RU2448660C1 - Method for surgical management of genital prolapse complicated with stress urine incontinence - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, surgical gynaecology. Vaginal uterectomy is followed by implantation of a synthetic Perigee system from a transobturative approach. A sling is formed at the level of a middle urethra. A front end of the implanted system is fixed to paraurethral tissues of the lateral urethra. A triangular flap of the posterior vaginal wall and uterosacral ligaments are sutured together. A plastic surgery on levator is performed. The method provides preserved vaginal length, prevented genital prolapse and stress urine incontinence, eliminates urethral hypermobility.

EFFECT: sling fixation prevents intraoperative system displacement and provides a reliable pelvic support in connective tissue dysplasia.

2 ex

Description

The invention relates to medicine, operative gynecology, and can be used in the surgical treatment of genital prolapse, complicated by stress urinary incontinence.

There are many known operations aimed at treating genital prolapse, which in turn have a large number of modifications. However, this (over 300 types) difference in surgical benefits for this disease is not effective enough due to the high percentage of complications that appear already in the first 3 years after surgery (Medvedev S.N. Combined laparovaginal access in the treatment of patients with genital prolapse. Diss. Cand. Medical Sciences. - M. 2000; 11-75).

More than 200 surgery modifications have been proposed for the treatment of stress urinary incontinence. At the same time, the treatment of genital prolapse in combination with urinary incontinence in women has not been sufficiently studied and covered in modern literature. Currently, many questions remain regarding the prevention and prevention of relapse of prolapse and urinary incontinence in women after surgical correction (Gagarina S.V., Chunaeva E.A. Reconstructive surgery for stress urinary incontinence and prolapse of the genitals. - Urology 2008. - № 1, p. 35-38.)

In this regard, the surgical treatment of genital prolapse, complicated by stress urinary incontinence, requires two stages of surgery to treat genital prolapse and the correction of stress urinary incontinence.

The most famous operation for genital prolapse is vaginal extirpation of the uterus, which includes the following steps: dissection of the anterior vaginal wall, separation with a blunt and sharp path of the vaginal wall from the bladder. After the final separation of the bladder from the wall of the vagina, it is separated from the cervix and peritoneum in an upward direction, dissecting the prebubular tissue. Next, the cervix is pulled up to the fold, the incision of the posterior wall is brought to the place where the sacro-uterine ligaments leave the uterus. The walls of the vagina exfoliate slightly up and sideways to expose the uterine vessels and cardinal ligaments. The uterus is removed into the opening of the wound. Strong clamps are sequentially applied along the uterine ribs, starting from the cardinal ligaments, then clamps are placed along the uterine body on each side. The uterus is cut off. Tissues taken in clamps: ligaments, vessels, uterine ends of the tubes sheathed. The bladder is fixed with interrupted sutures imposed in the transverse direction; a continuous suture is applied to the vaginal wall incision. Perform vaginal plastic surgery, levoroplasty (Hirsch X., Keser O., Ikle F. Operative gynecology. Transl. From English. - M .: Geotar medicine. 2007; 217-236, 242-257).

The vaginal extirpation of the uterus according to McCall is also known, which is performed with genital prolapse in order to strengthen the dome of the vagina and prevent post-hysterectomy prolapse, which consists in suturing the sacro-uterine ligaments at a distance of 3-5 cm from their ends. The posterior edge of the peritoneum between the sacro-uterine ligaments can be included in the suture. With a very wide divergence of the ligaments, a triangular wedge is cut out between them. McCall made three such stitches. Tying the sutures is postponed until the end of the operation or until the start of posterior colporography. The sacro-uterine ligaments bring it closer to the middle of the rectal-uterine cavity, move the vagina inwards and fix it (Hirsch X., Keser O., Ikle F. Operative gynecology. Transl. From English - M .: Geotar medicine. 2007; 233-235 )

The disadvantages of these methods of surgical treatment of genital prolapse:

- do not provide the physiological position of the pelvic organs (bladder, urethra, vagina);

- lead to a shortening of the length of the vagina and its excessive narrowing;

- do not provide sufficient fixation of the ligamentous apparatus to the walls of the vagina;

- a high percentage of recurrence of genital prolapse.

Also known vaginal extirpation of the uterus in the Mayo modification, which consists in suturing the ligaments of the uterus, to which the walls of the vagina are fixed. The needle is injected immediately at the upper corner of the wound through the vaginal mucosa, fascia and peritoneum of the bladder, the upper segment of the connected uterine ligaments and punctured through the described layers in the opposite direction of the opposite edge of the wound. The second suture is made with the same thread, capturing the edges of only the vaginal mucosa, medial to the previous injection for a more tight connection of the edges of the mucosa. There are several such joints, retreating 1.5-2 cm down from the first. With these sutures, the vaginal wall is fixed to interconnected ligaments of the uterus, which strengthen the vaginal wall in the stump of the sacro-uterine ligaments. With this stitching, the stumps of the ligaments are extraperitoneally located (Kulakov VI, Selezneva ND, Krasnopolsky VI Operational gynecology. - M .: Medical book. 1998; 315-319).

