RU2741197C1 - Method of simultaneous combined surgical treatment of urinary incontinence combined with prolapse of pelvic organs - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to operative urogynecology. Three working trocars are installed: two symmetrically to the right and left on the borders of the lateral and middle one-third of the lines connecting the umbilicus with the front upper iliac spines, and one is pararectal to the right of the border of the upper and middle one-third of the line connecting the umbilicus and upper edge of pubic bone. Method comprises accessing a pre-bubble space, separating the Gimbernat ligaments, in the bladder neck region, an anterior vaginal wall is separated, colpovesicosuspension is combined with double non-absorbable ligatures by suturing the anterior-lateral walls of the vagina within the neck of the urinary bladder and fixing them to the Gimbernat ligaments. Parietal peritoneum is opened above the lateral surfaces of the first sacral vertebra at the level of the cape and over the posterior surface of the uterine cervix or vaginal stump at sac lateral uterus ligament points (SUL), tunnels are formed under peritoneum on SUL course on both sides. Posterior surface of the uterine cervix or a vaginal stump is fixed by means of sutures fixing an implant having an oval platform and symmetrically extending "sleeves" from it, which are carried out through the created tunnels and fixed by non-absorbable sutures to the presacaraxis on each side, peritoneum defects are sutured.EFFECT: method enables reliable elimination of urinary incontinence of all types with simultaneous elimination of prolapse of pelvic organs and restoration of sexual function by single-step and single-stage fixation by implant of whole organocomplex - uterus, bladder, uterine ligaments, cervix or vaginal stump, which enables to restore the physiological functions of the lumbar pelvic apparatus and normal anatomy of the vaginal walls.1 cl, 4 ex, 1 dwg

Description

The technical field to which the invention relates

The invention relates to medicine, in particular to operative urogynecology, and can be used in the surgical treatment of urinary incontinence of any type in combination with pelvic organ and vaginal prolapse.

State of the art

The known method of laparoscopic promontofixation (patent RU 2612518, 09.03.2017). Under general anesthesia with endotracheal intubation, the patient is placed in the inferior lithotomy position with the legs resting on the universal patella. A Foley 18-20 French catheter is inserted into the bladder. After emptying the bladder, 5 ml of sterile saline is injected into the bladder. The laparoscope is inserted through a vertical supra-umbilical incision and three punctures of the anterior abdominal wall are made. After examining the internal organs, the patient is transferred to the Trendelenburg position of 30-35 degrees and the pelvic organs are examined. If necessary, bowel loops are suspended by stitching fatty suspensions and fixing them to the anterior abdominal wall outside the operating field. With conventional or ultrasonic laparoscopic scissors, a longitudinal incision of the parietal peritoneum is made below the bifurcation of the aorta and lateral to the median sacral vein, going further slightly to the right and down along the sacral cavity to the isthmus of the uterus in the area of attachment of the sacro-uterine ligaments. The peritoneum is separated from the underlying tissues, forming a tunnel for placement of the mesh implant. The U-shaped end of the synthetic implant is fixed to the sacro-uterine ligaments with two non-absorbable sutures. Three non-absorbable sutures are placed between the mesh implant and the isthmus of the uterus. The proximal end of the implant is fixed to the presacral ligament. After control of hemostasis and sanitation of the operating field, peritonization is performed. The operation is complemented by the plastic surgery of the sacro-uterine ligaments according to MacCoul or obliteration of the posterior space in the modification of Moschcowitz and colpoperieolevatoroplasty.

The disadvantage of this method is the unilateral implementation of the implant, which requires additional plastics of the sacro-uterine ligaments to completely eliminate prolapse, the impossibility of creating support for the middle part of the urethra, which, after elimination of prolapse, leads to increased symptoms of stress urinary incontinence.

