RU2209605C2 - Method for performing median colporhaphy - Google Patents

Abstract

FIELD: medicine, urogynecology. SUBSTANCE: in case of uterine and vaginal prolapse one should separate and remove fragments of anterior and posterior vaginal walls. Separated surfaces of bladder of rectum should be connected. Between separated surfaces one should apply implant out of porous titanium nickelide at sizes corresponding to those in separated surfaces. In peculiar case, larger separated surface should be sutured up to the sizes of lesser one. The present innovation enables to provide normal bladder's and rectum's functioning and prevents relapses of uterine and vaginal prolapse. EFFECT: higher efficiency. 1 cl, 1 dwg, 2 ex

Description

 The invention relates to medicine, namely to urogynecology.

 The omission and prolapse of the internal genital organs is one of the leading places in the structure of gynecological morbidity. Severe forms of prolapse in a certain sense are a mutilation that violates a woman's life. Surgical treatment, which allows to fully rehabilitate such women, has not only medical, but also social significance [Petrova V.D., Buyanova S.P., Ioseliani M.N., Popov A.A., Rizhinashvili I.D., Smolnova T.Yu. Tactics of treatment of patients with prolapse of the vaginal dome after hysterectomies. - Akush. and gynec. - 2000. - 4. - S. 50].

 Improving the treatment of genital prolapse has been relevant for many decades. This is due to the high frequency of this pathology, reaching 15-28% of cases of gynecological morbidity and the lack of treatment effectiveness, leading in 33% of cases to relapse prolapse. The disease is common among women of all age groups and always progresses, accompanied by the development of structural and functional disorders. These circumstances require new approaches to the choice of surgical tactics, optimization of surgical interventions, to minimize the number of relapses after surgical treatment [Krasnopolsky V.I., Buyanova S.N., Savelyeva I.S. Rehabilitation of patients with prolapse and prolapse of the internal genital organs. - Vestn. Ross assoc. Akush. and gynec. - 1997. - 1. - S. 105; Makarov O.V., Maso E.B., Krivoborodov G.G., Medvedev S.N. Combined surgical treatment of genital prolapse. - Akush. and gynec. - 2000. - 1. - S. 40-41; Petrova V.D., Buyanova S.N., Ioseliani M.N., Popov A.A., Rizhinashvili I.D., Smolnova T.Yu. Tactics of treatment of patients with prolapse of the vaginal dome after hysterectomies. - Akush. and gynec. - 2000. - 4. - P. 50].

 Modern women lead a more active life in old age. In many cases, the quality of life could be improved with the help of relatively small operations, but in practice this is rarely possible [Ischenko A.I., Chushkov Yu.V., Slobodyanyuk A.I., Samoilov A.R., Malyuta L.V. . Surgical treatment of patients with prolapse and prolapse of the uterus in combination with stress urinary incontinence. - Akush. and gynec. - 2000.- 1. - S. 32].

 A known method of vaginal extirpation of the uterus as a radical elimination of prolapse of the internal genital organs [Pathology of the cervix / Ed. IN AND. Krasnopolsky. - M .: Medicine, 1997. - S. 219; Hirsch H.A., Keser O., Ikle F.A. Operative Gynecology: Atlas: Trans. From English / Ed. IN AND. Kulakova, I.V. Fedorova. - M.: GEOTAR MEDICINE, 1999. - S. 243]. A known way to eliminate genital prolapse is the "Manchester operation" [Cervical Pathology / Ed. IN AND. Krasnopolsky. - M .: Medicine, 1997. - S. 219; Rembaise I.P. Operative gynecology. - Kiev: Zdorovya, 1985. - S. 133; Operative Gynecology / Ed. IN AND. Kulakova. - N. Novgorod: Publishing house NGMA. 1999. - S. 312].

The disadvantages of these methods are:
- operations are traumatic;
- high relapse rate, which reaches within 3 years after surgery 33%:
- difficult to perform:
- the architectonics of the small pelvis is violated:
- the possibility of exacerbating impaired function of neighboring organs, in particular the bladder, etc.

