腹腔镜骶骨固定术治疗盆腔器官脱垂的临床研究

发布时间：2018-02-02 21:01

本文关键词： 盆腔器官脱垂腹腔镜骶骨固定术并发症　出处：《山东大学》2014年硕士论文　论文类型：学位论文

【摘要】：背景及目的盆腔器官脱垂(Pelvic Organ Prolapse,POP)是一种影响中老年女性身体健康和生活质量的常见盆底功能障碍性疾病(Pelvic Floor Dysfunction,PFD)。可表现为不同程度的子宫脱垂、阴道穹窿脱垂和阴道前后壁脱垂,严重影响患者的泌尿功能、排便功能及性生活质量。手术是中重度盆腔器官脱垂的主要治疗手段。关于盆腔器官脱垂手术治疗的研究已证实传统手术(如经阴子宫切除术+阴道前、后壁修补术)的复发率较高。近十年来,经阴植入网片(transvaginal mesh,TVM)的盆底修复术广泛应用于临床。在2008年及2011年,美国食品药品监督管理局(Food and Drug Administration,FDA)先后两次提出了与TVM副作用有关的安全警示,2012年8月美国强生公司的Prolift盆底修补系统宣布全球退市。由于受适应症的严格限制,现在TVM在临床上的应用较前明显减少。 1962年Lane首次报道了阴道骶骨固定术治疗阴道穹窿脱垂,1994年Nezhat报道了腹腔镜阴道骶骨固定术。阴道骶骨固定术通过采用自身筋膜或人工合成补片将阴道穹窿于腹膜后悬吊于S1前纵韧带,达到上提阴道顶端的目的,并能保留年轻患者的生育功能和性功能。此术式经历了几十年的改进后,被认为是中盆腔缺陷治疗的经典金标准。 2012年,我院开始开展腹腔镜子宫／阴道骶骨固定术(Laparoscopy Sacrocolpopexy, LSC)治疗中重度POP患者,并对所有手术患者术后恢复情况进行跟踪,定期随访并行问卷调查。本文旨在对我院行LSC治疗患者的临床资料进行研究,评价该手术的临床疗效,为选择适合POP患者的最佳术式提供试验依据,为提高手术安全性和有效性提供理论参考。对象和方法对2012年1月至2013年12月山东大学第二医院妇科诊断为“中重度子宫/阴道穹窿脱垂伴不同程度阴道壁脱垂”的63例中老年女性患者行腹腔镜骶骨固定术治疗。采用统计学SPSS19.0统计软件对手术患者的临床资料及术后随访数据进行统计学分析,计量资料采用均数士标准差(Mean±SD)表示,手术前后的指标变化及问卷评分进行配对t检验处理。本文从以下几个方面展开了本研究： 1.查阅病历及手术记录,分析腹腔镜骶骨固定术用于治疗器官脱垂患者的一般资料、术中及围手术期相关指标及围手术期并发症的发生情况； 2.术后复查,通过盆腔器官脱垂定量分期法(POP-Q)比较手术前后器官的脱垂分度来评价解剖学疗效； 3.术后跟踪随访,通过盆底功能障碍性疾病症状问卷(PFDI-20)和盆底疾病生活质量影响问卷简表(PFIQ-7)得分来评价手术的功能学疗效； 4.术后跟踪随访,通过性生活质量问卷(PISQ-12)得分,评价患者术后性生活情况,评估患者对手术的满意度； 5.通过对术后患者的随访问诊,了解患者术后有无出现相关不适症状及有无并发症,了解患者的主观满意度,记录患者术后中期并发症情况。结果 1.患者术前脱垂分度(仅统计POP-QⅡ-Ⅳ度脱垂例数) (1)子宫脱垂Ⅱ-Ⅳ度33例,阴道穹窿脱垂Ⅱ度12例； (2)阴道前壁脱垂Ⅱ-Ⅳ度63例； (3)阴道后壁脱垂Ⅱ-Ⅳ度27例。 2.手术相关参数及围手术期并发症 (1)平均手术时间为(144.92.±32.27)min,术中平均出血量为(44.97±13.22)ml,术后平均住院天数为(5.94±2.60)天。 (2)围手术期并发症：1例急性尿潴留,1例下腹坠痛,1例下肢静脉血栓。对症治疗及时有效,3例患者均在对应治疗后均治愈或好转出院。 3.随访期临床疗效、患者主观满意度 (1)解剖学恢复：术后POP-Q分度指示点与术前相比,差异有统计学意义(P0.05)。术后门诊复查,解剖位置恢复理想。腹腔镜骶骨固定术的客观治愈率约为98.4%,主观治愈率为100%；Burch手术的治愈率为94.44%。 (2)盆底功能恢复：术后PFDI-20和PFIQ-7评分与术前相比差异具有统计学意义(P0.05),肠道功能、泌尿功能较前改善,生活质量明显提高。 (3)性生活改善：术后1年PISQ-12评分与术前相比差异具有统计学意义(P0.05),自诉性生活质量改善明显,性生活满意度提高。 4.手术中期并发症术后随访：1例腰部疼痛,对症治疗后缓解；1例新发下尿路症状,症状轻,暂观察。结论 1.腹腔镜骶骨固定术适应症(中盆腔缺陷)可适当拓宽：该手术也适用POP-Q分度为子宫中重度脱垂(Ⅱ-Ⅳ度)伴阴道前壁重度脱垂(Ⅲ-Ⅳ度)的患者。 2.腹腔镜骶骨固定术创伤较小,恢复较快,但手术操作相对复杂,对手术者腹腔镜下操作技术要求高。 3.腹腔镜骶骨固定术恢复脱垂脏器解剖位置理想,能够保留足够的阴道长度及容纳度,患者性生活满意度高。 4.腹腔镜骶骨固定术近期治愈率高,围手术期并发症少,出现急性尿潴留、下腹坠痛、下肢静脉血栓各1例；中期并发症出现腰部疼痛和新发下尿路症状各1例；远期治愈率及并发症有待进一步进行随访及研究。
[Abstract]:Background and purpose