Closest to the proposed method is laparoscopic bilateral cervicosacropexy and vaginosacropexy: new surgical treatment oprion in women with pelvic organ prolapse and urinary incontinence. Socol Rexhepi, MD, Entela, Mall Martin Rexhepi, MD MD, PhD, and Sebastian Ludwig, MD Journal of Endourology, Volume 32, Number 11, November 2018 Mary Ann Liebert, Inc. Pp. 1058-1064). Under general combined endotracheal anesthesia, a single injection of a prophylactic dose of an antibiotic is performed. The patient is placed on her back in a lithotomy position. A temporary catheter is placed in the bladder. Depending on the presence of the uterus, a probe is inserted into the vagina to identify and manipulate the vaginal fornix intraoperatively, if necessary. The patient is fixed in the Trendelenburg position of 25 degrees. Carboxyperitoneum is created, five trocars are inserted. The sites of exit and attachment of the sacro-uterine ligaments in the cervical region are identified by means of elevation of the uterus or vaginal stump with a vaginal probe and at the sacral vertebrae. The peritoneum is opened above the fornix of the vagina for its exposure. Prosthetics of the sacro-uterine ligaments is performed with a standardized synthetic structure (mesh) made of polyvinylalidine fluoride PVDF (Dynamesh CESA or VASA; FEG Textiltechnik mbH Company, Aachen, Germany). The central part of this structure is fixed to the cervix or vaginal fornix using three non-absorbable sutures. The peritoneum is opened over the first sacral vertebra by 1.5 cm on each side. The clamp is performed under the peritoneum along the sacro-uterine ligaments from 2 sides towards the cervix or vaginal stump. Each sleeve of PVDF mesh is pulled by a clamp through the created tunnel under the peritoneum on each side of the pelvis. PVDF mesh sleeves are fixed with three titanium screw clips to the prevertebral fascia of the first sacral vertebra. All defects of the peritoneum are sutured. The bladder catheter is removed 3 hours after surgery.

However, the method has the following disadvantages:

• Insufficiency of the pubo-urethral ligament is not eliminated, thus, the stress component of urinary incontinence remains, and in some cases even increases

• Cystocele is not eliminated, which is a factor in the preservation of difficulty urinating, the presence of residual urine, infectious and inflammatory complications.

• A large number of trocar approaches are used, which increases the risk of complications associated with their installation

• The standardized mesh has a 4 cm central platform, which requires a large tissue dissection in the cervix or vaginal stump, thus disrupting tissue nutrition over a large area of the vaginal wall, increasing the risk of implant arrosion through the tissues of the vaginal fornix.

• Fixation of the proximal sleeves with screw-in staples carries the risk of infectious and inflammatory complications in the sacrum

• There is no correction for low rectocele, sexual dysfunction associated with pelvic floor muscle divergence and gaping genital fissure.

The technical problem solved in the present invention is the elimination of urinary incontinence of all types with the simultaneous elimination of pelvic organ prolapse and restoration of sexual function.

Disclosure of the essence of the invention

The achieved technical result is a reliable elimination of urinary incontinence of all types with the simultaneous elimination of pelvic organ prolapse and restoration of sexual function due to one-stage and one-stage fixation by means of an implant of the entire organocomplex - the uterus, bladder, uterine ligaments, cervix or vaginal stump, which allows to restore physiological functions the ligamentous apparatus of the small pelvis and the normal anatomy of the vaginal walls.

The technical result is achieved due to the following set of essential features:

three working trocars are installed: two symmetrically on the right and left at the borders of the lateral and middle third of the lines connecting the navel with the anterior superior spines of the iliac bones and one pararectally to the right of the border of the upper and middle third of the line connecting the navel and the upper edge of the pubic bone; due to this arrangement of trocar approaches, a physiologically correct exit to the region of the sacro-uterine ligaments is achieved, the possibility of creating a retroperitoneal tunnel, access to the fixation points of the colposuspension and the implant;

access the pre-vesicular space, isolate the Gimbert ligaments, isolate the anterior-lateral walls of the vagina in the area of the bladder neck, perform colpovesicosuspension with double non-absorbable ligatures by suturing the anterior-lateral walls of the vagina in the region of the bladder neck and fixing them to the Gimbert's ligaments; Thus, a structure is created that performs the function of the pubo-urethral ligament, and the stress type of urinary incontinence is eliminated.

