RU2566925C1 - Method of treating type iii urinary incontinence in previously operated patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: type III urinary incontinence is corrected in previously operated patients. An anterior vaginal wall is incised; paraurethral spaces are mobilised; the skin is incised in a pubic region. A urethral sling tension is generated to provide urethral coaptation. The above sling is a synthetic band for sling operations containing perforator needles at the ends. The anterior vaginal wall is incised 0.5-1 cm in length within a middle one-third of the urethra. The paraurethral spaces are mobilised along an inner surface of pubic bones in the lateral direction 1-2 cm in length towards the pubic region. The band for sling operations are inserted by means of the perforator needles through the incision of the anterior vaginal wall along the paraurethral spaces, inserted into the skin incisions into the pubic region. The sling ends are tied up under an aponeurosis of the anterior abdominal wall subcutaneously with preserving the generated tension.

EFFECT: method enables eliminating type III urinary incontinence in the previously operated patients with coarse cicatrical adhesions surrounding the urinary tract.

1 dwg, 1 ex

Description

The invention relates to medicine, urology and can be used to treat type III urinary incontinence in previously operated patients.

Female urinary incontinence sling is currently the gold standard in surgical treatment.

Known transobturator sling urethropexy (TVT-0) (http://uroportal.com.ua/publ/operacii_v_urologii/operacii_tottvt_tvt_otvtsecur_nederzhanie_mochi_nikolaev/19-1-0-74), which consists in the fact that the patient is placed on an operating table or . After processing the surgical field, a F18 Foley catheter is inserted into the bladder; urine is evacuated. Then, the front wall of the vagina and paraurethral tissues are hydrotreated (0.9% sodium chloride solution or 0.5% novocaine). At a distance of 10-15 mm from the external opening of the urethra, a longitudinal incision is made of the anterior wall of the vagina (mucosa, submucous and adventitia) 15 mm long. Surgical scissors carry out limited mobilization of paraurethral spaces in the direction of the lower branches of the pubic bones (at an angle of approximately 45 ° to the sagittal plane) to a depth of 15-20 mm. Then, with a pointed scalpel, skin punctures are performed at the points of the subsequent exit of the tip of the tool. They are located bilaterally in the projection of the upper medial sector of the obstructive openings. You can localize puncture sites using the following procedure. On palpation in the area of the inguinal fold (slightly more lateral), the edge of the lower branch of the pubic bone is determined (it forms the medial circumference of the obstructive opening). The puncture point is located at a distance of 5-7 mm laterally from the palpable edge of the lower branch of the pubic bone at the level of the clitoris. Before passing the instrument through the tissues, it is necessary to fix the sling loop in his ear, the tip of the instrument is installed paraurethrally at an angle of 45 degrees to the sagittal plane (through an incision in the front wall of the vagina). The instrument is carried out in the direction of skin punctures: through the urogenital diaphragm, the internal obstructive muscle, the obstructive membrane, the external obstructive muscle. After the tip of the instrument appears from a skin puncture, the endoprosthesis loop is removed from it. The tool is deleted. Traction of the sling by the loop in the cranial direction is carried out until the endoprosthesis itself, the tape, exits through the skin puncture. A similar manipulation is carried out from the opposite side, as a result of which the sling is placed under the middle third of the urethra in the transobturator position. The bladder is filled with 300 ml of 0.9% NaCl solution. The catheter is removed. The synthetic sling tension is adjusted under the control of a cough sample. The patient is asked to cough or strain, and in case of fluid loss, the loop is pulled in the cranial direction. The optimal is the minimum sufficient tension of the sling to prevent loss of fluid. It is necessary to set the sling so as not to cause an acute retention of urine due to strong tension, but if the sling is installed with insufficient tension, then urinary incontinence will remain. At the final stage of the operation, the ends of the tape are cut below the skin level, the integrity of the skin is restored with single seams. “Excesses” of the vaginal mucosa are not excised, since this can lead to erosive complications, when suturing the anterior wall of the vagina, they are then monitored so that the endoprosthesis is not “trapped” in the suture. The bladder is catheterized, vaginal tamponade is performed with sterile wipes moistened with a water-soluble ointment (Levosin or Levomekol). The Foley catheter is removed on the second day.

