RU2262314C1 - Method for surgical reconstruction of vesicovaginal septum at prolapse of anterior vaginal wall and cystocele - Google Patents

Abstract

FIELD: medicine, urogynecology.

SUBSTANCE: one should suture urethrovesical segment and bladder's bottom, suture vesicovaginal fascia, apply purse-string suture onto overstretched posterior wall and bladder's bottom to provide simultaneous shift of bladder's bottom into area of urovesical sphincter, apply and fix netting out of titanium nickelide between restored posterior urethral wall, bladder and vesicovaginal fascia modeled according to the site of application within the borders against separated urethral segment up to uterine cervix by capturing lateral walls of urethra, bladder and maintaining muscular-fascial formations up to internal surface of pubic bone arches. The suggested innovation enables to restore normal anatomotopographic position of uterine cervix and bladder's bottom and prevent the relapse of prolapse of anterior vaginal wall and cystocele.

EFFECT: higher efficiency of surgical reconstruction.

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Description

The invention relates to medicine, namely to urogynecology.

The problem of prolapse and prolapse of the vagina and uterus remains relevant for many years. According to most authors, the results of surgical treatment of genital prolapse are far from satisfactory. Despite the variety of proposed methods of surgical treatment, relapses persist, which is associated with the failure of the restored muscles of the pelvic floor and with the imperfection of the surgical treatment [Surgical gynecology / Ed. V.I. Kulakova. - N. Novgorod: Publishing House NMGA, 1999. - S.285].

The prolapse and prolapse of the internal genital organs in women is almost always accompanied by bladder dysfunction. The most common urinary incontinence with stress. The main task of urogynecology at the present time around the world is the diagnosis and treatment of various forms of urinary incontinence [Krasnopolsky V.I., Buyanova S.N., Petrova D.Yu., Balashov V.I. Diagnosis of types of urinary incontinence in women with genital prolapse // Vestn. Ross Assoc. Akush. - gin. - 1999. - No. 3. - S.53; Pushkar D.Yu. Diagnosis and treatment of complex forms of urinary incontinence in women // Akush. and gin. - 2000. - No. 1. - C.3].

The main reason for the prolapse and prolapse of the anterior vaginal wall, the formation of cystocele and urinary incontinence with tension in women is a birth injury. Damage (tears) of the vesicovaginal fascia, muscle and connective tissue elements connecting the fascia with the bladder and the anterior wall of the vagina occurs. Bubble-vaginal fascia loses its anatomical and topographic and functional perfection, laid down by nature and ceases to play the role of a functional support for the urethra and bladder. Under the action of intra-abdominal and intravesical pressure, the cystic-vaginal fascia overstretches along the midline, which leads to the prolapse and prolapse of the anterior vaginal wall and posterior wall of the bladder with the formation of cystocele. As a result of prolonged “wearing” of a hernia in the vesicovaginal septum, significant muscle diastases, atrophy and rigidity of the latter occur. The fascial frame is overstretched, thinned, loses strength and the ability to secure adhesion after surgical reconstruction.

The omission of the anterior wall of the vagina and the posterior wall of the bladder in combination with cystocele is an indication for surgical treatment.

The most common method of surgical treatment of prolapse and prolapse of the anterior vaginal wall and cystocele is anterior colporography. During this operation, defects in the muscles and fascia of the vesicourethral region are restored.

A known variant of anterior colporography is known as colpovesicorraphia cum duplicatione fasciae praevesicalis. A longitudinal midline incision is made on the front wall of the vagina, starting 0.5-1 cm below the external opening of the urethra and ending without reaching 1 cm to the front lip of the cervix. After this, the vaginal mucosa is separated with a scalpel to the right and left of the urethral canal and the bottom of the bladder until they are completely released. The fascia is dissected by a longitudinal midline section and both halves of the fascia are sharply separated from the bladder in the direction of the descending arch of the bosom and the walls of the pelvis. A series of knotted sutures in the transverse direction is directly arched in the transverse direction directly on the muscles of the urethra and the region of the Lietot triangle. Next, the fascia is sutured as a closed floor of a double-breasted frock coat. The free edge of the left flap is sewn with a continuous catgut seam to the inner surface of the right flap, then the free edge of the right fascia flap is sewn with a continuous catgut seam to the outer surface of the left flap. A continuous catgut suture is applied to the vaginal mucosa.

