RU2476176C2 - Method of surgical treatment of prolapse of anterior wall of vagina in women with preserved cervix - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to gynecology. Vagina and underlying fascia are dissected from transvaginal access in 2.5-3 cm from urethra orifice. Mesh implant with four sleeves is passed by means of guides through proximal and distal parts of tendinous arch of pelvic fascia on perineum. Sleeves are brought out and sewn to each other from two sides without tension above obturating membrane. Implant ids fixed to anterior surface of cervix. Posterior wall of vagina is dissected in 3-4 cm from external os in area of posterior fornix. Cervix is fixed to extraperitoneally exposed from both sides sacro-uterine ligaments with 1.5 cm wide prolene tape. Free sleeves of tape are brought out through medial parts of sacrospinous ligaments from two sides on perineum.

EFFECT: method ensures reconstruction of neofascia due to fixation of implant in anterior part of pelvis bottom and fixation of cervix with prolene tape to the strongest structures of pelvis minor.

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Description

The invention relates to gynecology, in particular to operative gynecology.

In Russia, prolapse of the pelvic organs to one degree or another occurs in every 10th woman, and in the group of the late reproductive age - in every 3rd.

Today, there are more than a hundred methods for the surgical treatment of pelvic organ prolapse. These are various methods of vaginal, transabdominal, laparoscopic and robotic surgery, which are successfully performed in our country. However, any surgical treatment for prolapse is associated with a high relapse rate.

Many surgical methods for treating pelvic organ prolapse did not live up to expectations, accompanied, despite its diversity, by a high risk of relapse - from 33 to 58% (12).

The prerequisite for the development of prolapse and an increase in the number of relapses are often undifferentiated forms of connective tissue dysplasia, in which the use of methods using their own, obviously insolvent tissues is doomed to failure, which justifies the wider use of implants. Of the proposed biological and synthetic prostheses, synthetic materials are currently preferred due to fewer complications and higher efficiency (7, 11). There are more than a dozen methods for surgical reconstruction of the pelvic floor using synthetic prostheses.

The modern concept of surgical treatment of genital prolapse should consist of "replacing" the old destroyed pelvic fascia with a new one, with its fixation to the anatomically strong structures of the small pelvis.

The concept of “replacement” surgery is advanced and is reflected in the introduction of new techniques. The transvaginal technology of conducting a synthetic free implant without tension (tension free vaginal mesh) using conductors quickly meets this goal.

According to a systematic review and meta-analysis of randomized trials with the use of mesh technologies in the surgical treatment of genital prolapse, an increase in efficiency of up to 75% -92% was noted (9). Relapses using synthetic materials in the reconstruction of the pelvic floor vary from 5.2 to 8.3% (2). The difference with the results without the use of synthetic materials is obvious.

However, today there is still no consensus on the use of mesh implants in pelvic surgery. Opponents of the use of implants are based on a small number of randomized trials and an increase in the frequency of complications associated with foreign material: erosion, dyspareunia, infectious complications, mesh protrusion (6).

Controversial and debatable aspects of the use of mesh materials are specific complications associated with the presence of foreign material.

According to the results of various researchers, the frequency of erosion during colporography with the installation of synthetic materials can reach 15-30% (13). However, the likelihood of this complication is sharply reduced to 0.5-5% (5), subject to recommendations for the use of type I nets based on the classification of P.K. Amid (1997).

The requirements for an “ideal implant” are also complemented by high elasticity, strength, low wick ability, biological compatibility, versatility and accessibility of the application technique, and economic feasibility.

We are supporters of the use of mesh-technologies in young women, as one of the most significant causes of genital prolapse and their relapses, researchers consider signs of “weakness” of connective tissue detected more often in “young” women (3). This fact is a good reason for the use in women with poor connective tissue, according to the general principles of herniology, additional strengthening materials that can initiate the body's reaction in the form of fibrosis and the formation of dense connective tissue (8).