 The closest way to the claimed, eliminating genital prolapse, is median colporography of Lefora-Neugebauer. It is indicated for the loss of the uterus and vagina in women of advanced (senile) age who do not live sexually, with contraindications to radical operations for health reasons. The operation is as follows. From the mucous membrane of the posterior wall of the vagina, a trapezoidal (rectangular) flap is cut 3-4 cm wide and 6-7 cm long. Its base is located in the upper corner of the wound. The same flap of the vaginal mucosa is cut out from the anterior wall of the vagina (at a distance of 1.5-2 cm from the external opening of the urethra down and 2 cm anterior to the external pharynx of the cervix). Then the wound surfaces of the anterior and posterior walls of the vagina are connected. Initially, the edges of the wound adjacent to the cervix are connected. After this, the edges of the wound of the side walls are gradually sutured. Peri-bubble and peri rectal fiber are connected with thin catgut sutures. As a result of stitching of wound surfaces, the vagina is connected in the middle by a wide strip, to the left and to the right of which it remains along a narrow channel connected to the vaginal vault. When stitching wound surfaces, care must be taken not to flash the wall of the bladder or rectum. The last row of sutures is applied to the edges of the wound at the opening of the vagina [Pathology of the cervix / Ed. V.I. Krasnopolsky. - M .: Medicine, 1997. - S. 219; Rembaise I.P. Operative gynecology. - Kiev: Zdorovya, 1985. - S. 133; Operative Gynecology / Ed. IN AND. Kulakova. - N. Novgorod: Publishing house NGMA, 1999. - S. 319]. It is generally accepted that the shape and size of the separated front and back flaps of the vaginal wall should be the same [Davydov SP, Khromov BM, Sheiko V.Z. Atlas of gynecological operations. - L .: M., 1973. - S. 106]. Failure to comply with this requirement leads to a relapse of the disease.

The disadvantages of the method selected as a prototype are:
- it is difficult to examine the cervix in case of bleeding;
- Relapses of the disease due to stretching and thinning of the created vaginal septum under the influence of persisting intra-abdominal, intravesical and intrarectal pressure are observed;
- urinary retention is often replaced by stress urinary incontinence;
- the mechanism of occurrence of constipation due to severe rectocele is not eliminated;
- the imbalance between cysto - and rectocele limits the possibility of using the operation of median colporography;
- when stitching the separated sections of the anterior and posterior walls of the vagina, there is a risk of injury to the bladder and rectum.

 The objective of the invention: to ensure the normal functioning of the bladder, rectum and the prevention of relapse in women with prolapse of the uterus and vagina in old age and severe somatic pathology when performing median colcorrafia surgery.

The task is achieved in that:
1. A method for performing median colporography with prolapse of the uterus and vagina, including separating and removing flaps of the anterior and posterior walls of the vagina, connecting the separated surfaces, characterized in that a porous titanium nickelide implant with a porosity of 40-60% is installed between the separated surfaces of the bladder and rectum. , 0.2 mm thick, with dimensions corresponding to the dimensions of the separated surfaces.

 2. The method according to claim 1 is characterized in that if there is a disproportion between the cysto and rectocele, flaps of different sizes are separated and removed, the large separated surface is sutured to a smaller size, and the dimensions of the implant are selected in accordance with the dimensions of the smaller surface.

The novelty of the method:
- for the first time, an implant made of porous permeable titanium nickelide with a porosity of 40-60% with a thickness of 0.2 mm, corresponding to the dimensions of the separated surfaces of the anterior and posterior walls of the vagina, is used for the first time for the vaginal septum created during midline colporography;
- in the presence of a pronounced imbalance between the fallen front and back walls of the vagina, the flaps of the walls of the vagina are cut out in different sizes, the large separated surface is sutured to a smaller size, and the dimensions of the implant correspond to a smaller surface.

 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., Ziganshin R. IN. et al. Medical materials and shape memory implants. - Tomsk: Publishing house of Tomsk University, 1998. - S. 168-193]. Porous titanium nickelide implants germinate well with soft tissues and acquire the elastic properties of these tissues [Dambaev G. Ts., Gunter V. E., Rodionchenko AA, Itin V.I. et al. Porous permeable implants in surgery. - Tomsk: TPU Publishing House. 1996. - S. 116-119].

 An implantable plate made of porous permeable titanium nickelide, located between the walls of the bladder and rectum, is tightly fixed by surrounding tissues under the action of intraperitoneal, intravesical, and intrarectal pressure and its additional fixation becomes unnecessary. It sprouts surrounding tissues and creates a rigid fixation of the bladder, urethra and rectum. The implant determines the size of the created vaginal septum, takes on the effect of intra-abdominal, intravesical and intrarectal pressure, making it impossible to thin the septum.

 When using an implant made of porous titanium nickelide, the separated walls of the bladder and rectum grow together not with each other, but with the implant. It becomes possible to cut out the flap of the required size (large) on the most overstretched wall of the vagina, and by applying separate sutures to the separated surface, reduce it to the appropriate size of the separated surface on the opposite wall of the vagina.