The length of the fascia flap is on average 5 cm, width 4-5 cm; as a result of stitching both flaps together, an adhesion area of 20-25 cm ² is obtained. The process of planar fusion is ensured by the presence of constant intra-abdominal and intravesical pressure directed towards the urogenital diaphragm. The strength of the wall is thus guaranteed by a doubled cross-sectional area [A.M. Mazhbits. Operative urogynecology. - M: M, 1964. - S.56-60].

The disadvantages of this method are:

- a high relapse rate, which within 3 years after surgery reaches 33%;

- cannot be used in those women in whom the vesicovaginal fascia is sharply thinned, stretched, atrophic, and it is technically not possible to separate it from the bladder wall either in an acute or blunt way.

The main causes of disease recurrence after surgical reconstruction of the vesico-vaginal septum by restoring damaged tissues are:

- trophic processes in the tissues adjacent to the bladder, muscles, fascia, the anterior wall of the vagina remain unchanged;

- the hormonal background before and after the operation remains the same;

- intra-abdominal and intravesical pressure before and after surgery practically does not change and is often elevated;

- non-compliance by patients with recommendations for the prevention of recurrence of the disease (light labor, therapeutic exercises, wearing a bandage, physiotherapy, etc.).

Object of the invention: restoration of the normal anatomotopographic position of the neck and bottom of the bladder, prevention of recurrence of prolapse of the anterior vaginal wall and cystocele after surgical correction of prolapse of the anterior vaginal wall and bladder.

The problem is achieved by the surgical reconstruction of the vesicovaginal septum with the prolapse and prolapse of the anterior vaginal wall and cystocele. The proposed method includes suturing the urethrovesical segment and the bottom of the bladder, suturing the vesicovaginal fascia. Elimination of the cystocele, strengthening of the levelical segment is performed with a purse string suture on the overstretched posterior wall and the bottom of the bladder, which ensures simultaneous movement of the bottom of the bladder in the level of the levelical sphincter. Then, the separated part of the urethra and bladder is reinforced with a mesh of superelastic titanium nickelide filament. The mesh is installed between the reconstructed posterior wall of the urethra and bladder and the vesico-vaginal fascia, and is modeled at the site of installation from the separated part of the urethra to the cervix. It is fixed by separate seams. It covers the lateral walls of the urethra, bladder and supporting muscular-fascial formations to the inner surface of the arches of the pubic bone.

The novelty of the method: for the first time after suturing by a purse-string suture of the overstressed posterior wall and the bottom of the bladder with simultaneous movement of the bottom of the bladder into the region of the levelical sphincter, between the formed posterior wall of the urethra and bladder and the vesicovaginal fascia are installed, modeled at the installation site and the mesh is fixed from the thread titanium nickelide in the range from the separated part of the urethra to the cervix with girth of the lateral walls of the urethra, bladder and supporting muscular-fascial formations to the inside her pubic bone surface arcs.

Moreover, the totality of the features of the invention allows to obtain the following effects:

- the mesh made of superelastic titanium nickelide filament is able to repeat the shape of any surface without preliminary deformation, which allows fixing not only the restored posterior walls of the urethra and bladder, but also the lateral walls of the urethra and bladder, and the tissues supporting them to the internal arc of the pubic bone, which is significantly increases the area of the strengthened vesicovaginal septum in its weakest section;

- the mesh made of a superelastic titanium nickelide filament has a superelastic effect and, when the bladder is filled with urine under the influence of increasing intravesical pressure and during its subsequent emptying, participates in all deformation processes of the tissues surrounding it, since it is able to repeatedly return to its original state, providing plasticity and reliable strength of the formed vesicovaginal septum;

- the use of a mesh of ultrafine filament of titanium nickelide in the reconstruction of the vesicovaginal septum eliminates injury to surrounding tissues during their fusion;

- the use of an implant in the form of a mesh of titanium nickelide filament allows reconstruction of the vesicovaginal septum when it is impossible to suture the vesicovaginal fascia as a double-breasted coat.