This is especially true for women with obviously insolvent connective tissue, usually of reproductive age, with a characteristic “aggressive” course of the disease with the formation of combined forms of prolapse and prolapse of the internal genital organs (Shalaev O.N., 2008).

The front wall of the vagina is most often affected by VET, undergoing more trauma in childbirth and experiencing a greater influence of fluctuations in estrogen levels. About 80% of reconstructive interventions on the pelvic floor are performed with cystocele correction. The maximum percentage of recurrent forms of omission, more than 40%, occurs precisely after operations on the anterior part of the pelvic floor [Fenner Dee E., 2010].

Some authors describe the significant contribution of apical support to the formation and magnitude of cystocele [Hsu Y, Rooney K, Summers A]. Summers et al. determine the role of apical support as a 50% component that forms the condition of the anterior vagina.

B. Fatton recommends adding sacrospinal fixation to the front mesh implant to provide apical support for cystocele correction.

With isolated correction of the anterior part of the pelvic floor using mesh technology, the frequency of significant (≥II stage POP-Q) prolapse of the initially intact parts: posterior in 46%, apical in 14%. [Mariëlla I.J. Withagen et al.].

The prototype of the method we developed for the surgical treatment of pelvic organ prolapse using synthetic material was the transvaginal synthetic implant without tension using conductors (Transvaginal Mesh Procedures for Pelvic Organ Prolapse, No.254, February 2011, http://www.sogc.org/ guidelines / documents / gui254TU1102E.pdf).

There are many common techniques for transvaginal mesh implant, but we consider it necessary to further improve these techniques.

According to our observations, the tendon arch of the pelvic fascia was absent or poorly expressed in 33.4% of women, and according to the literature, in 50-70% of women (4). This may increase the risk of recurrence of prolapse of the anterior vaginal wall (FIG. 1).

We have proposed a new method for surgical treatment of genital prolapse using a mesh implant established by transvaginal access.

Today on the medical market there are many synthetic implants for surgical reconstruction of the pelvic floor.

However, we use an implant made of a non-absorbable cut in a single block mesh (figure 2), made of a material with polypropylene monofilaments with a diameter of not more than 0.07 mm, surface porosity of less than 40 g / m ² and bulk porosity of 98.

These grid parameters create a unique structure, which, in turn, helps to increase its flexibility. A lightweight endoprosthesis for reconstructive surgery of the pelvic floor has exceptional softness and high bulk porosity. Due to the combination of high bioinertness indicators and special structural and mechanical properties, the mesh ensures the formation of a thin, delicate and uniform scar in the implantation zone. The endoprosthesis is highly resistant to infection. The mesh has excellent strength, durability and surgical adaptability and has a suitable porous structure, which is necessary for more efficient germination of collagen.

The mesh implant for reconstruction of the anterior section has a ready-made original shape, the cervix is fixed with a mesh tape up to 1.5 cm wide.

The use of additional support points when fixing the mesh implant allows you to use a lighter mesh, which, accordingly, reduces the number of complications, such as erosion, incomplete healing of the vaginal mucosa, dyspareunia, etc.

As a device to facilitate the conduct of a synthetic implant and fix it to reliable structures of the pelvic floor, reusable conductors can be used.

The technical result of this invention is the effective treatment of patients with a preserved cervix when lowering the anterior wall of the vagina by creating neofascia instead of destroyed, which is ensured by a certain method of placement and fixation of the mesh implant in the anterior part of the pelvic floor and additional mandatory fixation of the cervix by the prolene ribbon to the most durable structures of the small pelvis, which prevents the possible subsequent protrusion of the walls of the vagina with an increase in yushnogo pressure, and also due to the use of facilitated due to specific structure of the mesh implant. Additional strengthening of the cervix by the above method allows you to restore the apical part of the pelvic floor, usually combined with prolapse of the anterior part, thereby contributing to the preservation of the length of the vagina, reducing dyspareunia.

The method is as follows.