 It is known that one of the factors of stress urinary incontinence in women is the loss of the ability of the urethra to snuggle tightly against the vesicle-vaginal septum, which is enhanced by weakness of the supporting tissue and lowering of the vagina, and a decrease in its tone [Salov P.P. Combined dysfunction of the pelvic organs (SFTO). - Novosibirsk: AOZT OFSET. 1994. - S. 59]. Using an implant made of porous permeable titanium nickelide creates a solid base for fixing the levelical region of the bladder, which eliminates one of the factors of stress urinary incontinence.

 Many women with genital prolapse suffer from constipation. An increase in the capacity of the rectum weakens its sensory sensitivity to tension (volume-threshold sensitivity) and, possibly, inhibits the bowel movement. [Salov P.P. Combined dysfunction of the pelvic organs (SFTO). - Novosibirsk: AOZT OFSET. 1994. - S. 27]. An implant made of porous titanium nickelide, growing through the tissues of the rectum, forms an area of active resistance to overstretching of the rectum, which increases the sensitivity of its baroreceptors, that is, one of the mechanisms of constipation (constipation) with pronounced rectocele is eliminated.

 The operation of midline colporography is performed in women who do not live sexually; therefore, the impossibility of further sexual activity does not play a role for the patient.

 The use of rigid and flexible hysteroscopes now allows you to examine the cervix and biopsy cancer-suspicious areas through the vaginal canals formed during midline colporography. Another drawback of median colporography is becoming insignificant.

 Thus, the use of a porous permeable implant to increase the efficiency of the median colporafia surgery for genital prolapse in women is theoretically and experimentally justified.

 The invention is illustrated in the drawing, which shows a diagram of the operation.

 The method is as follows.

 From the front wall of the vagina with a sharp scalpel we cut out and remove the flap of a rectangular shape 2-3 • 5-6 cm (depending on the width of the fallen vagina). The width of the flap side corresponds to the longitudinal section of the vagina, one narrow side is 1.5-2 cm below the external opening of the urethra, and the second is at the transitional fold of the mucous membrane of the anterior part of the vaginal fornix. Then we cut out and remove the flap of the same size (2-3 • 5-6 cm) and shape from the back wall of the vagina. With catgut sutures, we connect the edges of the transverse sections of the anterior and posterior walls of the vagina lying in front and behind the cervix. Between the separated surfaces of the bladder and rectum we place a rectangular-shaped implant made of porous permeable titanium nickelide of the ТН-1П grade with a porosity of 40-60%, a thickness of 0.2 mm, a width of 2-3 cm and a length of 5-6 cm, respectively, according to the size of the separated flaps. Then we connect the lateral edges of the anterior and posterior vaginal walls of the refreshed rectangles with catgut sutures. The operation ends with suturing the lower transverse edges of the incisions. The implant is between the bladder (top), the rectum (bottom) and the stitched front and back walls of the vagina around the perimeter. At the same time, on both sides of the created vaginal septum, two narrow vaginal canals are formed, communicating with each other at the level of the cervix.

 With a pronounced imbalance between the prolapsed anterior and posterior walls of the vagina, a rectangular flap of 2-3 • 5-6 cm in size is cut out on the smaller wall of the vagina, and a large (necessary) size flap is on the larger wall of the vagina. By overlaying separate seams on a large, separated surface, make it appropriate in size (2-3 • 5-6 cm) and the shape of the separated surface opposite the vaginal wall. Subsequently, the operation continues as described above.

 Clinical example 1.

 Patient S., 71 years old, was admitted to the department of planned operative gynecology on 04/14/99 with a diagnosis of muscle failure of the pelvic floor of the III degree, prolapse of the uterus, cysto and rectocele.

 04/18/99, in a planned manner, under epidural anesthesia, an operation was performed: median colporography with strengthening of the vaginal septum with an implant made of porous titanium nickelide.

 During the operation, a rectangular flap 3 • 5 cm was removed from the anterior wall of the vagina with a sharp scalpel. The flap side width corresponds to a longitudinal section of the vagina, one narrow side is 2 cm below the external opening of the urethra, and the second is at the transitional fold of the anterior mucosa vaginal fornix. Then, a flap of the same size and shape was removed from the posterior wall of the vagina. Catgut sutures connected the edges of the transverse sections of the anterior and posterior walls of the vagina, lying in front and behind the cervix. A rectangular TN-1P porous permeable titanium nickelide implant with a porosity of 40-60% 0.2 mm thick, 3 cm wide and 5 cm long (corresponding to the size of the separated flaps) was placed between the separated sections of the bladder and rectum. Then catgut sutures connected the lateral edges of the anterior and posterior vaginal walls of the refreshed rectangles. The operation ended with suturing the lower transverse edges of the incisions. The implant was located between the bladder (top), the rectum (bottom) and the stitched front and back walls of the vagina (from the sides around the perimeter). At the same time, on both sides of the created vaginal septum, two narrow vaginal canals were formed, communicating with each other at the level of the cervix.

