RU2808371C1 - Method of treating posthysterectomy prolapse using vaginal anterior approach using polypropylene implant with restoration of rectovaginal and pubocervical fascia - Google Patents

Abstract

FIELD: medicine; operative urology; gynecology.

SUBSTANCE: after preliminary hydrodissection, a longitudinal incision is made in the layer between the detrusor and the pubocervical fascia in the anterior wall and dome. Then the hernial sac is isolated without opening the abdominal cavity, and the edges of the pubocervical and rectovaginal fascia are isolated. The edge of the separation of the above fascia corresponds to the boundary of the disappearance of vaginal folding, the stumps of the cardinal and uterosacral ligaments are identified in their middle part and grabbed with clamps extraperitoneally and sutured with non-absorbable ligatures bilaterally. A lateral dissection of the vagina is performed until the tendinous arches of the pelvic fascia are exposed on both sides, the tendinous arch of the pelvic fascia is opened on the left using a sharp method, and the anterior surface of the sacrospinal ligament is exposed with the index finger. A puncture is formed according to the in-out principle using a transsacrospinal tunneler. Similar manipulations are performed on the opposite side; the ends of the polypropylene tape are passed through the middle sections of the sacrospinal ligaments. The rectovaginal fascia is fixed with a continuous non-absorbable suture with a thread to the mesh prosthesis, the stumps of the cardinal and uterosacral ligaments are sutured together. Fascia is fixed to the rectovaginal fascia and to polypropylene tape along the midline using non-absorbable ligatures. The edge of the pubocervical fascia is fixed to the cardinal and uterosacral ligaments in the center, to the polypropylene tape with separate non-absorbable sutures. The vaginal wound is sutured with a continuous Vicryl 2.0 suture, the tape is pulled under tension onto the skin of the buttocks, while the vaginal walls assume a normal anatomical position.

EFFECT: method allows to reduce the risk of damage to tissues and pelvic organs during surgery, since it does not require extensive intrapelvic dissection and allows not to use “large-scale”, “heavy” wide prostheses; it also reduces technical difficulties in eliminating anatomical defects of the pelvic floor, allows to achieve good functional results, restores the correct direction of the proximal part of the vagina, and helps to eliminate the risk of damage to the ureters and hypogastric nerve.

9 cl, 5 ex

Description

The invention relates to medicine, surgical urology and gynecology.

Hysterectomy is one of the most commonly performed operations in gynecology. About 65% of all hysterectomies are performed on women aged 40-44 years, 19% of hysterectomies are performed on women aged 50-69 years, 12% are performed on patients under 30 years of age, and another 4% are performed on women 70 years of age or older. The risk of developing prolapse after hysterectomy is 5.5 times higher in women whose initial indication for hysterectomy was pelvic organ prolapse compared with other indications.

Prolapse occurs after both abdominal and vaginal hysterectomy and is an unpleasant and difficult problem for both the patient and the doctor. The exact incidence of vaginal wall prolapse after hysterectomy is difficult to determine, as the rate varies from 0.2% to 43%. The risk of prolapse is believed to be higher after vaginal hysterectomy compared to abdominal hysterectomy, with the incidence increasing 5-fold. This is not surprising, since vaginal access is usually performed specifically for uterine prolapse. In addition, when performing a hysterectomy, the blood supply to the fascia and uterosacral ligaments is disrupted after crossing the uterine artery, which over the years leads to their atrophy.

Posthysterectomy vaginal dome prolapse is often associated with a cystocele, rectocele, or enterocele, making this condition difficult to treat. In addition to standard symptoms, this group of patients often exhibits symptoms of difficulty urinating, chronic pelvic pain, as well as symptoms of an overactive bladder and constipation. This symptom complex was described by P. Petros and was called “posterior fornix syndrome”. Often, all these symptoms are associated with failure of the connective tissue structures of the pelvis and, as a consequence, dysfunction of the levator muscles, since with anatomically correct reconstruction these symptoms are leveled out in 75-90% of cases. The frequency of these symptoms does not correlate with the stage of prolapse.

The gold standard for this pathology is laparoscopic sacrocolpopexy, the essence of which is to suspend the vaginal dome to the promontory of the sacrum using a polypropylene prosthesis. With good anatomical results, this operation is not always feasible and is not without its disadvantages: a longer, more labor-intensive operation under general anesthesia, the need to enter the abdominal cavity, a larger amount of synthetic material used, in addition, in the postoperative period, intractable constipation and various symptoms of urination disorders often occur.

