经阴植入网片治疗重度盆腔器官脱垂的远期疗效分析

发布时间：2018-06-01 14:48

本文选题：重度盆腔器官脱垂 + 盆底重建　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景:盆腔器官脱垂(pelvic organ prolapse,POP)是指由于盆底支持组织缺损或松弛而引起的盆腔脏器脱离正常的解剖位置,子宫脱垂是指子宫从正常位置沿阴道下降,宫颈外口达坐骨棘水平以下,美国国立研究院(National Institutes of Health,NIH)指出,POP是指任何阴道节段的前缘达到或超过处女膜缘外1cm以上。手术治疗可有效地缓解因盆腔器官脱垂引起的不适症状,并能有效地提高患者的生活质量。手术治疗的目的:1.解剖学组织复位;2.恢复或者保持正常的膀胱功能;3.恢复或者保持正常的直肠功能;4.恢复或者保持正常性功能。手术治疗盆腔脏器脱垂的方法有:传统的经阴道子宫切除术和前、后壁修补术;阴道封闭术;曼氏手术;骶棘韧带固定术等[1]。传统手术为应用自体筋膜进行盆地重建,文献报道复发率30%,部分重度POP的患者难以达到解剖学复位,并且随着时间进展,复发率更高。人工合成网片在治疗盆腔脏器脱垂中应用,能同时纠正中央缺陷以及侧方缺陷,降低POP的复发,提高患者生活质量。本研究通过对齐鲁医院经阴道植入网片盆底重建术的患者的长期随访,分析经阴道植入网片盆底重建术的远期疗效。目的:探讨经阴道植入网片盆底重建术治疗重度盆腔器官脱垂的远期疗效方法:采用回顾性研究的方法,对2008年1月到2015年12月之间,在山东大学齐鲁医院行经阴道植入网片的盆底重建术(TVM)105例的重度POP病例进行术后随访调查,手术方法为经阴道植入前路网片前盆重建术,经阴道后路植入网片后盆重建术,经阴道植入全盆网片的全盆重建术。通过对患者临床资料的分析,评估经阴道植入盆底重建术手术相关指标及围手术期并发症;通过门诊复查,行妇科检查,用盆腔器官定量分期法(POP-Q)量化脱垂严重程度,并将盆底重建术术前和术后进行统计学对比分析,评估经阴道植入网片盆底重建术的客观临床疗效;根据盆底障碍影响简易问卷-7(PFIQ-7)、盆底功能障碍问卷(PFDI-20)和盆腔器官脱垂性功能问卷(PSIQ-12)得分,通过对术前及术后患者问卷得分进行统计学比较,评估经阴道植入网片盆底重建术后患者的主观临床疗效;通过规律随访以及定期复查,评估经阴道植入网片盆底重建术术后盆腔器官脱垂复发情况以及术后远期并发症的情况。统计学分析:采用SPSS16.0进行统计学分析。计数资料以频数或者比率表示,计量资料以均数士标准差表示,采用配对t检验进行比较,以P0.05视为差异有统计学意义。结果：1.经阴道植入网片盆底重建术治愈率:1.1根据ICS标准1年、3年、5年治愈率分别为94.7%、87.1%、80.4%;1.2根据复合标准1年、3年、5年治愈率分别为94.7%,91.4%、88.2%。2.经阴道植入网片盆底重建术患者临床资料及一般情况:2.1经阴道植入网片盆底重建术术后共随访患者105例,有效随访患者95例,有效随访率为90.5%(95/105)。2.2患者平均年龄为63.9±10.5岁,产次为1.8±0.7次,BMI为29.5±9.8kg/m2,难产病史患者占30.5%(29/95),既往子宫切除史患者占24.25%(24.25),绝经后患者占87.0%(83/95),慢性腹压增加患者占48.4%(46/95)。2.3经阴道植入网片盆底重建术患者术前POP-Q分期:术前POP-Q分期Ⅲ-Ⅳ期的患者为95例,其中,盆底前腔室Ⅲ-Ⅳ期脱垂患者为55例,占57.9%,盆底中腔室Ⅲ-Ⅳ期患者为47例,占49.5%,盆底后腔室Ⅲ-Ⅳ期脱垂患者18例,占18.9%。3.经阴道植入网片盆底重建术手术相关指标及围手术期并发症3.1经阴道植入网片盆底重建术手术相关指标:手术平均时间为79± 11mmin,手术术中出血量为90.3±50mL,手术后平均尿管留置时间为6±1天,手术后平均住院时间为5±1天。3.2经阴道植入网片盆底重建手术围手术期并发症:手术中膀胱损伤1例(1.1%),手术后泌尿系感染2例(2.1%),手术后尿潴留3例(3.2%),手术后下肢静脉血栓形成3例(3.2%)。4.经阴道植入网片盆底重建手术治疗重度POP临床疗效4.1客观临床疗效:应用国际统一评价体系POP-Q分期进行评估:经阴道植入网片盆底重建手术患者1年后复查POP-Q分期中的Aa,Ba,Ap,Bp以及C点与术前相应位置对比分析有显著疗效(P0.005),手术前及手术后阴道总长度差异无统计学意义(P=0.012);4.2主观临床疗效:4.2.1完成盆底障碍影响简易问卷(PFIQ-7)调查的患者95例,术后随访得分与术前得分对比显示术后患者生活质量提高(P0.005);4.2.2完成盆底障碍影响简易问卷(PFIQ-7)调查的患者95例,术后随访得分与术前得分对比显示术后患者生活质量提高(P0.005);4.2.3完成盆腔器官脱垂性功能问卷(PSIQ-12)调查的患者65例,术后随访得分与术前得分对比,显示术后性生活质量有改善(P0.005)。5.经阴道植入网片盆底重建术治疗重度POP术后复发及远期并发症5.1经阴道植入网片盆底重建术术后复发率为5.3%(5/95)。其中3例为保留子宫的经阴道植入全盆网片的全盆重建术。在95位患者中,经阴道植入全盆网片的全盆重建术共为5例,该术式的术后复发率为60%(3/5)。5.2经阴道植入网片盆底重建术术后晚期并发症:网片暴露4例(4.2%),网片侵蚀1例(1.1%),阴道壁溃疡1例(1.1%),阴道壁肉芽肿2例(2.1%),术后新发尿失禁3例(3.2%),术后顽固性腹股沟疼痛1例(1.1%);5.3经阴道植入网片盆底重建术再次手术率:因脱垂复发再手术率为3.2%(3/95),因术后并发症在手术率为6.3%(6/95);结论:1.经阴道植入网片盆底重建术是治疗重度POP的安全、有效的手术方式,并在解剖学复位、提高患者生活质量以及提高性生活质量指标评估中,疗效可得到肯定;2.重度盆腔器官脱垂患者,保留子宫的经阴道植入全盆网片全盆重建术术后复发风险明显高于伴子宫切除的全盆重建术。
[Abstract]:Background: pelvic organ prolapse (POP) refers to the dissection of pelvic organs caused by pelvic floor support or relaxation. Uterine prolapse refers to the descent of the uterus from the normal position along the vagina and the level of the cervix to the level of the sciatic spine, the National Institute of the United States (National Institutes of Health,) NIH) pointed out that POP means that the anterior edge of any vaginal segment reaches or exceeds 1cm above the hymen margin. Surgical treatment can effectively relieve the discomfort caused by pelvic organ prolapse and effectively improve the quality of life of the patient. The objective of surgical treatment: 1. anatomic tissue relocations; 2. restoration or maintenance of normal bladder function; 3. recovery Or maintain normal rectal function; 4. restore or maintain normal function. Surgical treatment of pelvic viscera prolapse is: traditional transvaginal hysterectomy and anterior, posterior wall repair; vaginal closure; mansoni surgery; sacral spine ligament fixation and other traditional [1]. operations for the use of autologous