FIG. 5  shows a perspective view of the system for preparing the opening on the bladder wall according to the first embodiment of the invention, prior to insertion through the opening; 
         FIGS. 5   a  to  5   f  are longitudinal half section views along line VV of  FIG. 5 , illustrating the successive phases of preparing the opening formed on the wall by means of the system according to the first embodiment of the invention; 
         FIG. 6  is a perspective view of the bladder wall with a tubular portion formed at its opening, ready for reconnection to the patient&#39;s urethra; 
         FIG. 7  is an exploded perspective view of the supporting body according to a second embodiment of the invention; 
         FIG. 8  is a view similar to  FIG. 5 , illustrating the system for preparing the opening in the organic wall according to the second embodiment of the invention, prior to insertion through the opening; 
         FIGS. 8   a - 8   f  are longitudinal half section views along line VIII-VIII of  FIG. 8 , illustrating the various successive phases of preparing the opening formed on the wall by means of the system according to the second embodiment of the invention; 
         FIG. 9  is a schematic view of a partial sectional elevation showing a first step of using the anastomosis system of the invention, associated with a patient&#39;s urethra that is to be anastomosed or reconnected to the tubular portion formed on the bladder wall by means of the preparation system according to the first embodiment of the invention; 
         FIGS. 10   a  to  10   c  are longitudinal half section views along line IX-IX of  FIG. 9 , illustrating the successive phases of an anastomosis between the patient&#39;s bladder and urethra using the system according to invention, the opening of the bladder wall having been prepared by means of the preparation system according to the first embodiment of the invention; 
         FIG. 11  is a longitudinal half section view along line IX-IX of  FIG. 9  similar to those of  FIGS. 10   a  to  10   c , illustrating the step of ejecting the internal clamping elements after anastomosis of the tubular portion, formed on the bladder by means of the preparation system according to the first embodiment of the invention, and the patient&#39;s urethra, and of cutting the connecting elements and suture elements, enabling the anastomosis system according the invention to be withdrawn from the patient&#39;s body; 
         FIG. 12  is a longitudinal half section view of the wall of the bladder and urethra of the patient after anastomosis using the system according to the invention, and withdrawal of said system from the patient&#39;s body. 
     
    
    
     DETAILED DESCRIPTION OF THE DISCLOSURE 
     In the different figures, the same references denote identical or similar elements. 
       FIG. 1  illustrates an organic wall P having an opening O, and an organic hollow tube C having an open end E. 
     In the following description, it is assumed that this wall P is part of a bladder V and that the opening O in it was created during a prostatectomy. Furthermore, the organic hollow tube C considered in the context of the present description is the patient&#39;s urethra, of which the open end E, resulting from a prior resection of the urethra in its membranal area that was performed during the prostatectomy, needs to be reconnected to the wall P of the bladder V during an anastomosis operation in order to restore communication between the bladder and the terminal opening of the urethra opposite the urethral meatus, which is open at this end E. 
       FIG. 2  shows a sectional diagram of the wall P of the bladder V which has been deformed to shape a tubular portion T at the opening O, said tubular portion T being intended for end-to-end reconnection during an anastomosis operation at the end E of the urethra C that is opposite the urethral meatus. 
     A first aim of the invention is to propose a system SP, SP′ for preparing the wall P of the bladder V so as to form this tubular portion T at the opening O. 
     A second aim of the invention is to propose an anastomosis system SA for establishing the end-to-end connection of the tubular portion T, formed by means of said system SP, SP′ at the opening O created on the wall P of the bladder V, and the patient&#39;s urethra. 
     In  FIG. 3 , a complete system for performing an anastomosis SA between a patient&#39;s bladder and urethra is represented. The anastomosis system SA comprises a system SP for preparing the opening O of the wall P of the bladder V according to a first embodiment. This system SP comprises:
         a supporting body  1  defining a longitudinal axis X and having a proximal portion  1   a  and a distal portion  1   b , said distal portion  1   b  being adapted for insertion through the opening O, and   an applicator  8  having a proximal control portion  8   b  for manipulation by the surgeon, a distal portion  8   a  to which the proximal portion  1   a  of the supporting body  1  is intended to be connected during a first operating phase or tubular portion creation phase, and a central elongate portion  8   c.          

     The anastomosis system SA further comprises a probe  9  having a proximal control portion  9   b  for manipulation by the surgeon, a distal portion  9   a  to which the proximal portion  1   a  of the supporting body  1  is intended to be connected during a second operating phase or anastomosis phase, and a central elongate portion  9   c.    
     In the embodiment illustrated in  FIG. 3 , the distal portion  8   a  of the applicator  8  has a housing  8   d  for receiving the proximal portion  1   a  of the supporting body  1 . The distal portion  8   a  of the applicator  8  is equipped with a deployment device  2  which will be described in more detail below. 
     As can also be seen in  FIG. 3 , the distal portion  9   a  of the probe  9  has a housing  9   d  for receiving the proximal portion  1   a  of the supporting body  1 . The distal portion  9   a  has a plurality of slots  95  opening into the central housing  9   d  whose usefulness will be described below. 
     In a manner not detailed in the figures, in either of the illustrated embodiments of the preparation system SP, the distal portions  8   a ,  9  of the applicator  8  and probe  9  are shaped for assembly in a complementary manner to the proximal end of the supporting body  1 ,  1 ′, for the purposes of controlling the various devices provided on or within said supporting body  1 ,  1 ′. Various embodiments are possible for this, as long as the applicator  8  and probe  9  are able to transmit the control movements of these devices from their proximal portion  8   b ,  9   b  visible in  FIG. 3 . In the example shown, these proximal portions  8   b ,  9   b  are in the form of a manually actuated device comprising a handle  84 ,  94  and various control elements, such as a trigger  81 ,  91 , a knob  82 ,  92  that can be rotated and moved in translation, or a locking button  83 ,  93 . 
     Alternatively, it could be arranged so that the proximal portion of the applicator  8  and/or probe  9  is mechanically connected to an interface linked to a robotic arm, to allow control of the system(s) by a computer under surgeon supervision, particularly in a context of computer-assisted surgery performed remotely. 
       FIG. 4  illustrates an exploded perspective view of a supporting body  1  that is part of an anastomosis system SA comprising a preparation system SP according to a first embodiment of the invention. 
     In this figure, the connecting elements  33  intended to pass through the wall P of the bladder V, and the suture elements  44  intended to pass through the urethra, have not been represented in order to improve clarity; these elements, which are in the form of threads made of bioresorbable materials, are particularly visible in  FIGS. 5   a  to  5   f ,  10   a  to  10   f ,  11  and  12 . 
     As can be seen in  FIG. 4 , the supporting body  1  is in two parts  101 ,  102  which are movable relative to each other along the longitudinal axis X. 
     The first part, which will be considered here as the fixed part, is in the form of a generally cylindrical member  101  extending along the longitudinal axis X and comprising two hollow cylindrical portions of different outside diameters: a proximal portion  105  having an outside diameter corresponding substantially to the inside diameter of the housings  8   d ,  9   d  provided in the distal portions  8   a ,  9   a  of the applicator  8  and probe  9 , and a distal portion  103  having an outside diameter greater than that of the proximal portion  105 . 
     The proximal portion  105  is axially open at its proximal end and has a plurality of radial slots  1051  along its periphery, here six in number, which connect its inside space to the outside. In the distal extension of these slots  1051 , the proximal portion  105  has grooves  1052  on its outer surface which are not radially open to the inside space of the proximal portion  105  and in which the bottom has a longitudinal channel  1053  which opens axially into a corresponding slot  1051  on the proximal side, and into the inside space of the distal portion  103  on the distal side. 