There is a known method (RU, patent 2446750, published 04/10/2012) for the treatment and prevention of posthysterectomy prolapse in previously operated women. When using this technique, vaginal access is made to the vaginal dome. Then the dome of the vagina, the stumps of the cardinal and uterosacral ligaments are rigidly fixed extraperitoneally with a thread to the middle of a synthetic tape 1.5x50 cm. Using a measuring tape, measure the distance from the introitus to the top of the vaginal dome and set aside the resulting indicator from the middle of the synthetic tape in opposite directions, adding to it by 4 cm on each side, and make marks with a marker. Next, 2.0 cm above the symphysis pubis, a 2.0 cm long skin incision is made along the midline, and then two similar incisions are made bilaterally, 3.0-4.0 cm away from it in each direction. Then the synthetic tape is passed through the urogenital diaphragm in the paravesical space with perforation of the aponeurosis of the external oblique muscle of the abdomen and removed through the lateral skin incisions on the anterior abdominal wall on the corresponding side. Using the edges of the synthetic tape, the vaginal dome is pulled up to the previously applied mark. After this, both free ends of the synthetic tape are passed into the subcutaneous fatty tissue above the aponeurosis and removed through a midline incision, where they are fixed together with a prolene thread, and then freely immersed in the subcutaneous fatty tissue without rigid fixation to the aponeurosis.

A known method (RU, patent 2673916, published 12/03/2018) is transvaginal surgical prevention of posthysterectomy prolapse of the vaginal dome. A vaginal hysterectomy is performed. Channels are formed to the obturator membranes, the sacrospinous ligaments are isolated on both sides, while leaving the extraperitoneal uterosacral and cardinal ligaments on both sides. After peritonization and formation of the vaginal dome, channels are formed to the ischial spines and sacrospinous ligaments. Next, using non-absorbable suture material, an element of a synthetic mesh implant is fixed to each of the specified sacrospinous ligaments, 1.5-2 cm away from the ischial spines; at the final stage, colpoperineolevatoroplasty and colporrhaphy are performed. After peritonization and formation of the vaginal dome, the uterosacral and cardinal ligaments are sutured together, forming a ligamentous monoblock, which is fixed to the upper third of the posterior vaginal wall with slowly dissolving ligatures. Two pieces of mesh synthetic tape are used as an implant, and the end of each implant tape is fixed with non-absorbable ligatures to the corresponding sacrospinous ligament on each side. After this, the vaginal dome is placed in a physiological position, the specified implant tapes are sutured in the area of their intersection with slowly dissolving ligatures to the cardinal and uterosacral ligaments sewn together and to the middle of the vaginal dome. Then, using conductors, the free end of one tape is fixed to the right sacrospinous ligament. It is brought out through the left obturator opening into the left inguinal fold at the level of the clitoris, pulling the tape under tension so as to provide support for the pelvic organs. The free end of the second tape, fixed to the left sacrospinous ligament, is brought out through the right obturator foramen into the right inguinal fold at the level of the clitoris, pulling the tape with tension so as to provide support for the pelvic organs, the excess ends of the tapes are cut off and removed, leaving the implant in the wound .

Also known (RU, patent 2538796, published 04/10/2015) is a method of vaginal extraperitoneal colpopexy with a perforated polypropylene implant. An implant made of polypropylene mesh with holes and individual sizes for each patient in the shape of an isosceles trapezoid is installed subfascially without tension. The height of the trapezium is defined as the distance from the introitus to the top of the vaginal dome. The wide base of the trapezoid is equal to half the distance between the inner surfaces of the ischial tuberosities plus two centimeters. The narrow base of the trapezoid is equal to the width of the cervix plus two centimeters. Two polypropylene sleeves are fixed to the sides of the mesh adjacent to the wide base of the trapezoid with a non-absorbable thread on the left and right. Pass the sleeves through the obturator holes. The posterior edge of the polypropylene mesh is fixed to the paracervical tissues when preserving the uterus or to the McCall suture when performing a hysterectomy. The anterior edge of the mesh is fixed to the pubocervical fascia at the anterior vaginal incision. The vagina is sutured without excision of excess mucosa.

