RU2262313C1 - Method for reconstruction of vesicovaginal septum at prolapse of anterior vaginal wall and bladder - Google Patents

Abstract

FIELD: medicine, urogynecology.

SUBSTANCE: one should suture urethrovesical segment and bladder's bottom, suture vesicovaginal fascia and anterior vaginal wall, 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, suture the edges of vesicovaginal fascia with super elastic ligature made of titanium nickelide with sutures at stitch length being about 5-6 mm, distance between sutures being about 5-6 mm both in longitudinal and cross-sectional direction as a netting in area from separated urethral segment up to uterine cervix by capturing lateral walls of urethra, bladder and maintaining muscular-fascial elements 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 // Vesti. 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 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 intraperitoneal and intravesical pressure, the bladder-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 vesical-vaginal 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 at 0.5-1 cm below the external opening of the urethra and ending not 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 incision, and both halves of the fascia are separated in a sharp way from the bladder towards 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-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 .: Medicine, 1964. - S.56-60].

The disadvantages of this method are:

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

- can not be used in those women whose vesicovaginal fascia is sharply thinned, stretched, atrophic, and it is technically not possible to separate it from the wall of the bladder by either an acute or blunt route.

The main causes of disease recurrence after surgical reconstruction of the vesicovaginal 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 anterior wall of the vagina, urethra, neck and bottom of the bladder, prevention of recurrence of prolapse of the anterior wall of the vagina and bladder after surgical correction of prolapse of the anterior wall of the vagina 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 posterior wall of the bladder. The proposed method includes suturing the urethrovesical segment and the bottom of the bladder, suturing the vesicovaginal fascia and the anterior wall of the vagina. 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. The edges of the vesicovaginal fascia are sutured and sutured with a superelastic thread of titanium nickelide with sutures with a stitch length of 5-6 mm with a distance between the sutures of 5-6 mm in the longitudinal and transverse directions according to the type of mesh in the area from the separated part of the urethra to the cervix and the inner surface of the pubic arches bones with the capture of the walls of the urethra, bladder and supporting muscular-fascial elements. The novelty of the method:

- for the first time during reconstruction of the bladder-vaginal septum when lowering the anterior wall of the vagina and bladder after suturing with a purse-string suture of the overstretched posterior wall and the bottom of the bladder while moving the bottom of the bladder to the level of the levelical sphincter;

- sew the edges of the vesicovaginal fascia and stitch it with a superelastic thread of titanium nickelide with sutures with a stitch length of 5-6 mm with a distance between the sutures of 5-6 mm in the longitudinal and transverse directions according to the type of mesh on the area from the separated part of the urethra to the cervix and the inner surface of the arches pubic bones with the capture of the walls of the urethra, bladder and supporting muscular-facies elements.

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

- reinforcement of the vesicovaginal septum with a superelastic thread of titanium nickelide allows to strengthen its largest area;

- the created structure as a result of reinforcing the vaginal-vaginal fascia with a superelastic thread of titanium nickelide possesses all the functional properties of the vaginal-vaginal septum and, when the urinary bladder is filled with urine under the influence of increasing intravesical pressure, and during its subsequent emptying, participates in all deformation processes of the surrounding tissue, providing reliable strength of the formed vesicle;

- superelasticity and strength of the titanium nickelide filament allows you to save the structural strength during repeated deformations;

- the use of reinforcing the vesicovaginal fascia with a thread of titanium nickelide during reconstruction of the vesicovaginal septum eliminates trauma to surrounding tissues during their fusion

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., Ziganshin R. IN. et al. Medical materials and shape memory implants. Tomsk: Publishing house of Tomsk University, 1998. - S.168-193].

In order to strengthen the restored urethrovesikovaginal septum, the vesicovaginal fascia was flashed with a superelastic thread of titanium nickelide with a diameter of 0.1 mm of TN-10 grade. It does not absorb, has superelastic properties and is able to repeatedly return to its original state after unloading. Sutures were stitched with stitches of 5-6 mm in length with a distance between the stitches of 5-6 mm in the longitudinal and transverse directions according to the type of mesh with the capture of adjacent tissues of the urethra, bladder and supporting muscular-fascial elements, which ensures their solid fusion. During and after tissue fusion, the thread ensures the stability of the formed vaginal-vaginal septum to excessive deformation and allows you to reliably perform the role of a functional support for the urethra and bladder.

Thus, the reconstruction of the bladder-vaginal septum with the reinforcement of the restored bladder-vaginal fascia, posterior wall of the urethra and bladder with a superelastic thread of titanium nickelide during surgical treatment of prolapse of the anterior wall of the vagina and bladder in women is theoretically and experimentally substantiated.

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

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

Figure 2 shows the restoration of the vesicovaginal fascia when matching the edges (7 - suture).

In Fig.3, the location of the joints made by a thread of titanium nickelide to restore the vesicovaginal fascia (3 - joints in the longitudinal direction, 4 - joints in the transverse direction).

