RU2338474C1 - Transobturatory method with application of own flap from wall of vagina and mucous uterine neck at stressful incontience of urine in combination with prolapse of genitals - Google Patents

Abstract

FIELD: medicine; gynecology.

SUBSTANCE: perform implant bracing using transobturatory technics. Thus separate a flap of the oval form of which form a flap-bandage of the rectangular form on the forward wall of vagina and mucous uterine neck, amputate an uterine neck, and the length ablated part depends on degree of elongation of the neck, then carry out back vaginoperineoplasty.

EFFECT: prevention of postoperative complications; maintenance of an independent emiction next days after operation; absence of individual intolerance and improvement of neogenesis in the field of an operational wound at the expense of own tissue.

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Description

The present invention relates to medicine, namely to operative gynecology.

There is a method of surgical treatment for stress urinary incontinence - transobturator technique using a mesh with absorbable central part. The method is based on the following steps: the front wall of the vagina is dissected along the midline 1 cm below the external opening of the urethra to the level of the neck of the bladder; the formation of channels for transplants laterally, in the direction of the obstructive holes; at the clitoris level, a 0.5 cm long incision is made above the obturator openings to guide the hook-shaped transobturator conductor needle through the obturator openings; the mesh is fixed with a conductor needle and is pulled through the obturator openings on both sides; fixation of the mesh at the level of the neck of the bladder; wound closure (Obstetrics and gynecology, popular science magazine No. 6., 2004., p. 35-38). However, this method has several disadvantages: in some cases in the postoperative period there is a pronounced bend of the neck of the bladder due to mesh tension, pain and temperature reaction, implant rejection, impaired self-urination for up to 10 days, discomfort and sensation of a foreign body in the wound, high cost of the grid. This requires long-term catheterization of the bladder in the postoperative period, the appointment of antispasmodics and analgesics, antibiotic therapy, financial costs, with individual intolerance to the mesh - its removal, which requires repeated surgery. Stress urinary incontinence is often combined with elongation of the cervix and lowering of the walls of the vagina, in this regard, it is necessary to combine several operations simultaneously, in particular T-sling and reconstructive plastic surgery.

The technical result is the prevention in the postoperative period of pathological bending of the neck of the bladder, the absence of pain and temperature reaction, self-urination on the 2nd day after the operation, the absence of discomfort and individual intolerance, the improvement of regeneration in the area of the surgical wound due to its own tissue.

The proposed method is illustrated by the following drawings.

Figure 1 shows a diagram of the preparation of fragments of the mucosa along the front wall of the vagina and cervix in a rectangular shape. Figure 2 - allocation of the vaginal mucosa and the formation of channels for transplants. In Fig.3 - the formation of a removed flap of the vaginal mucosa and cervix of a stretchless dressing. Figure 4 - location and fixation of the mucous dressing at the level of the neck of the bladder, amputation of the cervix.

The proposed method is as follows. The cervix 1 of the uterus is fixed with bullet forceps and lowered onto itself, an oval-shaped flap 2 is cut out and separated on the front wall of the vagina and the mucous membrane of the cervix 2, from which a rectangular-shaped patch-strip 3 is additionally cut out. The flap is longitudinally divided into two halves, the ends are connected with vicryl sutures, thereby forming a sufficient length of the bandage 3. Section 4 begin, departing from the external opening 5 of the urethra by 1 cm, and end circulatory behind the neck. Vaginal mucosa 6 is isolated paraurethrally, at the level of the neck of the bladder and channels 7 are formed with finger 8. Above the obturator holes, at the clitoris level, a skin incision 9 of 0.5 cm length is made and a hook-shaped Transobturator needle-conductor 10 passes through the obturator holes to the bladder neck. The bandage 3 is fixed to the eye of the conductor needle, pulled through the obturator holes in the projection of the femoral fold and fixed on the skin. The same thing is done on the other hand. A central 11 part of the dressing is placed under the neck of the bladder. The cervix is amputated with a scalpel. The length of the amputated part depends on the degree of elongation of the neck. The wound is sutured with continuous vicryl. Plastic processing of the remaining cervix produce its mucosa; The principle of this treatment is to connect the mucous membrane of the neck and cervical canal so that the wound surface of the neck is covered with vaginal mucosa. The operation is completed with posterior colpoperineolevatoroplasty.

The proposed method prevents the use of a foreign implant, the absence of pain and the reaction temperature in the postoperative period helps to restore urination for 2 days. This technique provides significant cost savings, the steps of this method are technically simple, the duration of the operation is on average 45-60 minutes.

The proposed method operated on 10 patients with urinary incontinence in combination with elongation and prolapse of the cervix.

We give examples of clinical use of the proposed method.

Example 1. Patient Vedernikova A.P. 42 years old, No. 32147.

Diagnosis: cervical elongation in combination with stress urinary incontinence. Local status: The external genitalia are developed correctly, according to the female type. When straining from the genital fissure, the cervix hangs down 6 cm from the vulvar ring, is hypertrophied, non-eroded, the external pharynx is slit-shaped. When straining and coughing, outflow of urine occurs. Reception Valsalva positive.