The operation is usually performed under regional spinal or epidural anesthesia (other methods of analgesia may be used). The patient is placed on the operating table in a lithotomy position. The surgical field is treated with antiseptic solutions, then the bladder is emptied.

Carry out transvaginal access. A longitudinal incision is made of the vaginal mucosa, retreating 2.5-3 cm proximal to the external opening of the urethra. It is necessary to dissect not only the vaginal mucosa, but also the underlying fascia to reduce the risk of erosion in the postoperative period.

Then carry out the reconstruction of the anterior pelvic floor. To do this, use a mesh implant, which has four sleeves for fixation.

Through the conductors through the proximal and distal sections of the tendon arch of the pelvic fascia spend sleeves for fixation, two sleeves on both sides, and bring them to the skin of the perineum. After excretion, they are stitched together with non-absorbable filaments without subcutaneous tension over the obstructive membrane. The excess fabric of the sleeves is cut off, and the remaining ends are immersed in the fabric. The free edges of the implant are fixed to paraurethral tissues and the anterior surface of the cervix, without piercing the mucous membrane of the cervix, using non-absorbable threads. Additionally, a transverse incision is made of the mucous membrane of the posterior wall of the vagina, departing 3-4 cm from the external pharynx in the central part of the posterior fornix (Fig. 3). Through this incision, the cervix is fixed by plication to its posterior surface and the sacro-uterine ligaments of the prolene tape 1.5 cm wide extraperitoneally on both sides using non-absorbable sutures. The free sleeves of the tape by means of conductors are passed through the medial sections of the sacro-spinous ligaments from two sides and then brought out through the skin incisions to the perineum laterally and below the anus. The vaginal wall is sutured with a continuous absorbable suture. Separate sutures suture skin incisions in the perineum.

The bladder is catheterized, tight vaginal tamponade is performed with sterile wipes with antibacterial ointments. After 24 hours, the catheter and tampon are removed.

According to the proposed methodology, 116 patients were operated on. The follow-up period was 3.7 years. During this time, one case of an asymptomatic course of recurrence of the anterior vaginal wall was noted (stage I according to POP-Q).

Erosion, incomplete healing in the early and late postoperative period was not noted.

The results of using a mesh implant in combination with fixation of the cervix by the prolene tape in the surgical treatment of genital prolapse have shown their high efficiency as neofasciogenesis technologies in women with preserved cervix and prolapse of the anterior vaginal wall.

Example 1

B-naya Chernova V.G., 64

Post-menopause.

P-1 Perineal rupture.

Gynecological diseases: uterine fibroids

Complaints about the feeling of a foreign body in the vagina, pulling pains in the lower abdomen, dyspareunia.

POPQ: VA + 1.5 VR-1, C-3 D-5

Ultrasound: Cystocele 3, rectocele 0

Diagnosis: Ptosis of the anterior vaginal wall 3 tbsp with the formation of cystocele 3, high rectocele.

02/26/2009 Operation: Reconstruction of the anterior pelvic floor with additional strengthening of the cervix using a mesh implant according to the claimed methodology.

The operation time is 1.20 minutes. Blood loss 100 ml

There were no complications.

POPQ after surgery: VA-2 VR-2 S-7 D-9

The patient was discharged on time.

Example 2

B-naya Abramova V.I., 50

KUDI: insufficiency of the internal urethral sphincter

MRI: uterine fibroids

Ultrasound: Cystocele 3, transverse defect

rectocele 0,

apex 1

urethral hypermobility

POPQ: Ba + 1.5, BP-2, S-2, D-7

Somatic diseases: hr. hemorrhoids, osteochondrosis, mitral valve prolapse, biliary dyskinesia, varicose veins of the lower extremities. In the family, the prolapse of the walls of the vagina in mother and grandmother. An examination revealed dysplasia of connective tissue 3 tbsp.

P-1 Episiotomy

Gynecological diseases: adenomyosis.