     The distal portion  103  is axially open at its distal end and defines an inside space communicating with the inside space of the proximal portion  105 . The grooves  1052  arranged in the proximal portion  105  extend axially into a proximal portion  1030  of the distal portion  103  and define a plurality of housings  1031  whose usefulness will be further described below. These grooves  1052  stop axially inside the proximal portion  1030  of the distal portion  103 . The housings  1031  have a through-opening in their base that connects the inside space of the distal portion  103  with the outside, providing space e to allow the passage of each associated connecting thread  33  as is particularly visible in  FIG. 5   a.    
     The proximal portion  1030  of the distal portion  103  also has notches  1032  on its outer surface which lie in the axial extension of the housings  1031 . The distal portion  103  has an annular groove  1033  and a distal portion  1034 . The notches  1032  open axially inside the housing  1031  on the proximal side and inside the channel  1033  on the distal side. 
     The distal portion  103  also has a plurality of radial slots  1035  along its periphery, aligned circumferentially with slots  1051 , radially connecting the inside space of the distal portion  103  with the outside, and opening axially at the distal end of the distal portion  103 . The utility of these radial slots  1035  will be described in more detail below. 
     The proximal portion  1030  of the distal portion  103  has a generally cylindrical outer surface in which are arranged the housings  1031  provided for releasably receiving internal clamping elements  11 , here in the form of inner plates made of a bioresorbable material, said plates  11  for example fitting tightly inside said housings  1031 . 
     Still referring to  FIG. 4 , the second part of the supporting body  102 , which will be considered here as the movable part, comprises a generally cylindrical member  104  having a bullet-nose distal end  1041 , and a rod  106  extending along the longitudinal axis X of which the distal end  1061  is connected to the cylindrical member  104 , for example by screwing or by force-fitting. In addition, the rod  106  has a proximal end  1062  adapted for insertion along the longitudinal axis X through the fixed part  101  of the supporting body  1 , so as to project proximally beyond the proximal end of said fixed part  101 , and intended to be connected to the applicator  8  in order to control the movement of the movable part  102  relative to the fixed part  101 . 
     The cylindrical member  104  has a plurality of radial slots  1042  along its periphery, here six in number, connecting its inside space with the outside and aligned circumferentially with slots  1035  provided on the fixed part  101  of the supporting body  1 . 
     A feedthrough and anchoring device  3  is arranged between the fixed part  101  and movable part  102  of the supporting body  1 . This device  3  comprises a plurality of needles  31  of which the proximal end releasably supports anchoring elements  32  in the form of hollow cylinders which for example fit tightly on the distal end of the needle  31  with which it is associated, and to which are attached the second ends  332  of the connecting threads  33 , the first end  331  of said threads  33  being connected to a traction device advantageously provided at the applicator. Advantageously, the hollow anchoring cylinders  32  are made of a bioresorbable material. 
     Each of the needles  31  is supported at a distal portion by a plurality of connecting rods, here a proximal rod  34  and two distal rods  35 , hinged so as to define a deformable parallelogram mechanism. For this purpose, the distal rods  35  supporting each needle  31  are hinged on the movable part  102  of the supporting body  1 , and on the distal portion of the needle  31  that they support; the proximal rod  34  is hinged on a slider  36  movable in translation along the rod  106  and on the distal portion of the needle  31  that it supports. A resilient element, which here is in the form of a coil spring  37  of frustoconical shape, is arranged so that it is compressed for at least a portion of the axial travel of the slider  36 . 
     The slider  36  also has a plurality of radial through-slots  365  allowing a certain displacement of the proximal rods  34 . The radial slots  1042  provided on the cylindrical member  104  of the movable part  102  of the supporting body  1  allow a certain displacement of the distal rods  35 . 
     As can also be seen in  FIG. 4 , the supporting body  1  concentrically receives a hollow shaft  70  adapted to slip onto the rod  106  of the movable part  102  of the supporting body  1 , and to be rotatable about the longitudinal axis X with respect to said rod  106 . An annular ring  71  having a plurality of through-openings  711  is threaded onto the hollow shaft  70  so as to rotate in a floating manner. When the shaft  70  is placed inside the proximal part  101  of the supporting body  1 , the ring  71  fits tightly over a corresponding bearing surface of said proximal part  101 . Furthermore, the hollow shaft  70  is secured to a mandrel  72  having a plurality of through-holes and attachment holes  721  for suture threads  44  (not represented in  FIG. 4 ). 
     The hollow shaft  70  has a distal end  701  and a proximal end  702  adapted for insertion along the longitudinal axis X through the fixed part  101  of the supporting body  1  so as to project in the proximal direction beyond the proximal end of said fixed part  101 , and intended to be connected to the applicator  8  in order to control the shaft  70 . The shaft  70  and mandrel  72  are part of a clamping device  7  whose operation will be further described below. 
     In the example represented, the slider  36  of the feedthrough and anchoring device  3  is mounted to be movable in translation along the longitudinal axis on a distal portion of the hollow shaft  70 , and the compression spring  37  presses against a radial face of mandrel  72 . 
     Still in  FIG. 4 , one can see that the supporting body  1  also concentrically receives a generally cylindrical tiered member  50 , movable in translation along the longitudinal axis X relative to the fixed part  101  of the supporting body  1 . This tiered member  50  is adapted to be threaded onto the hollow shaft  70  and has three cylindrical portions of different outside diameters: a proximal portion  501 , a central portion  502 , and a distal portion  503 . 
     The proximal portion  501  has a proximal end  5012  adapted for insertion along the longitudinal axis X through the fixed part  101  of the supporting body  1 , so as to project proximally beyond the proximal end of said fixed part  101 , and intended for connection to the applicator  8  in order to control the tiered member  50 . 
     A plurality of longitudinal channels  504 , aligned circumferentially with the radial slots  1035  provided on the fixed part  101  of the supporting body  1 , are provided on the outer surface of the proximal and central portions  501 ,  502 . These channels  504  terminate at their distal end in a ramp  505  formed in the distal portion  503  and extending distally outwardly in the radial direction until it opens onto the outer surface of the distal portion  503  of the tiered member  50 . The distal portion  503  has a plurality of radial through-slots  507  on its outer surface, aligned circumferentially with the channels  504  and having proximal ends which open axially inside the ramps  505 . 
     Moreover, the distal portion  503  and central portion  502  have a plurality of radial through-slots  508  angularly offset to the channels  504  and defining on the distal portion  503  a plurality of wedges  500  extending as the axial extension of the channels  504 . At their distal end, each wedge  500  has an ejection face  509  that is part of an ejection device  5  and is adapted to cooperate with the inner plates  11  in order to eject them from their housings  1031  in the radial direction, as will be further described below. 
     Furthermore, each of these ejection wedges  500  has two arms separated by a through-slot  507  and joined at their distal end by a cutting blade  506  that is part of an cutting device  6 . 
     When the tiered member  50  is in place inside the fixed part  101  of the supporting body  1 , the wedges  500  are inserted into slots  1051  provided in the proximal portion  105  of the fixed part  101  of the supporting body  1  and can move inside them by sliding along the bottom of grooves  1052 . 
     Finally, the supporting body  1  concentrically receives a hollow sleeve  40  movable in translation along the longitudinal axis X relative to the fixed part  101  of the supporting body  1 . The sleeve  40  has a proximal end  402  adapted for insertion along the longitudinal axis X through the fixed part  101  of the supporting body  1  so as to project proximally beyond the proximal end of said fixed part  101 , and intended for connection to the applicator  8  for the purpose of controlling the displacement of the sleeve along the longitudinal axis. 
     The sleeve  40  is suitable for slipping onto the proximal portion  501  of the tiered member  50  and supports a plurality of resiliently flexible needles  41  suitable for inserting into the channels  504  of the tiered member  50  and for cooperating with the ramps  505  during operation. 
     The distal end of each needle releasably supports anchoring elements  42  in the form of hollow cylinders which, for example, fit tightly onto the distal end of the needle  41  with which it is associated, and to which are fixed the second ends  442  of the suture threads  44 , the first end  441  of said threads  44  being connected to the tightening device  7 , and more precisely at the attachment openings  721  of the mandrel  71 . 
