RU2800897C1 - Method of simultaneous treatment of cystocele and stress urinary intention using synthetic implant - Google Patents

Abstract

FIELD: medicine, urology, gynecology.

SUBSTANCE: anterior colporrhaphy is performed with the release of triangular sheets of tissues of the anterior wall of the vagina. The anterior wall of the vagina is separated along with the pubocervical fascia to the descending branches of the pubic bones with the release of the middle and proximal parts of the urethra and the bladder is separated from the cervix. A synthetic implant is placed under the bladder. Then, the threads fixed at the ends of the implant are passed through the obturator holes of the pelvic bones with the help of conductors, the implant is fixed with the help of the threads fixed on it to the skin of the perineum. With separate interrupted sutures, the pubocervical fascia is sutured over the installed implant with the capture of the cervix with a proximal suture.

EFFECT: method allows to increase the effectiveness of treatment, reduce the risk of recurrence in the postoperative period, prevent the development of penetrations and protrusion of the implant into adjacent organs.

1 cl, 4 ex

Description

The present invention relates to the field of medicine, in particular to urology and gynecology, and can be used in the surgical treatment of patients suffering from stress urinary incontinence caused by the prolapse of the anterior vaginal wall with the formation of a cystocele.

Pelvic organ prolapse, that is, isolated or combined prolapse or prolapse of the pelvic organs, is one of the most frequently detected pathological conditions in women of working age, which in the Russian Federation accounts for one third of the total number of gynecological diseases. Surgical interventions for uterine and vaginal prolapse are ranked third after operations for benign tumors and endometriosis.

The main treatment for prolapse is surgical correction of prolapsed pelvic organs. There are a large number of methods for surgical correction of genital prolapse, which, on the one hand, indicates a detailed study of this problem, and on the other hand, unsatisfactory results of surgical treatment. Inadequate surgical treatment and lack of prevention explains the high recurrence rate.

The widespread use of synthetic prostheses in the surgical correction of genital prolapse and stress urinary incontinence led to the emergence of specific complications in the early and late postoperative periods (Divakova, T.S. Mesh-associated complications of pelvic floor surgery /T.S. Divakova, E.A. Mitskevich// Achievements of fundamental, clinical medicine and pharmacy: materials of the 68th scientific session of the university staff, Vitebsk, January 31-February 1, 2013 / edited by V. P. Dekaylo; Vitebsk State Medical University . un-t. - Vitebsk, 2013. - S. 108-110). We are talking about the so-called implant-associated complications associated specifically with the implantation of synthetic mesh materials in the form of migration of a prosthesis fragment into the bladder or urethra, paravesical hematoma, suppuration in the prosthesis bed, suppuration along the “prosthesis sleeves”, wrinkling and displacement of the prosthesis. Most authors agree on the preferred use of mesh implants to correct cystocele in elderly patients with systemic connective tissue dysplasia.

A known method for the correction of cystocele in patients of reproductive age using implants. As implants, trapezoidal titanium mesh implants made of "titanium silk" are used. The implant is fixed with a smaller base at the level of the bladder neck with three non-absorbable threads in the area of the midpoint of the base and symmetrically on both sides and a large base at the level of the cervix in the area of the midpoint of the base and symmetrically on both sides. Conduct transobturatory ligatures tucked into the conductor, previously fixed to the corners of the implant. The ligatures are removed subcutaneously and brought together on each side until the optimal tension of the implant is created. The ligatures are connected alternately on both sides, sutured on the anterior wall of the vagina (RF patent for the invention RU 2661865 C1, published on 07/19/2018).

The main disadvantage of the known method of cystocele correction is the development of implant-associated complications, namely, protrusions towards the vagina due to the lack of a fascial layer between the installed implant and the vaginal wall.

As the closest analogue, a method for the simultaneous treatment of cystocele and stress urinary incontinence, based on pelvic floor plasty at the expense of one's own tissues, including anterior colporrhaphy, was chosen. On the anterior wall of the vagina, a median longitudinal incision is made from a point 1 cm downward from the external opening of the urethra to the anterior fornix. Two incisions perpendicular to it are performed, one in the region of the vaginal vault and the second at the level of the urethro-vesical segment. Two rectangular sheets are formed between the incisions for cystocele correction and two triangular sheets - for the installation of a synthetic loop. The bladder is immersed with a purse-string suture. One of the rectangular sheets is brought under the other and fixed with separate interrupted sutures, the second rectangular sheet is fixed on the opposite side over the first in the form of a duplication. Then, the normal anatomical position of the urethra is restored by installing a synthetic loop under the triangular sheets (RF patent for the invention RU 2628656 C1, published on August 21, 2017).