fascia for basin reconstruction, the literature reports recurrence rate. 30%, the patients with partial severe POP are difficult to achieve anatomical reduction, and the recurrence rate is higher as time progresses. The application of artificial synthetic mesh in the treatment of pelvic organ prolapse can correct the central defects and lateral defects, reduce the recurrence of POP and improve the quality of life of the patients. This study through the vaginal implantation of the pelvic floor in the Qilu Hospital Long term follow-up of patients with reconstructive surgery, the long-term effect of pelvic floor reconstruction with transvaginal implant was analyzed. Objective: To explore the long-term effect of pelvic floor reconstruction by transvaginal implant surgery for severe pelvic organ prolapse: a retrospective study was performed between January 2008 and December 2015 at Qilu Hospital of Shandong University. After pelvic floor reconstruction (TVM), 105 cases of severe POP cases were followed up. The operation method was the anterior pelvic reconstruction of the vagina implantation, the posterior pelvic reconstruction through the vagina, and the whole basin reconstruction of the whole pelvis through the vagina. The pelvic floor weight was evaluated through the analysis of the patient's clinical data and the pelvic floor weight was evaluated by vaginal implantation. The related indicators and perioperative complications were established. Through the outpatient review, gynecologic examination, the pelvic organ quantitative staging (POP-Q) was used to quantify the severity of prolapse, and the preoperative and postoperative statistical analysis of pelvic floor reconstruction was carried out to evaluate the objective clinical efficacy of the reconstruction of the pelvic floor of the transvaginal implant. The score of simple questionnaire -7 (PFIQ-7), pelvic floor dysfunction questionnaire (PFDI-20) and pelvic organ prolapse function questionnaire (PSIQ-12) was used to evaluate the subjective clinical effect of the patients after pelvic floor reconstruction by vaginal implantation, and to evaluate the vagina through regular follow-up and periodic reexamination. Recurrence of pelvic organ prolapse after pelvic floor reconstruction and postoperative long-term complications. Statistical analysis: statistical analysis was carried out by SPSS16.0. Count data were expressed in frequency or ratio, measured data were represented by the standard deviation of the number of men, compared with paired t tests, and P0.05 was regarded as a statistical difference. Results: 1. the cure rate of pelvic floor reconstruction by transvaginal mesh: 1.1 according to the ICS standard 1 years, 3 years, 5 years cure rate is 94.7%, 87.1%, 80.4%; 1.2 according to the compound standard 1 years, 3, 5 year cure rate respectively is 94.7%, 91.4%, 88.2%.2. transvaginal implantation of pelvic floor reconstruction of patients with clinical data and general situation: vaginal implantation net pelvic 105 cases were followed up and 95 cases were followed up effectively. The average age of the effective follow-up was 90.5% (95/105).2.2, the average age of the patients was 63.9 + 10.5 years, the birth time was 1.8 + 0.7 times, the BMI was 29.5 + 9.8kg/m2, the patients with the history of dystocia accounted for 30.5% (29/95), 24.25% (24.25), postmenopause patients accounted for 87% (83/95), and chronic abdominal pressure. Preoperative POP-Q staging of patients with 48.4% (46/95).2.3 via vaginal implant pelvic floor reconstruction: 95 cases of pre operation POP-Q stage III IV stage, of which 55 cases were in the anterior chamber of pelvic floor, 55 cases, 57.9%, 47 patients in the pelvic floor cavity and 49.5%, 18 patients with stage III IV prolapse in pelvic floor posterior chamber, accounting for 18.9%.. 