UA136603U - METHOD OF TREATMENT OF PELVIS PROLAPSY AND URINARY INHENTION IN WOMEN - Google Patents

Abstract

A method of treating pelvic prolapse and urinary incontinence in women by laparoscopic intervention, fixation of the uterus with an implant by inserting a probe, which conducts an implant - a ureteral catheter in the round ligament of the uterus or near it, fixing the implant with clips, corrugation round uterine ligaments, and the catheter contains a strengthening thread placed inside, and the fixation of the strengthening thread is carried out on the proximal and distal edges of the round ligament of the uterus.

Description

The useful model belongs to medicine, namely operative gynecology and urology, and can be used in the surgical treatment of pelvic organ prolapse and stress urinary incontinence in women.

According to world statistics, the frequency of prolapse of the pelvic organs in women (POMT) reaches 7895, while the frequency of stress urinary incontinence (SNS) occurs in 50-82 95 cases (See "Gynecology: national guidance" edited by V.I. Kulakova, I.B. Manukhina, H.M.

Savelievoi, M., GEOTAR - Media, 2011, p. 1088). This pathology significantly reduces the quality of life, is detected at late stages and usually requires surgical intervention.

The main methods of surgical correction of pelvic organ prolapse and its complications in the form of urinary incontinence are known (see "Prolapse of internal genital organs and stress urinary incontinence in women: pathogenesis, clinic, diagnosis, modern approaches to treatment". Divakova

T.S., Reproductive health in Belarus 2009, Mo. 5, p. 21-37, "Operative gynecology. Atlas" translated from English, H. Hirsch, O. Kezer, F. Ikle; under the editorship V.I. Kulakova, I.V. Fedorova, M., GEOTAR,

Medicine, 1999 656, "Prosthetic reconstruction of the pelvic floor by vaginal access: a modern view of the problem", D.D. Shkarupa, N.D. Kubin, Experimental and clinical urology. M., 2015, Mo. 1, p. 88-93).

These are such methods as: 1) paraurethral administration of volume-forming drugs, 2) reconstructive plastic surgery of the vagina (with organ loss), 3) correction of the bladder neck, 4) ventrofixation, 5) simultaneous fixation of the uterus and correction of the neck/urethra of the urinary bladder bubble

However, known methods do not provide the necessary effectiveness of surgical treatment, as there is a possibility of serious complications and recurrences. None of the known methods eliminate pelvic organ prolapse, correcting stress incontinence does not eliminate its cause - pelvic organ prolapse, which often leads to a recurrence of urinary incontinence.

There are known methods of treatment of pelvic organ prolapse and stress urinary incontinence by performing simultaneous, one-time operations, which allow solving this pathology pathogenetically (see Lebedeva E.A. "Simultaneous laparoscopic cholecystectomies and

On gynecological operations in the combined pathology of the gallbladder and pelvic organs", Diss. Candidate of Medical Sciences, Moscow, 2010, p. 123; Magdiev T.Sh. "Combined operations in abdominal surgery" Surgery. 1999. , Mo b, pp. 54-55. Maistrenko, N.A. "Simultaneous endovideosurgical interventions in diseases of the uterus and appendages combined with uncomplicated forms of gallstone disease", Journal of Obstetrics and Women's Diseases, 2008, vol. 57, Mo Z, pp. 18-23).

However, simultaneous operations do not provide the necessary effectiveness of surgical treatment, as there is a possibility of serious complications and relapses, such as the occurrence of an autoimmune reaction to a foreign object with the development of a septic condition, which requires a repeat operation to remove the mesh and a repeat operation to eliminate the pathology, the short-term effectiveness of the treatment , operations without preserving the organ, which exclude the possibility of further pregnancy.

A known method of treating pelvic organ prolapse and stress urinary incontinence is sacrocolpopexy, an operation to correct pelvic organ prolapse. The known method consists in restoring the vaginal vault by fixing a special mesh that supports the organ in its correct anatomical position (see "Gynecology. National guidelines" edited by V.I. Kulakova, I.B. Manukhin, M. Savelievoi, M. , "-EOTAR MEDIA", 2011, p. 869). The operation can be performed both laparoscopically and open. When performing laparoscopic vaginopexy, amputation or extirpation of the uterus, posterior uterine colpopexy according to Vyp (for stress urinary incontinence) can be performed ), suturing of paravaginal defects. Sacrocolpopexy is performed using a TEP system, which is a polypropylene mesh.

