RU2455955C1 - Method of operative correction of genital prolapse - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, gynecology. In women determined are content of C-terminal telopeptides and oxyproline in blood and pyrilinks-D in urine. If content of C-terminal telopeptides in blood is higher than 0.6 ng/ml, oxyproline in blood is higher than 180 mmol/l, pyrilinks-D in urine is higher than 8.0 nmol DPID/mmol creatinine women after vaginal hysterectomy, colpoperineolevatoroplasty, carried out are strengthening of muscles of pelvic floor with application of mesh materials, sacrovaginopexy.

EFFECT: method makes it possible to select volume of operative treatment in patients taking into account pathogenesis with higher markers of connective tissue dysplasia, makes it possible to reduce risk of development of genital prolapse recurrence and reduce number of complications which appear with application of synthetic materials.

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Description

The invention relates to medicine, namely to gynecology, can be used when choosing a method for surgical treatment of women with genital prolapse. The method can be used in specialized gynecological institutions.

The omission and prolapse of the internal genital organs is a fairly common pathology, which refers to abnormalities of the position of the genital organs [National Guide. Gynecology. Edited by Kulakov. 2007. 857-879].

To date, the theory of systemic dysplasia of connective tissue has become widespread in the development of this pathology [Radzinsky V.E. Perineology. 2006; 14-96].

The brighter the manifestations of dysplasia at the multiple organ level, the earlier, already at a young age, genital prolapse occurs, more pronounced, more difficult to surgical correction, which leads to a high relapse rate [Smolnova T.Yu., Buyanova S.N. et al. Connective tissue dysplasia as one of the possible causes of urinary incontinence in women with genital prolapse. 2001. 25-30].

It should be noted that today the majority of reliable biochemical methods, the use of which is necessary for verification of connective tissue diseases, is not available to a practical doctor. That is why a comprehensive approach to the detection of DST using the history of the patient’s disease and life, the unified principles of clinical and instrumental examination of the patient and the unified diagnostic criteria, including the most significant markers of collagen breakdown, is so important.

The frequency of relapses after operations aimed at correcting genital prolapse depends on the correctness of the chosen method of treatment, the characteristics of the connective tissue and muscle structures of the uterus supporting and fixing apparatus, pelvic floor muscles, and vaginal walls [Makarov O.V. Surgical treatment of patients with prolapse and prolapse of the uterus and vagina. / Obstetrics and gynecology. 2001.59-60].

There are works that consider the definition of C-terminal telopeptides as a defining moment in the appointment of metabolic therapy aimed at correcting collagen synthesis [Zhdanova MS Genital prolapse in women with connective tissue dysplasia, management tactics. Abstract. Cand. honey. sciences. 2009]. So, with indicators below 0.6 ng / ml in women with genital prolapse as a conservative therapy or for the purpose of preoperative preparation, they are limited to the appointment of hormone replacement therapy, with indicators equal to and above 0.6 ng / ml, in addition to hormone replacement therapy, they are prescribed metabolic therapy.

However, despite the large number of different operations and their modifications, the frequency of relapse in the postoperative period remains high.

Optimization of the treatment of genital prolapse taking into account the etiopathogenesis of this disease, including the determination of the functional state of connective tissue and the pelvic floor, the use of adequate surgical treatment, allows to achieve high efficiency in the treatment of genital prolapse [Smolnova T.Yu., Buyanova SN, et al. Connective tissue dysplasia as one of the possible causes of urinary incontinence in women with genital prolapse. 2001. 25-30].

A detailed understanding of the changes taking place with this pathology leads to the emergence of new surgical technologies using synthetic materials, using which satisfactory results are achieved. However, the use of synthetic materials is fraught with possible complications: erosion, pain, the development of dyspareunia, relapse prolapse, the need to remove the prosthesis, which should be warned patients before treatment [Slobodyanyuk B.A. Comparative analysis of laparoscopic and vaginal approaches in the treatment of genital prolapse using synthetic materials. Abstract. Cand. honey. sciences. M., 2009].

The authors set the task to develop a method for the differential surgical treatment of women with genital prolapse.

