RU2448661C1 - Method for surgical management of elongated uterine neck combined with genital prolapse complicated with stress urine incontinence - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to gynaecology. A method is based on the Manchester operation. A cervicectomy procedure is followed by transobturator implantation of a synthetic Perigee system under a neck of urinary bladder. A front end of the implanted system is fixed at the level of a middle urethra to form a sling.

EFFECT: method provides preventing recurrent genital prolapse and stress urine incontinence due to eliminating urethral hypermobility and ensuring reliable organ fixation in a physiological position.

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Description

The invention relates to medicine, namely to gynecology, and can be used in the surgical treatment of cervical elongation in combination with genital prolapse complicated by stress urinary incontinence when there are no indications for removal of the uterus (without vaginal extirpation of the uterus).

It is known that surgical treatment of cervical elongation in combination with genital prolapse, complicated by stress urinary incontinence, involves the implementation of additional stages of the operation, including the correction of genital prolapse and anti-stress surgery.

The closest analogue of the invention is the "Manchester" operation, classic and in the form of modifications, which consists in a wedge-shaped incision of the mucosa of the anterior wall of the vagina, the upper corner of which is located 1.5-2 cm below the external opening of the urethra with a transition into a circular incision around the cervix on 3-4 cm above the level of the external uterine pharynx, separation of the bladder, intersection, ligation and flashing of the cardinal ligaments with their subsequent fixation to the front surface of the cervix with deep sutures after e sphenoid amputation strengthening pubic-cervical fascia typical kolpoperineorrafii (A.N.Strizhakov, A.I.Davydov Vaginal Surgery Atlas -.. M .: OSLN, 2008. - S.250-256). In the presence of genital prolapse and stress urinary incontinence, additional pelvic floor strengthening and anti-stress surgery are required.

Disadvantages:

- the physiological position of the pelvic organs (bladder, urethra) is not achieved,

- hypermobility of the urethra is not excluded,

- a high percentage of relapses, especially with connective tissue dysplasia and severe defects in the anterior pelvic regions.

The objective of the invention is to develop a method for the simultaneous treatment of cervical elongation in combination with genital prolapse complicated by stress urinary incontinence, which will not only eliminate pathological changes in the cervix in women of reproductive age, but also reliably restore pelvic floor defects, thereby minimizing the risk of recurrence of genital prolapse and stress urinary incontinence.

The technical result consists in the prevention of recurrence of genital prolapse, the exclusion of hypermobility of the urethra and fixation of organs in the physiological position, with a combination of elongation of the cervix with genital prolapse and stress urinary incontinence, by combining the strengthening of the anterior and posterior parts of the pelvic floor by strengthening its own ligamentous apparatus of the pelvic organs and the formation of a synthetic midurethral sling.

We found that a certain location and fixation of the synthetic sling - at the level of the middle urethra - allows to prevent implant displacement during surgery, as well as to avoid hypermobility of the urethra, on the one hand, and to provide a reliable bandage of the pelvic organs with connective tissue dysplasia, on the other hand. .

SUMMARY OF THE INVENTION

Amputation of the cervix, shortening of the cardinal ligaments and their fixation to the anterior surface of the cervix are performed. After amputation of the cervix, a synthetic implant is placed transobturatorically using the Perigee system under the neck of the bladder. Position it so that the front edge of the implant is at the level of the middle section of the urethra, forming a sling. The front edge of the implant is fixed to the middle part of the urethra by suturing between the implant and paraurethral tissues in the region of the lateral parts of the urethra.

The method is as follows.

A permanent Foley catheter is inserted into the bladder. The vagina is naked in the mirrors. The cervix is captured by bullet forceps and reduced. After hydropreparation, a longitudinal section of the anterior vaginal wall is made, departing from the external part of the urethra 1.5 cm and up to 1-1.5 cm from the external pharynx of the cervix, after which the incision passes into a circular section of the anterior vaginal wall. With scissors of Metzenbaum, the walls of the vagina are widely separated from the underlying tissues. The side walls of the vagina are widely separated to the sides. For lateral separation, Arcus Tendineus m. Levator Ani and the upper and lower edges of the locking hole (reference points for subsequent implant placement). The bladder is exposed. The supernatal fascia is crossed with scissors and the bladder is carefully moved up. At the same time, the legs of the pubic-cervical fascia and cardinal ligaments are clearly visible. The bladder is allocated laterally towards the sciatic-pubic branch of the pelvic bone. The cardinal ligaments on the clamps intersect, are ligated. The pubic-cervical fascia is sutured with 3-4 horizontal intermittent vicryl sutures (long absorbable ligature). A wedge-shaped amputation of the elongated cervix is performed, suturing on the cervix according to Fothergill - cardinal ligaments are sutured with 2-3 deep vicryl sutures to the front surface of the cervix. A Perigee synthetic implant is installed as follows: through the minimum incisions at 4 points (the two upper at the clitoris, laterally to the edge of the sciatic-pubic branch of the pelvic bone, the lower two 3 cm lower and 2 cm lateral to the upper), the conductor needles are inserted from the outside in through obturator openings for the neck of the bladder (the handles of the upper needles are positioned at an angle of 45 ° to the midline of the patient and pass through the upper edge of the obturator hole, the ends of the lower needles are directed to the sciatic spine through the lower edge of the obstructive versty). After each holding of the needle, a corresponding connector with an implant sleeve is attached to it and each implant sleeve is drawn with the needle in the opposite direction through the corresponding incisions from the inside out. The implant is placed under the neck of the bladder freely, without tension, covering it with previously fixed ligaments (the transobturator technique of the implant using the Perigee system is described on the website: www.ams-russia.ru).