The disadvantages of this method of treatment:

- the occurrence of various types of urinary disorders, which can lead to the development of psychoemotional disorders in patients;

- does not provide the physiological position of the pelvic organs (bladder, urethra, vagina);

- leads to a shortening of the length of the vagina;

- a high percentage of recurrence of genital prolapse.

Many methods have been proposed for fixing a synthetic prosthesis to tissues during the correction of genital prolapse. For example, rigid fixation of the implant to the bone elements of the pelvis allows you to further strengthen the organs of the small pelvis in order to avoid the occurrence of relapses.

Disadvantages:

- the development of pelvic pain, dyspareunia due to the formation of excess tissue tension, rigidity of the created structure;

- do not provide the physiological position of the pelvic organs (bladder, urethra, vagina).

Arrangement of the prosthesis in a tension-free state (U.Ulmsten. B.Jacquetin and M. Cosson) using transobturator or ischiorectal access for mesh attachment made it possible to maintain elasticity and avoid overstrain of the vaginal tube, to prevent the development of a pain syndrome (V.I. Krasnopolsky, A .A. Popov, S. L. Gorsky, et al. “Possibilities and prospects of minimally invasive methods for the correction of stress urinary incontinence” - Surgery, 2007).

Disadvantage:

- does not provide the physiological position of the pelvic organs: bladder, urethra, vagina.

The closest analogue of the invention is a method of vaginal extirpation of the uterus (O.V. Makarov, patent RU No. 2248187 from 03.24.03). The method consists in the following: a dissection of the anterior wall of the vagina is performed, separation with a blunt and sharp path of the vaginal wall from the bladder. After its final separation from the fascia to the lateral edges, it is separated from the cervix and peritoneum in an upward direction with dissection of the prebubble tissue. The cervix is pulled upward to the bosom, an incision is made in the posterior wall to the place of discharge of the sacro-uterine ligaments from the uterus. After exfoliation of the vaginal wall, cardinal ligaments and uterine vessels are exposed. The uterus is removed into the opening of the wound. Along the ribs of the uterus, clamps are sequentially applied, starting with the cardinal ligaments, then clamps along the body of the uterus on each side. The uterus is cut off. Tissues taken in clamps: ligaments, vessels, uterine ends of the tubes, sheathed. The bladder is fixed with interrupted sutures. Shorten and fix the round ligaments to the vaginal vaults and suture them under the urethra in the form of an impromptu sling, shorten the cardinal ligaments and fix them to the middle part of the vagina. Excision of a triangular flap from the posterior wall of the vagina and suturing of the sacro-uterine ligaments are performed, a continuous suture is applied to the incision of the vaginal wall. The posterior wall of the vagina is separated from the rectum as much as possible, the rectal-vaginal fascia is sutured with separate sutures with the creation of duplicature from the vaginal wall, and levatoroplasty is performed.

The disadvantage of this method is the use of its own tissues for fixing the vaginal dome, which, if the patient has connective tissue dysplasia, creates a risk of relapse. The reason for this is not only (and not so much) in the technique of the operation itself, but in the initial connective tissue failure, observed to one degree or another in half of patients with genital prolapse.

The objective of the invention is to develop a method for the simultaneous surgical treatment of genital prolapse and stress urinary incontinence, which would provide for reliable strengthening of the pelvic organs in physiological position.

The technical result consists in the prevention of recurrence of genital prolapse and stress urinary incontinence by eliminating urethral hypermobility, ensuring reliable fixation of organs in the physiological position, as well as maintaining the length of the vagina by combined strengthening of the anterior and posterior pelvic floor and fixation of the pelvic organs: vagina, urethra bladder due to the strengthening of the own ligamentous apparatus of the pelvic organs and the formation of a synthetic midurethral sling.

Due to the consistent strengthening of the round, cardinal, sacro-uterine ligaments, as well as the preservation of vaginal tissue, the physiological length of the vagina is maintained.

We found that a certain location and fixation of the synthetic sling at the level of the middle section of the urethra helps to prevent implant displacement during surgery, as well as to avoid hypermobility of the urethra, on the one hand, and to provide a reliable bandage of the pelvic organs with connective tissue dysplasia, on the other hand.

