RU2499569C2 - Method of surgical treatment of posterior vagina wall prolapse in women, living sexual life - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: substance: invention relates to operative gynecology and can be applied in treatment of women, living sexual life with posterior vagina wall prolapse. For this purpose reconstruction of posterior part of pelvis floor is realised. For this purpose two diametrical cuts of posterior vagina wall mucous membrane are preliminarily performed: on in the area of posterior commissure and second with 3-4 cm indent from external orifice of uterus cervix. Tunnel is formed by separation of tissues between rectovaginal septum and anterior wall of rectum with preparation scissors. Placement of mesh implant is realised through formed tunnel, with two proximal branches being passed through medial parts of sacrospinal ligaments and brought out on skin of perineum more laterally and lower than anus by means of guides. Two distal branches of implant are passed from two sides through muscle, lifting anus, and is brought on skin of perineum more laterally than posterior commissure by means of guide. After smoothing net implant in formed tunnel on surface of rectum, free ends of implant are fixed to posterior labia of uterus cervix in projection of internal orifice by non-absorbable sutures, without puncturing uterus cervix mucosa, and to tendious center of perineum in the area of posterior commissure of perineum; excess of free ends of branches is cut off subcutaneously and submerged into tissues; vaginal wall is sutured with uninterrupted absorbable suture, skin cuts in the area of perineum are sutured with interrupted sutures.

EFFECT: method makes it possible to ensure effective treatment of patient living sexual life with prolapse of posterior vagina wall by creation of neo-fascia instead of destroyed one, which is ensured due to definite method of placement and fixation of mesh implant in formed sub-mucous membrane tunnel, which contributes to reduction of dyspareunia, associated with scar in vagina, as well as due to application of mesh implant made lighter as a result of definite structure.

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Description

The invention relates to gynecology, in particular to operative gynecology.

In Russia, prolapse of the pelvic organs to one degree or another occurs in every 10th woman, and in the group of the late reproductive age - in every 3rd.

Today, there are more than a hundred methods for the surgical treatment of pelvic organ prolapse. These are various methods of vaginal, transabdominal, laparoscopic and robotic surgery, which are successfully performed in our country. However, any surgical treatment for prolapse is associated with a high relapse rate.

Many surgical methods for treating pelvic organ prolapse did not live up to expectations, accompanied, despite its diversity, by a high risk of relapse - from 33 to 58% (12).

The prerequisite for the development of prolapse and an increase in the number of relapses are often undifferentiated forms of connective tissue dysplasia, in which the use of methods using their own, obviously insolvent tissues is doomed to failure, which justifies the wider use of implants. Of the proposed biological and synthetic prostheses, synthetic materials are currently preferred due to fewer complications and higher efficiency (7, 11). There are more than a dozen methods for surgical reconstruction of the pelvic floor using synthetic prostheses.

The modern concept of surgical treatment of genital prolapse should consist of "replacing" the old destroyed pelvic fascia with a new one, with its fixation to the anatomically strong structures of the small pelvis.

The concept of “replacement” surgery is advanced and is reflected in the introduction of new techniques. The transvaginal technology of conducting a synthetic free implant without tension (tension free vaginal mesh) using conductors quickly meets this goal.

According to a systematic review and meta-analysis of randomized trials with the use of mesh technologies in the surgical treatment of genital prolapse, an increase in efficiency of up to 75% -92% was noted (9). Relapses using synthetic materials in the reconstruction of the pelvic floor vary from 5.2 to 8.3% (2). The difference with the results without the use of synthetic materials is obvious.

However, today there is still no consensus on the use of mesh implants in pelvic surgery. Opponents of the use of implants are based on a small number of randomized trials and an increase in the frequency of complications associated with foreign material: erosion, dyspareunia, infectious complications, wrinkling of the mesh (6).

Controversial and debatable aspects of the use of mesh materials are specific complications associated with the presence of foreign material.

According to the results of various researchers, the frequency of erosion during colporography with the installation of synthetic materials can reach 15-30% (13). However, the likelihood of this complication is sharply reduced to 0.5-5% (5), subject to recommendations for the use of type I nets based on the classification of P.K. Amid (1997).

The requirements for an “ideal implant” are also complemented by high elasticity, strength, low wick ability, biological compatibility, versatility and accessibility of the application technique, and economic feasibility.

We are supporters of the use of mesh-technologies in young women, as one of the most significant causes of genital prolapse and their relapses, researchers consider signs of “weakness” of connective tissue detected more often in “young” women (3). This fact is a good reason for the use in women with poor connective tissue, according to the general principles of herniology, additional strengthening materials that can initiate the body's reaction in the form of fibrosis and the formation of dense connective tissue (8).