The technical result consists in the simultaneous prevention of recurrence of genital prolapse, reducing the invasiveness of the intervention and reducing the number of complications associated with the use of synthetic materials.

In other words, the selection of patients for additional correction of genital prolapse eliminates the need for its implementation in all cases, which allows to reduce the volume of surgery in a certain contingent of patients and thereby reduce the morbidity and complications caused by the use of synthetic materials.

The proposed method takes into account the condition of connective tissue in women with genital prolapse when choosing a method for its operative correction.

The authors empirically established diagnostically significant objective indicators - criteria for choosing a method of surgical treatment: a certain level of C-terminal telopeptides and hydroxyproline in the blood, pyrilix-D in the urine, which reliably characterize the connective tissue pathology.

The invention consists in the following.

Women with genital prolapse who are planning surgical treatment aimed at correcting genital prolapse are determined with the content of C-terminal telopeptides in the blood, oxyproline in the blood, and pyrilix-D in the urine. At the level of C-terminal telopeptides greater than 0.6 ng / ml, oxyproline more than 180 mmol / l, pyrilinx-D more than 8.0 nmol DPID / mmol creatinine, vaginal extirpation of the uterus, colpoperineolevascularoplasty is supplemented with sacrovaginopexy or pelvic floor muscle strengthening using mesh materials.

The method is as follows.

When examining women, they pay attention to the severity of genital prolapse. A thorough physical examination is carried out to identify signs of connective tissue dysplasia, a clinical and laboratory study. Including blood tests to determine the level of C-terminal telopeptides formed during the degradation of type 1 collagen, hydroxyproline in the blood, pyrilinx-D in the urine.

The determination of C-terminal telopeptides can be carried out using various diagnostic systems, such as, for example, the enzyme-linked immunosorbent analyzer Stat Fax 2100 [Kadurina TI, Gorbunova VN Connective tissue dysplasia. 2009].

Quantitative determination of the content of oxyproline in blood serum can be carried out by the Stegmann method, which is based on the oxidation of oxyproline with chloramine B to pyrrole-2-carboxylic acid, which gives a colored compound with idimethylaminobenzaldehyde. The determination of the optical density of the colored solution can be carried out on an FEK-M spectrophotometer [Butyukova V.A., Eremina V.P., Dzhumaeva T.I. Study of blood plasma oxyproline with myopia. 2009].

Quantitative determination of deoxypyridinoline (DPD) in urine is performed on IMMULITE 2000 analyzers. The IMMULITE 2000 Pyrilincs-D test (Deoxypyridinoline) is based on a solid phase chemiluminescent immunoassay. Since the concentration of deoxypyridinoline in the urine varies to evaluate the data obtained, the results of the determination of DPD must be normalized to the concentration of creatinine in the urine. For this, they are expressed as the ratio: DPD (nmol / L) / creatinine (mmol / L). Conversion factor: Creatinine (mg / dl) × 0.088 = creatinine (mmol / L). DPD values are expressed in nmol / L by default. Standard values: 3.0-7.4 nmol DPID / mmol creatinine [Kadurina T.I., Gorbunova V.N. Connective tissue dysplasia. 2009].

At the level of C-terminal telopeptides greater than 0.6 ng / ml, oxyproline more than 180 mmol / l, pyrilinx-D more than 8.0 nmol DPID / mmol creatinine, women with genital prolapse should be supplemented with vaginal extirpation of the uterus and coloperine neuroplasty with sacrovaginopexy or muscle strengthening bottom using mesh materials.

Vaginal extirpation of the uterus is carried out as follows.