the parietal peritoneum is opened above the lateral surfaces of the first sacral vertebra at the level of the promontory and above the posterior surface of the cervix or vaginal stump at the sites of origin of the sacro-uterine ligaments (CCL), tunnels are formed under the peritoneum along the CCM on both sides; creation of tunnels reduces the risk of damage to nerve fibers from the stretch receptors of the bladder, fibers of the ligaments, improves the positioning of the implant

to the posterior surface of the cervix or vaginal stump with the help of sutures, an implant is fixed, which has an oval-shaped platform and "sleeves" symmetrically extending from it, which are passed through the created tunnels and fixed with non-absorbable sutures to the presacral fascia on each side; defects of the peritoneum are sutured. The oval shape of the implant is easier in subsequent peritonization, narrow sleeves provide easier healing, the response of the surrounding tissues to the implant decreases with effective restoration of the function of the sacro-uterine ligaments. The fixation of the sleeves laterally from the promontory of the sacrum eliminates the risk of damage to nerve fibers, blood and lymph vessels.

Moreover, the implant can be made, for example, of a polypropylene mesh.

Brief Description of Drawings

FIG. 1 shows a schematic view of a synthetic polypropylene implant, where 1 is a platform, 2 is a "sleeve"

The implant is a mesh structure made, for example, of polypropylene, which has a platform, mainly 3 cm long and 2 cm wide, as well as 2 "sleeves", each sleeve is 10 cm long and 5 mm wide.

Implementation of the invention

Under endotracheal anesthesia, the patient is placed in a dorsal lithotomy position with the head end lowered by 20-25 degrees. A temporary urethral Foley catheter No. 16 is installed in the bladder, the balloon is filled with a sterile saline solution of 15 ml, the bladder is emptied. A manipulator is installed in the vagina to elevate the anterior wall and uterus to a physiological position. A skin incision is made along the upper edge of the navel, and a laparoscope is installed. A carboxyperitoneum of 12 mm Hg is created.

Three working trocars with a diameter of 5 mm are installed: two symmetrically at the boundaries of the lateral and middle third of the lines connecting the navel with the anterior superior spines of the iliac bones on the right and left and one pararectally (mainly 2 cm) to the right of the border of the upper and middle third of the line connecting the umbilicus and the upper edge pubic bone.

A transverse approach opens the parietal peritoneum along the anterior wall between the lateral folds, provides access to the prevesical space, bluntly separates the Gimbert's ligaments in the area of the pubic articulation, lateral and above it, and the antero-lateral walls of the vagina in the area of the bladder neck. Colpo-vesicosuspension is performed with double non-absorbable ligatures by suturing the antero-lateral walls of the vagina in the region of the bladder neck and fixation to the Gimbert ligaments. Next, the parietal peritoneum is opened, above the lateral surfaces of the first sacral vertebra at the level of the promontory. The parietal peritoneum is opened above the posterior surface of the cervix or the vaginal stump at the sites of the sacro-uterine ligaments (MCL). In a blunt way, a tunnel is formed under the peritoneum along the CCM. An implant is formed from a polypropylene mesh, which has the following parameters: an oval-shaped fixation area, mainly 3 cm long and 2 cm wide, from which "sleeves" extend symmetrically, mainly having dimensions - 10 cm long and 5 mm wide. The mesh is placed in the abdominal cavity. The oval-shaped implant site is fixed to the posterior surface of the cervix or to the vaginal stump using 3 non-absorbable sutures.

The “sleeves” are held by means of a clamp through the created tunnels and fixed to the presacral fascia with 2 non-absorbable sutures on each side. Fixation is performed outside the location of blood vessels and nerve fibers.

After hemostasis control, all peritoneal defects are sutured with absorbable sutures.

