RU2404714C2 - Method for surgical treatment of stress urinary incontinence in boys - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention is related to medicine, urology. Bulbous urethra is exposed down to pelvic floor in perineum through semilunar cut. Needles with prolene tapes are pulled paraurethrally at the right and at the left retropubically onto front abdominal wall (TVT) and through locking holes along wing-shaped channel-like conductor (TVT-O). At the same time loops are produced, which are arranged on bulbous urethra. Loops are tightened until urine leaking stops in case of provoked increase of intra-abdominal pressure. Method is applicable for boys with defects of urinary tracts development, besides, effect continues along with child growth.

EFFECT: invention helps to increase efficiency of surgical treatment of stress urinary incontinence in boys as a result of unidirectional closure of urethra in various areas.

5 dwg

Description

The invention relates to medicine, in particular to urology, and can be used in the surgical treatment of stress urinary incontinence in boys aged 7 to 16 years.

Stress urinary incontinence is a condition in which, with tension in the abdominal muscles and an increase in intra-abdominal pressure during coughing, physical exertion, abrupt rising, running, walking, etc. there is an involuntary uncontrolled leakage of urine. The cause of this may be a weakening of the muscles of the pelvic floor, leading to sagging of the bladder. Such sagging leads to compression of the neck of the bladder and a change in the angle of location relative to the urethra.

For the treatment of stress urinary incontinence in men, electrostimulation methods and implant surgery were used (artificial bladder sphincter, In Vance Male System implantation, which is a mesh made of synthetic material (MESH). The mesh is implanted through access to the perineum and fixed to the pubic bones.

These methods are not suitable for the treatment of urinary incontinence in boys from 7 to 16 years old.

Urinary incontinence in children has a complex genesis and is due to various pathology options in the organ system "detrusor-sphincter-pelvic floor". In most cases, the cause of urinary incontinence in children is functional forms that do not require surgical treatment. Malformations of the lower urinary tract, obvious or latent disorders of innervation, leading to urinary incontinence, require surgical treatment.

Surgical methods are the best treatment for stress urinary incontinence.

A known method of surgical treatment of urinary incontinence in men, which allows creating the possibility of controlled compression of the urethra, including partial overlapping of the urethra by creating compression with its own tissues, is used as an autograft from the wide fascia of the thigh, in the crotch part on the border of the scrotum they produce longitudinal skin section, allocate the urethra, around which the fascia is held in the form of a loop with the subsequent formation of two channels, the free ends of the fascia are pulled through these channels and stitched with non-absorbable suture material (RF patent No. 2185779, CL AB 17/00 from 07/27/2002).

The disadvantage of this method is the relatively low treatment efficiency, increased invasiveness of the method and the inability to use it for the treatment of urinary incontinence with tension in boys aged 7 to 16 years.

The known system "TYT-tension-free vaginal tape", proposed by UI Ulmsten and PEPetros in 1990, which consists in the occlusion of the urethra during physical exertion due to contraction of the muscles of the anterior abdominal wall. Its modifications are further proposed with the passage of prolene tapes through the locking holes - in 2001, the operation “TOT” (Delorme, France), in 2003, its modification by a group of Belgian surgeons “TVT-O - Transobturator vaginal tape Inside-Out.” In adult practice, single attempts were made to implant prolene tapes in the TVT modifications, TVT-O, THAT in men.

The problem to be solved by the claimed invention is aimed at increasing the effectiveness of the surgical treatment of urinary incontinence during exertion in boys with developmental defects and impaired innervation of the pelvic floor muscles, epispadias, as well as myelodyspasia, cerebral hernias (condition after surgical treatment), and - simplification of technology and reducing the morbidity of the operation.

