Method for treating the cases of male enuresis

FIELD: medicine.

SUBSTANCE: method involves applying sling urethropexy. Pneumoextraperitoneum is created by means of trocar introduced under the pubis. Then, longitudinal perineotomy and paraurethral tissue dissection is carried out to the right and to the left towards the descending branches of pubic bones to pelvic fascia. The urethra is moved to its left. TVT needle is introduced under descending branch of pubic bone to the right of the urethra. The pelvic fascia is perforated in away that needle tip enters retropubic space laterally with respect to the prostate and in front of the urinary bladder. The needle is brought along the posterior pubic bone surface and exits via abdominal wall outside pulling one end of polypropylene ribbon. The like manipulations are accomplished at the left side to form a loop around the urethra tightly adjacent to bulbocavernous muscles. Final ribbon fixation is carried out after having eliminated the pneumoextraperitoneum and having removed the trocar.

EFFECT: simplified operation; avoided intra- and postoperative complications and recidivation.

The invention relates to the field of medicine and will find application in urology in surgical correction of urinary incontinence in men.

Involuntary urination (enuresis) was defined by the International society for continence (International Continence Society ICS)in dealing with this problem, as a phenomenon, representing the social and medico-hygienic problem. According to the literature functional complications of adenomectomy standing on the 3rd place after infectious-allergic and organic complications. It is established that at potadromous adenomectomy incontinence occurs in 0.1% of cases, when crespuzyrna - 1-3%, with perineal - 2-5%. For the successful treatment of urinary incontinence after adenomectomy need to know the anatomic and functional status of the bladder and the switching apparatus. Normal passive retention of urine is due to the relaxation of the detrusor, elastic properties of the posterior urethra, and the active retention of urine due to the contractility of the external sphincter. There are 5 types of incontinence:

total incontinence, characterized by a constant flow of urine regardless of the position of the body,

stress incontinence of urine that occurs during physical activity and the increase in intra-abdominal pressure,

- orthostatic incontinence, etc who are in the upright position of the patient, while in the horizontal position, you receive the urge to urinate and the patient urinates on their own,

- episodic incontinence that occurs regardless of time, body position and physical activity,

- incontinence of urine, develops as a result of frequent imperative urge to urinate.

Conservative treatment consists of physical therapy in combination with pharmacological and physical effects,

Therapeutic exercise is carried out for all patients. Along with the physical exercises that are beneficial for the cardiovascular and nervous system, are special exercises aimed at strengthening the sphincter of the bladder and rectum, and pelvic floor muscles (contraction of the sphincter of the urinary bladder mimicking interrupted urine stream; voltage sphincter of the anus, bike, scissors). The exercises are performed for 20-30 minutes a day for 4-6 months.

Drug treatment is aimed at eliminating the conditions that increase intra-abdominal pressure: constipation, strong and frequent cough. When hyperreflection bladder with the aim of raising the threshold of the gallbladder reflex appoint antiholinergicescoe drugs (oxybutynin, tolterodine, tropishade), rectal candles with belladonnas, installations in the bladder of restoreproperty. Under the influence of these drugs increases the volume of the bladder, decreased intravesical pressure increases be resistance. To stimulate the sphincter of the bladder is used neostigmine, midodrin. Physical therapies combined with the introduction of ATP, nicotinamide, Riboflavin (replenishes the energy consumption of the sphincters of the bladder when Fes).

Physical methods. Since 1970, the treatment is widely used electrical stimulation. For electrostimulation use of superficial, cutaneous, urethral, rectal and anal electrodes. Urethral electrodes are alternately supplied to the external and internal sphincter of the bladder; the indifferent electrode is placed on the skin in the area of the sacrum. The course of treatment - 10 sessions for 10 minutes Under the influence of electrical stimulation trophic processes in the receptors, nervous system and spinal centers, resulting in increased excitability of the muscles of the sphincter. In addition, direct electrical stimulation is an effective treatment of concomitant chronic prostatitis.

Sound stimulation. The sound emitter mounted on the crotch, pressing against the skin. The procedure consists of two sessions of 10 minutes each with a break of 60 minutes. The course of treatment - 10 sessions. The treatment effect due to the conversion is of the electrical signals, optimal for direct electrical stimulation, mechanical.

Comprehensive conservative treatment is effective in approximately 80% of cases of incontinence.

The indications for surgical treatment are orthostatic and total incontinence, which most often marks the inefficiency of conservative treatment, and all other types of urinary incontinence after conservative treatment without effect. In some cases when selecting patients for surgical treatment are the result of a research profile be pressure, which is determined by the functional length of the urethra and maximum vnutriuretralnami pressure. The study is performed at rest and during stimulation of the sphincter of the bladder; the results are compared and it is predicted efficiency or inefficiency of conservative treatment.