An important aspect is the assessment of sexual function before and after surgical treatment. The frequency of de novo dyspareunia when installing synthetic non-absorbable materials ranged from 2.3 to 16.7% (de Tayrac R., Deffieux X., Gervaise A. et al. Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse // J Reprod Med 2005. - Vol. 50. - P.75-80). But at the same time, when researching JN. Nguyen et al. (2008) it turned out that de novo dyspareunia was observed more often with colporography without the use of a mesh prosthesis - in 16% versus 9% of dyspareunia when using synthetic material. The author connects the presence of dyspareunia with the formation of a scar on the vaginal wall. (Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized controlled trial // Obstet Gynecol. - 2008. - Vol.111. - N4. - P.891-8).

The prototype of the method we developed for the surgical treatment of pelvic organ prolapse using synthetic material was the transvaginal synthetic implant without tension using conductors (Transvaginal Mesh Procedures for Pelvic Organ Prolapse, No. 254, February 2011, http://www.sogc.org/ guidelines / documents / gui254TU1102E.pdf).

There are many common techniques for transvaginal mesh implant, but we consider it necessary to further improve these techniques.

Shrinkage of the mesh due to incomplete expansion in the distal posterior wall increases the risk of incomplete healing and erosion of the vaginal mucosa, leading to the development of dyspareunia. The presence of a scar on the back of the vagina when installing a mesh implant increases the risk of developing dyspareunia.

We have proposed a new method for surgical treatment of genital prolapse using a mesh implant established by transvaginal access.

Today on the medical market there are many synthetic implants for surgical reconstruction of the pelvic floor.

However, we use an implant made of a non-absorbable mesh cut in a single block, made of a material with polypropylene monofilaments with a diameter of not more than 0.07 mm, surface porosity of less than 40 g / m ² and volume porosity of 98.

These grid parameters create a unique structure, which, in turn, helps to increase its flexibility. A lightweight endoprosthesis for reconstructive surgery of the pelvic floor has exceptional softness and high bulk porosity. Due to the combination of high bioinertness indicators and special structural and mechanical properties, the mesh ensures the formation of a thin, delicate and uniform scar in the implantation zone. The endoprosthesis is highly resistant to infection. The mesh has excellent strength, durability and surgical adaptability and has a suitable porous structure, which is necessary for more efficient germination of collagen.

The mesh implant has a finished original shape with four sleeves for fixation.

The use of additional support points when fixing the mesh implant allows you to use a lighter mesh, which, accordingly, reduces the number of complications, such as erosion, incomplete healing of the vaginal mucosa, dyspareunia, etc.

As a device to facilitate the conduct of a synthetic implant and fix it to reliable structures of the pelvic floor, reusable conductors can be used.

The technical result of this invention is the effective treatment of patients living sexually with the lowering of the posterior wall of the vagina and the formation of rectocele by creating neofascia instead of destroyed, which is ensured by a certain method of installation and fixation of the mesh implant in the formed submucous tunnel, which helps to reduce the risk of erosion, reduce dyspareunia, associated with the scar on the vagina and its full expansion in the distal, as well as through the use of lung due to the specific structure of the mesh implant itself.

The method is as follows.

The operation is usually performed under regional spinal or epidural anesthesia (other methods of analgesia may be used). The patient is placed on the operating table in a lithotomy position. The surgical field is treated with antiseptic solutions, then the bladder is emptied.

The reconstruction of the posterior pelvic floor is as follows.

Two transverse sections of the mucous membrane of the posterior wall of the vagina are preliminarily carried out: one in the region of the posterior commissure and the second after 3-4 cm from the external pharynx of the cervix. Using dissecting scissors, a tunnel is formed by separating the tissues between the rectovaginal septum and the anterior rectal wall (Fig. 1). A mesh implant is installed through the formed tunnel, and two proximal implant arms are guided through the medial sections of the sacro-spinous ligaments and brought out to the perineal skin laterally and below the anus. Two distal sleeves of the implant with the help of a conductor are carried out on both sides through the muscle that raises the anus and is brought out to the perineal skin laterally to the posterior commissure. After expanding the mesh implant in the formed tunnel on the surface of the rectum, the free edges of the implant are fixed with non-absorbable threads to the posterior lip of the cervix in the projection of the internal pharynx, without piercing the mucous membrane of the cervix, and to the tendon center of the perineum in the region of the posterior perineal commissure; the excess free ends of the sleeves are cut subcutaneously, and the remaining ends are immersed in tissue; the vaginal wall is sutured with a continuous absorbable suture, cuts of the skin in the perineal region are sutured with separate sutures.