 In the postoperative period, analgesics, antibiotics, and physiotherapy were prescribed. Self urination from 1 day, stool for 6 days. The postoperative period proceeded correctly, healing of sutures by primary intention. Discharged home 05/05/99

 Inspected in dynamics: after 3 months, 1, 2 years. There were no signs of recurrence of genital prolapse, the implant does not manifest itself negatively. The woman did not present urogynecological complaints, the stool is daily. According to ultrasound and radiographs of the pelvis around the tissue implant of a conventional echostructure. There is no discomfort in the vagina and perineum.

 Example 2

 Patient G., 69 years old, was admitted to the department of planned operative gynecology on March 15, 1999 with a diagnosis of pelvic floor muscle insufficiency of the III degree, uterine prolapse, severe rectocele, III degree obesity, coronary heart disease, II degree hypertension, varicose veins of the lower extremities .

 March 18, 1999, in a planned manner, under an epidural anesthesia, an operation was performed: median colporography with strengthening of the vaginal septum with an implant made of porous titanium nickelide.

 During the operation, a rectangular flap 3 • 5 cm was removed from the anterior wall of the vagina with a sharp scalpel. The flap side width corresponds to a longitudinal section of the vagina, one narrow side is 2 cm below the external opening of the urethra, and the second is at the transitional fold of the anterior mucosa vaginal fornix. The back wall of the vagina was significantly larger than the front in size. Therefore, a flap of rectangular shape 5 • 9 cm was separated on it and removed. With separate cotton sutures placed on the separated surface of the rectum, its dimensions were reduced and brought to 3 • 5 cm. Catgut sutures connected the edges of the transverse sections of the anterior and posterior vaginal walls lying in front and behind the cervix. A rectangular TN-1P porous nickelide implant with a porosity of 40-60% 0.2 mm thick, 3 cm wide and 5 cm long (corresponding to the size of the separated flap of the anterior vaginal wall) was placed between the separated sections of the bladder and rectum. Then catgut sutures connected the lateral edges of the anterior and posterior vaginal walls of the refreshed rectangles. The operation ended with suturing the lower transverse edges of the incisions. The implant was located between the bladder (top), the rectum (bottom) and the stitched front and back walls of the vagina (from the sides around the perimeter). At the same time, on both sides of the created vaginal septum, two narrow vaginal canals were formed, communicating with each other at the level of the cervix.

 In the postoperative period, analgesics, antibiotics, antiplatelet agents, antihypertensive drugs, anticoagulants, vitamins, physiotherapy were prescribed. Self urination from 2 days, stool for 6 days. The postoperative period proceeded correctly, healing of sutures by primary intention. Discharged home 04/05/99

 Inspected in dynamics: after 3 months, 1, 2 years. There were no signs of recurrence of genital prolapse, the implant did not manifest itself negatively. The woman did not present urogynecological complaints, the stool is daily. According to ultrasound and radiographs of the pelvis around the tissue implant of a conventional echostructure. There is no discomfort in the vagina and perineum.

 Thus, 5 women aged from 65 to 72 years with loss of the uterus and vagina were operated on. All operated on during the observation there were no signs of recurrence of the disease. The implant did not manifest itself negatively, was well visualized on echo and radiographs.

Using this method gives the following effect:
1. The strength of the created vaginal septum increases, which prevents the recurrence of the disease.

 2. A solid base is created for the bladder and rectum, which leads to the normalization of their functions.

 3. The technique of surgery is simplified and the risk of damage to the bladder and rectum is reduced.

 4. Allows you to perform an operation with pronounced imbalances in the size of the anterior and posterior walls of the fallen vagina.

Claims (2)

 1. A method for performing median colporography with prolapse of the uterus and vagina, including the separation and removal of flaps of the anterior and posterior walls of the vagina, the connection of the separated surfaces of the bladder and rectum, characterized in that a porous titanium nickelide implant is inserted between the separated surfaces of the bladder and rectum with a porosity of 40-60%, a thickness of 0.2 mm, dimensions corresponding to the dimensions of the separated surfaces.  2. The method according to p. 1, characterized in that in the presence of a disproportion of stretching of the front and back walls of the vagina, flaps of different sizes are separated and removed, a larger flap is cut out on the wall of the vagina having a larger stretch and, accordingly, a larger separated surface is obtained than on the other wall , the large separated surface is sutured to a smaller size, and the dimensions of the implant are selected in accordance with the dimensions of the smaller separated surface.