SUMMARY OF THE INVENTION

In the surgical treatment of genital prolapse, complicated by stress urinary incontinence, vaginal extirpation of the uterus is performed. Shorten the uterine round ligaments, fix them to the vaginal arches and suture under the urethra in the form of a sling, shorten the cardinal ligaments and fix them to the middle part of the vagina. Then, a synthetic implant is installed using transobturator access using the Perigee system under the neck of the bladder.

Position it so that the front edge of the implant is at the level of the middle section of the urethra, forming a sling. After that, the front edge of the implant is fixed to the middle part of the urethra by suturing between the implant and paraurethral tissues in the region of the lateral parts of the urethra. A triangular flap is excised from the posterior wall of the vagina and the sacro-uterine ligaments are sutured together. A continuous suture is applied to the vaginal wall incision. Levatoroplasty is performed.

The method is as follows.

The patient does not lie on her back in a lithotomy position, shifting as far forward as possible so that her buttocks protrude above the edge of the table. Dissect the anterior wall of the vagina, separate with a blunt and sharp path of the vaginal wall from the bladder. The bladder is separated from the cervix in an upward direction with dissection of the prebubble tissue. The cervix is pulled up to the bosom, an incision is made in the posterior wall of the vagina to the place where the sacro-uterine ligaments leave the uterus. After exfoliation of the vaginal wall, the uterine vessels and cardinal ligaments are exposed. The uterus is removed into the opening of the wound. Along the ribs of the uterus, clamps are sequentially applied, starting with the cardinal ligaments, then clamps along the body of the uterus on each side. The uterus is cut off. Tissues taken in clamps (ligaments, vessels, uterine ends of the tubes) are sheathed. Shorten and fix the round ligaments to the vaginal arches, shorten the cardinal ligaments and fixate them to the middle part of the vagina.

A Perigee synthetic implant is installed as follows: through minimal incisions at 4 points (the upper two at the clitoris, laterally to the edge of the sciatic-pubic branch of the pelvic bone, the lower two 3 cm lower and 2 cm lateral to the upper), the conductor needles are inserted from the outside inward through the obstructive openings under the neck of the bladder (the handles of the upper needles are positioned at an angle of 45 ° to the midline of the patient and pass through the upper edge of the obstructive opening, the ends of the lower needles are directed to the sciatic spine through the lower edge of the obstructive tverstiya). After each holding of the needle, a corresponding connector is attached to it with the sleeve of the implant, and each sleeve of the implant is drawn with the needle in the opposite direction through the corresponding incisions from the inside out. The implant is placed under the neck of the bladder freely, without tension, covering it with previously fixed ligaments (the transobturator technique of the implant using the Perigee system is described on the website: www.ams-russia.ru). The front edge of the implant (which is the upper position in the patient’s lithotomy position) is sutured to the middle part of the urethra by suturing between the implant and paraurethral tissues in the region of the lateral urethra, and the posterior edge of the implant (which is the lower position in the patient’s lithotomy position) is fixed to the back (in the lithotomy the patient's position of the lower) part of the cystocele and cervix. The excess implant is cut off. The implant should be placed exactly on the vaginal tissues, without the formation of duplicates (prevention of erosion, extrusion).

Then, a triangular flap is excised from the posterior vaginal wall and sutured sacro-uterine ligaments, a continuous suture is applied to the incision of the vaginal wall. The posterior wall of the vagina is separated from the rectum as much as possible, the rectal-vaginal fascia is sutured with separate sutures with the creation of duplicature from the vaginal wall, and levatoroplasty is performed.

To prove the possibility of realizing the specified purpose and achieving the above technical result, we present the following data.

Patient S., 63 years old, was admitted to the gynecological department of MSC No. 33 with a diagnosis of complete loss of the uterus and vaginal walls, pelvic floor muscle failure, stress urinary incontinence. Concomitant diseases: hypertension 2 degrees, 2 stages, medium risk. Obesity 2 degrees.

The patient complained of urinary incontinence during coughing, a change in body position, physical activity, a sensation of a foreign body in the external genital area, and a feeling of discomfort when walking.

Anamnesis: Postmenopause for 16 years. For 9 years, the gynecologist was not observed. For 4 years, urinary incontinence during coughing, a change in body position, physical activity, and intermittent difficulty in urinating were worried. The last 5 months have noted a feeling of discomfort when walking.

During a gynecological examination, sagging of the anterior wall of the vagina beyond the genital gap was noted. Valsalva's test is positive. A comprehensive urodynamic study (KUDI) revealed stress urinary incontinence. Ultrasound of the bladder, kidney pathology was not detected.

The treatment according to the proposed method.