     In the embodiment illustrated in  FIG. 4 , the sleeve  40 , needles  41 , and tiered member  50  are part of a suturing device  4  which will be further described below. The ejection device  5  and cutting device  6  here are part of this suturing device  4 . 
     The sleeve  40 , needles  41 , and tiered member  50  here are part of a suturing device  4  whose operation will be further described below. 
     Thus, in the embodiment illustrated in  FIG. 4 , all the elements carried by the supporting body  1 , when in their initial configurations, fit within a cylinder whose diameter corresponds to the outside diameter of the distal portion  103  of the fixed part  101  of the supporting body  1 . Preferably, this diameter is smaller than the diameter of the opening O present on the wall P so as to allow insertion of the distal portion  1   a  of the supporting body through the opening O. 
     We will now describe a first operative phase of preparing the opening O created on the bladder wall P, so as to form a substantially tubular portion thereon, making use of the preparation system SP according to the first embodiment of the invention. 
     For this purpose, as can be seen in  FIG. 5 , the proximal portion  1   a  of the supporting body  1  is inserted along its longitudinal axis X into the housing  8   d  defined in the proximal portion  8   a  of the applicator  8 , and the distal portion  1   b  of the supporting body  1  extends distally from said proximal portion  8   a  of the applicator  8 . 
     In this  FIG. 5 , one can see that in the first embodiment of the preparation system SP according to the invention, the distal portion  8   a  of the applicator supports a deployment mechanism  2  comprising a plurality of support members  23 , particularly visible in  FIGS. 5   a  to  5   f , releasably supporting external clamping elements  22  to be placed facing the respective portions of an annular surface S of the wall P centered about the opening O. 
     The deployment mechanism  2  is able to move the external clamping elements  22  between a retracted configuration, shown in  FIG. 5 , where they are folded in the direction of the longitudinal axis X on the proximal end  1   a  side of the supporting body, and a deployed configuration where they are away from the longitudinal axis X and flare out substantially perpendicularly thereto. 
     The distal portion  8   a  of the applicator  8 , fitted in this manner with the supporting body  1  in the initial configuration, and having external clamping elements  22  in the collapsed configuration, may advantageously be inserted through a trocar TR placed on the abdominal wall of the patient, and control of the various devices can be accomplished by means of the proximal portion  8   b  of said applicator  8  from outside the patient&#39;s body, typically during endoscopic surgery. 
     The applicator  8  fitted with the supporting body  1  is then manipulated by the surgeon so that the body  1  approaches the bladder V, until the distal portion  1   a  of said body is introduced into the opening O formed in the wall P, centering the longitudinal axis X within the opening O and engaging the distal end  1041  first. The bullet-nose shape of this end  1041  facilitates placement. 
     The external clamping elements  22 , here six in number, are in the form of outer plates made of a bioresorbable material and are releasably supported on support members  23 , for example by having complementary shapes. 
     The distal portion  8   a  of the applicator  8  and the proximal portion  1   a  of the supporting body  1  advantageously have indexing elements for fixing the supporting body  1  to the end of the applicator  8  so that the outer plates, supported by the applicator  8 , are angularly aligned circumferentially with the inner plates  11  supported by the distal portion  1   b  of the supporting body  1 . 
     Furthermore, the deployment mechanism  2  advantageously has a stop member  20  adapted to cooperate with the wall P to limit the insertion of the supporting body  1  through the opening O. 
     As can be seen in  FIGS. 4 and 5 , the assembly formed by the distal portion  8   a  of the applicator  8  and the supporting body  1  has rotational symmetry about the longitudinal axis X and can be divided into a plurality of identical basic modules uniformly distributed circumferentially. In the example shown, this assembly can be divided into six basic modules each extending over an angular range of about 60° and comprising an inner plate  11 , an outer plate  22 , a connecting thread  33  provided to connect the inner plate  11  and outer plate  22  after passing through the wall P, and a suture thread  44  provided to connect the inner plate  11  and outer plate  22  after passing through the urethra. 
       FIGS. 5   a  to  5   f , as well as  10   a  to  10   f ,  11  and  12 , illustrate just one of these modules. The reader will understand that what is visible in these figures applies to each of the other five modules. 
     Thus,  FIGS. 5   a  to  5   f  show the various steps of preparing the opening O by means of the preparation system SP according to the first embodiment of the invention. 
     In  FIG. 5   a , the system SP is partially illustrated in its initial configuration and when placed at the opening O. 
     In this initial configuration of the preparation system SP, the deployment mechanism  2  is in the configuration with the outer plate  22  collapsed and supported by the support member  23 , the feedthrough and anchoring device  3  is in the configuration where the second end  332  of the connecting thread  33  is retracted, this end  332  being at a radial distance d1 from the longitudinal axis X that is less than the radius r1 of the opening O, the inner plate  11  is received within its housing  1031  provided on the supporting body, and the ejection  5  and cutting  6  device, here formed by a wedge  500 , is in the inactive configuration. 
     The suturing device  4  is also in the configuration where the second end  442  of the suture thread is retracted. This device will come into play during the second operative phase, or anastomosis phase, and its operation will be further described below in relation to  FIGS. 10   a  to  10   c  and  11 . For clarity, the suture thread  44  is not represented in  FIGS. 5   a  to  5   f.    
     Returning to  FIG. 5   a , one can see that in this first placement step, the supporting body  1  is inserted through the opening O until the stop member  20  comes in contact with the outer surface of the wall P, or the surface on the proximal side. This stop member  20  thus limits the insertion of the supporting body  1  through the opening O. In addition, the abutment of the stop member  20  against the wall P ensures correct axial positioning of the deployment mechanism  2  for the plate  2 . 
     In a manner not represented in detail in the figures, the stop member  20  is integral to the distal portion  8   a  of the applicator  8 . 
     In  FIG. 5   a , one will note that the stop member  20  rotatably supports a support member  23  which is in the form of a generally Y-shaped fork having a lower arm  231  rotatably mounted on the stop member  20  and two upper arms  232  cooperating with a cavity  222  of complementary shape provided on the outer plate  22  to provide releasable support for said plate  22  on the support member  23  and visible in particular in  FIG. 9 . One of these upper arms  232  and part of the cavity  222  are visible in  FIG. 5   f.    
     The lower arm  231  has a plurality of peripheral gear teeth, adapted to cooperate with a rack provided on a distal portion of a sheath  24  mounted to be movable in translation inside the distal portion  8   a  of the applicator  8  and which can be controlled from the proximal portion  8   b  thereof. In the case of sequential deployment of the external clamping elements, the sheath  24  can be divided into as many parts as there are to be successive deployment sequences; each of these parts is intended to control the deployment of one or more clamping elements between the retracted configuration and the deployed configuration, and can be successively controlled from the proximal portion  8   b  of the applicator  8 . 
     In the collapsed configuration of the deployment mechanism  2 , the support  23  and the outer plate  22  extend substantially parallel to the longitudinal axis. 
     Also visible in  FIG. 5   a  is the path of a connecting thread  33  within the supporting body  1 . This thread  33  has a first end  331  adapted for connection to a traction device (not represented) built into the applicator  8 . The thread  33  traverses the proximal portion  1   a  of the supporting body  1  within a space provided for this purpose, and extends substantially for the length of the hollow shaft  70 . This thread  33  then emerges into a free space e provided in the supporting body  1  and located under the inner plate  11  received in its housing  1031 . The connecting thread  33  then passes through the inner plate  11  by a through-hole  110 , and changes direction again as it follows the outer surface of the plate  11 ; then it passes through the notch  1032  and is fixed by its second end  332  to an anchoring element  32  releasably supported by a needle  31 . 
     Referring now to  FIG. 5   b , the sheath  24  has been moved by appropriate controls along an axial path C1 in the direction of arrow F1, which has caused the support member  23  to pivot due to the engagement of its teeth with the rack supported by the sheath, resulting in a deployed configuration of the outer plate  22  where it lies substantially perpendicular to the longitudinal axis X, facing a portion of the annular surface S of the wall P visible in  FIG. 5 . 