Titanium nickelide is referred to as biomechanical materials. It meets the following requirements: high corrosion resistance; slight elution of the alloy ingredients; electrochemical stability; lack of biological problems (toxicity, carcinogenicity, discomfort); affinity for body tissues; the presence of high mechanical properties (hardness, elasticity, low fatigue, abrasion); elasticity similar to the elasticity of living tissues. [Zotov V.A. Treatment of patients with complex ventral hernias using titanium nickelide // Implants with shape memory. - Tomsk, 2000. - No. 1-2. - S.111.].

It has been experimentally established that titanium nickelide products are easily disinfected and sterilized, do not have toxicity, do not have a carcinogenic effect, are biologically compatible with the tissues of the human body [Gunter V.E., Dambaev G.Ts. Ts., Sysolyatin P.G., Ziganypin R. IN. et al. Medical materials and shape memory implants. - Tomsk: Publishing house of Tomsk University, 1998. - S.168-193].

A mesh of titanium nickelide was used as an implant. Mesh dimensions: width 4-5 cm, length 6-7 cm. Thread with a diameter of 0.1 mm. The mesh size is 3-5 mm. The mesh of titanium nickelide filament (brand TN-10) does not absorb, does not interfere with the growth of adjacent tissues of the urethra, bladder and the surrounding muscle-fascial elements with vesicovaginal fascia. Fused with surrounding tissues, the mesh ensures the stability of surrounding tissues to excessive deformation. It takes on the main function of the cystic-vaginal fascia, to provide functional support for the urethra and bladder and the resistance of the cystic-vaginal septum to the effects of intravesical and intraperitoneal pressures.

Thus, the reconstruction of the vesico-vaginal septum with the reinforcement of the restored posterior wall of the urethra and bladder with a mesh of titanium nickelide in the treatment of prolapse of the anterior vaginal wall and cystocele in women is theoretically and experimentally substantiated.

The invention is illustrated in figures 1, 2, 3, 4.

Figure 1 shows the grid 3.

Figure 2 shows a diagram of the sutures that eliminate the cystocele (1 - sutures on the urethra, 2 - purse string suture on the separated back wall and the bottom of the bladder).

Figure 3 shows the grid fixation scheme (3 - a grid of superelastic titanium nickelide filaments, 4 - seams that fix the grid to the back wall of the bladder).

Figure 4 shows the general scheme of the operation (1 - sutures on the urethra, 3 - mesh, 5 - the bladder, 6 - urethra, 7 - sutures on the cystic-vaginal fascia, 8 - suture on the anterior wall of the vagina, 9 - cervix) .

The method is as follows:

A longitudinal midline incision is made on the front wall of the vagina, starting 0.5-1 cm below the external opening of the urethra and ending without reaching 1 cm to the front lip of the cervix. After this, the vaginal mucosa is separated with a scalpel to the right and left of the urethral canal and the bottom of the bladder until they are completely released. The fascia is dissected by a longitudinal midline section and both halves of the fascia are sharply separated from the bladder in the direction of the descending arch of the bosom and the walls of the pelvis. After separation of the urethrovesical wall and the posterior wall of the bladder, the bottom of the bladder is separated from the cervix 9 for 2-3 cm. A series of knotted sutures 1 are arched in the transverse direction directly to the muscles of the urethra. A purse string suture 2, covering the overstretched posterior wall and the bottom of the bladder separated from the cervix, eliminates the cystocele and the bottom of the bladder moves to the level of the levelical sphincter (Figure 2). Then, to the reconstructed posterior wall of the urethra and bladder within the boundaries from the separated part of the urethra to the cervix, by separate sutures 4, a mesh 3 of a superelastic titanium nickelide thread (thread thickness 0.1 mm) along its width (4-5 cm) in the middle of the length ( 6-7 cm) (Figure 3). The lateral walls of the urethra and bladder, the tissues supporting them, are covered by a mesh along their length, and are fixed to them by separate sutures 4 to the inner edge of the arch of the pubic bone. Next, the fascia is sutured as a closed floor of a double-breasted frock coat. The free edge of the left flap is sewn with a continuous cattut suture to the inner surface of the right flap, then the free edge of the right fascia flap is sewn with a continuous catgut suture 7 to the outer surface of the left flap. With a thinned, overstretched and atrophic fascia, when it is impossible to double-breasted suturing of the fascia, it is sutured by matching the edges with a continuous seam. A continuous catgut suture is applied to the vaginal mucosa 8. A general arrangement of the mesh of a superelastic titanium nickelide filament and the result of the operation are presented in FIG. 4.