P.V. the vagina is capacious, the uterus is not enlarged, dense, painless, mobile, in the center of the pelvis. The area of the appendages without pathological formations, mucous discharge.

The operation was performed under spinal anesthesia as follows: the cervix was fixed with bullet forceps and lowered onto itself, an oval-shaped flap was cut and an oval-shaped flap was cut out and an oval-shaped flap was cut out along the front wall of the vagina and the mucous membrane of the cervix. The flap was longitudinally divided into two halves, the ends were connected with vicryl sutures, thereby forming a bandage of sufficient length. The incision began, departing from the external opening of the urethra by 1 cm, and ended circulatoryly behind the neck. Vaginal mucosa was isolated paraurethrally, at the level of the bladder neck, and channels were formed with a finger. A skin incision 0.5 cm long was made above the obturator holes, at the clitoris level, and a hook-shaped transobturator conductor needle passed through the obturator holes to the neck of the bladder. The bandage was fixed by the eye of the conductor needle, pulled through the obturator openings in the projection of the femoral fold and fixed on the skin. The same thing was done on the other hand. The central part of the dressing was fixed under the neck of the bladder. The cervix was amputated with a scalpel. The length of the amputated part depends on the degree of elongation of the neck. Plastic processing of the remaining cervix made its mucosa; the principle of this treatment was to combine the mucous membrane of the neck and cervical canal. The wound was sutured with continuous vicryl. The operation was completed with posterior colpoperineolevatoroplasty. In the postoperative period: on the first day, the temperature is 37.2 ° C, spontaneous urination on the 2nd day, the pain reaction is minimal, lack of discomfort and individual intolerance, wound healing by primary intention.

After a month, a follow-up examination of the patient.

The condition is satisfactory. There are no complaints. When straining and coughing, urine does not run out. Reception Valsalva negative. Local status: the vagina is narrow, the cervix is 1.5 cm long, cylindrical, the mucosa is pale pink, the external pharynx is shaped like a pupil. A soft, painless cord is palpated in the projection of the patch.

Postoperative scar along the front and back wall of the vagina in the form of a roller, soft, painless.

Example 2. Patient Shakirova 3-X. 44 years old, No. 25841.

Diagnosis: prolapse of the walls of the vagina and cervix in combination with stress urinary incontinence.

Local status: The external genitalia are developed correctly, according to the female type. When straining and coughing, outflow of urine occurs. Reception Valsalva positive.

O.Z. the cervix is cylindrical, hypertrophied, there is nabotova gland on the front lip, when straining it hangs on the walls of the vagina from the vulvar ring by 5 cm.

P.V. the vagina is capacious, the uterus is anterior, not enlarged, the area of the appendages without pathological formations, the mucous discharge.

The operation was performed under spinal anesthesia as follows: the cervix was fixed with bullet forceps and lowered onto itself, an oval-shaped flap was cut and an oval-shaped flap was cut out and an oval-shaped flap was cut out along the front wall of the vagina and the mucous membrane of the uterus. The flap was longitudinally divided into two halves, the ends were connected with vicryl sutures, thereby forming a bandage of sufficient length. The incision began, departing from the external opening of the urethra by 1 cm, and ended circulatoryly behind the neck. Vaginal mucosa was isolated paraurethrally, at the level of the neck of the bladder, and channels were formed with a finger. A skin incision 0.5 cm long was made above the obturator openings, at the clitoris level, and a hook-shaped transobturator conductor needle passed through the obturator openings to the neck of the bladder. The bandage was fixed by the eye of the conductor needle, pulled through the obturator holes in the projection of the femoral fold and fixed on the skin. The same thing was done on the other hand. The central part of the dressing was placed under the neck of the bladder. The cervix was amputated with a scalpel. The length of the amputated part depended on the degree of neck elongation. Plastic processing of the remaining cervix made its mucosa; the principle of this treatment was to combine the mucous membrane of the neck and cervical canal. The wound was sutured with continuous vicryl. The operation was completed with posterior colpoperineolevatoroplasty. The postoperative period was uneventful, healing by primary intention.

Control inspection in a month.

The condition is satisfactory. There are no complaints. When straining and coughing, the flow of urine is not observed. Reception Valsalva negative. Local status: narrow vagina, cervix 1.5 cm long, pale pink, external pharynx in the form of a pupil. In the projection of the patch, the bandage has a slightly noticeable, painless cord. There is no discomfort. Postoperative suture along the front and back wall in the form of a roller, painless.

Claims (1)

A method for the surgical treatment of stress urinary incontinence in combination with the prolapse and prolapse of the internal genital organs, including fixation of the implant using transobturator technique, characterized in that an oval-shaped flap is removed from the front wall of the vagina and cervical mucosa, from which a rectangular bandage is formed, the neck is amputated. uterus, while the length of the amputated part depends on the degree of elongation of the neck, after which the posterior colpoperineolevatoroplasty is performed.

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