Figure 4 shows the general scheme of the operation (3 - sutures with a thread of titanium nickelide on the restored vesical-vaginal fascia in the longitudinal direction, 4 - sutures with a thread of titanium nickelide on the restored vesical-vaginal fascia in the transverse direction, 5 - the urethra, 6 - the bladder, 7 - suture on the vesicovaginal 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 at 0.5-1 cm below the external opening of the urethra and ending not 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 incision, and both halves of the fascia are separated in a sharp way from the bladder towards 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 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 area of the urethovesical sphincter. 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 kettut stitch to the inner surface of the right flap, then the free edge of the right fascia flap is sewn with a continuous kettut stitch to the external surface of the left flap. With a thinned, overstretched and atrophic fascia, when it is impossible to double-breasted fascia suturing, it is sutured by matching the edges with a continuous suture 7. After that, the restored vesicovaginal fascia is sutured with super-elastic titanium nickelide thread with stitches with a stitch length of 5-6 mm with a distance between stitches of 5-6 mm mm in longitudinal 3 and transverse 4 directions according to the type of mesh on the area from the separated part of the urethra 6 to the cervix 9 and the inner surface of the arches of the pubic bone with the capture of the adjacent walls of the urethra, bladder I and their supporting muscular-fascial elements. A continuous catgut suture is applied to the vaginal mucosa 8. A general arrangement of the ultrafine titanium nickelide filament and the result of the operation are presented in FIG. 4.

Clinical example 1:

Patient E., 63 years old, was admitted to the department of planned operative gynecology on 04/22/02 with a diagnosis of Poor pelvic floor muscles of the III degree, cysto and rectocele, stress incontinence.

04/25/02, an operation was performed under epidural anesthesia: anterior colporography, reconstruction of the vesical-vaginal septum with reinforcement of the vesicovaginal fascia with ultra-thin thread of titanium nickelide, posterior colporography with levoroplasty.

A longitudinal midline incision was made on the front wall of the vagina, starting at 0.5 cm below the external opening of the urethra and ending not 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 is dissected by a longitudinal midline section, and both halves of it are separated in a sharp way from the bladder in the direction of the descending arch of the bosom and the walls of the pelvis. After isolation of the urethrovesical 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. 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 kettut stitch to the inner surface of the right flap, then the free edge of the right fascia flap is sewn with a continuous kettut stitch to the external surface of the left flap. The reconstructed vesicovaginal fascia was stitched with a superelastic titanium nickelide thread with sutures with a stitch length of 5-6 mm with a distance between the sutures of 5-6 mm in the longitudinal and transverse directions according to the type of mesh in the area from the separated part of the urethra to the cervix and the inner surface of the cervical bone with a grip adjacent walls of the urethra, bladder and supporting muscular-fascial elements. 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 2 days, stool for 5 days. The postoperative period was uneventful, healing of sutures by primary intention. Discharged home 05/13/02

Inspected in dynamics: after 3, 6, 12, 18 months. There were no signs of recurrence of genital prolapse. The woman did not present urogynecological complaints. According to ultrasound and radiographs of the pelvis of the tissue in the area of the vesical-vaginal septum of a conventional echostructure. There is no discomfort in the vagina, perineum and during sexual activity.

Clinical example 2.

Patient Zh., 56 years old, was admitted to the department of planned operative gynecology on 04.17.02, with a diagnosis of Poor pelvic floor muscles of the III degree, incomplete prolapse of the uterus, cysto and rectocele. Bladder dysfunction.

04/23/02, an operation was performed under epidural anesthesia: anterior colporography, reconstruction of the vesical-vaginal septum with reinforcement of the vesicovaginal fascia with ultra-thin thread of titanium nickelide, 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 cut off sharply from the bladder in the direction of the descending arch of the bosom and the walls of the pelvis. After isolation of the urethrovesical 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. Due to the pronounced thinning of the vaginal-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 catgut suture. The reconstructed vesicovaginal fascia was stitched with a superelastic titanium nickelide thread with sutures with a stitch length of 5-6 mm with a distance between the sutures of 5-6 mm in the longitudinal and transverse directions according to the type of mesh in the area from the separated part of the urethra to the cervix and the inner surface of the cervical bone with a grip adjacent walls of the urethra, bladder and supporting muscular-fascial elements. 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 2 days, stool for 5 days. The postoperative period was uneventful, healing of sutures by primary intention. Discharged home 05/16/02

Inspected in dynamics: after 3, 6, 12, 18 months. There were no signs of recurrence of genital prolapse. The woman did not present urogynecological complaints. According to ultrasound and radiographs of the pelvis of the tissue of the vesical-vaginal septum 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 bladder. The titanium nickelide thread did not manifest itself negatively, it was well visualized on echograms.

Using this method gives the following effect:

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

2. Stitching of the vesico-vaginal fascia with grasping the adjacent walls of the urethra and the bladder promotes their growth and allows you to restore the lost anatomy and function of the vesico-vaginal septum and reliably eliminate prolapse of the anterior wall of the vagina and bladder.

3. Allows you to strengthen the vesicovaginal fascia over a larger area than when wound as a double-breasted frock coat.

4. Allows you to simplify the technique of reconstruction of the vesicovaginal septum, refusing to suture the vesicovaginal fascia as a double-breasted coat.

5. Increases the effectiveness of anterior colporography, which allows you to abandon its more complex and traumatic options when eliminating the prolapse and prolapse of the anterior wall of the vagina and bladder.

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

7. Allows you to reduce the effect of the presence of a foreign body to a minimum.

Claims (1)

A method for reconstructing the vesical-vaginal septum during lowering and prolapse of the anterior wall of the vagina and bladder, including suturing the urethrovesical segment and the bottom of the bladder and suturing the vesicovaginal fascia and the anterior wall of the vagina, characterized in that the overgrown posterior wall and the bottom of the urine are sutured with a purse string suture and the bottom of the urine bladder into the level of the levelical sphincter, the edges of the vesical-vaginal fascia are sutured and stitched with a superelastic thread of titanium nickelide with a stitch length of 5-6 mm, a distance between the sutures of 5-6 mm in the longitudinal and transverse directions according to the type of mesh in the area from the separated part of the urethra to the cervix and the inner surface of the arches of the bones with the capture of the adjacent walls of the urethra, bladder and supporting them muscle and fascial elements.

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