A new method in approaching uterine prolapse" Anchoring uterine isthmus with strip at the rectus abdominis muscle , procedure Saba Nahedd

Saba Nahedd MD, PhD Institute for Mother and Child Care Department of Obstretics and Gynecology Polizu Hospital, Bucharest, Romania Email: sabanahedd@gmail.com

ABSTRACT Introduction The uterus prolapse means the uterus descent into the vaginal axis and outside it, accompanied by the movement, to the same direction, of the vagina walls and the adjacent portions of the urinary bladder and rectum.Material and methodsBetween 25.10.2012 and 01.03.2015 were hospitalized and operated in Polizu Hospital with the new surgical procedure for anchoring uterine isthmus with strip at the rectus abdominis muscle a total of 42 cases.These cases were hospitalized with a diagnosis of uterine prolapse gr II - III cystocele per - magna, which after clinical and laboratory investigations "mictional cystography" fractional curettage biopsy, resection with cervical loop diathermy to exclude associated pathology in especially neoplazic, was surgical intervention.In the 42 cases we performed a new therapeutic method for resolving uterine prolapse: Anchoring uterine isthmus with strip at the rectus abdominis muscle , procedure Saba NFor this procedure I have invented a kit : Saba s Strips which contains: a special isthmic strip, strip sub urethral, S & N clamp for anchoring isthmus.Technical problems which resolve this procedure consist in: anchoring the isthmic strip on the back of the isthmus uterine and the free part of the strip is fixed on the front of the isthmus to in order to prevent the slipping, so all the weight of the uterus is maintained by strip as a hammock, the second strip are attached to the junction suburethral and then anchored to the rectus abdominals muscle sheath by counter suprapubic incision. So the repositioning of uterus in anatomical , intermedian, position without opening rectovaginal space not to train elitro-rectocele.Conclusions.The technique has the advantage of a complete and effective surgical treatment of uterine prolapse gr.II and III and cystocele per magna because:1. It solved the uterus prolapse and cystocele per magna and brings back to its anatomical position.1. Placing the uterus in the intermediary, normal, position avoid the extension of rectovaginal space and consequently prevents the occurrence of rectocele and elitrocel.1. Solve incontinence effort by using suburethral strip.1. Use polypropylene material that fits the threads nerezorbable rectus abdominis sheath, independent tissue hormone, makes the chances of recurrence to become as small or almost nonexistent in the 42 cases where the replaces was "zero".1. Surgical approach is exclusively vaginal avoiding incidents and accidents when opening peritoneal cavity.

Introduction

Uterus is held in the pelvic cavity by the muscle, tissues and ligaments forming the pelvis floor.Through the uterine prolapse it means the descent of the uterus into the vaginal axis and outside it, accompanied by the movement, to the same direction, of the vagina walls and the adjacent portions of the urinary bladder and rectum.That is, it is a gradual drop in the small pit of the uterus, as a result of relaxing muscles and inextensible fibrous tissues of the perineum (muscles which will form the basis basin), as well as the means to support the components small pit.The causes and risk factors that determine this pathology are: Several childbirths, difficult childbirth with heavy weight, are the main cause of relaxing and loosening muscles that resulting in uterus prolapse loss of muscle tone associated with advancing age and reducing the quantity of estrogen post menopause, excess weight, chronic cough, chronic constipation can contribute to or worsen uterus prolapse.This explains the herniation, and the uterus prolapse, respectively, outside the vulvar commissure in various degrees with the occurrence of clinical symptoms, consisting of heaviness in the lower portion of the pelvis, walking lumbar pain, urination and sexual intercourse pain, the sensation that "something is going to fall out / sits on a ball ", the introitus irritation and vaginal ulceration, stress urinary incontinence (SUI).All these symptoms create a biological and social discomfort for the female patients.The uterus prolapse is often associated to stress urinary incontinence (SUI), loss of some urine drops, sometimes masked by the excessive prolapsing uterus through the urethra bended.SUI association is mentioned in 73% of cases, and 50-60% respectively in the empty bladder dysfunction (ELLERK MANN, 2001) In clinical practice, both cystocele and SUI and loss of load bearing wall above contribute to urethral hypermobility and consequently to the conditioning pathogenic etiology of SUI (De LANCEY, 2002)Is mentioned that after any surgical treatment for correcting the uterus prolapse, there must also be considered the correction of the stress urinary incontinence which is sometimes masked.