     In this deployed position, an anchoring portion  220  formed in the outer plate  22  and designed to retain the anchoring cylinder  32  to which the second end of the connecting thread  33  is fixed, is at a predetermined radial distance d from the longitudinal axis X. 
     Turning to  FIG. 5   c , traction in the direction of arrow F2 exerted on the rod  106  causes movement of the movable part  102  of the supporting body  1  with respect to the fixed part  101  of the body  1  along a first axial path, until the proximal end  1041  of the cylindrical member  104  and a distal stop surface  361  of the slider  36  come into contact. This axial path C2 of the movable part  102  relative to the fixed part  101 , visible in  FIG. 5   b , causes deformation of the deformable-parallelogram mechanism consisting of the proximal rod  24  and distal rods  35 . The feedthrough and anchoring device  3  is then in an intermediate deployed configuration where the second end  332  of the thread  33  is positioned facing the anchoring portion  220  of the outer plate  22  in the radial direction. In this position, the outer plate  22  and the second end  332  of the connecting thread  33  are facing each other radially, and are on opposite sides of the wall P axially. 
     By continuing the displacement of the rod  106  as indicated by arrow F3, visible in  FIG. 5   d , this causes movement of the movable part  102  relative to the fixed part  101  along a second axial path, driving the slider  36  via radial contact with the cylindrical member  104  and compressing the spring  37  to bear against a proximal face of the slider  36  and against a radial face of the mandrel  71 . This drives the needle  31 , by means of the connecting rods  34 ,  35 , along the second axial path. 
     This second axial path can be defined in different ways, for example as the stroke required to move the spring  37  from its free state, where it is not subject to any stress, to a compressed state where its turns are touching. In any event, the second axial stroke is dimensioned so that the second end  332  of the connecting thread  33  and the anchoring cylinder  32  which supports it crosses through the wall P and outer plate  22  by passing through the anchoring portion  220 . In the embodiment illustrated, the needle  31  has a tip  310  for piercing the wall P, on its proximal end. 
     By releasing the traction exerted on the rod  106 , the relaxation of the spring causes the feedthrough and anchoring device  3  to return to its configuration shown in  FIG. 5   c . During this return movement, the needle  31  releases the anchoring cylinder  32  to which the second end  332  of the connecting thread  33  is attached, this cylinder  32  catching on the anchoring portion  220  of the outer plate  22 .  FIG. 9  shows a non-limiting example of cooperation between the anchoring cylinder  32  and the anchoring portion  220 . 
     Next, by pushing the rod in the direction of arrow F4 visible in  FIG. 5 , the feedthrough and anchoring device  3  is returned to its retracted configuration. 
     It is now in the configuration shown in  FIG. 5   e , where the second end  332  of the connecting thread  33  is anchored by the anchoring cylinder  32  on the anchoring portion  220  of the outer plate  22  after having traversed the wall P. 
     Alternatively, it can be arranged so that the abovementioned two axial paths cause compression of the spring  37 ; then, by releasing the rod  106  from the configuration in  FIG. 5   d , the feedthrough and anchoring device  3  is returned directly to its retracted position by the release of the spring  37 . 
     At this point, and as shown in  FIG. 5   f , traction is exerted on the first end  331  of the connecting thread  33  in the direction of arrow F5 by means of the traction device arranged in the applicator  8 . 
     The traction exerted on this first end  331  is transmitted by the thread  33  to the second end  332  anchored on the outer plate  22  and initially causes the support member  23  holding the outer plate  22  to pivot towards the longitudinal axis X, on the distal side of the supporting body  1 . As it does so, the outer plate  22  begins to deform the wall P by means of its contact with a portion of the annular surface S surrounding the opening O. 
     By continuing to exert traction on the first end  331  of the connecting thread  33 , this causes the release of the releasable attachment of the outer plate  22  to the support member  23 , the upper arms  232  of the support member  23 , originally housed in the complementary cavity  222  of the outer plate  22  for example by fitting tightly therein, then exiting said cavity  222 . 
     By pulling even further on the first end  331  of the connecting thread  33 , the outer plate  22  deforms the wall P by pressing against the inner plate  11  housed in the supporting body  1 ; the wall P is then sandwiched between said inner plate  11  and said outer plate  22 . 
     Advantageously, a return prevention device is provided between the connecting thread  33  and the inner plate  11 , to prevent the outer plate  22  from relaxing its pressure against the inner plate  11  when the first end  331  of the connecting thread  33  is no longer being pulled. For this purpose, the connecting thread  33  may for example have a beaded portion cooperating with the through-hole  110  provided on the inner plate  11  for the passage of the connecting thread  33 , in order to prevent slackening of the portion of thread  33  connecting the outer plate  22  to the inner plate  11 . 
     Subsequently or simultaneously, the deployment mechanism  2 , having released the outer plate  22 , is returned to its retracted configuration shown in  FIG. 5   a , the sheath moving in the distal direction. 
     The applicator  8  is then disconnected from the supporting body  1  and can be removed from the patient&#39;s body through the trocar TR. 
     In  FIG. 6 , all six basic modules of the supporting body  1 , to which must be added the six corresponding outer plates, are represented after the step illustrated in  FIG. 5   f  and the disconnection and removal of the applicator  8 .  FIG. 6  shows a perspective view of the tubular portion T shaped on the wall P around the opening O by means of the preparation system SP in the first embodiment of the invention. This tubular portion T extends here between the outer plates  22  and the cylindrical portion of the supporting body  1  receiving the inner plates  11 . 
     Thus, in this embodiment, the biasing elements which tighten and juxtapose the outer plates  22  on the supporting body, and more specifically on the inner plates  11  supported by the supporting body  1 , in order to gradually deform the annular surface S of the wall P centered around the opening O so as to, on the one hand, shape on the organic wall P a tubular portion P extending along the longitudinal axis X, and on the other hand, form an anchoring clamp composed of said outer plates  22 , comprise the connecting threads  33  associated with a device for exerting traction on these threads  33 . 
     At this stage one could actuate the ejection device  5  to eject the inner plates  11  from the supporting body, as well as the cutting device  6  to cut the connecting threads  33  in order to be able to remove the supporting body  1  from the patient&#39;s body, only leaving within the patient&#39;s body the inner and outer plates  11 ,  22  each connected by a connecting thread  33  of which the second end  332  is secured to an anchoring cylinder  32 , all of these elements preferably being made of a bioresorbable material. 
     The shape of the tubular portion T formed on the wall can then be maintained by the mutual contact of the inner plates  11  which retain each other in a circular configuration, or by a retaining element, for example in the form of a telescoping notched ring, holding the inner plates  11  and/or outer plates  22  in a circular configuration and put in place after removal of the supporting body  1 . 
     One can then see how the anchoring clamp formed by the outer plates  22  could be used to reconnect the formed tubular portion T to an organic or inorganic hollow tube, for example manually by the surgeon. 
     However, in the context of the present description, the first operative phase of creating the tubular portion is followed by a second operative phase of anastomosis intended to reestablish an end-to-end connection of the patient&#39;s urethra to the tubular portion T formed at the created opening on the bladder wall P, by means of the anastomosis system SA proposed by the invention. The ejection device  5  and cutting device  6  are thus only actuated after this reconnection is established, as will be further described below in relation to  FIGS. 9 ,  10   a  to  10   c ,  11  and  12 . 
     Alternatively, it could be arranged so that the connecting threads  33  are cut by means of an additional ad hoc tool before advancing to the second operative phase of anastomosis. 
     Prior to this, the invention proposes a second embodiment of a system SP′ for preparing the bladder wall P to form a tubular portion T which extends from its opening O. 
     This preparation system SP′ according to the second embodiment makes use of an applicator  8 ′ identical to the applicator  8  of the first embodiment, except for the deployment device  2 ′ which differs from the one in the first embodiment. Its operation will be detailed in relation to  FIGS. 8   a  to  8   f.    