The disadvantage of this method, as well as other known methods for the treatment of cystocele and stress urinary incontinence, is the plastic at the expense of their own tissues, which compromised themselves earlier, leading to a high probability of relapse in the postoperative period.

The technical problem to be solved by the developed method is to increase the effectiveness of treatment, reduce the risk of relapse in the postoperative period, including implant-associated complications.

The technical result obtained by using the claimed invention is the absence of penetration and protrusion of the implant into adjacent organs.

The technical result is achieved by the fact that the method for the simultaneous treatment of cystocele and stress urinary incontinence, including anterior colporrhaphy with the release of triangular sheets of tissues of the anterior vaginal wall, the installation of a synthetic implant, according to the invention, after corporrhaphy, the anterior vaginal wall is separated along with the pubocervical fascia to the descending branches of the pubic bones with the release of the middle and proximal parts of the urethra, separation of the bladder from the cervix, while the synthetic implant is installed under the bladder, the threads fixed at the ends of the implant are passed through the obturator openings of the pelvic bones with the help of conductors, the implant is fixed with the help of the threads fixed on it to the skin perineum, with separate interrupted sutures, the pubocervical fascia is sutured over the installed implant with the capture of the cervix with a proximal suture.

The technical result is achieved due to the fact that a barrier is formed from the sutured pubocervical fascia between the installed mesh of the implant and the anterior wall of the vagina, which prevents the development of penetrations and protrusions into adjacent organs. To separate the implant from the anterior wall of the vagina, the pubocervical fascia is additionally sutured. In the claimed method, a small area prolene implant is used, which provides functional replacement of the connective tissue that led to the development of prolapse with an outcome in stress urinary incontinence.

The method is carried out as follows.

Under aseptic conditions, after infiltration with saline solution with adrenaline, the anterior vaginal wall is dissected along the midline to the anterior vaginal fornix with the release of triangular tissue sheets of the anterior vaginal wall. The dissection is carried out with an indent from the external opening of the urethra by 1.5 cm. Next, the anterior wall of the vagina is separated (separated) together with the pubocervical fascia to the descending branches of the pubic bones with the release of the middle and proximal parts of the urethra, the bladder is additionally separated from the cervix. Then a synthetic implant is placed under the bladder, for example, a mesh large-mesh implant made of prolene, polypropylene or polydiaxanone. Next, the threads fixed at the ends of the implant are passed through the obturator holes of the pelvic bones with the help of conductors, the implant is fixed with the help of the threads fixed on it to the skin of the perineum. Additionally, on top of the installed implant, the previously crossed pubocervical fascia is sutured with separate interrupted sutures, made of non-absorbable material, with the proximal suture capturing the cervix. Excess tissues of the anterior vaginal wall are excised, and the vaginal wall is sutured with a continuous suture of a long-term absorbable suture material.

Below are examples of the implementation of the claimed method for the simultaneous treatment of cystocele and stress urinary incontinence.

The method was tested on 67 patients with verified cystocele and stress urinary incontinence for 2 years. Also, the condition of the patients was monitored for 1 year after surgical treatment.

Example #1.

Patient N., 52 years old. She complained of involuntary leakage of urine during physical exertion (coughing, sneezing, lifting weights), feeling of a foreign body in the vagina for 6 years.

On vaginal examination: the body of the uterus is not enlarged, painless on palpation and displacement. Appendages on both sides are not enlarged, painless on palpation. The cough test is positive.

Clinical diagnosis: prolapse of the vaginal walls of the 2nd degree. Cystocele, stress urinary incontinence. Rectocele.

The patient underwent surgical treatment in the amount of anterior colporraffia with retropubic urethropexy of the TOT type and suturing of the pubocervical fascia. Posterior colporraffia. Levatoroplasty. Plication of the anterior wall of the rectum.