Known transobturator sling urethropexy (T0T) (http://dr-gorohov.ru/articles/surgerv_for incontinence.php), which consists in the fact that a patient with urinary incontinence is installed urethral catheter. A longitudinal incision is made of the anterior vaginal wall 3 cm, under the middle urethra. The middle urethra is secreted in layers. Then, a conductor under the urethra is inserted through a puncture on the right side of the inner thigh surface, the end of the loop is attached to it, and the conductor with the loop is brought back. The loop goes through the locking hole. Similarly perform on the left. Check the loop tension, set the loop exactly under the urethra and suture the wounds of the anterior vaginal wall. The ends of the loop are cut off, the injection sites are sutured with single seams. The incontinence surgery is over.

The disadvantages of these methods are that when performing transobturator sling urethropexy (TVT-0, T0T), the synthetic tape (sling) is carried out through the urogenital diaphragm, internal obturator muscle, obstructive membrane, and external obturator muscle, as a result of which the sling is located in the transobturator position , i.e. horizontally, thereby not ensuring coaptation of the urethra (closure of the walls) and cessation of urinary incontinence in the presence of gross paraurethral scar-adhesions (periurethral fibrosis).

Known postadilone sling urethropexy (TVT) (http://www.pharmateca.ru/ru/archive/article/6072), which consists in the fact that above the womb, in the place of the proposed incisions (directly above the pubic bones, departing 2 cm from midline), for the purpose of hydropreparation, 10 ml of an isotonic sodium chloride solution is introduced. Using a standard muscle needle and moving it deeper, an additional 10 ml of 0.9% NaCl is introduced into each area above the womb until aponeurosis of the rectus abdominis muscle. The next step, after the gel is introduced into the urethra, a Foley catheter No. 18Ch is inserted and the urine is evacuated. Then, having retreated 5-7 mm from the external opening of the urethra, 5-7 ml of 0.9% NaCl is injected under the vaginal mucosa, followed by an additional 5 ml paraurethral on each side. After this, a longitudinal incision is made of the anterior vaginal wall in the area of the middle part of the urethra up to 1 cm long. Limited mobilization of paraurethral spaces is performed by the acute route from both sides. The next step is the insertion of a probe conductor into the lumen of the Foley catheter, with which the bladder is deflected deflectively when holding needles with a loop. Then, the pusher handle is connected to the needle, and the TVT device is ready to hold the prolene tape from the vagina to the suprapubic region. Conducting needles begins paraurethrally and continues paravesically, perforating the pelvic diaphragm and aponeurosis of the rectus abdominis muscle, leading the needles to suprapubic wounds. After holding the needle, cystourethroscopy is performed to exclude possible perforation of the bladder. In case of detection of needles in the bladder, they are removed into the area of the vaginal wound, and the needle is held again. Next, the loop in a plastic casing without tension is installed in the area of the middle part of the urethra, after which the casing is removed. Due to its special properties, the prolene loop is independently fixed to paraurethral tissues. The front wall of the vagina is restored with separate seams of Vicryl 3.0. Suprapubic wounds are sutured with one suture.

The disadvantages of this method are that the performance of posterior-sling urethropexia (TVT) in the presence of a periurethral scar-adhesion process does not allow coaptation of the urethra and the cessation of urine leakage without tension and fixation of the sling in a tension state, since in the absence of fixation of the sling after the cessation of effort, creating tension, is shifted back due to periurethral cicatricial-commissural changes, without preserving the previously created tension.

A known method for the surgical treatment of stress urinary incontinence in women (RF patent No. 2083166, 1995), adopted as a prototype, including cutting a skin flap, fixing it in the neck region of the bladder and suprapubic region, cut out a skin flap corresponding in size to the fixation zone in the region the bladder, and stitch it in the corners with non-absorbable ligatures, then along the side walls of the bladder percutaneously puncture the tissues and the anterior wall of the vagina through which ligatures are removed and tied over the apo neurosis in the suprapubic region.