     In this second embodiment, and as can be seen in particular in  FIG. 7 , the supporting body  11  is a single hollow part that is generally cylindrical. 
     The sleeve  40 ′, needle  41 ′, and tiered member  50 ′ that appear in  FIG. 7  are part of a suturing device  4 ′, and have substantially the same characteristics as the sleeve  40 , needle  41 , and tiered member  50  described for the first embodiment in relation to  FIG. 4 ; therefore they will not be described further in the context of this second embodiment. 
     Similarly, the ejection device  5 ′ and cutting device  6 ′ visible in  FIG. 7  and forming part of the suturing device  4 ′ are similar to the ejection device  5  and cutting device  6  described for the first embodiment in relation to  FIG. 4 ; therefore they will not be described further in the context of this second embodiment. 
     For these various elements of the second embodiment, the same references will be used as in the first embodiment, but with the addition of the ′ symbol. 
     For clarity in  FIG. 7 , the connecting elements  33 ′ intended to pass through the wall P of the bladder V, and the suture elements  44 ′ intended to pass through the urethra, have not been represented; these elements, which are in the form of threads made of bioresorbable materials, are particularly visible in  FIGS. 8   a  to  8   f ,  10   a  to  10   f ,  11  and  12 . 
     Referring to  FIG. 7 , the supporting body  1 ′ has a proximal portion  105 ′ substantially identical to the proximal portion  105  of the fixed part  101  of the supporting body  1  described in detail in relation to  FIG. 4 , and will not be detailed further in the description of the second embodiment. 
     In this second embodiment, the supporting body  1 ′ has a distal portion  103 ′ comprising a proximal portion  1030 ′ similar to the proximal portion  1030  of the distal portion  103  described for the first embodiment. This proximal portion  1030 ′ essentially defines housings  1031 ′ for receiving inner plates  11 ′ opening radially outwards and communicating with the inside space of the supporting body so as to provide a space e′ for each associated connecting thread  33 ′ as is particularly visible in  FIG. 8   a.    
     The distal portion  103 ′ of the supporting body also has a distal portion  1034 ′ of generally frustoconical shape whose diameter decreases in the distal direction. This frustoconical distal portion  1034 ′ has a bullet-nose distal end  1036 ′. The external design of this frustoconical distal portion  1034 ′ facilitates insertion of the distal portion  103  of the supporting body through the opening O. 
     This distal portion  103 ′ also has a plurality of radial through-slots  1033 ′ that connect the inside space it defines with the outside. The usefulness of these slots  1031 ′ will be described later. 
     The supporting body  1 ′ according to the second embodiment concentrically receives the suturing device  4 ′, mentioned previously but not described in detail, and a clamping device  7 ′ and feedthrough and anchoring device  3 ′. 
     The feedthrough and anchoring device  3 ′ is in the form of a rod  106 ′ extending along the longitudinal axis X and movable in translation along said axis relative to the supporting body  1 ′. The rod  106 ′ has a distal shank  1061 ′ carrying a plurality of resiliently flexible needles  31 ′ each releasably supporting, on their proximal end, an anchoring element  32 ′ to which is fixed the second end  332 ′ of an associated connecting thread  33 ′. Each anchoring element  32 ′ is here in the form of a cylinder having a frustoconical proximal end and a housing for receiving the proximal end of the needle  31 ′ with which it is associated. 
     The rod  106 ′ also has a proximal end  1062 ′ adapted to project proximally beyond the proximal end of the supporting body and intended to be connected to the applicator  8 ′ for the purposes of controlling the movement of said rod  106 ′. 
     The feedthrough and anchoring device  3 ′ according to this second embodiment further comprises an element  36 ′ defining a ramp  360 ′ for the flexible needles  31 ′; here it is in the form of a rotationally symmetrical element having a distal end  361 ′ of smaller diameter and a proximal end  362 ′ of larger diameter. In other words, the diameter of the element  36 ′ increases gradually in the proximal direction between its distal end  361 ′ and its proximal end  362 ′. 
     This element  36 ′ is mounted in an integral manner on a distal end  701 ′ of a mandrel formed in this second embodiment by a hollow shaft  70 ′ ending at its distal end in an annular flange  72 ′ having a plurality of through-holes and attachment holes  721 ′ for the suture threads  44 ′ (not represented in  FIG. 7 ). 
     This hollow shaft  70 ′ is adapted to be threaded onto the rod  106 ′ and to rotate on said rod about the longitudinal axis. Once in place with the rod  106 ′ inside the supporting body  1 ′, the proximal end  702 ′ of the hollow shaft  70 ′ protrudes proximally beyond the proximal end of the supporting body  1 ′, and is intended for connection to the applicator  8 ′ for the purposes of controlling the shaft  70 ′. 
     Finally, again as is visible in  FIG. 7 , the tiered member  50 ′ is adapted to be threaded onto the hollow shaft  70 ′, and the sleeve  40 ′ supporting the flexible needles  41 ′ is adapted to be threaded onto the tiered member  50 ′. 
     The assembly thus formed comprises the feedthrough and anchoring device  3 ′, the clamping device  7 ′, and the suturing device  4 ′. This assembly is intended for insertion into the supporting body  1 ′. 
     Once inserted into the supporting body  1 ′, the proximal ends  402 ′,  5012 ′ of the sleeve  40 ′ and the tiered member  50 ′ protrude proximally beyond the proximal end of the supporting body  1 ′, and are intended to be connected to the applicator  8 ′ for the purposes of controlling the suturing device  4 ′. 
     Thus, in the embodiment illustrated in  FIG. 7 , the set of elements supported by the supporting body  1 ′, when they are in their original configurations, fit within a cylinder having a diameter corresponding to the largest outside diameter of the distal portion  103 ′ of the supporting body  1 ′. Preferably, this diameter is smaller than the diameter of the opening O present on the wall P, to allow insertion of the distal portion  1   a ′ of the supporting body through said opening O. 
     We will now describe a first operative phase of preparing the opening O, arranged on the bladder wall P, so as to form a substantially tubular portion at the opening, making use of the preparation system SP′ according the second embodiment of the invention. 
     For this purpose, as can be seen in  FIG. 8 , the proximal portion  1   a ′ of the supporting body  1 ′ is inserted along its longitudinal axis X into the housing  8   d ′ defined in the proximal portion  8   a ′ of the applicator  8 ′, and the distal portion  1   b ′ of the supporting body  1 ′ extends distally from said proximal portion  8   a ′ of the applicator  8 ′. 
     In this  FIG. 8  one can see that, in the second embodiment of the preparation system SP′ of the invention, the distal portion  8   a ′ of the applicator supports a deployment mechanism  2 ′ comprising a plurality of support members  23 ′, visible in particular in  FIGS. 8   a  to  8   f , releasably supporting external clamp elements  22 ′ intended to be positioned facing and then in contact with respective portions of an annular surface S of the wall P centered about the opening O. 
     This deployment mechanism  2 ′ is adapted to move the external clamping elements  22 ′ between a retracted configuration, shown in  FIG. 8 , where they are folded in the direction of the longitudinal axis X on the proximal end  1   a ′ side of the supporting body  1 ′, a deployed configuration where they are away from the longitudinal axis X and flare outward substantially perpendicularly to said axis, and a collapsed configuration where they are folded in the direction of the longitudinal axis X on the distal end side of the supporting body  1 ′ while deforming the wall P, as will be explained in more detail in relation to  FIGS. 8   a  to  8   f.    
     The distal portion  8   a ′ of the applicator  8 ′, equipped with the supporting body  1 ′ in its initial configuration, and having external clamping elements  22 ′ in the collapsed configuration, may advantageously be inserted through a trocar TR placed on the abdominal wall of the patient, and the various devices may be controlled from outside the patient&#39;s body by means of the proximal portion  8   b ′ of said applicator  8 ′, typically during endoscopic surgery. 