Pelvic organ prolapse (Pelvic Organ, Prolapse, POP) is a kind of elderly women's health and quality of life of common pelvic floor dysfunction (Pelvic Floor, Dysfunction, PFD). The performance of different degrees of uterine prolapse, vaginal vault prolapse and anterior vaginal wall prolapse after, seriously affect the patient's urinary function, quality function and sexual life in defecation. Surgery is the main treatment of severe pelvic organ prolapse.
Study on pelvic organ prolapse surgery confirmed the traditional surgery (such as vaginal hysterectomy and vaginal wall repair, after) the high recurrence rate. In the recent ten years, transvaginal mesh implantation (transvaginal mesh, TVM) of the pelvic floor repair is widely used in clinic. In 2008 and 2011, the United States the food and Drug Administration (Food and Drug Administration, FDA) two times successively put forward safety warning related side effect of TVM, Prolift pelvic floor repair system in August 2012 Johnson announced the delisting. Due to the global restrictions in TVM, now in the clinical application of significantly reduced.
In 1962 Lane first reported sacrolcolpopexy treatment of vaginal vault prolapse, 1994 Nezhat reported laparoscopic sacrolcolpopexy. Sacrolcolpopexy by using self fascia or synthetic patch will be suspended in the vaginal fornix in retroperitoneal S1 anterior longitudinal ligament, to mention at the top of the vagina to, and can retain the young patients reproductive function and sexual function. This type of operation has improved after decades are considered in the classical gold standard treatment of pelvic defects.
In 2012, our hospital laparoscopic uterine / sacrolcolpopexy (Laparoscopy Sacrocolpopexy, LSC) in the treatment of patients with severe POP, and the recovery of all patients after the operation of tracking, regular follow-up parallel questionnaire. This paper aims to study on the clinical data of LSC patients in our hospital, the clinical curative effect evaluation of the operation and to provide the experimental basis for selection for optimal operation of patients with POP, in order to improve the operation safety and effectiveness and provide a theoretical reference.