Menopause

Complaints before surgery: urinary incontinence during physical exertion, constipation. DST no.

Diagnosis: Ptosis of the anterior vaginal wall 3, cystocele 3, posterior wall 2, rectocele 0, apical prolapse 1. Stress urinary incontinence.

Operation: 04/27/2010 Reconstruction of the anterior part of the pelvic floor with additional strengthening of the cervix using a mesh implant according to the claimed technique.

Intraoperative: tendon arches are weakly expressed on both sides, paravaginal defect on the right, blood loss of 70 ml

After the POPQ operation:

After 2 months POP-Q: Front 0-1 st, back 0 st, apex 0 st

VA-2 VR-3 S-8 D-9

Complaints of urinary incontinence does not show minor pain in the perineum immediately after surgery. After 1 month the pain stopped. B-naya discharged on time.

Example 3

B-naya Sidorova O.N., 49 years old

Somatic diseases: hr. hemorrhoids, osteochondrosis

P-2 Rapid birth, episiotomy

Gynecological diseases: adenomyosis

The history of this disease: the prolapse of the walls of the vagina for 14 years with a gradual progression. Conducted conservative treatment - Kegel exercises.

Complaints about the feeling of a foreign body in the vagina, drawing pains in the lower abdomen.

Diagnosis: Omission of the anterior wall 3, cystocele 3, posterior 1, rectocele 0, apical prolapse 1, mixed urinary incontinence

Ultrasound: cystocele 3, rectocele 0, apical region 1, urethral hypermobility

MRI: cystocele, asymmetry of the muscles that raise the anus

POPQ: VA + 3 VR-2 C + 1 D-4

KUDI: stress urinary incontinence

03/17/2010 Operation: Reconstruction of the anterior wall of the vagina with additional strengthening of the cervix using mesh materials according to the claimed method + urethropexy transobturator access.

POPQ after surgery: anterior 1 tbsp; apex 0; posterior 0

VA-2 VR-3 S-7 D-9

B-naya discharged on time.

After a year of observation, there is a lack of prolapse of the walls of the vagina, urinary incontinence. There is an improvement in the condition, including the posterior wall of the vagina.

Claims (1)

A method for surgical treatment of prolapse of the anterior vaginal wall in women with a preserved cervix, including reconstruction of the pelvic floor by installing an implant using vaginal access, characterized in that the anterior part of the pelvic floor is reconstructed, using a mesh implant that has four arms for fixation ; the implant is made of a non-absorbable mesh cut out by a single block, made of a material with polypropylene monofilaments with a diameter of not more than 0.07 mm, surface porosity of less than 40 g / m ² and volume porosity of 98; carry out a longitudinal incision of the vaginal mucosa, retreating 2.5-3 cm proximal to the external opening of the urethra, and dissect the vaginal mucosa and the underlying fascia; by means of conductors, through the proximal and distal sections of the pelvic fascia tendon arch, conduct sleeves for fixation, two sleeves on both sides, and bring them to the skin of the perineum, after removal they are sutured together with non-absorbable sutures without tension subcutaneously above the obstruction membrane, the excess tissue of the sleeves is cut, and the remaining ends are immersed in tissue; the free edges of the implant are fixed to the paraurethral tissues and the anterior surface of the cervix, without piercing the mucous membrane of the cervix, using non-absorbable threads; additionally, a transverse incision is made of the mucous membrane of the posterior wall of the vagina, departing 3-4 cm from the external pharynx in the central part of the posterior fornix, through which the cervix is fixed by plication to its posterior surface and the sacro-uterine ligaments of the prolene tape up to 1 wide extraperitoneally on both sides , 5 cm using non-absorbable threads, the free sleeves of the tape through the conductors lead through the medial sections of the sacro-spinous ligaments on both sides and then through the skin incisions on the crotch of the lat eral and below the anus; the vaginal wall is sutured with a continuous absorbable suture, cuts of the skin in the perineal region are sutured with separate sutures.

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