     The applicator  8 ′ fitted with the supporting body  1 ′ is then manipulated by the surgeon so that the body  1 ′ approaches the bladder V, until the distal portion  1   a ′ of said body is inserted into the opening O formed in the wall P, centering the longitudinal axis X within this opening O and engaging the distal end  1036 ′ first. The bullet-nose shape of the end  1036 ′ and the frustoconical shape  1034 ′ provided on the supporting body  1 ′ facilitate this insertion. 
     The external clamping elements  22 ′, here six in number, are in the form of outer plates made of a bioresorbable material and are releasably supported on the support members  23 ′, for example by having complementary forms. 
     The distal portion  8   a ′ of the applicator  8 ′ and the proximal portion  1   a ′ of the supporting body  1 ′ advantageously have indexing elements which allow fixing said supporting body  1 ′ to the end of the applicator  8  so that the outer plates  22 ′, supported by the applicator  8 ′, are angularly aligned circumferentially with the inner plates  11 ′ supported by the distal portion  1   b ′ of the supporting body  1 ′. 
     As can be seen in  FIGS. 7 and 8 , the assembly formed by the distal portion  8   a ′ of the applicator  8 ′ and the supporting body  1 ′ has a rotational symmetry about the longitudinal axis X and can be divided into a plurality of identical basic modules regularly distributed circumferentially. In the example represented, this assembly can be divided into six basic modules each extending over an angular range of about 60° and each comprising an inner plate  11 ′, an outer plate  22 ′, a connecting thread  33 ′ provided for connecting the inner plate  11 ′ and outer plate  22 ′ after having passed through the wall P, and a suture thread  44 ′ provided for connecting the inner plate  11 ′ and outer plate  22 ′ after having passed through the urethra. 
       FIGS. 8   a  to  8   f  illustrate one of these modules. The reader will understand that what is visible in these figures also applies to each of the other five modules. 
       FIGS. 8   a  to  8   f  therefore illustrate the various steps in preparing the opening O by means of the preparation system SP′ according to the second embodiment of the invention. 
     In  FIG. 8   a , the system SP′ is partially illustrated in its initial configuration when in place at the opening O. 
     In this initial configuration of the preparation system SP′, the deployment mechanism  2 ′ is in the configuration with the outer plate  22 ′ collapsed and supported by a support member  23 ′, the feedthrough and anchoring device  3 ′ is in the configuration where the second end  332 ′ of the connecting thread  33 ′ is retracted, this end  332 ′ being at a radial distance d1′ from the longitudinal axis X that is less than the radius r1 of the opening O, the inner plate  11 ′ is received within its housing  1031 ′ provided on the supporting body  1 ′, and the ejection  5 ′ and cutting device  6 ′, formed here by a wedge  500 ′, is in the inactive configuration. 
     The suturing device  4 ′ is also in the configuration where the second end  442 ′ of the suture thread is retracted. This device will come into play during the second operative phase, or anastomosis phase, and its operation will be further described below in relation to  FIGS. 10   a  to  10   c  and  11 . For clarity, the suture thread  44 ′ is not represented in  FIGS. 8   a  to  8   f.    
     Returning to  FIG. 8   a , one can see that in this first placement step, the supporting body  1 ′ is inserted through the opening O until a positioning element  20 ′ reaches the outer surface of the wall P, or the surface on the proximal side. 
     In a manner not represented in detail in the figures, the positioning element  20 ′ is integral with the distal portion  8   a ′ of the applicator  8 ′. 
     In  FIG. 8   a , one can see that the positioning element  20 ′ rotatably supports a support member  23 ′ which is in the form of a generally Y-shaped fork having a lower arm  231 ′ rotatably mounted on the positioning element  20 ′ and two upper arms  232 ′ cooperating with a complementary cavity  222 ′ provided on the outer plate  22 ′ to ensure the releasable support of said plate  22 ′ on the support member  23 ′. One of these upper arms  232 ′ and part of the cavity  222 ′ are visible in  FIG. 8   f.    
     The lower arm  231 ′ has a plurality of peripheral gear teeth, adapted to cooperate with a rack provided on a distal portion of a sheath  24 ′ mounted to be movable in translation inside the distal portion  8   a ′ of the applicator  8 ′ and which can be controlled from the proximal portion  8   b ′ thereof. In the case of sequential deployment of the external clamping elements, the sheath  24 ′ can be divided into as many subparts as there are to be successive deployment sequences; each of these subparts is intended to control the deployment of one or more clamping elements between the retracted configuration, the deployed configuration, and the collapsed configuration, and can be successively controlled from the proximal portion  8   b ′ of the applicator  8 ′. 
     In the collapsed configuration of the deployment mechanism  2 ′, the support  23 ′ and the outer plate  22 ′ lie substantially parallel to the longitudinal axis. 
     Also visible in  FIG. 8   a  is the path of a connecting thread  33 ′ within the supporting body  1 ′. This thread  33 ′ has a first end  331 ′ adapted for connection to a traction device (not represented) built into the applicator  8 ′. The thread  33 ′ traverses the proximal portion  1   a ′ of the supporting body  1 ′ within a space provided for this purpose and extends substantially for the length of the hollow shaft  70 ′. This thread  33 ′ then emerges into a free space e′ provided in the supporting body  1 ′ and located under the inner plate  11 ′ fitted into its housing  1031 ′. The connecting thread  33 ′ then passes through the inner plate  11 ′ by a through-hole  110 ′, and changes direction again as it follows the outer surface of the plate  11 ′; then it passes through the notch  1032 ′ and is fixed by its second end  332 ′ to an anchoring element  32 ′ releasably supported by a flexible needle  31 ′. 
     Referring now to  FIG. 8   b , the controls have moved the sheath  24 ′ along an axial path C1′ in the direction of arrow F1′, which has caused the support member  23 ′ to pivot due to the engagement of its teeth with the rack supported by the sheath, resulting in a deployed configuration of the outer plate  22 ′ where it lies substantially perpendicular to the longitudinal axis X, facing a portion of the annular surface S of the wall P visible in  FIG. 7 . 
     Advantageously, in this deployed position, at least one catch hook or tooth  223 ′ provided on the outer plate  22 ′ catches on a portion of the annular surface S of the wall P visible in  FIG. 7 . 
     Turning to  FIG. 8   c , the sheath  24 ′ has again been moved by appropriate controls along an axial path C2′ in the direction of arrow F2′, which has caused the support member  23 ′ to pivot due to the engagement of its teeth with the rack supported by the sheath, resulting in a collapsed configuration of the outer plate  22 ′ where it is folded in the direction of the longitudinal axis X on the distal end side of the supporting body. The tooth  223 ′ having caught on the wall P, as the outer plate  22 ′ folds it pulls along a portion of the annular surface S of the wall P and deforms it so that it is pressed against the supporting body, and more specifically against the inner plate  11 ′. 
     Thus, in this second embodiment, the biasing elements arranged to tighten and juxtapose the outer plates  22 ′ on the supporting body  1 ′, and more precisely on the inner plates  11 ′ supported by the supporting body  1 ′, in order to progressively deform the annular surface S of the wall P centered around the opening O so as to, on the one hand, shape on the organic wall P a tubular portion P extending along the longitudinal axis X, and on the other hand, form an anchoring clamp consisting of said outer plates  22 ′, comprise the deployment mechanism  2 ′. 
       FIG. 8   d  illustrates a subsequent step in the operation of the preparation system SP′ according to the second embodiment of the invention. During this step, the intent is to maintain or lock in the configuration shown in  FIG. 8   c  the outer plate  22 ′ and inner plate  11 ′ gripping the wall P, by means of a connecting thread  33 ′ linking said inner and outer plates  11 ′,  22 ′. 