Known (RU, patent 2307618, publ. 10.10.2007) is a method of laparoscopic colpofixation during hysterectomy, including removal of the uterus and formation of the vaginal dome using vaginal access, vaginopexy using laparoscopic access, with the formation of extraperitoneal canals, passing through them the elements fixing the stumps of the uterine ligaments, removing and fixation of the latter over the aponeurosis of the external oblique abdominal muscle, characterized in that after removal of the uterus, using vaginal access on one side, 10-15 mm away from the free edge of each stump, the stumps of the cardinal and uterosacral ligaments are sutured with a non-absorbable ligature, capturing the vaginal wall , one of the ends of the ligature, after tying the knot, is cut off, and the other is placed in the abdominal cavity, the stumps of the cardinal and uterosacral ligaments are similarly sutured on the other side, after which the vaginal dome is formed, then, under the control of a laparoscope, lateral trocars are inserted into the abdominal cavity, piercing the anterior abdominal wall, moving medially 2-4 cm from the superior anterior iliac spine on each side, then to form the extraperitoneal canal, one trocar is removed and a uterine probe-conductor with a hole at the working end (hereinafter referred to as probe) is inserted into the formed canal, not reaching the peritoneum. , advance it under the control of a laparoscope extraperitoneally under the base of the stump of the round uterine ligament of the same side, perforate the peritoneum with the probe in the area of the stump of the sacrouterine ligament and pass the probe into the abdominal cavity, using a manipulator inserted through the lateral trocar of the opposite side, pass the free end through the hole of the probe ligatures fixing the stumps of the ligaments on the side of the formed extraperitoneal canal and remove it by reversing the probe from the abdominal cavity, similarly remove the other end of the ligature from the opposite side, after which, using a guide, one of the ends of the ligatures is passed over the aponeurosis of the external oblique abdominal muscle in the subcutaneous fatty tissue to to the place where the other end of the ligature is removed, the ends of the ligatures are tightened and tied together, completing vaginopexy.

Another method of laparoscopic colpofixation is also known (RU, patent 2182470, published on May 20, 2002), which can be performed in combination with hysterectomy performed via vaginal access. Colpofixation is carried out using a minimally invasive vaginal approach: the vaginal dome, the stumps of the cardinal and uterosacral ligaments are rigidly fixed with a prolene thread to the middle of a 1.5×50 cm synthetic tape, the distance (d) from the introitus to the top of the vaginal dome is measured with a sterile measuring tape and set aside from the middle synthetic tape in opposite directions, the resulting indicator (d) adding 4 cm to it on each side (taking into account the average thickness of the anterior abdominal wall above the pubis) and making marks with a marker, after which 2.0 cm above the pubic symphysis, a skin incision of length 2.0 cm, and then bilaterally, departing from it 3.0-4.0 cm in each direction, two similar incisions are made; using a guide tool, the synthetic tape is passed through the urogenital diaphragm in the paravesical space with perforation of the aponeurosis of the external oblique muscle of the abdomen and removed through the lateral skin incisions on the anterior abdominal wall from the corresponding side beyond the edges of the mesh brought above the skin, the dome of the vagina is pulled up to the previously applied mark on the synthetic tape, using a guide tool, both free ends of the tape are passed into the subcutaneous fatty tissue above the aponeurosis and removed through a midline incision, where they are fixed together with a polypropylene thread, and then freely immersed in the subcutaneous fatty tissue without rigid fixation to the aponeurosis, the integrity of the bladder is assessed by cystoscopy , the vaginal mucosa is restored with vicryl sutures.

The disadvantage of all of these methods is the significant risk after surgical complications.

The technical problem to be solved by the developed method is to restore the anatomy of the pelvic floor, adequate urination and defecation, improve the quality of life of patients and restore sexual life.

The technical result achieved by implementing the developed method is to increase the effectiveness of treatment while simultaneously reducing its trauma and reducing the risk of developing postoperative pelvic pain. To achieve the specified technical result, it is proposed to use the developed method for treating post-hysterectomy prolapse.