There is a method of treating urinary incontinence in men in A.S. No. 1519662 (1989), the essence of which consists in cutting out the flaps of the tunica of the corpora cavernosa of the penis, a certain tension stitched together, thus squeezing the urethra, which allows you to hold a certain volume of urine in the bladder. The disadvantages of this method include the fact that after the operation occurs artificially induced inframe italina obstruction of urinary tract, and the nature of the liberation of the patient from the urine is reduced to a pronounced muscles of the abdominal wall by external influences. In addition, artificially created conditions for the emergence of chronic partial retention of urine can lead to the formation of stones in the bladder and the development of secondary inflammatory processes.

There is a method of treating urinary incontinence in men on Young H.H. (// European Urology. - 2000. No. 3. - v.38. - R-362), the essence of which is that at the first stage of the operation through the open lumen of the bladder (MP) longitudinally cut through the wall of the MP in the area of his neck and between the mouths of the ureter on the entire thickness of the detrusor, and then use bumerangue /return/ needle stitch, so that after tying formed fold wall MT. At the second stage of the operation through a separate incision in the perineum cut through the scar tissue surrounding the urethra and the neck of the MP to plicatio tissue “external urethral sphincter”. The disadvantages of this method: the trauma due to the presence of the reception dissection of the bladder wall and suturing it bumerangue needle, the possibility of occurrence of inflammatory processes through dissection of the scar, the impossibility of a stable functional strengthening the tone of the circular sphincter.

The prototype of the invention, the selected method of surgical treatment of Nigeria the Oia urine for men patent No. 2185779 (2002), the essence of which is that an autograft from the broad fascia of the thigh partially block the urethra by creating compression. Around the urethra in the form of a loop hold the fascia. The free ends of the fascia output. On the lower pole of the scrotum produce transverse skin incision. From the perineal incision to form two channels. The channels converge in the operating wound of scrotum. The free ends of fascia stretch through the channels, sew non-absorbable suture material. The cuts on the perineum and scrotum sew. This method swingaway urethropexy using autotransplanted allows you to adjust the compression of the urethra, however, is traumatic.

Thus, it can be stated that the standard surgical methods traumatic, are associated with prolonged hospital stay and discomfort due to the surgical incision. Do not exclude the occurrence of complications and recurrence.

These drawbacks are eliminated in the invention.

The task of the invention is to reduce the morbidity, prevention of complications and recurrence.

The problem is solved by swingaway urethropexy, namely, that pre-exercise pneumoperitoneum by introduced above the pubic trocar, and then perform a longitudinal perineotomy and carry out the Diss is the Ktsia paraurethral tissue on the right and left toward the descending branches of the pubic bone to pelvic fascia, the urethra shift to the left, the needle V® video endoscopic control imposed under the descending branch of the pubic bone to the right of the urethra, perforare pelvic fascia so that the tip of the needle at an angle of at least 35 degrees to the sagittal plane hit pozadine space lies lateral to the prostate gland and anterior to the bladder, hold the needle by the posterior surface of the pubic bone and is brought out through the abdominal wall to the outside, holding one end of the polypropylene tape, then a similar manipulation is done with the left hand for the formation of a loop around the urethra, close to bulbocavernosus muscles. When this final fixation of the tape is carried out after the elimination of pneumoperitoneum and removal of the trocars.

The technical result obtained in the practical application of this method of treatment of urinary incontinence in men, is the ease and accessibility of execution, the exception intraoperative and postoperative complications and recurrence.

Patent information search conducted on domestic and foreign scientific medical and patent literature has revealed a known method of treatment of stress incontinence in women, called TVT®, or Free Synthetic Loop, requiring minimal surgical what about the intervention, developed by Professor U. Ulmsten at the University hospital, Uppsala in Sweden - RF patent for the invention №2161916, 2001 Device TVT® - Free Synthetic Loop is a unique innovation and is a polypropylene mesh, covered with plastic covers, with needles on the ends. With needles TVT® is injected into the woman's body through a small incision on the front wall of the vagina and placed under the middle part of the urethra, providing reliable support, thereby eliminating the cause of the incontinence. Both needles are ejected through the anterior abdominal wall and then removed. Plastic covers are removed after adjusting the position of the loop. The technique was widely used in urology for the treatment of urinary incontinence in women. However, in men, this technique is not used in view of the anatomical features - the presence of prostate cancer and paraprosthetic venous plexus in close proximity to the paths of the needle punch. Our studies showed that the implementation of the TVT® men is possible with the use of video endoscopic equipment and the creation of pneumoperitoneum practicing some special methods of operation.