The patient was discharged on the 6th day after the operation in a satisfactory condition. Control examination after 2, 3 months and 1 year after the operation. Cough test and Valsalva test were negative. Control ultrasound of the pelvic floor - the synthetic loop is located correctly, the architectonics of the small pelvis is restored and within the normal range.

Example #2.

Patient K., 42 years old. She complained of involuntary leakage of urine during physical exertion (coughing, sneezing, lifting weights), sensation of a foreign body in the vagina, pain during intercourse for 4 years. History of childbirth with a large fetus with traumatization of the perineum.

On vaginal examination: the body of the uterus is not enlarged, painless on palpation and displacement. Appendages on both sides are not enlarged, painless on palpation. The cough test is positive.

Clinical diagnosis: Cystocele 3 degrees. Stress urinary incontinence.

The patient underwent: plastic surgery of the anterior wall of the vagina according to the above method.

The patient was discharged on the 6th day after the operation in a satisfactory condition. Control examination after 2, 3 months and 1 year after the operation. Cough test and Valsalva test were negative. Control ultrasound of the pelvic floor - the synthetic loop is located correctly, the architectonics of the small pelvis is restored and within the normal range.

Example #3

Patient Z., 47 years old. She complained of a sensation of a foreign body in the perineum, a feeling of incomplete emptying of the bladder. Earlier, 2 years ago, the patient underwent surgical treatment in the following volume: anterior and posterior colporrhaphy. Levatoroplasty.

On vaginal examination: the body of the uterus is not enlarged, painless on palpation and displacement. Appendages on both sides are not enlarged, painless on palpation. The cough test is positive. Prolapse of the anterior wall of the vagina with the formation of a cystocele is noted. When coughing, there is leakage of urine from the urethra.

Clinical diagnosis: Prolapse of the vaginal walls of the 3rd degree. Cystocele. Stress urinary incontinence.

The patient underwent plasty of the anterior wall of the vagina according to the claimed method.

The patient was discharged on the 6th day after the operation in a satisfactory condition. Control examination after 2, 3 months and 1 year after the operation. Cough test and Valsalva test were negative. Control ultrasound of the pelvic floor - the synthetic loop is located correctly, the architectonics of the small pelvis is restored and within the normal range. On the 3rd day of the postoperative period, the volume of residual urine was assessed - 10 ml.

Example #4

Patient O., 72 years old. She complained of uterine prolapse, impaired urination, defecation, urine leakage when sneezing and coughing. Suffering from prolapse of the pelvic organs for a long time.

Vaginal examination: The cervix extends beyond the vulvar ring by 5 cm. The body of the uterus is enlarged up to 9-10 weeks, painless on palpation. Appendages are not defined. The cervix is hypertrophied.

Clinical diagnosis: Omission of the walls of the vagina 4 degrees. Stress urinary incontinence. Large uterine fibroids, a symptom of postmenopausal growth. Hypertrophy of the cervix.

The patient simultaneously underwent vaginal hysterectomy with appendages. Plastic surgery of the anterior wall of the vagina according to the claimed method. Posterior colporrhaphy, levatoroplasty, plication of the anterior wall of the rectum.

The patient was discharged on the 8th day after the operation in a satisfactory condition. Control examination after 2, 3 months and 1 year after the operation. Cough test and Valsalva test were negative. Control ultrasound of the pelvic floor - the synthetic loop is located correctly, the architectonics of the small pelvis is restored and within the normal range.

Claims (1)

A method for the simultaneous treatment of cystocele and stress urinary incontinence, including anterior colporrhaphy with the release of triangular sheets of tissues of the anterior vaginal wall, the installation of a synthetic implant, characterized in that after corporrhaphy, the anterior wall of the vagina is separated along with the pubocervical fascia to the descending branches of the pubic bones with the release of the middle and proximal parts of the urethra, the bladder is separated from the cervix, while the synthetic implant is installed under the bladder, fixed at the ends thread implant through the obturator openings of the pelvic bones with the help of conductors, fix the implant with threads attached to it to the skin of the perineum, the pubocervical fascia is sutured over the installed implant with separate interrupted sutures with the capture of the cervix with a proximal suture.