Material and Method

From date 25/10/2012 to 01/03/2015 in Polizu Hospital were hospitalized and operated a total of 42 cases using this new process. These cases were hospitalized with a diagnosis of uterine prolapse grade II III, cystocele permagna (very big), which after clinical and laboratorial investigations: " micturating cystography" fractional curettage biopsy, resection with diathermic loop to exclude cervical pathology associated, especially the neoplazic that have benefited from this technique. For the 42 cases, we performed a new therapeutic method for correcting the uterine prolapse "Anchoring uterine isthmus with strip at the rectus abdominis muscle, procedure Saba N."For this process I have invented a kit called "Strip SABA" (Fig.1) with the approval of the OSIM by Resolution no. 23012, 23013 /30.12.2013, Patent no. 020,476, which includes:

A special isthmic strip (Fig.2) made of polypropylene, long with a width of 1.2 cm, the ends of which is attached an non absorbable wire. To one of the ends is attached another free strip forming the letter Y. A suburethral strip (Fig.3) all from the same material with a length of 10 cm and a width of 1.2cm at its ends are connected to one wire. An S & N clamp for anchoring uterine isthmus (Figure 4) which has two arms welded together, the top has 2 holes. The clamp is provided with an additional ring to indicate the inclination angle for forming tunnels. It is also equipped with two arms 2.5 cm (right and left) that shows inclination towards urethral meatus.Technical problems which resolve this procedure consist in: anchoring the isthmic strip on the back of the isthmus uterine and the free part of the strip is fixed on the front of the isthmus in order to prevent the slipping, so all the weight of the uterus is maintained by strip as a hammock, the second strip is attached to the junction suburethral and then anchored to the rectus abdominal muscle sheath by transverse suprapubic incision is approximately 5 cm. So the repositioning of uterus in anatomical , intermedium, position without opening rectovaginal space not to train elitro-rectocele.

Results and discussion:Absence of a consensus on the actual existence of an optimal and efficient the surgical procedure in such a context morbid anatomical and clinical development led me to the this surgical technique with the following operating time:Time 1.The incision in "T" reversed to 1.5 cm of cervical orifice to the external urethral tubercle (Fig 5)Time 2. Removal of the bladder from the anterior wall and the bladder from the uterine cervix. (Fig.6).Time 3. Creating tunnels retropubiene (Fig.7)Time 4. Continue the circular incision on the posterior face of the uterine cervix and vaginal mucous of the rectum off (Fig.8)Time 5. Clamping, sectioning and ligation cardinal ligament of approximately 1 cm (Fig 9)Time 6. Fixing a "long" istmic strip to the lateral and posterior faces of the uterine isthmus (Fig 10)Time 7 Fixing the free "short" the isthmic strip on the anterior face of the uterine isthmus (Fig.11)Time 8. Transverse suprapubic incision for 5 cmTime 9. With the S & N clamp the ends of the suburethral strip wire are mounted into the top hole and the ends of the isthmic strip wire in the inferior hole, that passes through two tunnels previously formed (Fig.12)Time 10. Anchoring and ligation suburethral strip threads to the lateral extremities of straight muscle aponeurosis abdomininal under the guide of a well graded urinary until to obtain a lengthening of the urethra with 1.5cm (Fig.13)Time 11. Anterior colpectomy followed by anterior colporafy and posterior cervical incision suture. (Fig.14)Time 12. Anchoring median the isthmic strip wire ends to the rectus abdominis muscle sheath (Fig.15)Time 13. Pulling and ligation of the uterine isthmus wires (Fig.16)Time 14: Suprapubic incision sutureTime 15: Posterior colpoperineoraphy with the myorrhaphy of the annus raising muscles. (Fig.17)For this technique there can be made cervical amputation, when we have injuries colposcopy or hypertrophic elongation of the cervix, then continue with the previously mentioned time operators.The 42 operated cases were aged between 31-81 years with predominant age 60 (age three)From the total cases operated with the process "Anchoring uterine isthmus muscles rectus abdominis sheath" was necessary in 32 cases amputation of the cervix due to an injury or colposcopy marked hypertrophic elongation of the cervix.In all the previously mentioned cases there was performed the pre-surgery and post-surgery mictional cystography. The post-surgery mictional cystography showed the lower pole of the urinary bladder with irregular contour which is situated at the level of pubic symphysis ie the ascent of this pole that was much previously lowered below the lower margin of pubic symphysis.All these patients were externalized 6-7 days post-surgery with good bladder retention and bladder residual in the range of 0-40 ml and the disappearance of all symptoms accused upon hospitalizationDuring the immediate postoperative period, the urinary type Foley was kept for 3-4 days. The first 48 hours with permanent drainage, then with intermittent drainage (with an ampoule at the end of the probe Foley), to restore the bladder. At the same time, bladder instillation was performed with ampicillin (1gr), hydrocortisone hemisuccinate (1ampoule), lidocaine (1 ampoule) and in the last 48 hours an ampoule of Miostin is added to the bladder instalation and an ampoule of Miostin intramuscular to stimulate bladders muscular contraction. All patients were called to control at 1 month, 3 months, 6 months and then yearly. On clinical examination and questionnaire questions result that the cervix is in intermediana position, keeping time restraints and Valsalva maneuver.Mentioned that there was no case of relapse up to date.Conclusions:

The technique has the advantage of a complete and effective surgical treatment of uterine prolapse gr.II and III and cystocele per magna because: It solved the uterus prolapse and cystocele per magna and brings back to its anatomical position. Placing the uterus in the intermediary, normal, position avoids the extension of rectovaginal space and consequently prevents the occurrence of rectocele and elitrocel. Solve stress incontinence by using suburethral strip. Use polypropylene and the threads from non-absorbable material fixed to the rectus abdominis sheath, independent tissue hormone, makes the chances of recurrence to become as small or almost nonexistent in the 42 cases where the replaces was "zero". Surgical approach is exclusively vaginal avoiding incidents and accidents when opening peritoneal cavity. This number of cases (42) is still small, the time is too short (2 years and 4 months), but we will follow the patients over a period of 5 years, eventually even more, to demonstrate that a relapse to this technique does not exist, if the steps of the operation are strictly respected, since this technique is based on a polypropylene material and non-absorbable wires anchored to the rectus abdominis sheath, independent hormonal tissue (that does not relax with aging).

Fig.1 "Strip SABA"

Fig.2 Special isthmic strip Fig.3 Suburethral strip

Fig 4 S&N clamp for anchoring uterine isthmus

Fig.5. The incision in "T" reversed to 1.5 cm of cervical orifice to the external urethral tubercle

Fig.6 Removal of the bladder from the anterior wall and the bladder from the uterine cervix

Fig.7. Creating tunnels retropubiene

Fig.8 Continue the circular incision on the posterior face of the uterine cervix and vaginal mucous of the rectum off

Fig.9. Clamping, sectioning and ligation cardinal ligament of approximately 1 cm

Fig.10 Fixing a "long" istmic strip to the lateral and posterior faces of the uterine isthmus

Fig.11 Fixing the free "short" the isthmic strip on the anterior face of the uterine isthmus

Fig.12 With the S & N clamp the ends of the suburethral strip wire are mounted into the top hole and the ends of the isthmic strip wire in the inferior hole, that passes through two tunnels previously formed

Fig.13 Anchoring and ligation suburethral strip threads to the lateral extremities of straight muscle aponeurosis abdomininal under the guide of a well graded urinary until to obtain a lengthening of the urethra with 1.5 cm

Fig 14 Anterior colpectomy followed by anterior colporafy and posterior cervical incision suture.

Fig.15. Anchoring median the isthmic strip wire ends to the rectus abdominis muscle sheath

Fig.16. Pulling and ligation of the uterine isthmus wires

Fig.17. Posterior colpoperineoraphy with the myorrhaphy of the annus raising muscles

Preoperator Postoperator after 2 year and 5 month