The bladder is catheterized, tight tamponade of the vagina is performed with sterile wipes with antibacterial ointments. After 24 hours, the catheter and tampon are removed.

According to the proposed methodology, 100 patients were operated on. The follow-up period was 3.5 years. During this time, one case of an asymptomatic course of recurrence of the anterior vaginal wall was noted (stage I according to POP-Q).

Erosion, incomplete healing in the early and late postoperative period was not noted.

The results of using a mesh implant in the surgical treatment of genital prolapse have shown their high efficiency as neofasciogenesis technologies in women with the lowering of the posterior wall of the vagina.

Example 1

Alekseeva Irina Dmitrievna, born 37

The prolapse of the posterior wall III with the formation of rectocele III, dolichosigma.

Apical prolapse 1 tbsp. Omission of the front wall 1 tbsp. Cystocele 0. Stress urinary incontinence.

POPQ: Ba-1.5, BP + 1.5, S-1, D-4

In the anamnesis: hypothyroidism, hr. hemorrhoids, supravaginal amputation of the uterus due to uterine fibroids + shortening of the round ligaments by laparotomic access due to the prolapse of the walls of the vagina.

Ultrasound: cystocele 0, rectocele 3, apical region 1 tbsp, urethral hypermobility

MRI: rectocele

KUDI: mixed urinary incontinence

12.12.2008 Operation: reconstruction of the posterior pelvic floor with the installation of a mesh implant + urethropexy transobturator access.

We used the modification of reconstruction of the posterior part of the pelvic floor and tunneling of the posterior wall of the vagina that we proposed.

After the operation - POPQ: Ba-3, BP-2, S-7, D-9.

No urinary incontinence. There are no problems with bowel movements. Sex life is painless.

Notes improvement in clinical condition.

B-naya discharged on time.

Example 2

Shumkova N.N., 40 years old

MRI: rectocele expressed

Ultrasound: Cystocele 0, rectocele 3 (filled with feces, visualization difficult), apex 0, urethral hypermobility 0

POPQ: VA-2 VR + 1.5 C-7 D-9

Diagnosis: Ptosis of the posterior wall of the vagina 3, rectocele 3, cystocele 0, anterior wall 1, apical prolapse 0.

Operation: 03/17/2010 Reconstruction of the posterior pelvic floor using a mesh implant of the claimed method.

Intraoperative: blood loss 100 ml

After POPQ surgery: Front 0 st, back 0 st, apex 0 st

POPQ: VA-2 VR-2 S-7 V-9

After the operation, an improvement in bowel movements and the absence of a pain symptom during sexual activity are noted.

B-naya discharged on time.

Example 3

Ivanova M.A., 39

History: 2008 - front colporography. Manchester operation, kolpoperineolevatoroplasty. Since 2009 - again the prolapse of the walls of the vagina with the formation of rectocele.

Complaints: on the feeling of a foreign body in the vagina, drawing pains in the lower abdomen, prolapse of the hernial sac, difficulty urinating, manual allowance for bowel movements, frequent discharge from the genital tract.

POPQ before surgery: Ba-2 Bp + 2

Diagnosis: Omission of the anterior wall 0-1, cystocele 0, posterior wall 3, rectocele 3.

Ultrasound: Rectocele 3. Cystocele 0. Moderate hypermobility of the urethra.

03/31/2010 Surgery: Reconstruction of the posterior region using a mesh implant of the claimed method.

Blood loss 100 ml, operation time 45 min.

POPQ after surgery: anterior 1 tbsp, posterior 0-1, apical region 0 VA-2, VR-2

Complaints about difficulty urinating does not show. There is no pain during sexual activity and violation of bowel movements.

B-naya discharged on time.

Bibliography.

1. Amid P.K. Classification of biomaterials and their related complication in abdominal wall surgery // Hernia. - 1997 .-- Vol. 1. - P.15-21

2. Cosson M, Caquant F, Collinet P, Rosenthal C, Clave H, Debodinance P, Garbin O, Berrocal J, Villet R, Jacquetin B. Prolift for pelvic organ prolapse surgical treatment using the TVM group technique: a retrospective study of 96 women of less than 50 years old // - International Continence Society symposium, 2005, abstracts. - Montreal. - www.icsoffice.org

3. Diez-Itza I, Aizpitarte I, Becerro A Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: a review at 5 years after surgery // Int Urogynecol J Pelvic Floor Dysfunct. - 2007. - Vol. 18. - N11. - P.1317-24