The technique of vaginal extirpation of the uterus

Make a circular incision of the vaginal wall, retreating 5-6 cm from the external pharynx (or along the last transverse fold of the vagina). The closed Kupffer scissors inserted under the fascia exfoliate the bladder from the fascia covering it, moving the scissors to the upper corner of the wound (the ends of the scissors should be visible through the fascia so as not to injure the bladder). The fascia is cut through the middle section to the upper corner of the wound. The bladder is additionally separated from the fascia to its lateral departments, then from the cervix and peritoneum in an upward direction, dissecting the prebubular tissue. As a result, the peritoneum of the anterior arch is exposed, which is opened (anterior aacolpotomy). The cervix is pulled as far up to the fold. Capture the back wall of the vaginal fornix and dissect it with scissors (posterior colpotomy). The incision is brought to the place of discharge of the sacro-uterine ligaments. Three separate ligatures are placed on the back wall of the vagina, capturing the opened peritoneum, the threads are taken on the “holders”. Bullet forceps are placed on the front wall of the uterus and “dislocate” it into the anterior colpotomy opening of the wound. Clips are applied and stepwise cross the sacro-uterine, cardinal ligaments and bundles of uterine vessels on both sides. Clips are placed on the upper sections of the wide ligaments, including the round ligaments of the uterus and the stump of the uterine appendages (uterine ends of the tubes and their own ligaments of the ovaries), and cut off the uterus. Tissues taken in clamps (ligaments, vessels, stumps of appendages) are sutured with an opposing furrier suture. Suture begins from above, gradually removing the clamps. To create strong support for the bladder, the ligaments of the uterus are fixed to the walls of the vagina. For this purpose, the needle is injected immediately at the upper corner of the wound through the vaginal mucosa, fascia and peritoneum of the bladder, the upper segment of the connected uterine ligaments behind the mattress suture and injected through the described layers in the opposite direction of the opposite edge of the wound. The second seam is made with the same thread, capturing the edges of only the vaginal mucosa. There are several such seams, stepping 1.5-2 cm down from the first. With these sutures, the vaginal wall is fixed to the uterine ligaments interconnected. The last suture strengthens the vaginal wall in the stump of the sacro-uterine ligaments. With this suturing, the stumps of the ligaments are extraperitoneally located. The posterior vaginal fornix is closed with interrupted sutures, imposing them in the transverse direction. Kolpoperineolevatoroplasty is performed.

Technique of colpoperineolevatoroplasty.

A flap is cut from the skin of the perineum and the mucous membrane of the posterior wall of the vagina. To do this, clamp the base of the labia minora on both sides a little lower and outward from the openings of the ducts of the large glands of the vestibule, which corresponds to the lateral points of the flap intended for removal. By approaching the ends of the clamps, you can determine the height of the crotch, which will be created during the operation. A clamp is also applied in the center of the posterior wall of the vagina along the height of the flap to be cut out (usually at a distance of 5-7 cm from the posterior commissure). Side clips stretch to the sides. An incision is made from the lateral clamps applied to the base of the labia, along the skin of the perineum in a downward direction to the center at the border of the middle and posterior third of the perineum. The skin and mucous membrane on the perineal side are separated with a thin flap, then a vertical incision is made in the mucous membrane of the posterior wall of the vagina from the upper clamp to the separated lower flap. Next, the mucous membrane of the posterior wall of the vagina is separated to the left and to the right of the vertical incision. Separate the vaginal mucosa only in an acute way, holding the tip of the scalpel perpendicular to the detachable flap to cut it off in the form of a thin sheet. The mucous membrane is separated to the line connecting the upper corner of the flap with the points of application of the lateral clamps on the labia. The excess mucous membrane of the vagina is cut off, while the wound takes a triangular shape with an upper, acute angle in the depth of the vagina.

Next, levators are exposed, they are powerfully seized with a needle and the edges of the levators are stitched on both sides first in the upper part of the wound. The ends of the thread are clamped and pulled over, which facilitates the imposition of subsequent sutures on the levators and prevents trauma to the rectum. Below, a second and then a third seam is applied to the levators, pulling up on the previously imposed ligatures. Moreover, all ligatures imposed on the levators are not tied. Separate vicryl sutures are applied to the mucous membrane of the vagina, while it is advisable to further compare the upper parts of the levators directly under the formed posterior wall of the vagina. At this stage, it is important to form the back commissure correctly. To do this, it is necessary to symmetrically compare the stitched tissues, especially at the base of the labia minora. Tie the threads superimposed on the levators.

