女性盆底结构的三维可视化研究

发布时间：2018-09-18 15:32

【摘要】：研究背景与目的精准医疗(precision medicine,PM)是以个体化医疗为基础,结合患者生活环境和临床数据,实现精准的疾病分类及诊断,制定具有个性化的疾病预防和治疗方案。目前精准医疗在妇科手术中的运用研究尚缺乏。女性盆底解剖结构复杂,且位置深在,可及性差,但该部位是诸多妇科手术的关键部位,尤其是宫颈癌(cervical cancer,CC)和盆腔器官脱垂(pelvic organ prolapse,POP)病人的手术治疗与此间结构关系密切,是手术成败和术后并发症发生的关键部位所在。宫颈癌的发病率居妇科恶性肿瘤之首,广泛子宫切除术(radical hysterectomy,RH)是治疗早期宫颈癌的主要方法,但是术中并发症如出血,膀胱、直肠、输尿管损伤,术后并发症如排便、排尿功能障碍不能完全避免,重要原因是因为盆底解剖位置深在,结构毗邻复杂,尤其是宫颈周围结构(pericervical structures,PS),包括主韧带(cardinal ligament,CL)、骶韧带(uterosacral ligament,USL)、膀胱宫颈韧带(vesico-cervical ligament,VCL)、宫颈周围环(pericervical ring,CR)的三维结构及其毗邻关系未能完全了解。关于这一部分的研究各学者存在很大争议[1],影响到广泛子宫切除术的手术疗效以及宫颈癌后续的综合治疗。女性盆底功能障碍性疾病(pelvic floor dysfunction,PFD)是指盆底支持组织因损伤或退化等原因所致松弛而引发的疾病。主要包括压力性尿失禁(stress urinary incontinence,SUI)和POP。随着人口老龄化,PFD发病率逐年增高,严重影响中老年妇女身心健康及生活质量[2]。PFD程度较重的需要外科手术治疗,但传统手术的并发症和术后复发率均较高[3],原因在于术前对POP程度掌握不准确,未发现明确的复杂的盆底结构缺陷。随着盆底重建(pelvic floor reconstruction,PFR)外科的发展,术前准确评估盆腔器官及各结构之间的解剖关系、脱垂的程度并明确缺陷的具体部位,是制定综合诊疗措施、使患者获得有效的个性化治疗的前提,这些均需要对盆底解剖结构更详尽的了解。既往对女性盆底的解剖学研究主要依靠尸体解剖[4],近年来许多学者提出利用不同的方法研究盆底解剖[5-8],以加强对盆底结构的了解,目前关于盆底解剖结构的三维可视化研究已越来越受到重视。但是,前期的工作缺乏更为精细的形态解剖学研究,前期研究多为尸体解剖,尸体解剖有一定局限性:组织破坏较大,标本的可重复利用性差,空间可视化程度较差;磁共振成像(magnetic resonance imaging,MRI)和计算机断层扫描(computed tomogtaphy,CT)均为影像学研究,辨认精准结构特征不够准确,所以无法真正还原复杂精细的女性盆底解剖。因此需要在原有研究基础上优化相关指标,发现新的研究方法完善女性盆底解剖学研究。MRI具有较高的软组织分辨率,能多方位进行盆底结构扫描,已越来越多地运用于盆底结构的研究和POP的诊断;MRI无辐射,属于非侵入性检查,具有软组织分辨率高、动静态功能和多平面成像等特点,可全面评价盆腔器官脱垂和盆底形态,无疑是研究盆底解剖较好的手段[9,10]。但MRI属于影像学,所生成的图像色彩为灰阶,在辨认解剖结构细部特征时相对困难,尤其是软组织边界的界定较模糊,二维扫描图像质量易受体位、呼吸、肠蠕动等影响,因而不能最真实准确地体现女性盆底的精细解剖及毗邻关系。中国数字化人体(chinese visible human,CVH)数据集图像为真彩色,分辨率高,图像形变小,厚度薄,图像相互之间配准度高,随着数字医学的发展在多个领域有着广泛的应用前景[11,12]。结合MRI图像资料,CVH可望成为研究女性盆底解剖新的途径,真正实现女性盆底结构可视化,对指导各种妇科手术的实施有着指导意义。本研究拟利用CVH盆腔段数据集,结合健康正常志愿者女性盆腔横断位薄层MRI扫描图像,采用腹腔镜下广泛子宫切除术(laparoscope radical hysterectomy,LRH)中相关活体解剖,对正常女性宫颈周围结构进行三维重建,为妇科手术特别是RH及PFR手术的模拟教学、影像学诊断提供有力的形态学依据,为妇科临床和解剖基础教学提供三维可视化模型;同时利用子宫脱垂患者盆底矢状位MRI图像,建立POP盆底结构三维可视化模型,探讨子宫脱垂患者盆底MRI三维影像特征及临床诊断意义,真正实现女性盆底结构的精准化研究,为妇科临床精准诊治奠定基础。实验方法:1、选择3例无器质性病变的女性CVH数据集盆腔段数据,对盆腔器官和宫颈周围结构包括膀胱宫颈韧带、子宫骶韧带、子宫主韧带、宫颈周围环、盆腔血管、直肠系膜、膀胱侧间隙、直肠侧间隙及毗邻结构进行识别、分割,并进行三维重建;同时选择3例正常未生育女性志愿者,对盆腔进行横断位薄层MRI扫描,与CVH图像进行对照研究;选择LRH相关解剖图片进行对比。2、选取2013年9月至2014年6月子宫脱垂患者30例为研究组,选取健康女性20例为对照组,于静息位和Valsalva动作时行盆底MRI扫描;利用Amira软件,对图像进行测量及3D建模,对比研究各参数。3、统计学分析:数据处理采用SPSS 19.0统计分析软件,计量资料用均数±标准差表示,正态分布的数据采用的独立样本t检验或配对t检验。P0.05被认为差异有统计学意义。实验结果:1、基于CVH,利用Amira 5.2.2软件重建了女性骨盆、盆腔器官、膀胱宫颈韧带、子宫骶韧带、子宫主韧带、宫颈周围环、盆腔血管、直肠系膜、膀胱侧间隙、直肠侧间隙及毗邻结构的三维可视化模型,很好地显示了宫颈周围结构及其毗邻关系。2、在三维模型的基础上对膀胱宫颈韧带、子宫骶韧带、子宫主韧带、宫颈周围环等结构的长度、宽度、厚度进行量化及分段。3、基于MRI TSE T2WI序列,利用Amira 5.2.2商业软件,建立了脱垂组和对照组盆底结构的三维可视化模型,利用3D测量器分别量化PCL线、G1角、G2角、H线、M线、宫颈长度、C线、B线等参数。4、脱垂组和对照组组间两相位分别比较:PCL、H线、G1角、G2角、宫颈长度无显著性差异(p㧐0.05),M线、C线有显著性差异(P0.05),B线静息时无显著性差异(p㧐0.05),Valsalva动作时有显著性差异(P0.05);组内两相位差值比较:两组PCL均无显著性差异(p㧐0.05),M线、G1角、G2角、B线、C线有显著性差异(P0.05),H线对照组有显著性差异(P0.05),脱垂组无显著性差异(p㧐0.05)。结论:1、中国可视化人体数据集(CVH)提供了完整而精准的数据,利用该数据库,结合活体女性盆腔横断面薄层MRI影像资料,对比LRH相关解剖,分别重建了女性骨盆、盆腔器官、宫颈周围结构及重要的腹膜后解剖间隙以及盆腔血管神经,建立了正常女性盆腔三维可视化模型。2、在三维模型的基础上对膀胱宫颈韧带、子宫骶韧带、子宫主韧带、宫颈周围环等结构的长度、宽度、厚度进行量化及分段,对临床治疗宫颈癌及盆腔器官脱垂疾病有很好地临床指导意义,可望为临床精准诊治提供解剖依据。MRI TSE T2WI序列能清楚显示盆底结构且各项测量指标精准,是盆腔器官脱垂诊断分期和治疗决策的好方法。4、盆底三维可视化重建模型能清楚地显示各结构之间的关系,可以明确盆底缺陷的精确位置,是盆底手术模拟的好途径,可为解剖教学及进一步力学研究提供支持。
