Die operative Anatomie des Blasenverschlusses und ihre Bedeutung für die vaginale Operation der Streßinkontinenz

Abstract

The bladder closure mechanism works under the influence of a hydro-aerodynamic force that presses downward ("stress"). This "stress" is caused by the relative weakness of the pelvic floor. The structures running through the urogenital hiatus are compressed by the rectococcygeal and pubo-coccygeal muscles, which close the hiatus. The urogenital diaphragm bridges the slit in the levator ani muscles. It is made of the perineal membrane, the superior fascia, and the smooth and striated muscle lying between the two (M. sphincter urethrovaginalis, M. compressor urethrae). The superior fascia is an extension of the intraabdominal interior parietal fascia. The intraabdominal pressure stabilises the position of the urethrovesical region by pressing the intraabdominal contents and the subperitoneal connective tissue etc. closely together. The visceral fascia, the pubourethral ligaments, and above all, the connection to the superior fascia of the pelvis diaphragm anchor and regulate the paraurethro-vaginal region. The decompensation of this stress mechanism, usually caused by previous birth injury, leads to varied degrees of prolapse and incontinence. A rational therapy is the reconstruction of the damaged structures of the pelvis floor (diaphragma urogenitale, diaphragma pelvis, perineum etc.) in a complete individualised vaginal surgical reconstruction ("diaphragm repair"). This procedure makes a direct visualisation of the local situation and a control of the indication for surgery possible. If the suspensory apparatus is well anchored to the pelvis wall, reconstruction can be achieved. If this is not the case, a more sophisticated repair is necessary. If the indication is not correct and the limits of this method are ignored, or, if surgery is technically inadequate, this method will fall into disrepute.

Anatomy of the arcus tendineus fasciae pelvis in females

“…The anterior part of the LAM and the fascia to which the ATFP attached laterally have been cut to show the OIM. Richter (1988), DeLancey (1994a, and Weber and Walters (1997). Macroscopically, we observed a variable quantity of muscle fibers joining this fibrous connection.…”

“…From clinical experience it is known that the ability to prevent descent of the proximal urethra during periods of increased abdominal pressure is crucial to maintaining urinary continence. During vaginal examination of living females, the ATFP can be easily palpated through the lateral vaginal wall (Richter, 1988). The well-established fixation to the pelvis and the pull-out strength of the anterior ATFP, as has been described in this article, may explain why this structure has been used successfully as the anchor point for sutures in urethrosuspension procedures for urinary incontinence (Pit, 1998;Palma, 2001).…”

Nomenklaturproblematik am Beispiel vaginaler Streßinkontinenzoperationen

“…Stattdessen werden alle diese Strukturen in ihr als Paracervix und Parametrium bezeichnet [4][5][6][7]. Die zahlreichen unterschiedlichen Namen faszien/ihnlicher Formationen einschl, der sog.…”

“…ihrer Halteeinrichtung stellten -wie optisch dargestellt -einen weiteren widerspriichlichen Begriffsbereich dar [2,6]. Der Bereich Harnblase, Harnblasenhals und Harnr6hre samt ihrer bindegewebigen Umgebung bzw.…”

“…Seine morphologischen Substrate aber unt'er den Bezeichnungen Spatium perinei prof. und superficiale aufgeftihrt [1,4,6,9]. Das bis heute seit Jahrzehnten umstrittene Diaphragma urogenitale wird als Begriff durch eine Fugnote in der Nomenklatur infrage gestellt.…”