The front edge of the implant (which is the upper position in the patient’s lithotomy position) is sutured to the middle part of the urethra by suturing the implant and paraurethral tissues in the region of the lateral parts of the urethra. The excess implant is cut off.

This fixation significantly limits the typical urethral hypermobility in this condition, saving the patient from additional sling operations in the future. Excess mesh cut. Impose the front and rear seams along Sturmdorf. The walls of the vagina are stitched with a continuous vikrilovy seam. A typical colpoperineolevatoroplasty is produced.

To prove the possibility of realizing the specified purpose and achieving the above technical result, we present the following data.

Patient K., 36 years old, was admitted to the gynecological department of City Clinical Hospital No. 55 with a diagnosis of prolapse of the anterior and posterior walls of the vagina 2 tbsp. (POP-Q classification), elongation, cicatricial deformity of the cervix.

Complained of a feeling of a foreign body in the perineum, discomfort during movement, difficulties and discomfort during intercourse, as well as urinary incontinence during walking, coughing.

Anamnesis: for 3 years, the above complaints have been troubling. No treatment has been performed. A history of 2 births (last 4 years ago), complicated by rupture of the cervix and perineum. Suffers from varicose veins of the lower extremities, scoliosis of the thoracic spine, hypertensive vegetative-vascular dystonia. Both children have hernias of the anterior abdominal wall.

On examination, prolapse of the walls of the vagina, cysto- and rectocele, failure of the muscles of the pelvic floor, elongation, hypertrophy, cicatricial deformity of the cervix, chronic cervicitis were revealed. The length of the perineum is 2.5 cm, with CUD (complex urodynamic research) - stress urinary incontinence; ultrasound of the pelvic organs and bladder revealed no pathology.

The treatment according to the proposed method.

When observing the patient after 3, 9, 18, 24 months. no relapse was noted. Observation continues. The patient notes a significant improvement in the quality of life.

Patient B., 31 years old, was admitted to the gynecological department of MSCh No. 33 with a diagnosis of incomplete prolapse of the uterus and vaginal walls, elongation, hypertrophy, cicatricial deformity of the cervix.

Complaints about the feeling of a foreign body in the perineum, discomfort during movement, discomfort during intercourse, as well as involuntary urination during coughing, physical exertion.

Anamnesis: 2 births (2 years ago last), complicated by ruptures of the cervix and walls of the vagina. The feeling of discomfort and a foreign body in the perineum worried after 1 birth.

During examination revealed: cicatricial deformed uterine cervix extends beyond the genital fissure, cervical length 9 cm, perineal body length 2.5 cm. When CUD, stress urinary incontinence was detected.

The treatment according to the proposed method.

When observing the patient after 12, 24 months, no relapse was noted. Observation continues. The patient notes a significant improvement in the quality of life.

Thus, according to the claimed method, 23 women were operated on in the reproductive period with a diagnosis of cervical elongation in combination with genital prolapse complicated by stress urinary incontinence. Not a single recurrence of prolapse was observed when observed within 24 months. With CUD, stress urinary incontinence is absent.

Claims (1)

A method for surgical treatment of cervical elongation in combination with genital prolapse complicated by stress urinary incontinence, including amputation of the cervix, shortening of cardinal ligaments and their fixation to the front surface of the cervix, characterized in that they additionally transobturally install a polypropylene implant using the Perigee system under the neck of the urine bubble so that the front edge of the implant is at the level of the middle section of the urethra, forming a sling, after which the front edge is fixed I implant to the middle part of the urethra by suturing between the implant and paraurethral tissues in the region of the lateral parts of the urethra.