3. the related indexes of pelvic floor reconstruction by transvaginal implantation of net plate and perioperative complications 3.1 through vaginal implantation of pelvic floor reconstruction, the average time of operation was 79 + 11mmin, the amount of bleeding in the operation was 90.3 + 50mL, the average catheter indwelling time after operation was 6 + 1 days after operation, and the average hospital time after operation was 5 + 1 days.3.2 transvaginal. Perioperative complications: 1 cases (1.1%) of bladder injury in operation, 2 cases of urinary tract infection (2.1%) after operation, 3 cases of postoperative urinary retention (3.2%), 3 cases of lower limb venous thrombosis (3.2%) after operation (3.2%).4. transvaginal implantation of pelvic floor reconstruction for severe POP clinical effect of 4.1 objective clinical curative effect: applied international clinical effect: Application International The POP-Q staging of the unified evaluation system was evaluated: 1 years after the pelvic floor reconstruction of the vaginal implant, the Aa, Ba, Ap, Bp and C points were compared with the corresponding position before operation (P0.005), and there was no significant difference between the preoperative and postoperative vaginal length (P=0.012), and the 4.2 subjective clinical efficacy: 4.2.1 completion. 95 cases of simple questionnaire (PFIQ-7) were affected by pelvic floor disorder. The postoperative follow-up scores and preoperative scores showed that the patients' life quality was improved (P0.005); 4.2.2 completed pelvic floor disorders affecting 95 patients with simple questionnaire (PFIQ-7). The postoperative follow-up scores and preoperative scores showed that the quality of life was improved (P0.005) after the operation (P0.005); 4. 2.3 patients who completed the pelvic organ prolapse sexual function questionnaire (PSIQ-12) survey 65 cases, the postoperative follow-up scores and preoperative scores were compared, showing that the postoperative sex life quality was improved (P0.005).5. via vaginal implant pelvic floor reconstruction for the treatment of severe POP recurrence and long-term complications, 5.1 after the vaginal implant pelvic floor reconstructive surgery, the recurrence rate was 5. 3% (5/95). 3 of them underwent full pelvic reconstruction by transvaginal full pelvic mesh for retention of uterus. In 95 patients, total pelvic reconstruction by transvaginal full pelvic mesh was performed in 5 cases. The postoperative recurrence rate was 60% (3/5).5.2 via vaginal implant pelvic floor reconstruction: 4 cases (4.2%) were exposed to mesh and 1 cases (1.). 1%) 1 cases (1.1%) of vaginal wall ulcers, 2 cases of vaginal wall granuloma (2.1%), 3 cases of new urinary incontinence (3.2%) after operation, 1 cases of intractable inguinal pain after operation (1.1%), and 5.3 transvaginal reoperation rate of pelvic floor reconstruction: recurrence rate of recurrent prolapse was 3.2% (3 /95) and postoperative complication was 6.3% (6/95); conclusion: transvaginal implant network Pelvic floor reconstruction is a safe and effective method for the treatment of severe POP, and the curative effect can be affirmed in the anatomic reduction, the improvement of the quality of life and the improvement of the quality of life. 2. patients with severe pelvic organ prolapse, the risk of recurrence after the whole pelvic reconstruction of the uterus by transvaginal implantation of the uterus is obviously higher than that of the whole pelvic reconstructive operation. Total pelvic reconstruction with hysterectomy.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R713

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