Sacrovaginopexy can be performed by laparoscopic access and include fixation of the sacro-uterine ligaments with the rectovaginal septum to the promontorium, for which suture of the sacro-uterine ligaments and rectovaginal septum with non-absorbable suture material from the vagina is performed, then under the laparoscopic control, the thread is performed with a blunt non-rhinorotum method , stitch the periosteum of the promontorium and stitch the thread along the formed channel back into the vagina, which is connected with the second thread of the ligature, and fix the back wall of the vagina to the promotorium by binding these threads to control the tension of the vagina.

It is also possible to use mesh materials to perform additional fixation of the muscles of the pelvic floor, for example, the system for complete reconstruction of the pelvic floor GYNECARE PROLIFT, the system for reconstruction of the anterior and posterior parts of the pelvic floor GYNECARE PROLIFT.

The technique includes an incision of the vaginal mucosa, backing 2-3 cm proximal to the external opening of the urethra, through the dome of the vagina to the skin of the perineum. It is necessary to dissect not only the vaginal mucosa, but also the underlying fascia. The back wall of the bladder is widely mobilized with the opening of the cellular spaces of the obstruction spaces. The bony tubercle of the ischium is identified. Then, under the control of the index finger, the membrane of the obturator hole is percutaneously using special conductors in two places as far apart as possible with stylet lateral to arcus tendinous fascia endopelvina. Next, the anterior wall of the rectum is widely mobilized, ischiorectal cellular space is opened, bone tubercles of the ischial bones, sacrospinal ligaments are identified. Sacrospinal ligaments are perforated 2 cm medial from the site of attachment to the bone tubercle (safe area) through the perineal skin (3 cm lateral to the anus and 3 cm lower) with identical stylets.

Using conductors drawn through plastic stylet tubes, an original mesh prosthesis is placed under the vaginal wall, straightened without tension and fixation. The vaginal mucosa is sutured with a continuous suture. The polyethylene tubes are removed. Excess mesh prosthesis is cut off subcutaneously. Tightly plug the vagina.

The ability to implement the stated purpose and achieve the specified technical result is confirmed by the following data.

The authors examined 38 patients with genital prolapse. All patients underwent surgical treatment aimed at correcting genital prolapse.

As a result of the study, women were divided into two groups. Group I - 21 patients who underwent vaginal extirpation of the uterus, colpoperineolevatoroplasty and supplemented with sacrovaginopexy or pelvic floor muscle strengthening using mesh materials, following the recommendations of the claimed method.

Group II (control) included 17 women whose surgical intervention was limited to vaginal extirpation of the uterus with colpoperineolevatoroplasty. The operations were performed during the period when surgical treatment was carried out without taking into account the results of biochemical markers of collagen breakdown.

To evaluate the effectiveness of treatment of genital prolapse with surgical methods, a comprehensive examination of patients was performed, including questionnaires, filling out a urination diary, general examination of patients, vaginal examination, ultrasound, complex urodynamic examination, etc. The results of surgical treatment were evaluated on average after 7.0 ± 0.38 years (from 5 to 9 years).

In group I, when the content of C-terminal telopeptides was more than 0.6 ng / ml, oxyproline more than 180 mmol / l, pyrilinx-D - more than 8 nmol DPID / mmol creatinine, vaginal extirpation of the uterus, colpoperineoleoplasty with sacrovaginopexy or pelvic floor muscle strengthening were performed using mesh materials. In this group, in women in the postoperative period, prolapse of the walls of the vagina and prolapse of the stump of the vagina was not observed in any case during the follow-up period of up to 9 years.

In group II, in patients whose C-terminal telopeptide levels were determined to be more than 0.6 ng / ml, oxyproline more than 180 mmol / L, pyrilinx-D - more than 8 nmol DPID / mmol creatinine, vaginal extirpation of the uterus with coloperine-neuroplasty was performed. In this group, vaginal wall prolapse was observed in all cases.

We give examples.