According to the developed method, after preliminary hydrodissection in the layer between the detrusor and the pubocervical fascia, a longitudinal incision is made in the anterior wall and dome, then the hernial sac is isolated without opening the abdominal cavity, the edges of the pubocervical and rectovaginal fascia are isolated, and the edge of the separation of the above fascia corresponds to the boundary of the disappearance of vaginal folding, the stumps of the cardinal-sacrouterine ligaments are identified in their middle part and grabbed extraperitoneally with clamps and sutured with non-absorbable ligatures bilaterally, lateral dissection of the vagina is performed until the tendinous arches of the pelvic fascia are exposed on both sides, the tendinous arch of the pelvic fascia is opened on the left using a sharp method, the anterior surface of the sacrospinal ligament is exposed with the index finger , form a puncture according to the in-out principle using a transsacrospinal tunneler. similar manipulations are performed on the opposite side, the ends of the polypropylene tape are passed through the middle sections of the sacrospinal ligaments, the rectovaginal fascia is fixed with a continuous non-absorbable suture with a thread to the mesh prosthesis, the stumps of the cardinal sacrouterine ligaments are sutured together, fixed to the rectovaginal fascia and to the polypropylene tape along the midline using non-absorbable ligatures, the edge of the pubocervical fascia is fixed to the cardinal-cruciate ligaments in the center, to the polypropylene tape with separate non-absorbable sutures, “straightening” the fascia and eliminating not only transverse, but also paravaginal defects of the pubocervical fascia and parietal pelvic fascia, the vaginal wound is sutured with a continuous suture Vicryl 2.0, the tape is pulled under moderate tension onto the skin of the buttocks, while the vaginal walls assume a normal anatomical position.

When implementing the developed method, it is preferable to use an implant tape with the following characteristics: length - 20 cm, width - 1.2 cm, thread diameter - 0.15 mm, pore size 1.36x0.42 mm / 1.485x0.76, average weight - 70 g/m2, proportion of gaps in the total area - 85%, tensile strength 55 N (Newton), elongation 57.3, material of manufacture - bioinert polypropylene.

Typically, dissection identifies the bladder and abdominal organs.

When implementing the method, Alice clamps can be used.

In some embodiments of the developed method, the stumps of the cardinal-sacral ligaments are sutured with non-absorbable ligatures Ethibond 0, and the rectovaginal fascia is fixed with a continuous non-absorbable suture using 2-0 prolene thread.

Preferably. the stumps of the cardinal sacrouterine ligaments are sutured, fixed to the rectovaginal fascia and to polypropylene tape using non-absorbable ligatures, Ethibond 0

Mostly, the edge of the pubocervical fascia is fixed to the cardinal cruciate ligaments, to polypropylene tape with separate non-absorbable sutures Ethibond 2.0 over a length of 5-6 cm,

In some embodiments, after pulling the tapes as indicated, perineoplasty is performed using standard techniques.

The developed method is preferably implemented as follows. After preliminary hydrodissection in the layer between the detrusor and the pubocervical fascia, a longitudinal incision is made in the anterior wall and dome. The hernial sac is isolated in a partially sharp and blunt way without opening the abdominal cavity; during dissection, the bladder and abdominal organs should be identified, as they may be involved in the adhesive process. The edges of the pubocervical and rectovaginal fascia (high transverse defects) are identified using sharp and blunt means. The edge of the separation of the above fascia corresponds to the boundary of the disappearance of vaginal folding. The stumps of the cardinal sacrouterine ligaments are identified in their middle part and grasped extraperitoneally with Alice clamps and sutured with non-absorbable Ethibond 0 ligatures bilaterally. Lateral dissection of the vagina is performed using blunt and sharp means until the tendinous arches of the pelvic fascia are exposed on both sides. The tendinous arch of the pelvic fascia on the left is opened sharply. The index finger exposes the anterior surface of the sacrospinal ligament. A puncture is formed according to the in-out principle using a transsacrospinal tunneler. Similar manipulations are performed on the opposite side. The ends of the polypropylene tape are passed through the middle sections of the sacrospinal ligaments. The rectovaginal fascia is fixed with a continuous non-absorbable suture using 2-0 Prolene suture to the mesh prosthesis. The stumps of the cardinal-sacrouterine ligaments are sutured together, fixed to the rectovaginal fascia and to the polypropylene tape along the midline using non-absorbable ligatures Ethibond 0. The edge of the pubocervical fascia is fixed to the cardinal-sacrouterine ligaments in the center, to the polypropylene tape with separate non-absorbable sutures Ethibond 2.0 over a length of 5-6 cm, “straightening” the fascia and eliminating not only transverse, but also paravaginal defects of the pubocervical fascia and parietal pelvic fascia. The vaginal wound is sutured with a continuous Vicryl 2.0 suture. The tape is pulled under moderate tension onto the skin of the buttocks. In this case, the vaginal walls assume their normal anatomical position. According to indications, perineoplasty is performed using standard techniques.