In a known method, laparoscopy is performed under endotracheal anesthesia using three additional trocars. Open the back leaf of the parietal peritoneum above the level of the promontorium, which is highlighted to clearly visualize the transverse presacral ligament. The back leaf of the peritoneum is opened along the entire length from the promontorium to

Douglas space. The elements of the rectovaginal septum are distinguished: the front wall of the rectum, the back wall of the vagina up to the level of the muscles that raise the anus. The implant is a mesh prosthesis 3x15 cm made of polypropylene, fixed with non-absorbable sutures for the levators on both sides as distally as possible. Then, the implant is fixed with two identical stitches to the cervix or dome of the vagina during a hysterectomy. Then a mesh prosthesis 3x5 cm made of polypropylene 60 is fixed to the previously mobilized front wall of the vagina and sewn to the previously installed implant in the area of the dome of the vagina or the stump of the cervix. By moderately stretching, the prosthesis is fixed with one or two non-absorbable sutures to the transverse presacral ligament. At the last stage, peritonization is performed. If necessary, they also perform an operation for Birch.

However, the known method does not provide the necessary effectiveness of surgical treatment, as there is a possibility of severe complications and relapses: an autoimmune reaction with the development of a purulent-septic process due to the rejection of the mesh, a pronounced adhesion process.

The frequency of cystocele formation in the postoperative period in patients after sacrocolpopexy with the TEP system leads to the recurrence of urinary incontinence in 1.3-92 95 operations. In most countries, this method was prohibited by the EOA decision. In addition, the TEP system itself is quite expensive.

The closest analogue is the method of treating pelvic organ prolapse and urinary incontinence in women (see patent of Ukraine for a utility model Mo 109201 dated 01.31.2016, published on 08.10.2016,

IPC Ab6T1B 17/42) by performing laparoscopic intervention, fixation of the uterus with the help of an implant by inserting a probe through which a ureteric catheter is passed into the round ligament of the uterus or near it, fixation of the implant, corrugation of the round ligament of the uterus.

In a known method, the round ligaments of the uterus are first incised, retreating 2-5 mm from the point of entry of the round ligament of the uterus into the leaves of the parietal peritoneum of the side walls of the pelvis, then a probe is inserted into the canal of the round ligaments, a ureteric implant is carried out through it a catheter that is fixed to the round ligament with clips, while two clips are placed on the round ligament of the uterus, departing 2-5 mm from the departure of the round ligament of the uterus from the body of the uterus (proximal edge of the ligament), and two clips - on the distal edge of the round ligament of the uterus, if necessary, the ligament is fixed in the middle third.

However, the known method does not provide the necessary effectiveness of surgical treatment, as there is a probability of such complications as partial uterine discinnation a few years ago, elongating the distal and proximal ends of the round ligaments of the uterus, which do not have a rigid fixation.

The useful model is based on the task of improving the method of treating prolapse of the pelvic organs and urinary incontinence in women by laparoscopic intervention, in which

By introducing a new element and performing a new stage of fixation of the round ligament of the uterus, the efficiency of surgical treatment is improved by increasing the strength of the implant and the reliability of its fixation.

The task is solved by the fact that in the known method of treating prolapse of the pelvic organs and urinary incontinence in women by performing laparoscopic intervention, fixation of the uterus with the help of an implant by inserting a probe through which the implant - a ureteric catheter is placed in the round ligament of the uterus or near it, fixation of the implant, corrugation of the round ligament of the uterus, what is new, according to the claimed technical solution, is that the urinary catheter contains a strengthening thread placed inside it, and the fixation of the strengthening thread is carried out on the proximal and distal edges of the round ligament of the uterus.

What is also new is that the reinforcing thread is made of propylene.

The cause-and-effect relationship between the set of essential features of the claimed technical solution and the achieved result is that the new features, namely: - the use of a ureteric catheter, which contains a strengthening thread placed inside it; - implementation of fixation of the strengthening thread on the proximal and distal edges of the round ligament of the uterus, together with the known features of the method, ensure an increase in the effectiveness of surgical treatment due to an increase in the strength of the implant and the reliability of its fixation.

This is explained as follows.