The urethral catheter is removed the next day.

This method allows you to simultaneously eliminate urinary incontinence of any type and severity, cystocele, recto- and enterocele, failure of the pelvic floor muscles, excessive expansion of the vaginal canal without the use of significant tissue dissection with minimal risk of damage to adjacent organs, nerve structures, blood vessels and without the use of large meshes. size.

Example 1. Patient P., 41, was admitted with the Diagnosis: mixed urinary incontinence, severe severity. Genital prolapse POP-Q grade 3 (Ba + 3 C + 2 Bp-3). Upon receipt of a complaint about the sensation of a foreign body in the vagina, urinary incontinence with stress, coughing, sneezing, frequent urgent urge to urinate. Anamnesis: Pregnancy -2 Childbirth-2, large fetus. The above complaints are over a year old. On examination: the genital gap gapes, prolapse of the pelvic organs Ba + 2 C + 2 Bp-2 Cystocele 3 degrees. Marshall test is positive. ICIQ-SF - 14 points.

One-stage surgical treatment was performed according to the developed technique: laparoscopic colpovesicosuspension, bilateral cervicosacropexy, colpolevatoroplasty. The duration of the operation is 150 minutes, blood loss is 50 ml. The postoperative period was without complications. Spontaneous urination was restored for 1 day. Symptom regression was noted. The patient was discharged on the 3rd day.

Inspection after 1, 6, 12 months. There is no recurrence of displacement of the internal genital organs. Ba-3 C-3 Bp-3. ICIQ-SF - 0 points. No urinary incontinence.

Example 2. Patient L., 45 years old. Received with Diagnosis: Urinary incontinence of the urgency type, moderate. Genital prolapse POP-Q grade 3. Upon receipt of a complaint of a constant urge to urinate, urinary incontinence, difficulty urinating. Anamnesis: 2 childbirth, large fetus. The above complaints are more than 3 years old. On examination: the genital gap gapes, when straining the cervix protrudes from the vestibule of the vagina. Descent of the bladder 3 degrees, prolapse of the rectum 3 degrees. Ba + 3 C + 2 Bp + 3pb0.5, Marshall test is negative. ICIQ-SF - 11 points.

One-stage surgical treatment was performed according to the developed technique: laparoscopic colpovesicosuspension, bilateral cervicosacropexy, colpolevatoroplasty. The duration of the operation is 170 minutes, blood loss is 50 ml.

The postoperative period was without complications. Spontaneous urination was restored for 1 day. Symptom regression was noted. The patient was discharged on the 3rd day.

Inspection after 1, 6, 12 months. There is no recurrence of displacement of the internal genital organs. Ba-3 C-3 Bp-3, ICIQ-SF 3 points. Episodes of urinary incontinence no more than 1 time per week, a few drops.

Example 3. Patient Po., 41 years old, was admitted with the Diagnosis: Mixed urinary incontinence, moderate severity. Genital prolapse POP-Q grade 3 (Ba + 3 C + 2 Bp-3). Upon receipt of a complaint about the sensation of a foreign body in the vagina, urinary incontinence with stress, coughing, sneezing, physical exertion, frequent urge to urinate, painful intercourse. Anamnesis: Pregnancy -1 Childbirth-1, large fetus. The above complaints are more than 2 years old. On examination: the genital gap gapes, prolapse of the pelvic organs Ba + 2 C + 2 Bp-3 Cystocele of the 2nd degree. Marshall test is positive. ICIQ-SF - 12 points. FSFI index - pain domain 3 points.

A one-stage surgical treatment was performed according to the developed technique: laparoscopic colpovesicosuspension, bilateral cervicosacropexy. The duration of the operation is 140 minutes, blood loss is 50 ml. The postoperative period was without complications. Spontaneous urination was restored for 1 day. The patient was discharged on the 3rd day.