The method allows you to reduce the risk of damage to tissues and pelvic organs during surgery, since it does not require extensive intra-pelvic dissection and allows you to abandon “large-scale”, “heavy” wide prostheses; and reduces technical difficulties in eliminating anatomical defects of the pelvic floor, allowing to achieve good functional results. In addition, this method compares favorably with the previously described methods in the more correct position of the anterior and posterior walls of the vagina. By fixing the fascia not only to the mesh implant, but also to the cardinal-sacral ligaments, the depth of the vaginal walls, especially the posterior one, increases, which restores the correct direction of the proximal part of the vagina (level S2-S4). Identification and shortening of the uterosacral ligaments extraperitoneally eliminates the risk of damage to the ureters and hypogastric nerve. Adequate straightening of the pubocervical fascia due to its wide fixation to a polypropylene sling allows you to eliminate all possible defects with a minimum amount of mesh materials used.

The new technical result obtained by implementing the proposed method is that it significantly reduces the likelihood of developing pain after surgery due to the reduction of the dissection plane and the use of lightweight synthetic material reduced to a sling, minimizing the intraoperative effect on organs and tissues of the body, and reducing the possibility of postoperative complications and relapse of the disease. The use of synthetic material serves as a reliable prevention of prolapse and prolapse of the pelvic organs, as well as abdominal organs after a previously performed hysterectomy, as it allows you to fix the vaginal dome in a physiological position.

Below are specific examples of the implementation of the claimed method of treating post-hysterectomy prolapse.

1) Patient V., 69 years old

She entered the Urology Clinic of the First Moscow State Medical University named after. THEM. Sechenov:

Diagnosis: urogenital posthysterectomy prolapse III stage. according to POP-Q: cystocele stage II, prolapse of the vaginal stump stage IV, rectocele stage II.

Complaints: sensation of a foreign body in the vagina, urge urinary incontinence

History of the disease: in 2018, extirpation of the uterus and appendages was performed for uterine cancer. Since 2020, during self-palpation, she noted a bulge in the vaginal area, and since 2021, she began to notice an urgent urge to urinate, accompanied by urinary incontinence. Uses up to 2 pads per day, depending on drinking regime. Consulted at LDO No. 4, Clinical Hospital No. 2 of the First Moscow State Medical University named after. THEM. Sechenov. During examination, stage III urogenital prolapse was revealed, and surgical treatment was recommended. She was hospitalized as planned for surgical treatment.

Obstetric and gynecological history: pregnancies - 8, births - 2 (urgent, spontaneous, without features). Menopause from age 48. Local status. The lumbar region is visually unchanged. The symptom of tapping in the lumbar region is negative on both sides. The kidneys are not palpable. The bladder cannot be identified by palpation or percussion. Urination is frequent, painless, not difficult, urine is visually unchanged.

Pervagin am: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, a cough test for urine leakage is negative, and when the prolapse is reduced, it is negative. The vaginal stump is lowered, defined below the hymenal plane by 4 cm. The uterus with appendages is not defined. The vaginal mucosa is thinned, dry, pale.

Survey data:

PISQ 12: not sexually active (reason: lack of a sexual partner).

PFDI-20: 125 points PFIQ-7: 132 points Diagnostic examination data

Ultrasound of the pelvic organs: extirpation of the uterus with appendages. Free fluid in the pelvis is within normal limits. There is no volumetric pathology of the small pelvis.

Ultrasound of the kidneys and bladder: the right kidney measures 10.0 x 5.0 cm, with clear, even contours, homogeneous parenchyma up to 1.8 cm thick. No dilatation of the collecting system was detected. Kidney mobility is within normal limits. The left kidney measures 11.0 x 5.5 cm, with clear, even contours, homogeneous parenchyma up to 2.0 cm thick. No dilatation of the collecting system was detected. Kidney mobility is within normal limits.

Bladder with clear, even contours, volume 240 ml. Wall thickness - 3 mm. The volume of residual urine is 17 ml.