Example 1

Patient G., 66 years old, complained of a feeling of discomfort in the vagina, drawing pains in the lower abdomen. A history of 7 pregnancies, two births, the first complicated by ruptures of the perineum, 2 honey. abortion, without complications, 2 spontaneous abortions at short gestational stages, followed by curettage of the walls of the uterine cavity, without complications. Menopause is 14 years old. Concomitant pathology: umbilical hernia, scoliosis, myopia, chronic bronchitis, chronic cholecystitis, varicose veins of the lower extremities. With vaginal examination, the genital gap gapes, the legs of the levators are wide. Incomplete prolapse of the uterus and vaginal walls is determined.

Thus, based on complaints, medical history and gynecological examination, a preliminary diagnosis was established: incomplete prolapse of the uterus and vaginal walls, pelvic floor muscle failure.

Clinical and laboratory examination: C-terminal telopeptides 0.659 ng / ml, blood hydroxyproline 195 mmol / L, pyrilix-D 8.8 nmol DPID / mmol creatinine.

Produced vaginal extirpation of the uterus without appendages, kolpoperineolevatoroplasty. About 6 months after the operation, a feeling of discomfort in the vagina appeared, periodically short pulling pains in the lower abdomen, stopping on their own. Violations of the urinary system is not noted. With a gynecological examination, the omission of the vaginal dome is determined.

In this case, the patient developed a relapse in the postoperative period. An examination revealed an increase in all biochemical markers of collagen breakdown.

That is, for this patient, taking into account the increased levels of collagen breakdown markers of type I, the optimal method of surgical treatment would be to perform vaginal extirpation of the uterus, colpoperineolevatoroplasty with sacrovaginopexy, or strengthening the pelvic floor muscles using mesh prostheses.

Example 2

Patient M., 72 years old, complained of a foreign body feeling in the vagina, pulling pains in the lower abdomen. A history of 3 pregnancies, two births, without complications, 1 spontaneous abortion at short gestational stages, followed by curettage of the walls of the uterine cavity, without complications. Menopause 22 years. Concomitant pathology: chronic gastritis, varicose veins of the lower extremities, chronic hemorrhoids.

With vaginal examination, the genital gap gapes, the legs of the levators are wide. The incomplete prolapse of the uterus and the walls of the vagina, the failure of the muscles of the pelvic floor, is determined.

Clinical and laboratory examination: C-terminal telopeptides 0.72 ng / ml, blood hydroxyproline 182 mmol / L, pyrilix-D 8.4 nmol DPID / mmol creatinine.

Produced vaginal extirpation of the uterus without appendages, colpoperineolevatoroplasty, strengthening of the pelvic floor muscles using mesh material.

The postoperative period was uneventful. There were no complaints. Violations of the urinary system is not noted.

In this case, in a patient with increased biochemical markers of collagen breakdown in the postoperative period, relapse was not observed.

Example 3

Patient S., 67 years old, applied for the next examination. No complaints. A history of 3 pregnancies, three births, the first complicated by perineal tears. Menopause is 19 years old. Concomitant pathology: umbilical hernia, scoliosis, chronic bronchitis, chronic cholecystitis, varicose veins of the lower extremities. With a vaginal examination, complete loss of the uterus and the walls of the vagina, cysto-rectocele, failure of the muscles of the pelvic floor.

Clinical and laboratory examination: C-terminal telopeptides 0.57 ng / ml, blood hydroxyproline 158 mmol / L, pyrilix-D 7.2 nmol DPID / mmol creatinine.

Produced vaginal extirpation of the uterus without appendages, kolpoperineolevatoroplasty.

The postoperative period was uneventful. There were no complaints. Violations of the urinary system is not noted.

In this case, the patient has normal values of all biochemical markers of collagen breakdown. Therefore, the optimal treatment method was vaginal extirpation of the uterus, colpoperineolevatoroplasty, which was done.

Claims (1)

A method for the operative correction of genital prolapse, including vaginal extirpation of the uterus, colpoperineolevatoroplasty, characterized in that prior to the operation, the blood levels of C-terminal telopeptides, hydroxyproline and urine are determined using pyrilinx-D with a content of C-terminal telopeptides greater than 0.6 ng / ml , hydroxyproline more than 180 mmol / l, pyrilinx-D - more than 8 nmol DPID / mmol creatinine additionally perform sacrovaginopexy or pelvic floor muscle strengthening using mesh materials.