The use of a ureteral catheter, which contains a strengthening thread placed inside it; allows to increase the strength of the implant itself. Fixation of the reinforcing thread is carried out at a distance of 1-2 mm from the proximal and distal edges of the round ligament of the uterus, which increases the reliability of fixation of the implant. For the most reliable fixation of the implant to the round ligament of the uterus, the reinforcing thread is fixed along the round ligament with the first clip, and then, directing the thread in the opposite direction, it is fixed with the second clip.

The declared method of treatment is minimally traumatic, which is confirmed by both small blood loss and minimal postoperative pain and rapid (1-2 days) recovery of physiological functions. As a result, the length of stay of patients in the hospital is shortened.

Operative treatment by the claimed method allows you to combine it with many urological operations, which also makes the treatment of patients with associated diseases less traumatic.

The proposed method practically eliminates the likelihood of complications, such as an autoimmune reaction to a foreign material due to the fact that both the reinforcing thread inserted into the urinary catheter and the catheter itself do not cause autoimmune reactions, and also, introduced into the round the uterine ligament or fixed near it, exclude the contact of the pelvic organs with the implant, and, accordingly, in the future, the conditions for the occurrence of a purulent-septic process are eliminated.

The method is cost-effective. The cost of treatment does not increase due to the low cost of the reinforcing thread and material for fixing the ligamentous apparatus. And due to the saving of medicines, the reduction of the duration of the hospital period and the terms of rehabilitation of the patient, the cost of treatment is reduced.

The claimed method is carried out as follows.

Before surgery, an implant is prepared, for which a ureteral catheter is used

Mo 5 pull out the mandrel and cut off two segments of the ureteric catheter, each 10 cm long, using the distribution strips that are on the ureteric catheter, which corresponds to the average physiological norm of the length of the round ligament. A non-absorbable thread, such as propylene, is inserted into both parts of the ureteral catheter.

Under endotracheal anesthesia, laparoscopic intervention is performed using a camera and 2-3 additional trocars. At the first stage, the round ligaments of the uterus are incised, retreating 1-2 mm from the point of entry of the round ligament of the uterus into the leaves of the parietal peritoneum of the side walls of the pelvis. A probe is inserted into the canal of round ligaments. A ureteric catheter with a propylene thread placed in it is passed through the probe. The edges of the thread and the urinary catheter are fixed to the round ligament of the uterus with clips. Two clips are placed on the round ligament of the uterus with a removed propylene thread and one clip on the ureteral catheter, reinforced with a propylene thread, retreating 2 mm from the departure of the round ligament of the uterus from the body of the uterus to the so-called proximal edge of the round ligament of the uterus , similarly - to the distal edge of the round ligament of the uterus. For greater reliability of attaching the implant to the round ligament of the uterus, the first clip is placed on the thread located along the round ligament and the round ligament, then the thread is directed into

From the opposite direction - towards the distal end and fix the thread with the round ligament, the third clip is placed on the round ligament, the thread and the urinary catheter. The round ligament of the uterus is crimped and fixed in the middle third with 2-3 clips, depending on the length of the overstretched round ligament of the uterus.

If necessary, the second stage is a modified Birch operation. The modified operation according to Birch (angulation of the urethra) includes corrugation of the paraurethral vaginal tissue to the middle of the urethra, its fixation to the Cooper's ligament using non-absorbable suture material.

Example 1.

Patient B., born in 1952, was admitted with complaints of a foreign body feeling outside the vagina, pain in the lower abdomen; leakage of urine when laughing, sneezing, coughing, during physical exertion, when turning the body in a lying position, at rest. The examination was carried out in full. The diagnosis was made: Pelvic organ prolapse. Lowering of the front wall of the vagina. Cystocele of the 2nd degree. Stress urinary incontinence, severe, type 20. Simultaneous operation was performed under anesthesia (ventilation «5 IV) as follows.

At the first stage, the round ligaments of the uterus were incised, departing from the point of entry of the round ligament of the uterus into the leaves of the parietal peritoneum of the side walls of the pelvis by 1-2 mm. A probe was inserted into the canal of round ligaments. Through the probe, an implant - a ureteric catheter was inserted into the round ligament of the uterus. The ureteral catheter, reinforced with a propylene thread placed in it, is fixed to the round ligament of the uterus with clips at the edges of the thread and the ureteral catheter itself. Two clips are placed on the round ligament of the uterus with a removed propylene thread and one clip on the ureteral catheter, reinforced with a propylene thread, retreating 1-2 mm from the departure of the round ligament of the uterus from the body of the uterus (proximal edge of the ligament), similarly - on the distal edge of the round ligament of the uterus. The ligament is crimped and fixed in the middle third with 2-3 clips, depending on the length of the overstretched round ligament of the uterus. In the second stage, a modified Birch operation was performed: corrugation of the paraurethral vaginal tissue to the middle of the urethra and fixation of the vaginal tissue to Cooper's ligament. A urinary catheter was installed.

