RU2135099C1 - Method for performing plastic repair of vesicovaginal fistula - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making circular incision in the area adjacent to urinary bladder at the transvesicular stage some distance apart from fistula border. Ligatures are made around the fistula aperture. The ligatures are attached to catheter. The ligatures are brought through fistula canal towards the vagina. Danotti suture is put in on the renewed fistula borders facing the urinary bladder. The turned-inside-out fistula canal tissues are exsected at the vaginal stage. Danotti suture is put in on the vaginal wall. EFFECT: improved tightness of sutures; retained blood supply in the area under operation. 3 dwg

Description

 The invention relates to medicine, namely to urology.

 According to published data, at present, 0.5-0.6% of obstetric and gynecological interventions is complicated by the formation of genitourinary fistulas (A.F. Vozianov, A.V. Lyulko, P.S. Sernyak, Bubble and urethrogenital fistulas in women. 1991). 44.6% of the genitourinary fistulas are bladder-vaginal fistulas (D.V. Kan Guide to Obstetric and Gynecological Urology. M: Medicine, 1986).

 In 97% of cases, cystic-vaginal fistulas arise due to injuries during childbirth, obstetric and gynecological operations. In 85% of patients, cystic-vaginal fistulas occur after gynecological operations, 11% after childbirth, 4% after irradiation (A.F. Vozianov, A.V. Lyulko, P.S. Sernyak. Bubble-and urethrogenital fistulas in women. Kiev, Health, 1991).

 Only in 8-10% of cases is conservative treatment effective (D.V. Kan, Guide to Obstetric and Gynecological Urology. M .: Medicine, 1986). And, despite even numerous surgical interventions, some women cannot be cured. These patients make up 8-10% (A.F. Vozianov, A.V. Lyulko, P.S. Sernyak Bubble and urethrogenic fistulas in women. Kiev, Health, 1991).

 The greatest difficulty is the fistula located in the area of the mouth of the ureter. In this case, the operational allowance is carried out mainly by transvascular access. There are numerous methods of operations performed by transvescular access. Closest to our proposed solution is the following operation (D.V. Kan Guide to obstetric and gynecological urology. M .: Medicine, 1986). By the lower middle section between the navel and the pubic symphysis, the peribial space is exposed. The front wall of the bladder is isolated. Two provisional ligatures are placed on it and between them open the bladder for 4 - 5 cm. Revision of the bladder. If the fistula borders directly on the mouths of the ureters, then they are catheterized and plastic surgery is carried out under the control of catheters.

 Retreating 1.0 - 1.5 cm from the edges of the fistula, separate the wall of the bladder from the vagina, keeping at a safe distance from the mouths of the ureters.

 After achieving sufficient mobility of the edges of the wound and the ability to bring them closer without tension, separately, with the same care, the defects in the vagina and bladder are sutured. The wound of the vagina is sutured with single kapron or dacron threads, which are applied to its edges, and, after tightening them, form a “comb” facing the vaginal lumen. Then on the wound surface of the bladder impose matrix sutures with atraumatic needles with chrome catgut. The distance between the seams is 0.7 - 1.0 cm.

 The operation is completed with an epicystostomy or the bladder is sutured tightly, in this embodiment, the bladder is drained with a urethral catheter for 8 to 10 days.

The disadvantages of this method are the following:
1) Suturing of the wound of the vagina is done with kapron or dacron threads, and a “crest” should form, which should look into the vagina, but this is not always technically feasible. Turning into the cavity of the bladder, the sutures come in contact with urine, as a result of which they often become infected, which in the future can lead to divergence of the edges of the wound.

 2) Due to the fact that the seams on the bladder and vagina are located in a limited area (almost on the same surface), the blood supply to the tissues of this area is sharply worsened.

 3) During this operation, the part of the fistula facing the vagina remains unclosed, since the cystic-vaginal fistula does not always have a direct course.

 Given the above disadvantages, we have proposed plastic cystic-vaginal fistula in a combined way.

 The aim of the invention is to improve the results of surgical treatment of women with urogenital fistulas located near the mouths of the ureters, by improving the tightness of the joints and maintaining good blood supply to the tissues of the operated area.

 The method is as follows.

 The position of the patient on the operating table: lying on his back with legs apart, laid on the knees, which are lowered to the level of the table surface. The legs are fixed. The head end of the table is somewhat lowered.