The disadvantages of this method are that the method is quite traumatic, requires the collection of a free skin graft, then plastic closure of the skin defect after collection. High invasiveness due to the wide mobilization of the urethra, neck of the bladder and paraurethral spaces for the introduction of a finger, which is due to the way the needle is carried out from the inside out. The operation takes place in two stages, so the duration of the operation is long. A longer period of postoperative recovery due to the wide mobilization of the urethra, neck of the bladder and paraurethral spaces. The inability to perform this method in the presence of gross paraurethral cicatricial adhesions (urethral fibrosis of the urethra), since mobilization of the urethra and neck of the bladder in the conditions of gross paraurethral cicatricial adhesions (urethral fibrosis) is extremely difficult and increases the risk of damage to the urethra and bladder. The inability to create a sling tension, which ensures coaptation of the urethra and elimination of urine leakage, since ligatures will cut a skin flap when tensioned. The presence of a cosmetic defect in the form of a postoperative scar due to the collection of a skin flap.

The technical result of the invention is the creation of a method free from the above disadvantages.

The specified technical result is achieved by the fact that in the method for the treatment of urinary incontinence of type III in previously operated patients, including an incision of the anterior wall of the vagina, mobilization of the paraurethral spaces, skin incisions in the suprapubic region, through which the ends of the sling are brought out, connected and tied together above the anterior abdominal aponeurosis. walls subcutaneously, create a sling tension, which ensures coaptation of the urethra, as a sling, use a synthetic sling tape for sling operations containing at the ends of a perforated needle ry, an incision of the anterior wall of the vagina is performed in the region of the middle third of the urethra 0.5-1 cm long, paraurethral canals are mobilized along the inner surface of the pubic bones, 1-2 cm lateral of the urethra towards the suprapubic region, a synthetic tape for sling operations with needles -perforators are carried out through an incision of the anterior wall of the vagina along the paraurethral canals along the posterior surface of the pubic bones and are led into the formed skin incisions in the suprapubic region, the ends of the synthetic tape for sling op The operations are interconnected with the preservation of the previously created tension.

The invention is illustrated by the graphic materials presented in the figure.

An embodiment of the invention.

The patient is placed in a position for vaginal operations, on the back with legs divorced on supports according to Heppel. The genitals are treated with a solution of antiseptics, for example, pre-stained or similar, a Foley catheter No. 18 is installed. Then, an incision is made (1) of the anterior wall of the vagina in the region of the middle third of the urethra with a length of less than 1 cm. Next, bluntly using dissecting scissors, paraurethral spaces are mobilized 1-2 cm lateral to the urethra and towards the suprapubic region, along the inner surface of the pubic bones, forming paraurethral canals (2, 3). The bladder is emptied, a metal deflector is inserted into the Foley catheter No. 18, with the help of which the urethra and neck of the bladder are displaced from the midline to the opposite side from the perforated needle. In the suprapubic region at the level of the pubic joint, at least 3 cm lateral to the midline on both sides, skin sections (4; 5) up to 0.5 cm are formed with a scalpel, into which then the tape (6) will be pulled out for sling operations, for example, proline. The tape (6) for sling operations using needle perforators fixed to its ends (7; 8) is alternately passed through the previously formed paraurethral channels (2; 3) along the posterior surface of the pubic bones, the aponeurosis of the anterior abdominal wall is perforated and brought into the formed skin incisions (4; 5) in the suprapubic region. The urethral catheter is removed and without removing the perforating needles located in the paraurethral spaces, using a cystoscope, a control urethrocystoscopy with optics of 0 ° and 70 ° degrees is performed to exclude perforation of the bladder and urethra, the cystoscope is removed, the urethral catheter is reinstalled and the bladder is empty. Needles with fixed ends (7; 8) of the tape (6) for sling operations are brought out into the pubic region. Next, one of the perforating needles with a fixed end (7) of the tape (6) for sling operations, removed from the skin incision (4), is carried out again into the skin incision (4). Subcutaneous fat is perforated in the direction of the skin incision (5) and brought out into it, while the sling tape (6) is performed subcutaneously and placed over the aponeurosis of the anterior abdominal wall. Thus, the ends (7; 8) of the tape (6) for sling operations are brought out through one suprapubic skin incision (5). Perhaps subcutaneous holding of the tape (6) for sling operations in the opposite direction and its removal through the skin incision (4). Tape (6) for sling operations is installed under the middle third of the urethra. The bladder is filled up to 300 ml and the urethral catheter is removed. Then, by pulling the ends (7; 8) of the tape (6) for sling operations brought to the suprapubic region through a skin incision (5), tension is created to ensure coaptation of the urethra and the elimination of urethral leakage of urine. In the presence of gross paraurethral scar adhesions (periurethral fibrosis) in the paraurethral spaces, considerable effort is required. Keeping the tension of the tape (6) for sling operations, control the patency of the urethra with bougie No. 23. Further, the ends (7; 8) of the tape (6) for sling operations are connected with each other with the preservation of the previously created tension, while the node is placed subcutaneously above the aponeurosis. The excess ends (7; 8) of the tape (6) for sling operations are cut according to the skin level. The skin incisions (4; 5) and the incision (1) of the anterior vaginal wall are sutured using a 3/0 medical absorbable suture material. An urethral catheter is installed, the vagina is plugged.