     For this purpose, the feedthrough and anchoring mechanism  3 ′ is actuated so that the second end  332 ′ is moved from its retracted configuration where it is positioned at a radial distance d1′ from the longitudinal axis X, visible for example in  FIG. 8   c , to its anchored configuration where it is retained on the outer plate  22 ′ after having traversed the wall P. 
     This actuation is achieved by moving the rod  106 ′ in the direction of arrow F3′ along a path C3′. This displacement of the rod  106 ′ drives the flexible needle  31 ′ in axial translation by means of the shank  1061 ′. As it comes in contact with the ramp  360 ′ provided on the element  36 ′, the flexible needle  31 ′ bends radially outward, passes through a through-slot  1033 ′ arranged in the supporting body  1 ′, and obliquely traverses the tubular portion T formed on the wall P, as well as the anchoring portion  220 ′ provided on the outer plate  22 ′. 
     The path C3′ of movement of the rod  106 ′ will be dimensioned appropriately to allow the second end  332 ′ of the connecting thread  33 ′ and the anchoring cylinder  32 ′ which supports it to pass entirely through the wall P and outer plate  22 ′ by passing through the anchoring portion  220 ′. 
     For this purpose, in the embodiment illustrated, the needle  31 ′ has a tip  310 ′ for piercing the wall P, on its proximal end. 
     When the rod  106 ′ is released, the configuration illustrated in  FIG. 8   e  is reached, where the feedthrough and anchoring device  2 ′ returns to its retracted configuration; as the distal end of the needle  31 ′ is no longer subjected to force from the shank  1061 ′ of the rod, said needle  31 ′ returns naturally by elastic return to its rest position where it lies straight and substantially parallel to the longitudinal axis X. In doing so, it presses against the ramp  360 ′ and slides thereon while transmitting this return movement to the rod  106 ′ through its distal end integral with the shank  1061 ′. 
     During this return movement, the needle  31 ′ releases the anchoring cylinder  32 ′ to which the second end  332 ′ of the connecting thread  33 ′ is attached, this cylinder  32 ′ then catching on the anchoring portion  220 ′ of the outer plate  22 ′. 
     At this point, and as shown in  FIG. 8   f , traction is exerted on the first end  331 ′ of the connecting thread  33 ′ in the direction of arrow F5′ by means of the traction device arranged in the applicator  8 ′. 
     The traction exerted on this first end  331 ′ is transmitted by the thread  33 ′ to the second end  332 ′ anchored on the outer plate  22 ′ and causes the outer plate  22 ′ to press more tightly against the inner plate  11 ′, sandwiching the wall P between them. 
     Advantageously, a return prevention device is provided between the connecting thread  33 ′ and the inner plate  11 ′, to prevent the outer plate  22 ′ from relaxing its pressure against the inner plate  11 ′ when the first end  331 ′ of the connecting thread  33 ′ is no longer being pulled. For this purpose, the connecting thread  33 ′ may for example have a beaded portion cooperating with the through-hole  110 ′ provided on the inner plate  11 ′ for the passage of the connecting thread  33 ′, in order to prevent slackening of the portion of thread  33 ′ connecting the outer plate  22 ′ to the inner plate  11 ′. 
     Subsequently or simultaneously, the sheath  24 ′ is moved in the distal direction along arrow F6′ so as to cause the support member  23 ′ to pivot to a retracted position in the direction of the longitudinal axis X, on the proximal side of the supporting body  1 ′. This pivoting causes the release of the releasable attachment of the outer plate  22 ′ to the support member  23 ′, the upper arms  232 ′ of the fork formed by said support member  23 ′ exiting the complementary cavity  222 ′ provided on the outer plate  22 . 
     The applicator  8 ′ is then disconnected from the supporting body  1 ′ and can be removed from the patient&#39;s body through the trocar TR. 
     Thus, in this second embodiment, the biasing elements arranged to tighten and juxtapose the outer plates  22 ′ on the supporting body  1 ′, and more specifically on the inner plates  11 ′ supported by the supporting body  1 ′, in order to gradually deform the annular surface S of the wall P centered around the opening O so as to, on the one hand, shape on the organic wall P a tubular portion T extending along the longitudinal axis X, and on the other hand, form an anchoring clamp composed of said outer plates  22 ′, comprise the connecting threads  33 ′ associated with a device for exerting traction on these threads  33 ′, in addition to the deployment mechanism  2 ′. 
     At this stage one could actuate the ejection device  5 ′ to eject the inner plates  11 ′ from the supporting body  1 ′, as well as the cutting device  6 ′ to cut the connecting threads  33 ′ in order to be able to remove the supporting body  1 ′ from the patient&#39;s body, only leaving inside the patient&#39;s body the inner and outer plates  11 ′,  22 ′ each connected by a connecting thread  33 ′ of which the second end  332 ′ is secured to an anchoring cylinder  32 ′, all of these elements preferably being made of a bioresorbable material. 
     The shape of the tubular portion T formed on the wall can then be maintained by the mutual contact of the inner plates  11 ′ which retain each other in a circular configuration, or by a retaining element, for example in the form of a telescoping notched ring, holding the inner  11 ′ and/or outer plates  22 ′ in a circular configuration and put in place after removal of the supporting body  1 ′. 
     One can then see how the anchoring clamp formed by the outer plates  22 ′ could be used to reconnect the formed tubular portion T to an organic or inorganic hollow tube, for example manually by the surgeon. 
     However, in the context of the present description, the first operative phase of creating the tubular portion is followed by a second operative phase of anastomosis intended to reestablish an end-to-end connection of the patient&#39;s urethra to the tubular portion T formed at the created opening on the bladder wall P, by means of the anastomosis system  1  proposed by the invention. 
     In this second operative phase, the applicator  8 ,  8 ′ has been disconnected from the supporting body  1 ,  1 ′ and removed from the patient&#39;s body. The surgeon uses the probe  9 , which is identical in the two embodiments described above. The elements used during this second operative phase, or anastomosis phase, are substantially identical in either of the embodiments described. 
     This anastomosis or reconnection phase will therefore be described in relation to  FIGS. 9 ,  10   a  to  10   b ,  11  and  12 , where the preparation system SP according to the first embodiment is used, although it would apply as same manner using the described preparation system SP′ according to the second embodiment. 
     With reference to  FIG. 9 , after disconnecting and removing the applicator, the surgeon makes use of the probe  9 . The probe  9  is inserted into the urethra C from its meatus C, until it reaches the opposite end E visible in  FIG. 9 . It is understood that this end E results from a prior resection of the membranal area of the urethra, in particular when carried out as part of a prostatectomy. 
     As illustrated in  FIG. 9 , the probe  9  is inserted into the urethra so that the distal end  9   a  is positioned at the end E of the urethra C. To facilitate this positioning, the distal end  9   a  of the probe is preferably provided with a domed cap which, once the probe is positioned, is removed by the surgeon by an additional ad hoc tool. 
     The surgeon then brings together the tubular portion T formed on the bladder wall P and the end E of the urethra C. In practice, and in particular to prevent damage to the sphincter of the urethra C, preferably it is the wall P of the bladder V which is acted upon to bring its tubular portion T toward the end E of the urethra C. To achieve this, the surgeon can pull on the supporting body  1  or on the outer plates  24  as indicated by arrow F in  FIG. 9  in order to close the gap between the two organs to be anastomosed so that the mucous membranes of their respective edges are axially facing one another. 
     The surgeon then connects the distal end  9   a  of the probe  9  to the proximal portion of the supporting body  1 , the connecting and control elements (not represented) engaging with the proximal end  702  of the hollow shaft  70 , the proximal end  5012  of the tiered member  50 , and the proximal end  402  of the support sleeve  40  of the flexible needles  41 . 
     The distal portion  9   a  of the probe  9  and the proximal portion  1   a  of the supporting body  1  advantageously have indexing elements which allow attaching said supporting body  1  to the end of the probe  9  such that the flexible needles  41 , supported by the supporting body  1 , are angularly aligned circumferentially with the through-slots  95  provided on the distal portion  9   a  of the probe  9 . 