Clinical example 1:

Patient N., 56 years old, was admitted to the department of planned operative gynecology on 01/17/01 with a diagnosis of Poor pelvic floor muscles of the III degree, cysto and rectocele, urinary incontinence with tension.

On January 24, 01, an operation was performed under epidural anesthesia: anterior colporography, reconstruction of the vesicovaginal septum with reinforcement of the urethra and bladder with a mesh of ultrafine filament of titanium nickelide, posterior colporography with levator plastic.

A longitudinal midline incision was made on the front wall of the vagina, starting 0.5 cm below the external opening of the urethra and ending without reaching 1 cm to the front lip of the cervix. After this, the vaginal mucosa is separated with a scalpel to the right and left of the urethral canal and the bottom of the bladder. The fascia was dissected by a longitudinal midline section and both halves of the fascia were sharply separated from the bladder in the direction of the descending arch of the bosom and the walls of the pelvis. After separation of the urethro-vesical wall and the posterior wall of the bladder, the bottom of the bladder is separated from the cervix for 3 cm. 3 knotted sutures are laid in an arcuate direction in the transverse direction directly on the muscles of the urethra. A purse string suture covering the overstretched posterior wall and the bottom of the bladder separated from the cervix, cystocele was removed and the bottom of the bladder was moved to the level of the levelical sphincter. To the reconstructed posterior wall of the urethra and bladder within the boundaries from the separated part of the urethra to the cervix, the place of installation was modeled at the place of installation and the seams of titanium nickel filament were fixed with separate seams along its width (4 cm) in the middle of the length (6 cm). Further, the mesh is fixed by separate sutures to the side walls of the urethra and bladder, supporting their tissues to the inner surface of the arches of the pubic bone. Then, the fascia was sutured as a closed floor of a double-breasted frock coat. The free edge of the left flap is sewn with a continuous catgut seam to the inner surface of the right flap, then the free edge of the right fascia flap is sewn with a continuous catgut seam to the outer surface of the left flap. A continuous catgut suture is applied to the vaginal mucosa. The operation is completed with posterior colporography with levatoroplasty.

In the postoperative period, analgesics, antibiotics, and physiotherapy were prescribed. Self urination from 4 days, stool for 6 days. The postoperative period was uneventful, healing of sutures by primary intention. Discharged home 02/12/01

Examined in dynamics: after 3, 6, 12, 18 and 24 months. There were no signs of recurrence of genital prolapse, the implant did not manifest itself negatively. The woman did not present urogynecological complaints. According to ultrasound data and survey radiographs of the pelvis around the tissue implant of a conventional echostructure. There is no discomfort in the vagina, perineum and during sexual activity.

Clinical example 2.

Patient M., 48 years old, was admitted to the department of planned operative gynecology on March 12, 01, with a diagnosis of Poor pelvic floor muscles of the III degree, incomplete prolapse of the uterus, cysto and rectocele. Bladder dysfunction.

03/20/01, an operation was performed under epidural anesthesia: anterior colporography, reconstruction of the cystic-vaginal septum with reinforcement of the urethra and bladder with a mesh of ultrafine titanium nickelide filament, posterior colporography with levoroplasty.