The patient's condition in the postoperative period was stable. The Foley catheter was removed on the 3rd day of the postoperative period. The patient urinated freely, the urine was clear, in sufficient quantity, she did not notice pain in the lower abdomen and during urination, she stopped feeling the presence of a foreign body. When sneezing, coughing, laughing, walking, the urine is retained, the underwear is dry. She was discharged in a satisfactory stable condition. After 3 months, a follow-up examination was recommended. According to the control examination: when sneezing, coughing, laughing, walking for a long time, climbing stairs, lifting heavy objects - underwear is dry, there are no pains in the lower abdomen and when urinating, the feeling of the presence of a foreign body is also absent.

Example 2.

Patient K., born in 1944, was admitted with complaints of a foreign body feeling outside the vagina; leakage of urine when laughing, sneezing, coughing, during physical exertion. The examination was carried out in full. The diagnosis was established: Prolapse of the pelvic organs. Lowering of the front wall of the vagina. Cystocele of the 2nd degree. Stress urinary incontinence, moderate degree of severity, type 20. Simultaneous operation was performed under anesthesia (ventilation and IV) as follows.

The first stage: an implant - a ureteric catheter is placed along the probe, placing it near the round ligament of the uterus, the ureteric catheter is fixed, reinforced with a propylene thread placed in it, the corrugation of the round ligament of the uterus is carried out. The edges of the thread and the urinary catheter are fixed to the round ligament of the uterus with clips. Two clips are placed on the round ligament of the uterus with a removed propylene thread, and one clip is placed on the ureteral catheter, reinforced with a propylene thread, receding 1-2 mm from the departure of the round ligament of the uterus from the body of the uterus (proximal edge of the ligament), similarly - on the distal edge of the round ligament of the uterus. The ligament is crimped and fixed in the middle third with 2-3 clips, depending on the length of the overstretched round ligament of the uterus.

For more reliable fixation of the thread to the round ligament of the uterus, the thread is fixed along the round ligament with the first clip, and then, directing the thread in the opposite direction, it is fixed with the second clip. In the second stage, a modified Birch operation was performed: corrugation of the paraurethral vaginal tissue to the middle of the urethra and fixation of the vaginal tissue to Cooper's ligament. A urinary catheter was installed.

The patient's condition in the postoperative period was stable. The Foley catheter was removed on the second day of the postoperative period. The patient urinated freely, the urine was light, in sufficient quantity, she did not notice any pain during urination, she stopped feeling the presence of a foreign body. When sneezing, coughing, laughing, walking, the urine is retained, the underwear is dry. She was discharged in a satisfactory stable condition. After 3 months, a follow-up examination was recommended. According to the control examination: when sneezing, coughing, laughing, walking for a long time, climbing stairs, lifting heavy objects - underwear is dry, pain during urination, the feeling of the presence of a foreign body is absent.

Thus, the claimed method provides an increase in the effectiveness of surgical treatment by increasing the strength of the implant and the reliability of its fixation, as well as an increase in economic efficiency by reducing the duration of the hospital period, the patient's rehabilitation period and the amount of medication.

The claimed method can be implemented using known technologies and known devices, which confirms its industrial suitability.

Claims (2)

USEFUL MODEL FORMULA 1. The method of treatment of prolapse of the pelvic organs and urinary incontinence in women by laparoscopic intervention, fixation of the uterus with the help of an implant by inserting a probe, which is followed by an implant - a ureteric catheter in or near the round ligament of the uterus, fixation of the implant with clips, corrugation of the round ligament of the uterus, which differs in that the catheter contains a strengthening thread placed inside, and the fixation of the strengthening thread is carried out on the proximal and distal edges of the round ligament of the uterus. 2. The method of treating pelvic organ prolapse and urinary incontinence in women according to claim 1, which differs in that the reinforcing thread is made of propylene.