The technical features of surgical correction of urinary incontinence in boys are as follows:

- the technique of performing a sling operation should exclude the possibility of transposition of the prolene tape (loop) with the growth of the child and ensure the preservation of the treatment effect in the long term;

- the features of the surgical technique in children, in contrast to adults, are determined by the anatomical dimensions and defects of the pelvic bones, structural changes in the pelvic diaphragm and urethra;

- fixing the tape to the tissues of the urethra prevents "twisting" and the displacement of the tape;

- the controlled tension of the ends of the tape of any system (TVT, TVT-O, TOT), brought to the skin, is achieved by performing compression on the anterior abdominal wall until the urine has stopped flowing and by cystoscopic visual control of the closure of the urethral walls in the projection of the "loop" diligence;

- an important feature is the localization of the location of the tapes under a certain anatomical part of the urethra, while the urethra overlaps over a large extent in different places unidirectionally;

- the improvement in the effect of retention of urine is determined by an increase in the pressure gradient on the wall of the urethra and its length;

- the effect of the continent is achieved with a preserved controlled act of urination;

- better urine retention effect compared with implantation of monosling (single loop);

- features of the operation technique - perineal, transverse access, "dull" allocation of paraurethral spaces, optimization of visual control of intraoperative implantation of prlen tapes and their paraurethral placement throughout determine the simplicity, minimally invasive options, avoid complications - perforation of the urethra, bladder.

The task is achieved due to the following. Through the semilunar incision in the perineum, the bulbous part of the urethra to the pelvic floor is isolated, needles with prolene tapes are parauretally placed on the right and left side by side, taking into account the anatomical features of the pelvis on the anterior abdominal wall (TVT) and through the locking holes along the pterygoid channel conductor (TVT-O). In this case, loops are formed, which are located on the bulbous part of the urethra and tighten until the flow of urine ceases with an increase in intra-abdominal pressure. The ends of the prolene tapes are cut off and immersed under the skin of the anterior abdominal wall and above the obturator opening, after which the perineal wound is sutured tightly.

Before the operation, clinical studies are carried out, including a set of diagnostic methods: cystoscopy, urodynamic and electrophysiological methods, a compression diagnostic test to determine the features of the implantation of TVT, TVT-O, TOT and to obtain a stable, long-term positive effect taking into account the growth of boys.

For the operation, guiding needles, a pterygoid conductor, a pusher for guiding needles, a metal guiding probe, a free synthetic TVT loop and a free synthetic TVT-O loop obturator are used.

The method is as follows. Through a semilunar incision in the perineum, the bulbous part of the urethra to the pelvic floor is isolated. Needles with prolene tapes are paraurethrally left and right, taking into account the anatomical size and characteristics of the pelvic bones on the anterior abdominal wall (TVT) and through the locking holes along the pterygoid channel conductor - (TVT-O) with the formation of loops that are placed on the bulbous part of the urethra and pull up until the cessation of urine leakage with an increase in intra-abdominal pressure of the loop.

The ends of the prolene tape are cut off and immersed under the skin of the anterior abdominal wall and above the obturator opening, followed by suturing of the perineal wound tightly and draining the bladder for 5-7 days with a Folly catheter.

In the Children's City Hospital No. 9 named after G.N. Speransky, Moscow, from 2000 to 2007 Using the proposed technology, 18 boys aged from 8 to 17 years were operated on. Complications at the time of the surgical manual and in the early postoperative period were not observed in any patient. According to the results of the control urodynamic examination in children, a positive “cough” test and an increase in the gradient of intraurethral pressure were noted.

The advantage of the proposed method for surgical treatment of stress urinary incontinence in boys is minimally invasive (low invasiveness, shorter duration of intervention and postoperative rehabilitation), in the simplicity and high efficiency of the operation technique due to unidirectional closure of the urethra in different places, while the effect is preserved under stress, child's work. The method is applicable in boys with malformations of the urinary tract, epispadias, as well as with myelodyspasia, cerebrospinal hernia.

Claims (1)

A method for surgical treatment of stress urinary incontinence in boys, characterized in that the bulbar part of the urethra is secreted to the pelvic floor through a lunar incision in the perineum, needles with prolene tapes are parauretally placed on the right and left, laterally, taking into account the anatomical features of the pelvis on the anterior abdominal wall (TWT) and through the locking holes along the pterygoid channel-shaped conductor (TVT-O) with the formation of loops that are located on the bulbous part of the urethra and tighten until the flow of urine stops when annom increase intra-abdominal pressure, followed by cut-off ends of the strips and immersion prolene under the skin of the anterior abdominal wall and over the obturator foramen, then the crotch wound sutured tightly.