KUDI: the tone and sensitivity of the bladder are not impaired, hyperactivity is not detected.

Uroflowmetry: maximum speed - 16.3 ml/sec, average speed -8.9 ml/sec, residual urine - 10 ml.

To correct prolapse, the patient underwent surgical treatment using our technique using a polypropylene implant.

Progress of the operation:

The duration of the operation is 1 hour 54 minutes.

Blood loss - 50 ml.

The vaginal tampon and urethral catheter were removed on the 1st day after surgery.

Ultrasound: no residual urine. The CLS on both sides is not expanded.

The patient was discharged on the 3rd day.

When examined 1 month after surgery:

Complaints: no complaints

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

Survey data:

PISQ 12: not sexually active (reason: lack of a sexual partner).

PFDI - 20:25 points

PFIQ - 7: 0 points

Ultrasound: no residual urine. The CLS on both sides is not expanded.

Uroflowmetry: maximum speed - 17.8 ml/sec, average speed -10.0 ml/sec, residual urine - 12 ml.

When examined after 6 months:

Complaints: no complaints

Survey data:

PISQ 12: not sexually active (reason: lack of a sexual partner).

PFDI - 20:25 points PFIQ - 7: 0 points

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

When examined after 1 year:

Complaints: no complaints

Survey data:

PISQ 12: not sexually active (reason: lack of a sexual partner).

PFDI - 20:25 points PFIQ - 7: 0 points

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

When examined after 2 years:

Complaints: no complaints

Survey data:

PISQ 12: not sexually active (reason: lack of a sexual partner).

PFDI - 20:25 points PFIQ -7:0 points

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

2) Patient 3., 61 years old

She entered the Urology Clinic of the First Moscow State Medical University named after. THEM. Sechenov:

Diagnosis: urogenital prolapse III ct. according to POP - Q: cystocele stage II, prolapse of the vaginal stump stage III, rectocele stage II.

Complaints

sensation of a foreign body in the vagina, discomfort during sexual intercourse, frequent urination in small portions

History of the disease

At the age of 45, extirpation of the uterus and appendages was performed for external genital endometriosis. Over the past 5 years, I began to notice the above complaints. Consulted at LDO No. 4, Clinical Hospital No. 2. Upon examination, complete prolapse of the vaginal walls was revealed. She was hospitalized as planned for surgical treatment.

Obstetric and gynecological history: pregnancies - 4, births - 4 (the first three births were urgent, spontaneous, without any peculiarities; the fourth birth was breech presentation, births were operative). Surgical menopause from age 45.

Local status. The lumbar region is visually unchanged. The symptom of tapping in the lumbar region is negative on both sides. The kidneys are not palpable. The bladder cannot be identified by palpation or percussion. The external genitalia are formed correctly. Urination is frequent, painless, not difficult, urine is visually unchanged.

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, a cough test for urine leakage is negative, and when the prolapse is reduced, it is negative. The vaginal stump is lowered, defined below the hymenal plane. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

PER RESTUM: the perianal area is not changed. Pathological formations are not detected at the height of the finger.

Survey data:

PISQ 12: 12 points.

PFDI-20: 125 points

PFIQ-7: 132 points

Diagnostic data

Ultrasound of the pelvic organs: uterus, ovaries, cervix - removed, free fluid in the pelvis - not determined. No volumetric pathology of the small pelvis was detected.

Ultrasound of the kidneys and bladder: the right kidney measures 10.0 x 5.5 cm, with clear, even contours, homogeneous parenchyma up to 1.8 cm thick. No dilatation of the collecting system was detected. Kidney mobility is within normal limits. The left kidney measures 10.0 x 5.0 cm, with clear, even contours, homogeneous parenchyma up to 1.7 cm thick. No dilatation of the collecting system was detected. Kidney mobility is within normal limits. Bladder with clear, even contours, volume 220 ml. Wall thickness - 3 mm. The volume of residual urine is 50 ml. KUDI: normal tone and sensitivity of the bladder.

Uroflowmetry: maximum speed - 7.9 ml/sec, average speed - 4.6 ml/sec, residual urine - 45 ml.

To correct prolapse, the patient underwent surgical treatment using our technique using a polypropylene implant.

Progress of the operation:

The duration of the operation is 1 hour 50 minutes.