Inspection after 1, 6 months. Ba-3 C-3 Bp-3. ICIQ-SF - 0 points. The patient is carrying a pregnancy. At the time of examination 6 months after surgery, the pregnancy is 18 weeks. Postoperative FSFI Index - pain domain of 11 points, which corresponds to minimal symptomatology.

Example 4. Patient C., 68 years old. Received with Diagnosis: Mixed urinary incontinence, severe. Genital prolapse POP-Q grade 3. Upon receipt of a complaint of constant uncontrolled urinary excretion due to urge and any physical exertion, difficulty urinating. Anamnesis: 4 births through the vaginal birth canal. In 1996, the extirpation of the uterus with appendages, after which the above symptoms began to appear and gradually intensify. Conservative treatment without significant effect. During examination: the genital slit gapes, the vaginal stump, the bladder protrude from the vestibule of the vagina. Descent of the bladder 3 degrees, prolapse of the rectum 3 degrees. Ba + 3 Bp + 3, Marshall test is positive. ICIQ-SF - 18 points.

One-stage surgical treatment was performed according to the developed technique: laparoscopic colpovesicosuspension, bilateral cervicosacropexy, colpolevatoroplasty. The duration of the operation is 190 minutes, the blood loss is 100 ml.

The postoperative period was without complications. Spontaneous urination was restored for 1 day. The patient was discharged on the 4th day.

Inspection after 1, 6, 12 months. There is no recurrence of displacement of the internal genital organs. Ba-3 Bp-3, ICIQ-SF 4 points. Episodes of urinary incontinence less than 1 time per week, a small amount.

Operational interventions:

The claimed method performed 52 patients (group 1) with different forms of urinary incontinence and the presence of incomplete prolapse of the uterus with prolapse of the walls of the vagina, cystocele, failure of the pelvic floor muscles.

46 patients (group 2) underwent surgical intervention to eliminate urinary incontinence and correct pelvic organ prolapse according to standard techniques.

Examination after 1, 6, 12 months of patients in both groups of relapses in group 1 was not detected. However, in group 2, 13 patients (~ 30%) had recurrence of pelvic organ prolapse at various stages. In 5 of them, prolapse was accompanied by urinary incontinence.

Thus, the results of treatment indicate an effective, relapse-free course of the postoperative period in the long-term, which makes it possible to consider the use of the method of simultaneous surgical treatment of urinary incontinence with the restoration of pelvic organ prolapse as effective due to the elimination of any type of urinary incontinence, cystocele, recto- and enterocele, pelvic floor muscle failure without the use of traumatic or multi-stage interventions.

Claims (2)

1. A method of simultaneous combined surgical treatment of urinary incontinence in combination with pelvic organ prolapse by laparoscopic access, including the placement of trocars, the formation of a tunnel for the implant, fixation of the cervix or vaginal stump by means of an implant in the sacral region, characterized in that three working trocars are installed: two symmetrically to the right and left at the borders of the lateral and middle third of the lines connecting the umbilicus with the anterior superior spines of the iliac bones, and one pararectally to the right of the border of the upper and middle third of the line connecting the umbilicus and the upper edge of the pubic bone, access the prevesical space, isolate the Gimbert ligaments , in the area of the bladder neck, the anterior-lateral walls of the vagina are isolated, colpovesicosuspension is performed with double non-absorbable ligatures by stitching the anterior-lateral walls of the vagina in the area of the bladder neck and fixing them to the Gimbert ligaments, opening the parietal b ryushina above the lateral surfaces of the first sacral vertebra at the level of the promontory and above the posterior surface of the cervix or vaginal stump at the sites of discharge of the sacro-uterine ligaments (CML), form tunnels under the peritoneum along the CCM on both sides, to the posterior surface of the cervix or vaginal stump when with the help of sutures, an implant is fixed, which has an oval-shaped platform and "sleeves" symmetrically extending from it, which are passed through the created tunnels and fixed with non-absorbable sutures to the presacral fascia on each side, the defects of the peritoneum are sutured. 2. The method of claim 1, wherein the implant is made of a polypropylene mesh.

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