     Actuation of the suturing device  4 , bringing into play a plurality of suture elements  44 , will now be described with reference to  FIGS. 9 and 10   a  to  10   c.    
     In  FIG. 9 , the suturing device  4  is in the configuration where the second ends  442  of the suture elements  44  are retracted, said suture elements here being in the form of threads, preferably made of a bioresorbable material. 
     In this retracted configuration, the flexible needles  41 , releasably supporting hollow cylinders  42  to which are fixed the second ends  442  of the suture threads  44 , are received within longitudinal channels  504  provided in the tiered member  50  and visible in particular in  FIG. 4 . The second ends  442  of the suture threads  44  are then located at a radial distance d2 (visible in  FIG. 10   c ) which is less than the inside radius r2 of the urethra C. 
     In  FIGS. 10   a  to  10   c , only one basic module has been represented. It is understood that the description given in relation to this basic module applies to the other five, which are evenly distributed circumferentially. 
     Thus,  FIG. 10   a  illustrates the suturing device  4  after the flexible needle  41  has been moved in the direction of arrow F6 by acting on the proximal end  402  of the support sleeve  40 . 
     During this axial movement, the distal end of the needle  41  comes in contact with the ramp  505  provided on the tiered member  50 , at the distal end  504  of the channel in which it was completely housed in the initial configuration, this ramp which is part of the tiered member  50  initially being maintained in a fixed manner in the axial direction, for example by means of the probe, in a first axial position 
     The flexible needle  41  is then bent radially outward so as to pass through a through-slot  1051  arranged in the proximal portion  105  of the fixed part  101  of the supporting body  1 , then through a through-slot  95  arranged in the distal portion  9   a  of the probe  9 , and then passes at an angle through the end E of the urethra C. 
     The axial travel of the sleeve  40  will be dimensioned appropriately for the second end  442  of the suture thread  44  and the anchoring cylinder  42  that supports it to pass entirely through the end E of the urethra C. 
     For this purpose, in the embodiment illustrated, the needle  41  has a tip  410  for piercing the wall P, on its proximal end. 
     In the position illustrated in  FIG. 10   a , the suturing device  4  is in an intermediate deployed configuration, where the second end  442  of the suture thread  44  is positioned facing an anchoring portion  224 , visible for example in  FIG. 9 , provided on the associated outer plate  22 . 
     In this  FIG. 10   a , one can also see the path of the suture thread  44 . This thread  44  has a first end  441  connected distally behind an opening  721  provided on the mandrel  72 . The thread  44  then runs in the distal direction and successively passes through the opening  721 , an opening  711  formed on the annular ring  71  integral with the supporting body  1 , then passes through the inner plate  11  via a passage  120  provided for this purpose in said plate. The thread  44  then reaches the flexible needle  41  and runs along it until it reaches the anchoring cylinder  42 , to which its second end  442  is attached. 
     In the retracted configuration of the suturing device, the needle  41  is housed within its associated channel  504 , and the thread  44  exits the passage  120  on the distal side of the inner plate  11 , runs within the through-slot  507  formed in the wedge  500 , and emerges into the channel  504  at the ramp  505 . 
     Referring now to  FIG. 10   b , the tiered member  50 , of which the ramp  505  is a part, has been moved in the direction of arrow F7 by acting on its proximal end  5012  connected to the probe  9 , in order to reach a second axial position. As the flexible needle  41  is no longer in contact with the ramp  505 , it folds back by elastic return towards the longitudinal axis; by doing so, the needle  41  slightly deforms the end E of the urethra C and anchors the anchoring cylinder  42  supporting the second end  442  of the suture thread inside the complementary anchoring portion  224  provided on the outer plate  22 . 
     At this point, the needle  41  is moved in the direction of arrow F8 illustrated in  FIG. 10   c  so that it returns to its original configuration inside its associated channel  504 , having released the anchoring cylinder  42  carrying the second end of the suture thread  44  inside the anchoring portion  224  provided in the outer plate  22 . 
     Subsequently or simultaneously, the mandrel  72  is rotatably driven via the hollow shaft  70  connected at its proximal end  702  to the probe  9 . This mandrel  72  then pulls on the first end  441  of the suture thread  44  and winds it around the body of the mandrel  72 . By doing so, the end-to-end anastomosis between the tubular portion T of the wall P of the bladder V and the end E of the urethra C is pulled tighter. 
     Advantageously, the mandrel  72  is associated with a torque limiting system, arranged in the probe  9  controlling the rotation of the hollow shaft  70  integral with the mandrel  72 , or directly by a torque limiting device, for example a device with calibrated slip/friction arranged between said shaft  70  and said mandrel  72 . The tightness of the anastomosis can thus be adjusted in a precise and reproducible manner. 
     Advantageously, a return prevention device is provided between the suture thread  44  and the inner plate  11 , this device preventing slackening of the thread  44  and of the anastomosis when the first end  441  of the suture thread  44  is no longer being pulled. For this purpose, the suture thread  44  may, for example, have a beaded portion cooperating with the passage  120  provided on the inner plate  11  for the passage of the suture thread  44 , in order to prevent slackening of the portion of thread  44  connecting the outer plate  22  to the inner plate  11  via the urethra C. 
     Once the anastomosis between the patient&#39;s urethra C and bladder V has been established and tightened,  FIG. 11  illustrates a step of ejecting the inner plate  11  and cutting the connecting  33  and suture  44  threads. 
     To do this, the tiered member  50  is moved axially in the direction of arrow F9 in  FIG. 11 , until the ejection face  509  of the wedge  500  comes in contact with the inner plate  11 . As the ejection face  509  is sloped, this moves the inner plate  11  in the radial direction so that it emerges from its housing  1031  provided in the supporting body  1 . During this radial displacement, the inner plate  11  slightly compresses the bladder wall P at the tubular portion T as is clearly visible in  FIG. 11 . 
     Continuing its forward movement in the direction of arrow F9, the cutting blade  506  of the wedge  500  engages with the suture thread  44  and connecting thread  33  then catches them and cuts them against a radial face, which is for example part of the annular ring  71  integral with the supporting body  1 . 
     As the inner plate  11  has been ejected from the supporting body and the connecting  33  and suture  44  threads have been cut behind the inner plate  11 , the supporting body  1  can be removed from the work area and from the patient&#39;s body, through the probe. 
     Thus, if we consider the set of six basic modules, the elements remaining within the patient&#39;s body are limited to six inner plates  11 , six outer plates  22 , six connecting threads  33  each having an anchoring cylinder  32  at their end, and six suture threads  44  each having an anchoring cylinder  42  at their end, all these elements being preferably made of a bioresorbable material. 
     Finally, the operation of the system for performing anastomosis between the bladder wall P and the urethra C, according to the second object of the invention and for the case where a tubular portion is formed on the organic wall by a means other than the preparation system mentioned above, avoids a number of steps described for the first object of the invention. 
     In particular, the steps related to the deployment and placement of external clamping elements  22 ,  22 ′ on the wall P in order to form the tubular portion T do not apply to this second object. 
     Conversely, the description provided in relation to  FIGS. 8   d  to  8   f ,  9 ,  10   a  to  10   c ,  11  and  12 , detailing the various phases of feeding through and anchoring the connecting and suture threads  33 ′,  44 ′, as well as the phases of tightening these threads and the phases of ejecting the inner plates  11 ′ and cutting the threads  33 ′,  44 ′, apply to the system according to this second object. 
     Different options can be considered for defining a tubular portion on the wall P, making use of one or more external clamping elements  22 . One could, for example, provide only one external clamping element in the form of an elastically deformable ring having a plurality of anchoring portions uniformly distributed along its circumference that are intended to accommodate the anchoring elements for the connecting and suture threads, and put in place by slipping it around the flattened wall P, for example manually over a cylindrical portion of the supporting body. When placed in this manner, the ring would serve as an anchoring clamp for the connecting and suture threads.