Blood loss -100 ml.

The vaginal tampon and urethral catheter were removed on the 1st day after surgery.

Ultrasound: no residual urine. The CLS on both sides is not expanded.

The patient was discharged on the 3rd day.

When examined 1 month after surgery:

Complaints: moderate discomfort in the vagina

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

Survey data:

PISQ 12:44 points

PFDI - 20:0 points

PFIQ - 7: 0 points

Ultrasound: no residual urine. The CLS on both sides is not expanded.

Uroflowmetry: maximum speed - 18.4 ml/sec, average speed -11.2 ml/sec, residual urine - 18 ml.

When examined after 6 months:

Complaints: no complaints

Survey data:

PISQ 12:46 points

PFDI - 20:0 points

PFIQ - 7: 0 points

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

When examined after 1 year:

Complaints: no complaints

Survey data:

PISQ 12:46 points

PFDI - 20:0 points

PFIQ - 7: 0 points

Pervaginam: the external opening of the urethra is located in a typical place, the mucous membrane is not hyperemic, the cough test for urine leakage is negative. The walls of the vagina are wealthy. The vagina ends blindly. The uterus and appendages are not identified. The vaginal mucosa is pale pink.

Claims (9)

1. A method of treating post-hysterectomy prolapse with a vaginal anterior approach using a polypropylene implant with restoration of the rectovaginal and pubocervical fascia, characterized by the fact that after preliminary hydrodissection in the layer between the detrusor and pubocervical fascia, a longitudinal incision is made in the anterior wall and dome, then the hernial sac is isolated without opening the abdominal cavities, the edges of the pubocervical and rectovaginal fascia are isolated, while the edge of the separation of the above fascia corresponds to the boundary of the disappearance of vaginal folding, the stumps of the cardinal and uterosacral ligaments are identified in their middle part and grabbed extraperitoneally with clamps and sutured with non-absorbable ligatures bilaterally, lateral dissection of the vagina is performed until the tendon arches of the fascia are exposed pelvis on both sides, open the tendinous arch of the pelvic fascia on the left in a sharp way, expose the anterior surface of the sacrospinal ligament with the index finger, form a puncture according to the in-out principle using a transsacrospinal tunneler, similar manipulations are performed on the opposite side, the ends of the polypropylene tape are passed through the middle sections of the sacrospinal ligaments , the rectovaginal fascia is fixed with a continuous non-absorbable suture with a thread to the mesh prosthesis, the stumps of the cardinal and uterosacral ligaments are sutured together, fixed to the rectovaginal fascia and to the polypropylene tape in the midline using non-absorbable ligatures, the edge of the pubocervical fascia is fixed to the cardinal and uterosacral ligaments in the center, to polypropylene tape with separate non-absorbable sutures, the vaginal wound is sutured with a continuous Vicryl 2.0 suture, the tape is pulled under tension onto the skin of the buttocks, while the vaginal walls assume a normal anatomical position. 2. The method according to claim 1, characterized in that an implant tape with the following characteristics is used: length - 20 cm, width - 1.2 cm, thread diameter - 0.15 mm, pore size 1.36 × 0.42 / 1.485×0.76 mm, average weight - 70 g/m ² , proportion of gaps in the total area - 85%, tensile strength 55 N (Newton), elongation 57.3, material of manufacture - bioinert polypropylene. 3. The method according to claim 1, characterized in that during dissection the bladder and abdominal organs are identified. 4. The method according to claim 1, characterized in that Alice clamps are used. 5. The method according to claim 1, characterized in that the stumps of the cardinal-sacrouterine ligaments are sutured with non-absorbable ligatures Ethibond 0. 6. The method according to claim 1, characterized in that the rectovaginal fascia is fixed with a continuous non-absorbable suture using 2-0 prolene thread. 7. The method according to claim 1, characterized in that the stumps of the cardinal uterosacral ligaments are sutured, fixed to the rectovaginal fascia and to polypropylene tape using non-absorbable ligatures, Ethibond 0. 8. The method according to claim 1, characterized in that the edge of the pubocervical fascia is fixed to the cardinal-sacrouterine ligaments, to polypropylene tape with separate non-absorbable sutures Ethibond 2.0 over a length of 5-6 cm, 9. The method according to claim 1, characterized in that after pulling the tape, perineoplasty is performed according to indications.