 First step. Transvesical. A lower midline incision is made. The skin, subcutaneous tissue, and aponeurosis are dissected in layers. The muscles are bluntly getting divorced, the transverse fascia is dissected. Prevesical tissue with transverse fascia stupidly exfoliates upward. The bladder is taken on the holders, between which it opens. A revision of the bladder is performed (Fig. 1a). If the fistulous opening is located in close proximity to the mouths of the ureters, then they are catheterized. The circular section is slightly departing from the edges of the fistula (Fig. 1b). Around the fistulous opening are ligatures (Fig. 1c), which are fixed to the catheter (Fig. 2a), with which through the fistulous passage are displayed towards the vagina (Fig. 2b). On the updated edges of the fistulous passage from the side of the bladder, a Danotti suture is absorbed by absorbable sutures (Figs. 2c, 3a). The bladder is drained, sutured. Layer wound closure.

 Second phase. Extravaginal. Cicatricial tissue of the fistulous course, together with the ligatures, turn out towards the vagina (Fig. 2b). Scar tissue is excised from the vagina. A seam is Danotti (Fig. 3b).

 Example. Patient G. Kleshkova, 48 years old, medical history N 7884, was in the urology department of the Republican Clinical Hospital of the Ministry of Health of the RT from 04/09/97 to 05/26/97 with a diagnosis of recurrent vesicovaginal fistula. Bladder stone. Chronic secondary cystitis.

 The patient has a history of six fistuloplasty attempts, including one in the conditions of our clinic.

 04/21/97, cystoscopy was performed. On examination, the mucous membrane of the bladder is hyperemic, swollen, with the absence of a vascular pattern in the triangle. The mouths of the point shape, slightly bulge, behind the proposed transitional fold is determined by the rounded shape of the fistulous passage with a diameter of about 10 mm. In the bladder cavity, white calculus with a diameter of 30 mm. Conclusion: vesicovaginal fistula. Bladder stone. Secondary chronic cystitis in the acute stage.

 04/22/97 cystolithotripsy. Under intravenous potentiation, a cystoscope tube was held. The cystoscopic picture is the same (see 21.04.97). Cystolithotripsy was performed by mechanical crushing to small fragments. The latter are washed out of the bladder.

 05/05/97, Operation: plastic cystic-vaginal fistula in a combined way.

 Operation protocol.

 The position of the patient on the operating table: lying on his back with legs apart, laid on the knees, which are lowered to the level of the table surface. The legs are fixed. The head end of the table is somewhat lowered.

 Anesthesia: general intubation.

 First step. Transvesical. A lower midline incision was made with a layered dissection of the skin, subcutaneous tissue, and aponeurosis. The muscles are bluntly diluted, the transverse fascia is dissected. The prevesical tissue with the transverse fascia is bluntly peeled up. The bladder is taken on the holders, between which it is opened. The revision of the bladder. Immediately after the transitional fold, at a distance of about 8 - 9 mm from the mouth of the left ureter, a fistulous opening with a diameter of about 10 mm was found. Catheterization of both ureters was performed. Retreating 5 - 7 mm from the edges of the fistula, a circular incision was made. Around the fistulous opening, ligatures are placed, which are fixed to the catheter and with the help of the latter are removed through the fistulous passage towards the vagina. On the updated edges of the fistulous passage from the bladder, a Danotti suture is absorbed by absorbable sutures. Ureteric catheters brought out. The bladder is drained, sutured. The wound is sutured in layers.

 Second phase. Extravaginal. Cicatricial tissue of the fistulous course along with ligatures turned inside the vagina. Scar tissue is excised from the vagina. The stitch is Danotti.

Claims (1)

 A method for plasty of a vesicovaginal fistula located close to the mouths of the ureters by suturing the wall of the bladder and vagina, characterized in that at the first transvesical stage, a circular incision is made from the bladder side, slightly deviating from the edges of the fistula, and ligatures are applied around the fistulous opening , after which the ligatures are fixed to the catheter and removed with its help through the fistulous passage towards the vagina, then a Danotti suture is applied to the updated edges of the fistulous passage from the bladder, per w rum stage vaginal scar tissue fistula, twisted to the side of the vagina was excised, and the vaginal wall sutured Danotti.

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