Selection of patients was performed after a full examination, careful history taking (PECs which were included with the questionnaire for urinary incontinence, physical examination and urodynamic parameters). The purpose of this survey is to determine the type of incontinence to select the most effective method of intervention for this patient. In the survey, in addition to clinical studies, patients performed an ultrasound, x-ray (review snapshot, retrograde urethrography, voiding cystourethrography), urodynamic study (uroflowmetry, cystathioninuria, retropubically, electromyography of the external sphincter). Some patients in addition to urinary incontinence diagnosed urethral stricture and bladder neck, produzir, stones preduzeca, false the course of the urethra, funnel neck of the bladder. The nature of the detected violations indicates the need for individual choice of treatment for each patient with urinary incontinence.

The detailed implementation of the method is illustrated by the following clinical example.

Sick N s, 63 year history No. 134, was admitted to the urology Department 10.02.2001, with complaints of involuntary discharge of urine drops in the transition to upright posture, coughing, sneezing, exercise. From the anamnesis it is known that these complaints appeared immediately after the patient 1 year ago transurethral resection of the prostate for the first 6 months of the EB after surgery there was a slight decrease in intensity of symptoms, however, in the future condition without the speakers. The patient received conservative therapy in the form of training of the pelvic floor muscles, physiotherapy, midodrina hydrochloride, but without any visible effect.

Objectively - organs and systems without features. When viewed with natureway celebrated urine from the urethra drops. The skin of the glans penis redness.

Per rectum: prostate flattened, 3×3 cm, heterogeneous, painless, Magdalena groove smoothed.

MRI - pathology of the kidneys and bladder is not observed, the signs moderately expressed chronic prostatitis.

Uroflowmetry - maximum speed urination - of 18.3 ml/s with an average of 9.4 ml/s, the time to reach the maximum speed of urination - 10,4 C.

According to a comprehensive urodynamic studies - normotensives, normolipidemic, normoblastic bladder with normal tone and somewhat reduced contractile ability. IVO is not defined. Stop test is negative, for profilometry received a sharp decrease in urethral pressure in the projection of the external urethral sphincter (up to 35 cm H₂About), the decrease of the functional urethral length profile. The test on the threshold of abdominal pressure loss of urine are determined with increasing abdominal what about the pressure above 55 cm H ₂O.

On ascending urethrogram - the urethra is passable throughout, narrowing corresponding to the external urethral sphincter dramatically shortened to 2 mm. Pressure at which the contrast agent passes into the bladder, 35-40 mm H₂O.

When performing x-ray pelvis in lateral projection with contrast prostatic Department urethral angle of the prostate to the axis of the pubic symphysis is 35 degrees.

During transrectal ultrasound scan of the prostate are determined by the signs of moderately expressed chronic prostatitis, prostate volume - 22,3 cm³the volume of the transition zone - 7 cm³, the transverse size of the prostate - 42 mm, width paraproctitis venous plexus - 73 mm

The neurological examination - bulbocavernosus and anal reflexes saved, neurological pathology is not detected.

Based on the above data, the patient was diagnosed with Stress urinary incontinence 3 type (classification McGuire), the state after TUR of the prostate.

Given a sufficiently acute angle to the axis of the prostate to the axis of the pubic symphysis and moderate width paraproctitis venous plexus, the patient was performed swingova urethropexy perineal access with polypropylene mesh (needle type TVT®) under video endoscopic control is using equipment company “KARL STORZ” /Germany/. On the operating table the patient is located in lithotomies position.

Under intravenous anesthesia, after emptying the bladder catheter, made an incision in the skin and aponeurosis up to 2 cm immediately above the pubic joint. Then made blunt dissection of tissue by means of a finger with the aim of creating a cavity in predposylkam space for insertion of the first trocar. After dissection into the created cavity entered the trocar 10 mm fixed thereto by the finger of a rubber glove. Through the appropriate channel of the trocar into the rubber tank is fed with a sterile saline solution under a pressure of 100 cm H₂About hydraulic dissection of tissues preduzimamo space. Introduced into the trocar laparoscopy made a visual inspection of creating a cavity.

After a cavity pressure of 100 cm H₂On (800-1000 ml of liquid) and wait 2-3 minutes with the purpose of works of hemostasis created by the pressure of the fluid from the rubber tank is removed through the channel of the trocar and the trocar removed. Rubber tank removed from the trocar, and the trocar is again introduced into the created cavity. Then through the appropriate channel of the trocar into the cavity pumps air through insufflator with the aim of creating pneumoperitoneum.

Under the surveillance of the laparoscope through the incision up to 2 cm below the umbilical ring created in the second cavity, bypassing the peritoneal bag, entered the second trocar 10 mm Laparoscope ustanovlen in the upper trocar.

