RU2337633C1 - Method of treatment of stress urinary incontience of serious types - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: form muscular-fascio-aponeurotic flaps. Perform frontal colpotomy with exposure of an urethrovesical segment. Bring flaps under an urethra. Thus form the flaps from forward wall of a vagina of abdominal rectus muscles with capture of a site of abdominal rectus muscles at lateral edge from the both sides. Before bringing the flaps under urethra, lead each flap through the layer of abdominal rectus muscles. Grasp the flap from the mentioned above side and lead in a vaginal wound. Stitch the flaps in a subuteral space, forming a sling.

EFFECT: method allows to eliminate stress urinary incontinence of serious types with sphincteric prostration; to warn risk of damage of internal organs and improves quality of life of a woman.

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Description

The invention relates to medicine, in particular to urogynecology.

Known methods for the surgical treatment of stress urinary incontinence in combination with sphincter insufficiency, for example, methods of pubic-vaginal sling operations, the classic representative of which is the Goebel-Stäckel method. The main stages of this operation are: the formation of muscle-aponeurotic flaps, exposure of the urethrovesical segment, flaps through the retia after crossing over the bladder, and suturing of the flaps directly in the area of the sphincter of the bladder after a newly performed crossover (D.P. Chukhrienko et al. Uroginek Atlas. Operations. - K .: 1981. P.341, Epstein G.S., The Goebel-Stäckel Operation and its Experimental Justification (Urology, 1928, Volume 5, Issue 3, pp. 138-143).

The disadvantage of the above method is the intersection of flaps, which contributes in the early postoperative period to the occurrence of retention of urine and irritative symptoms. The formed sling cannot replace the sphincter function, because the distal ends of the flaps, namely the muscle part, inevitably undergo sclerosis.

Closest to the claimed method is the Goebel-Stäckel operation in the modification of Ryazantsev E.L. In accordance with this method, flap cutting is carried out dome-shaped, allowing in some cases to achieve a more complete formation of the latter, the used technique with notching facilitates the stitching of the aponeurosis (Ryazantsev E.L. 2 Russian scientific-practical conference - "Urinary incontinence in women: diagnosis, treatment, results. "St. Petersburg., 2001, C, 71-72).

The disadvantages of the method selected as a prototype are the intersection of the flaps and suturing of the free ends of the flaps to the sciatic-cavernous muscles, which often leads to excessive tension and, ultimately, to infravesical obstruction, thereby complicating the stages of rehabilitation of patients.

The objective of the invention is to improve the quality of surgery and the prevention of postoperative complications.

According to the invention, the problem is solved by the fact that in the method of treating stress urinary incontinence of heavy types form muscle-fascial-aponeurotic flaps, simultaneously perform anterior colpotomy with exposure of the urethrovesical segment, bring the flaps under the urethra each on the same side without performing a cross, sew, forming a sling.

The presence of fascia in the flap strengthens the latter. The passage of flaps through a layer of rectus abdominis muscles partially replaces the work of the sphincter apparatus, which prevents the occurrence of involuntary discharge of urine at the time of physical exertion. The absence of two crosses and the fixation of the free ends of the flaps to muscle tissue contributes to the formation of a free-lying loop, which eliminates the occurrence of urinary retention in the postoperative period.

The passage of flaps through a layer of rectus abdominis muscles before their passage into the pre-urethral space without performing a cross, according to the scientific, technical and patent literature, is unknown. Thus, the claimed invention meets the criterion of "inventive step".

The method is illustrated by drawings (figures 1 and 2). The position of the patient on the operating table is typical, as for gynecological operations. The operation consists of 2 stages (peritoneal and vaginal), which are performed simultaneously by a team of urologists and gynecologists.

The peritoneal stage is shown in figure 1. After standard treatment of the surgical field with antiseptic solutions, we perform laparotomy according to Pfannenstiel, dissecting the skin 1 and subcutaneous tissue 2. Separate the wound edges to the sides, exposing the aponeurosis 3 — the anterior wall of the vagina of the rectus abdominis muscles. Cross sections cut out two flaps 4 12 cm long and 2 cm wide with a capture of a section of rectus muscles 5 at the lateral edge on both sides. Each of the flaps 4 is carried out from the same side through the thickness of the rectus 5 muscles of the abdomen into the prevesical space 6 without performing a cross to the place of meeting with the tip of the branches of the forceps, carried out from the side of the vagina towards the finger.