Example.

Patient M., born in 1959. Received in the FSBI NNIIITO named after Y. L. Tsivyan of the Ministry of Health of Russia in August 2014 with complaints of total leakage of urine in orthostasis. After a comprehensive examination, specialist examinations, the clinical diagnosis was established: Urinary incontinence type 3, severe (Cervical cancer T3N0M0, combined treatment was carried out in 2009). Postradiation destruction of the posterior wall of the bladder, cystic-vaginal fistula (Marcius fistuloplasty, colposcleisis, was performed in 2011). Loop transobturation urethropexy was performed in 2013). Secondarily shriveled left kidney. Secondary, chronic pyelonephritis, latent course. In August 2014, treatment was carried out according to the proposed method with subsequent management. The postoperative period proceeded without any complications, after removal of the urethral catheter, completely controlled urination was restored with a satisfactory stream of urine, it retains urine, and there is no residual urine with ultrasound monitoring. During the control examination in September 2014, there were no complaints, completely controlled urination, a satisfactory stream of urine, it holds urine. It notes the improvement of social life and satisfaction with the results.

The advantage of the proposed method compared to the existing ones is that the method eliminates type III urinary incontinence in previously operated patients with gross paraurethral scar adhesions (periurethral fibrosis) around the urethra. Creates in such cases coaptation of the urethra, ensuring the elimination of urine leakage. Allows to achieve a high percentage of recovery in previously operated patients with type III urinary incontinence. The method is slightly traumatic, due to the low invasiveness, the rehabilitation process is accelerated. The method is carried out in one step, thereby reducing the execution time. There is no cosmetic defect.

A method for the treatment of type III urinary incontinence in previously operated patients is implemented on modern equipment using modern technologies and materials.

Claims (1)

A method for the treatment of type III urinary incontinence in previously operated patients, including an incision in the anterior vaginal wall, mobilization of paraurethral spaces, skin incisions in the suprapubic region, through which the ends of the sling are brought out, connected and tied together above the aponeurosis of the anterior abdominal wall subcutaneously, characterized in that they create the tension of the sling, which ensures coaptation of the urethra, as a sling, use a synthetic tape for sling operations, containing punch needles at the ends, a section of the anterior wall of the vagina and they are performed in the region of the middle third of the urethra 0.5-1 cm long, paraurethral canals are mobilized along the inner surface of the pubic bones, lateral to the urethra 1-2 cm long towards the suprapubic area, a synthetic tape for sling operations using needle punchers is carried out through an incision the front wall of the vagina along the paraurethral canals along the posterior surface of the pubic bones and is led into the formed skin incisions in the suprapubic region, the ends of the synthetic sling tape are connected with each other Anenij tension previously established.

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