Objects and methods
From January 2012 to December 2013, 63 cases of middle-aged and elderly women diagnosed as "moderate severe uteri / vaginal vault prolapse with different degrees of vaginal wall prolapse" were treated by laparoscopic sacral fixation in the second hospital of Shandong University.
The clinical data and postoperative follow-up data of the operative patients were statistically analyzed by statistical SPSS19.0 software. The data were measured by mean standard deviation (Mean + SD). The changes of indicators before and after operation and the score of the questionnaire were processed by paired t test.
This paper has carried out this study from the following aspects:
1. consult the medical records and operation records, analyze the general data, intraoperative and perioperative related indicators and perioperative complications of laparoscopic sacral fixation for the treatment of organ prolapse.
2. to evaluate the anatomical effect by comparing the prolapse of the organs before and after the operation of pelvic organ prolapse (POP-Q).
3. follow up and follow up were performed to evaluate the functional efficacy of the operation through the pelvic floor dysfunction symptom questionnaire (PFDI-20) and the pelvic floor disease quality of life questionnaire (PFIQ-7) score.
4. after the follow-up, the sexual life quality questionnaire (PISQ-12) was used to evaluate the patient's sexual life, and to evaluate the patient's satisfaction with the operation.
5. through postoperative follow-up visit, we can know whether there is any postoperative discomfort and complications, understand the subjective satisfaction of patients, and record postoperative complications.
Preoperation prolapse score of 1. patients (only the number of POP-Q II - IV prolapse cases)
(1) 33 cases of uterine prolapse and 12 cases of vaginal dome prolapse.
(2) 63 cases of prolapse of anterior vaginal wall and degree II - IV;
(3) 27 cases of the posterior wall prolapse of the vagina.
2. operation related parameters and perioperative complications
(1) the average operation time was (144.92. + 32.27) min, and the average bleeding amount was (44.97 + 13.22) ml during the operation, and the average postoperative hospital days were (5.94 + 2.60) days.
(2) perioperative complications: 1 cases of acute urinary retention, 1 cases of lower abdominal pain, 1 cases of venous thrombosis of lower extremities. Symptomatic treatment is timely and effective. 3 patients were cured or improved after corresponding treatment.
3. clinical efficacy of follow-up period and subjective satisfaction of patients
(1) anatomical recovery: postoperative POP-Q compared with preoperative indexing, the difference was statistically significant (P0.05). The patients were recovered. The anatomic location of laparoscopic sacral colpopexy objective cure rate is about 98.4%, the subjective cure rate was 100%; the cure rate of operation was 94.44%. Burch
(2) pelvic floor function recovery: postoperative PFDI-20 and PFIQ-7 scores were significantly different from those before operation (P0.05), intestinal function, urinary function improved and quality of life improved significantly.
(3) sexual life improved: there was a statistically significant difference in PISQ-12 score between 1 years after operation and preoperative period (P0.05).
4. medium-term complications of surgery
Postoperative follow-up: 1 cases of lumbar pain relieved after symptomatic treatment; 1 cases of new lower urinary tract symptoms, mild symptoms, temporary observation.
conclusion
1., the indications for laparoscopic sacral fixation (middle pelvic defects) can be widened: this operation is also suitable for patients with severe POP-Q prolapse (stage II to IV degree) and severe anterior vaginal wall prolapse (grade III to IV).
2. laparoscopic sacral fixation has less trauma and faster recovery, but the operation is relatively complicated, and the operation technique of the operator is high.
3. laparoscopic sacral fixation to restore the anatomical position of the prolapse organ is ideal. It can retain enough vaginal length and capacity, and the patient's sexual life satisfaction is high.
4. laparoscopic sacral fixation has high cure rate, perioperative complications, acute urinary retention, lower abdominal pain, lower extremity venous thrombosis in 1 cases; mid back pain and complications under the new urinary tract symptoms in 1 cases; long term cure rate and complications need further study and follow-up.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R713

【参考文献】