A longitudinal midline incision was made on the front wall of the vagina, starting 0.7 cm below the external opening of the urethra and ending not reaching 1 cm from the front lip of the cervix. After this, the vaginal mucosa is separated with a scalpel to the right and left of the urethral canal and the bottom of the bladder. The fascia is dissected by a longitudinal midline section and both halves of the fascia are sharply separated from the bladder in the direction of the descending arch of the bosom and the walls of the pelvis. After separation of the urethro-vesical wall and the posterior wall of the bladder, the bottom of the bladder is separated from the cervix for 3 cm. 3 knotted sutures are laid in an arcuate direction in the transverse direction directly on the muscles surrounding the urethra. A purse string suture covering the overstretched posterior wall and the bottom of the bladder separated from the cervix, cystocele was removed and the bottom of the bladder was moved to the level of the levelical sphincter. To the reconstructed posterior wall of the urethra and bladder within the boundaries from the separated part of the urethra to the cervix, a mesh of titanium nickelide filament is fixed with separate sutures along its width (4 cm) in the middle of the length (6 cm). Further, the mesh is fixed by separate sutures to the side walls of the urethra and bladder, supporting their tissues to the inner surface of the arches of the pubic bone. Due to the pronounced thinning of the cystic-vaginal fascia and the inability to allocate sufficient flaps to suture them as a closed floor of a double-breasted frock coat, the fascia was sutured by matching its edges with a continuous kettut suture. A continuous catgut suture is applied to the vaginal mucosa. The operation is completed with posterior colporography with isolated levatoroplasty.

In the postoperative period, analgesics, antibiotics, and physiotherapy were prescribed. Self urination from the 5th day, stool on the 6th day. The postoperative period was uneventful, healing of sutures by primary intention. Discharged home 04.04.01.

Examined in dynamics: after 3, 6, 12, 18 and 24 months. There were no signs of recurrence of genital prolapse, the implant does not manifest itself negatively. The woman did not present urogynecological complaints. According to ultrasound data and survey radiographs of the pelvis around the tissue implant of a conventional echostructure. There is no discomfort in the vagina and perineum. Sex life does not live.

Thus, 5 patients aged 39-65 years were operated on with pelvic floor muscle insufficiency III tbsp. in combination with cystocele and bladder dysfunction. All operated on control examinations had no signs of recurrence of prolapse of the anterior vaginal wall and cystocele. The implant did not manifest itself negatively, was well visualized on echo and radiographs.

Using this method gives the following effect:

1. A strong support is created for the levelical section of the bladder, which protects it from damage (repeated tears and overstretching) under conditions of increased intra-abdominal and intravesical pressure.

2. The size and shape of the implant used, its ability not to interfere with the accretion of adjacent tissues, make it possible to recreate the lost function of the cystic-vaginal septum to be a support for the urethra and bladder and reliably eliminate prolapse of the anterior vaginal wall and cystocele.

3. Increases the effectiveness of anterior colporography, which allows you to abandon its more complex and traumatic options while eliminating the prolapse and prolapse of the anterior vaginal wall and cystocele.

4. Allows you to abandon additional methods of fixing the bladder and the front wall of the vagina.

Claims (1)

A method of surgical reconstruction of the vesicovaginal septum with prolapse and prolapse of the anterior vaginal wall and cystocele, including suturing of the urethrovesical segment and the bottom of the bladder and suturing of the vesicovaginal fascia and the anterior vaginal wall, characterized in that the overgrowth of the overgrown bladder and the purse string suture are sutured with the simultaneous movement of the bottom of the bladder in the level of the levelical sphincter and between the formed posterior wall of the urethra and bladder and vesicovaginal fa A mesh of titanium nickelide filament is installed and fixed by the section, simulating it at the installation site in the boundaries from the separated part of the urethra to the cervix with grasping the lateral walls of the urethra, bladder and supporting muscular-fascial formations to the inner surface of the arches of the bone.

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