The vaginal stage is shown in figure 2. The patient is in a gynecological position, we treat the surgical field with antiseptics. A Foley catheter 18 CH 7 is inserted into the bladder. Vaginal mirrors expose the cervix 8. Fixing the front lip, we lower the vaginal part to the vestibule or beyond and a few back. Before anterior colpotomy, we do hydrotreating of tissues with 0.2% novocaine solution, which facilitates the implementation of this stage of the operation and significantly reduces the percentage of intraoperative complications. Then we perform anterior colpotomy. We make a longitudinal section of the mucous membrane of the anterior wall of the vagina 9, starting 1 cm below the opening of the urethra, and ending without reaching 2-3 cm from the opening of the uterus. On both sides, on the side and behind, we separate the urethra 10, the base of the bladder and its neck 11 to the lower edge of the horizontal branches of the pubic bones. On the back surface of the urethra 10 and the neck of the bladder 11 we impose a number of deep knotted sutures. With the divorced branches of the forceps, we grab the end of the right flap 4 from the same side and withdraw into the vaginal wound. In the same way we perform on the left side. Capture can be made for ligatures, preliminarily superimposed on the ends of the formed flaps. Next, we sew the flaps in the suburethral space. In this case, the first Z-shaped seams are applied distally, directly at the ends of the flaps. The result is a free-lying sling 12 in the suburethral space. Given that the muscles of the pelvic floor are always pathogenetically involved in the process, the operation is supplemented by colpoperineolevatoroplasty, thereby strengthening the pelvic floor. The mucous membrane of the vagina is restored by a continuous seam of Vicryl 3/0, and the wound on the abdomen is restored in the usual manner.

Example No. 1. Patient D., 58 years old, medical history No. 39010/110315. Entered the Department of Urology of the Research Institute of Emergency Medicine 03.12.01 with complaints of leakage of urine during exercise. Considers herself a patient since 1996, when the above complaints first appeared. It is known that in the past there were 10 pregnancies, 3 births and 7 abortions. Based on the patient’s complaints, physical and urodynamic examinations, the diagnosis was made: the main - stress urinary incontinence of type 3 with sphincter insufficiency, prolapse of the walls of the vagina, concomitant - obesity 3 tbsp. 12/04/01, the operation was performed by the claimed method, plastic of the anterior and posterior walls of the vagina, sphincteroleoplasty. In the postoperative period, antibacterial, infusion and symptomatic therapy was performed. The Foley catheter was removed on day 6, after which the woman herself urinated. Urination finally normalized by 7 days. In satisfactory condition 12/18/01 discharged home. During 1 year of dynamic observation of data for complications was not received. A follow-up examination, which included a conversation with a woman, filling out a urination diary, a modified questionnaire, and determination of functional and urodynamic statuses, was carried out in April 2006.

Example No. 2. Patient O., 50 years old, medical history No. 11437/86357, was admitted to the urology department of the Research Institute of Emergency Medicine 03.04.01 indicating the portion of urine leakage during coughing. Sick for about 7 seven years. It is known that in the past there were many pregnancies, the number of which is not remembered; childbirth alone. After the diagnosis, which included functional tests and urodynamic examination, the diagnosis was established: the main one is stress urinary incontinence of type 3, vaginal wall prolapse, cystocele, and concomitant bronchial asthma. 04/06/01 was performed the operation of the claimed method, the plastic walls of the vagina. The postoperative period was uneventful, without features. The Foley catheter was removed on day 6, after which the woman did not notice any previously noted symptoms or signs of difficulty urinating. Discharged 04/20/01 in satisfactory condition. Control examinations after 6 months, 1 year, 5 years did not reveal signs of urination disorders.

The proposed method allows to eliminate stress urinary incontinence of severe types with sphincter insufficiency, restore adequate urination, prevent the risk of iatrogenic damage to internal organs and, finally, gives a woman the opportunity to take her place in the structure of modern society. The operation is not contraindicated in women planning a pregnancy. This technique has been performed in the clinic since 1999. An analysis of immediate and long-term results allows us to recommend this operation as an operation of choice with the corresponding clinical picture.

Claims (1)

A method for the treatment of stress urinary incontinence of severe types, including the formation of muscle-fascial-aponeurotic flaps, anterior colpotomy with exposure of the urethrovesical segment, bringing the flaps under the urethra, characterized in that the flaps are formed from the front wall of the vagina of the rectus abdominis muscles with the capture of a portion of the rectus abdominis muscles in lateral edge on both sides, before summing up the flaps under the urethra, each flap is passed through a layer of rectus abdominis muscles, grabbed from the same side and brought into agalischnuyu wound, and then sutured grafts in poduretralnom space, forming a sling.

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