An anterior vaginal wall was dissected, and a blunt and sharp path of the vaginal wall from the bladder was separated. Separation of the bladder from the cervix in the upward direction with dissection of the prebubble tissue. The cervix is pulled upward to the fold, an incision is made in the posterior wall to the place where the sacro-uterine ligaments leave the uterus. After exfoliation of the vaginal wall, uterine vessels and cardinal ligaments are exposed. The uterus is removed into the opening of the wound. Clips are sequentially placed along the uterine ribs, starting with the cardinal ligaments, then clamps along the uterine body on each side. The uterus is cut off. Tissues taken in clamps (ligaments, vessels, uterine ends of the tubes) are sheathed. The bladder is fixed with interrupted sutures. Shortened and fixed round ligaments to the vaginal fornixes, shortened cardinal ligaments and their fixation to the middle part of the vagina. The Perigee synthetic implant was installed as follows: through minimal incisions at 4 points (two upper ones at the clitoris level, laterally to the edge of the sciatic-pubic branch of the pelvic bone, two lower ones 3 cm lower and 2 cm lateral than the upper), conductor needles were inserted from the outside through the obturator openings under the neck of the bladder (the handles of the upper needles are located at an angle of 45 ° to the midline of the patient and are drawn through the upper edge of the obturator hole, the ends of the lower needles are directed to the sciatic spine through the lower edge obturator foramen). After each passing of the needle, a corresponding connector with an implant sleeve is attached to it and each implant sleeve is withdrawn by the needle in the opposite direction through the corresponding incisions from the inside out. The implant is located under the neck of the bladder freely, without tension, covering itself with previously fixed ligaments. Then, the front edge of the implant (which is the upper position in the patient’s lithotomy position) was sutured to the middle part of the urethra by suturing the implant and paraurethral tissues in the region of the lateral urethra, and the posterior edge of the implant (lower) is fixed to the posterior (lower) part of the cystocele. Excess implant is cut off.

Then, a triangular flap was excised from the posterior vaginal wall and sutured sacro-uterine ligaments, a continuous suture was applied to the incision of the vaginal wall. The posterior wall of the vagina from the rectum is maximally separated, the rectal-vaginal fascia is sutured with separate vicryl sutures with the creation of duplicature from the vaginal wall, levatoroplasty.

As a result of the treatment, complete retention of urine was noted, the quality of life improved. On examination: there was no sagging of the anterior wall of the vagina and urethra during the Valsalva test; the absence of stress urinary incontinence is confirmed by CUD. During follow-up for 24 months, recurrence of prolapse and dysfunction of the lower urinary tract were not observed.

Patient K., 48 years old, was admitted to the gynecological department of City Clinical Hospital No. 33 with a diagnosis of incomplete prolapse of the uterus and vaginal walls, pelvic floor muscle failure, stress urinary incontinence. Concomitant diseases: PMK MP1, VVD according to the mixed type, varicose veins of the lower extremities.

Complained of urinary incontinence during physical exertion, frequent urination, sensation of a foreign body in the external genital area, discomfort when walking.

Anamnesis: PM a year ago. Childbirth - 2, complicated by ruptures of the walls of the vagina, perineum. After the first birth, prolapse of the walls of the vagina. Over the past 3 years, complaints about the sensation of a foreign body in the perineum, the last six months marks rapid urination, urinary incontinence during physical exertion. With a general clinical and laboratory examination, laboratory indicators are within normal limits. The treatment according to the proposed method. As a result of the treatment, complete retention of urine was noted, the quality of life improved. On examination: there was no sagging of the anterior wall of the vagina and urethra during the Valsalva test; the absence of stress urinary incontinence is confirmed by CUD. During follow-up for 24 months, recurrence of prolapse and dysfunction of the lower urinary tract were not observed.

Thus, according to the claimed method was operated on 11 women in perimenopause and 9 women in postmenopause with a diagnosis of genital prolapse complicated by stress urinary incontinence. Not a single recurrence of prolapse was observed when observed within 24 months.

Claims (1)

A method for surgical treatment of genital prolapse complicated by stress urinary incontinence, including vaginal extirpation of the uterus, shortening of the uterine round ligaments, their fixation to the vaginal arches and suturing under the urethra in the form of a sling, shortening of cardinal ligaments and their fixation to the middle part of the vagina, excision of the posterior flap the walls of the vagina and stitching of the sacro-uterine ligaments with each other, characterized in that they additionally transobturally install a polypropylene implant using a system s Peridzhi beneath the bladder neck so that the front edge of the implant was located at the middle of the urethra to form a sling, and then fix the front edge of the implant to the average urethral by suturing between the implant and the tissue in paraurethral side urethra.