植入网片盆底重建术的盆底超声形态学研究及手术并发症的分析

发布时间：2018-05-08 18:29

本文选题：盆底重建术 + 盆底形态学　；参考：《福建医科大学》2014年硕士论文

【摘要】：【目的】应用盆底超声影像技术，观察盆底重建手术（Transvaginal Placement ofSurgical Mesh，TVM）前后盆底形态改变及植入网片情况，回顾近年本机构TVM术后出现并发症患者的临床资料，评估TVM对盆底解剖学缺陷的影响，探讨TVM纠正盆底器官脱垂的机制，分析盆底超声在客观评估盆底重建术有效性及应用价值，总结TVM的并发症情况及术式的安全性，为盆底重建术的术前评估、术中引导、术后随访及并发症预防及治疗策略提供新思路和依据。【方法】 1.第一部分盆底重建手术前后盆底形态学改变的超声比较研究：收集2013年2月至2013年7月期间在本机构就诊且接受TVM治愈的POP患者，分别于术前和术后三个月在静息、valsalva和缩肛三种状态下进行盆底超声检查，比较手术前后肛提肌裂孔面积、断裂情况及厚度、膀胱颈位置及移动度、膀胱尿道角等参数变化。 2．第二部分盆底重建术网片位置和活动性的研究： POP接受TVM手术的患者62例，术后三个月应用盆底超声检查，分别在静息、valsalva和缩肛三种状态下对盆底进行容积扫描，在矢状面测量网片的长度、位置及放置层次；三维重建网片，测量网片横截面宽度，与肛提肌裂隙比例，观察网片活动情况。 3.第三部分经阴道使用网片的盆底重建术并发症的分析：回顾本机构在2007年6月至2012年6月期间，TVM出现并发症的49名POP患者的临床资料。【结果】 1.第一部分盆底重建手术前后盆底形态学改变的超声比较研究：三种状态下，手术后的肛提肌面积均较术前明显缩小约10%，统计学分析后有显著差异（静息：p＜0.001，valsalva：p=0.011，缩肛：p=0.011）。术后valsalva状态下膀胱后角及膀胱后角改变量明显缩小，经统计学分析后差异显著（p＜0.05）。盆底重建手术后患者的膀胱颈移动度、肛提肌厚度及断裂情况，较术前无显著性差异（p＞0.05）。 2.第二部分盆底重建术网片位置和活动性的研究：盆底超声下，重建术后植入的网片为线性强回声结构。从网片到耻骨联合距离来看，网片与耻骨联合的水平距离在缩肛运动时移动度较大（p＜0.001），网片与耻骨联合的垂直距离在valsalva动作时移动度较大（p＝0.016）。在不同状态下，矢状面及冠状面上网片的长度是变化的，valsalva时变长，缩肛时变短，相关参数经配对样本t检验分析后（p＜0.05）具有统计学差异。网片放置深度（95%医学参考值）：前壁0.72-0.84cm，后壁0.73-0.86cm；网片放置的位置（95%医学参考值）：前壁网片位于阴道20%-76%，后壁网片位于16%-75%；三维重建网片填补约82%-84%的肛提肌裂隙。 3．第三部分经阴道使用网片的盆底重建术并发症的分析根据POP-Q定量，患者在阴道前壁、子宫/穹窿及后壁的修复上得到了明显的改善（P＜0.001）。TVM并发症发生率为16.44%（49/298）：其中网片暴露20例(6.71%)；排尿困难12例（4.03%），分别为排尿费力5例、残余尿4例、尿失禁3例；术后疼痛5例（1.68%）；复发4例（1.34%）；术后血肿3例（1.01%）；术中膀胱损伤2例（0.67%）；手术失败2例（0.67%）；术中直肠损伤1例（0.34%）。【结论】 1．TVM是治疗POP的有效手段，主要通过填补及缩小肛提肌裂孔，纠正尿道与膀胱的正常解剖位置，达到“吊床样”托住脱垂组织的疗效，而不改善膀胱颈的形态、位置和肛提肌厚度及断裂情况； 2．盆底超声下网片相关参数的测量与患者所处的状态有关，，TVM的有效性及安全性与网片的长度、放置的位置及深度相关； 3. TVM会产生多种并发症，多数的并发症是能够预防和治疗的。并发症的发生与手术方式、患者阴道条件、围手术期护理、随访程度及手术操作密切相关，严格掌握适应症，提高手术技能，可有效的防治及降低并发症的发生； 4.盆底超声可用盆底重建术前后盆底改变的评估、术后网片位置及形态的观察；为今后开展TVM手术的术后随访提供新思路和依据； 5.评价TVM术式的有效性及安全性应结合临床问卷、临床检查及辅助影像学检查手段。
[Abstract]:Purpose of the project

To evaluate the effect of TVM on pelvic floor anatomy defect and to evaluate the effect of TVM on pelvic floor anatomy defect , and to evaluate the effect of TVM on pelvic floor anatomy defect , and to analyze the effect of TVM on pelvic floor anatomy defect .