In the urethra introduced metal bougie 18 Ch. Is a vertical midline incision of the perineum to 5 cm from the bottom edge of the scrotum. Performed acute and partially blunt dissection paraurethral tissue (right and left, manipulating introduced into the urethra by bougie) towards the branches of the pubic bone to pelvic fascia (fascia will not be opened) in width, enough for the introduction created paraurethral stroke of the index finger.

Using the bougie urethra slides to the left. Needle set TVT® c attached plunger under the control of the index finger (to avoid damage to the cavernous neurovascular bundle and the cavernous bodies of the penis) is carried out under the pubic articulation to the right of the urethra, abutting the tip of the pelvic fascia.

Produced light jerky movement of the needle and under visual control on the monitor endoscopic hours is determined by the location of the tip of the needle in pozadina space education bulging tissues.

Making sure the tip of the needle is located lateral to the prostate gland and anterior to the bladder was perforated with a needle pelvic fascia and holding it under the surveillance of the laparoscope by the posterior surface of the pubic bone, n is damaging the periosteum. Then, under the control of the eye selected avascular area of the anterior abdominal wall through which the point of the needle is brought out. The needle is fixed with a clamp.

On the left side is similar manipulation. When viewed from the damaged blood vessels patadyong space is not marked.

After holding both needles made cystoscopy. Damage to the bladder is not defined. Polypropylene mesh is cut and its edges are tightened to a snug fit hinges to bulbocavernosus muscles in the urethra (in perineal wound). After the deflation process, the elimination of predposylki cavity and removal of the trocars tissue of the anterior abdominal mesh down to the bottom and the excess mesh cut with scissors. Perineal wound and the wounds of the anterior abdominal wall is sutured skin sutures. The bladder has a urethral Foley catheter 18 Ch, the balloon is inflated to 20 ml. Imposed aseptic bandage.

The postoperative period was uneventful, seams wounds of the anterior abdominal wall were removed on the 4th day, perineal - 6 and 7th, the urethral catheter was removed on the 2nd day after the operation.

Self urination recovered, free, painless. Loss of urine when natureway and the cough is not defined. Performed on the 8th day of uroflowmetry maximum speed of urination is 12.4 m is/s, 1 month after the operation of 14.2 ml/S.

The inventive method of treating urinary incontinence in men tested and used in the urology Department. Treatment of 19 male patients with urinary incontinence after adenomectomy. The postoperative period in all patients was uneventful. All discharged from the hospital with no signs of incontinence, and monitoring of patients within 6-12 months. revealed no recurrence. The use of new synthetic materials, the whole complex of positive factors associated with the introduction of video endoscopic equipment, optical zoom, atraumatic microsurgical dissection of tissue with good hemostasis using mono - and bipolar electrodes, has significantly improved the results of operations and the quality of life of patients. The most suitable material for use in the execution of these operations is a polypropylene mesh, which is more compatible with biological tissues and can repositionability surgeon in the tissues, elastic in all directions, the large surface it comes in contact with tissues, intertest provides a minimal inflammatory response. An additional advantage of this method is the possibility of establishing two additional trocars in positronic areas for the introduction of instruments through which is possible to Galatia or clipping of damaged vessels in accidental damage or bleeding. Thus, this method of treating urinary incontinence in men has been highly effective and low-impact. The effectiveness of this method is over 90% with minor postoperative pain and discharge the majority of patients from hospital on the second day after the operation.

It has the following advantages over known:

- Easy

- Maloinvazivnojj

The intervention lasts 40-50 minutes

- Minimal scars - good cosmetic effect

Short hospitalization

- Faster recovery and return to normal activities.

The method can be widely used in urological hospitals.

A method of treating urinary incontinence in men by swingaway urethropexy, wherein the pre-create pneumoperitoneum by introduced above the pubic trocar, and then perform a longitudinal perineotomy and carry out the dissection paraurethral tissue on the right and left toward the descending branches of the pubic bone to pelvic fascia, the urethra shift to the left, the needle V under the video endoscopic control imposed under the descending branch of the pubic bone to the right of the urethra, perforare pelvic fascia so that the tip of the needle at an angle of at least 35° to the sagittal plane hit pozadine space lateral prestate the Noah gland and anterior to the urinary bladder, hold the needle by the posterior surface of the pubic bone and is brought out through the abdominal wall to the outside, holding one end of the polypropylene tape, then a similar manipulation is done with the left hand for the formation of a loop around the urethra, close to bulbocavernosus muscles, and the final fixing of the tape is carried out after the elimination of pneumoperitoneum and removal of the trocars.