4. Ersoy M; Sagsoz N; Bozkurt MC; Apaydin N; Elhan A; Tekdemir I. Important anatomical structures used in paravaginal defect repair: cadaveric study // Eur J Obstet Gynecol Reprod Biol. - 2004 .-- Vol.10. - N112 (2). - P.206-13

5. Fatton B, Amblard J, Jacquetin B. Is hysterectomy indicated during prolapsus treatment? // Ann Urol. - 2007 .-- Vol.41. - N3. - P.91-10

6. Huebner M, Hsu Y, Fenner DE. The use of graft materials in vaginal pelvic floor surgery // Int J Gynaecol Obstet. - 2006. - Vol, 92. - N3. - P.279-88

7. Kohli N., Miklos J.R // Use of Synthetic Mesh and Donor Grafts in Gynecologic Surgery // Current Women's Health Reports. 2001, 1: 53-60

8. Klinge U, Klosterhalfen B, Müller M, Schumpelick V. Foreign body reaction to meshes used for the repair of abdominal wall hernias // Eur J Surg. - 1999 .-- Vol. 165. - P.665-73

9. Larsen WI, Yavorek TA. Pelvic organ prolapse and urinary incontinence in nulliparous women at the United States Military Academy // Int Urogynecol J Pelvic Floor Dysfunct. - 2006 .-- Vol.17. - N3. - P.208-10

10. Migliari R, De Angelis M, Madeddu G, Verdacchi T. Tension-free vaginal mesh repair for anterior vaginal wall prolapse. European Urology. 2000; 38 (2): 151-155

11. Sylvia M. Botros Peter K. Sand // Cystocele and rectocele repair: More success with mesh. Surgical techniques // June 2006, Vol. 18, No.6

12. Whiteside J.L., Weber A.M., Meyn L.A., Walters M.D. // Risk factors for prolapsed reccurence after vaginal repair // Am J Obstet Gynecol. - 2004. - 191 (5): 1533-8

13. Winters JC, Fitzgerald MP, Barber MD. The use of synthetic mesh in female pelvic reconstructive surgery // BJU Int. - 2006 .-- Vol. 98 (Suppi 1). - P.70-6. - discussion 77

14. Nyarangi-Dix JN, Djakovic N, Kurosch M, Haferkamp A, Hohenfellner M., Reconstructive pelvic surgery. Current status and future perspectives, Reconstructive pelvic surgery. Current status and future perspectives.

15. de Landsheere L, Ismail S, Lucot JP, Deken V, Foidart JM, Cosson M., Surgical intervention after transvaginal Prolift mesh repair: retrospective single-center study including 524 patients with 3 years' median follow-up., Am J Obstet Gynecol. 2011 Jul 30.

16. Salil Khandwala & Chaandini Jayachandran, Transvaginal mesh surgery for pelvic organ prolapse - Prolift + M: a prospective clinical trial, Int Urogynecol J (2011) 22: 1405-1411

Claims (1)

A method for surgical treatment of prolapse of the posterior wall of the vagina in women living sexually, including reconstructing the pelvic floor by installing the implant with vaginal access, characterized in that they reconstruct the posterior part of the pelvic floor, using a mesh implant that includes four sleeves for fixation - two proximal arms and two distal; the implant is made of a non-absorbable mesh cut out by a single block, made of a material with polypropylene monofilaments with a diameter of not more than 0.07 mm, surface porosity of less than 40 g / m ² and volume porosity of 98; two cross sections of the mucous membrane of the posterior wall of the vagina are preliminarily carried out: one in the region of the posterior commissure and the second, 3-4 cm from the external pharynx of the cervix; with the help of dissecting scissors form a tunnel by separating the tissues between the rectovaginal septum and the anterior wall of the rectum; through the formed tunnel, a mesh implant is installed, while two proximal implant arms are guided through the medial sections of the sacro-spinous ligaments and brought to the perineal skin laterally and below the anus; two distal sleeves of the implant with the help of a conductor are carried out on both sides through the muscle that raises the anus and is brought out to the perineal skin lateral to the posterior commissure; after expanding the mesh implant in the formed tunnel on the surface of the rectum, the free edges of the implant are fixed with non-absorbable threads to the posterior lip of the cervix in the projection of the internal pharynx, without piercing the mucous membrane of the cervix, and to the tendon center of the perineum in the region of the posterior commissure; the excess free ends of the sleeves are cut subcutaneously and immersed in tissue; the vaginal wall is sutured with a continuous absorbable suture, cuts of the skin in the perineal region are sutured with separate sutures.

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