Methodology

1 . Comparative study of the morphological changes of pelvic floor before and after the first partial pelvic floor reconstruction :

All patients with POP were collected from February 2013 to July 2013 and were treated with TVM . The pelvic floor ultrasonic examination was performed three months before and after operation respectively in three states : resting , valsalva and anal sphincter , comparing the area of anal muscle cracking before and after operation , the fracture condition and thickness , the position of bladder neck , the degree of movement , and the urinary bladder urethral angle .

The operation failed in 2 cases ( 0.67 % ) .

In 62 patients with POP receiving TVM operation , pelvic floor ultrasonic examination was performed in three months after operation , and volume scanning was performed on the pelvic floor under three conditions of resting , valsalva and anal sphincter , respectively . The length , location and placement level of the mesh were measured in sagittal plane .
Three - dimensional reconstruction mesh , measure the cross - sectional width of the mesh , compare with the fissure ratio of levator ani muscle , and observe the activity of the mesh .

3 . Analysis of complications of pelvic floor reconstruction using mesh for the third part :

Review the clinical data of 49 POP patients with complications in the TVM between June 2007 and June 2012 .

The result is not valid .

1 . Comparative study of the morphological changes of pelvic floor before and after the first partial pelvic floor reconstruction :

Under three conditions , the area of levator ani muscle after operation was significantly reduced by about 10 % before operation , and significant difference was found after statistical analysis ( resting : p < 0.001 , valsalva : p = 0 . 011 , anal sphincter : p = 0 . 011 ) . There was no significant difference ( p > 0.05 ) between bladder neck movement , levator muscle thickness and fracture in patients with pelvic floor reconstruction .

2 . Study on the position and activity of the mesh of the second part of pelvic floor reconstruction :

The vertical distance between mesh and pubic symphysis was larger ( p < 0.001 ) . The vertical distance between mesh and pubic symphysis was larger ( p < 0 . 016 ) . The length of the mesh and pubic symphysis was significantly different in valsalva movement ( p = 0 . 016 ) . The depth of the net placement ( 95 % medical reference value ) : anterior wall 0.72 - 0.84 cm , posterior wall 0.73 - 0.86 cm ;
The position of the mesh placement ( 95 % medical reference value ) : the anterior wall mesh is located 20 % -76 % of the vagina and the posterior wall mesh is located at 16 % -75 % ;
The three - dimensional reconstruction mesh fills about 82 % to 84 % of the levator muscle fissures .

3 . Analysis of complications of pelvic floor reconstruction using mesh for the third part

According to the quantitative analysis of POP - Q , the incidence of TVM complication was 16.44 % ( 49 / 298 ) in the anterior vaginal wall , uterus / vault and posterior wall ( P & lt ; 0.001 ) .
There were 12 cases ( 4 . 03 % ) in dynuria , 5 cases of dyneresis , 4 cases of residual urine and 3 cases of urinary incontinence , respectively .
Postoperative pain was 5 cases ( 1 . 68 % ) .
There were 4 cases ( 1 . 34 % ) .
Postoperative hematoma was 3 cases ( 1.01 % ) .
Bladder injury in 2 cases ( 0.67 % ) ;
2 . Study on the position and activity of the mesh of the second part of pelvic floor reconstruction :
1 case ( 0.34 % ) of intra - operative rectal injury .

Conclusion

1 . TVM is an effective means of treating POP , mainly through filling and reducing anal muscle cracking , correcting the normal anatomic position of urethra and bladder , and achieving the curative effect of " hanging bed sample " to hold prolapse tissue without improving the shape , position and levator muscle thickness and fracture condition of bladder neck ;

2 . The measurement of relevant parameters of pelvic floor ultrasound is related to the state of the patient , the effectiveness and safety of TVM is related to the length of the mesh , the location and depth of the placement ;

3 . TVM can produce many complications , most of the complications can be prevented and treated . The incidence of complications is closely related to the operation mode , the patient ' s vaginal conditions , the perioperative nursing , the follow - up degree and the operation operation , strictly controls the indications , improves the operation skills , can effectively prevent and reduce the occurrence of complications ;

4 . Evaluation of pelvic floor change before and after pelvic floor reconstruction and observation of the position and morphology of the net sheet after operation ;
To provide a new idea and basis for the follow - up of TVM operation in the future ;

5 . Evaluation of the effectiveness and safety of TVM operation should be combined with clinical questionnaire , clinical examination and auxiliary imaging examination .

【学位授予单位】：福建医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R445.1;R713

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