改良型保留盆腔自主神经宫颈癌根治术的解剖及临床相关研究

发布时间：2018-06-03 22:00

本文选题：子宫颈肿瘤 + 广泛性子宫切除术　；参考：《北京协和医学院》2014年硕士论文

【摘要】：目的：对女性盆腔自主神经的分布进行解剖学询证；探讨开腹或腹腔镜下实施改良型保留盆腔自主神经宫颈癌根治术一保留神经平面的广泛性子宫切除术(nerve plane-sparing radical hysterectomy, NPSRH)的可行性及其对膀胱功能的影响;回顾性分析NPSRH手术对患者术后膀胱、直肠及性功能的改善作用及对预后的影响。方法：(1)解剖学研究方面,2013年3月至2014年1月,对10例女性新鲜尸体的盆腔标本进行大体解剖,识别盆腔自主神经并探索其与周围组织的关系。(2)手术技术研究方面,2012年7月至2013年11月,49例接受腹腔镜NPSRH的患者作为腹腔镜NPSRH组。2008年1月至2013年3月,102例ⅠB1期-ⅡA2期接受开腹NPSRH手术的宫颈癌患者设为开腹NPSRH组。选取同期接受开腹常规广泛子宫切除术(conventional radical hysterectomy, CRH)的204例宫颈癌患者设为开腹CRH组。要求开腹CRH组与开腹NPSRH组患者的年龄、病理类型及FIGO (International Federation of Gynecology and Obstetrics)分期等相关参数配平。比较开腹NPSRH组与开腹CRH组、开腹NPSRH组与腹腔镜NPSRH组的手术参数及术后近期膀胱功能恢复情况。(3)远期盆腔脏器功能评估及预后分析：比较研究组与开腹CRH组的远期膀胱、直肠及性功能恢复情况并对两组患者的预后进行比较。结果：(1)解剖学研究：于10例新鲜尸体标本中均发现盆腔自主神经位于同一神经平面内,其与输尿管关系密切。腹下神经部分分支未并入下腹下神经丛。于10例新鲜标本中(共20侧)中发现,17侧膀胱宫颈韧带后叶中含有两支由膀胱回流的静脉,3侧膀胱宫颈韧带后叶中含有三支静脉,其走行穿过盆腔自主神经平面。(2)手术技术研究：开腹NPSRH组手术时间较开腹CRH组明显延长(P=0.000)；两组患者的术中出血量、术中输血比例和术后并发症发生率比较,差异均无统计学意义(P0.05)；开腹NPSRH组术后导尿时间及住院时间较开腹CRH组均有显著缩短(P=0.000)；腹腔镜NPSRH组患者的年龄、体重指数、肿瘤分期、病理类型等各项参数,与开腹NPSRH组比较无统计学差异(P0.05)。腹腔镜NPSRH组手术时间与开腹NPSRH组比较有所延长,但无统计学意义(P=0.161),出血量及输血比例明显降低(P0.01)。腹腔镜NPSRH组的术后导尿时间及住院天数有明显缩短(P0.05)。(3)远期盆腔脏器功能评估及预后分析：问卷调查显示开腹NPSRH组的尿频、尿失禁、尿潴留、用力排尿、腹泻及便秘的发生率明显低于CRH组(P0.05)。两组患者在远期性功能方面无明显差异(P0.05)。两组患者的3年无复发生存率(RFS)及3年总生存率(OS)均无统计学意义(P0.05)。单因素及多因素分析显示,保留神经平面与否对患者3年RFS和3年OS无明显影响(P0.05)。结论：本研究发现盆腔自主神经位于同一平面内,与输尿管关系密切。腹下神经及其分支可能对膀胱起着主导支配作用,但尚需进一步组织病理证实。膀胱静脉变异性大,走行穿过盆腔自主神经平面。NPSRH手术于开腹及腹腔镜下均可行,并促进了患者术后膀胱功能恢复。腹腔镜NPSRH较开腹明显减少了术中出血,且在术后膀胱功能恢复方面具有优势。NPSRH手术改善了远期膀胱功能,在一定程度上改善了远期直肠功能,且不影响预后。
[Abstract]:Objective : To study the distribution of female pelvic autonomic nerve ;
To investigate the feasibility of the modified preservation of pelvic autonomic nerve cervical cancer radical hysterectomy ( NPAs ) and its effect on bladder function under open or laparoscopic surgery , and to retrospectively analyze the improvement of bladder , rectum and sexual function in patients after operation and the effect on prognosis .

Methods : ( 1 ) From March 2013 to January 2014 , the pelvic autonomic nerves were dissected to identify pelvic autonomic nerves and explore their relationship with surrounding tissues .

Results : ( 1 ) Anatomy study : The pelvic autonomic nerve was found in the same nerve plane in 10 fresh specimens .
There was no significant difference in intraoperative blood loss , intraoperative blood transfusion proportion and postoperative complication rate among the two groups ( P0.05 ) .
The time of urinary catheterization and the time of hospitalization were significantly shorter than those in the open group ( P = 0.000 ) .
The age , body mass index , tumor stage , pathological type and other parameters of the patients with laparoscopic NPAs group were significantly shorter than those in the open - abdominal NPAs group ( P0.05 ) . There was no significant difference between the two groups ( P = 0.161 ) , the bleeding volume and the blood transfusion ratio ( P0.05 ) .

Conclusion : The pelvic autonomic nerve is located in the same plane and is closely related to the ureter . The hypogastric nerve and its branches may play a dominant role in the bladder . However , it is necessary to further organize the pathology to prove that the operation of the NPAs is feasible in both open and laparoscopic . The operation of NPAs has the advantages of improving the long - term bladder function and improving the long - term rectal function to some extent , and does not influence the prognosis .
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R737.33

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