[Abstract]:BACKGROUND & OBJECTIVE Precision medicine (PM) is based on individualized medical care, combined with patient's living environment and clinical data, to achieve accurate disease classification and diagnosis, and to formulate a personalized disease prevention and treatment program. The structure is complex, and the location is deep, poor accessibility, but this part is the key part of many gynecological surgery, especially cervical cancer (CC) and pelvic organ prolapse (POP) patients with surgical treatment and this structure is closely related to the success of surgery and postoperative complications of the key location. Radical hysterectomy (RH) is the main treatment for early cervical cancer. However, intraoperative complications such as bleeding, bladder, rectum, ureter injury, postoperative complications such as defecation, urinary dysfunction can not be completely avoided. The important reason is that the anatomical position of the pelvic floor is deep and the structure is abundant. Complex adjacent structures, especially pericervical structures (PS), including the main ligament (CL), sacral ligament (USL), vesico-cervical ligament (VCL), pericervical ring (CR), and their adjacent relationships are not fully understood. Female pelvic floor dysfunction (PFD) refers to a disorder caused by relaxation of the pelvic floor supporting tissue due to injury or degeneration, including stress urinary incontinence (stre). With the aging of the population, the incidence of PFD increases year by year, which seriously affects the physical and mental health and quality of life of middle-aged and elderly women [2].Surgical treatment is needed for the patients with severe PFD, but the complications and recurrence rate of traditional surgery are higher [3], because the degree of POP is not accurately grasped before operation, and no clear results have been found. With the development of pelvic floor reconstruction (PFR) surgery, accurate preoperative assessment of the anatomical relationship between pelvic organs and structures, the extent of prolapse and the specific location of the defect are the prerequisites for comprehensive diagnosis and treatment and for effective personalized treatment of patients. In the past, the anatomy of female pelvic floor mainly relied on autopsy. In recent years, many scholars have proposed using different methods to study pelvic floor anatomy [5-8] in order to enhance the understanding of pelvic floor structure. At present, more and more attention has been paid to the three-dimensional visualization of pelvic floor anatomy. However, the previous work lacked more detailed morphological and anatomical studies. Most of the previous studies were autopsy, which had some limitations: large tissue destruction, poor reusability of specimens, poor spatial visualization; magnetic resonance imaging (MRI) and computed tomography (CT). It is difficult to restore the complicated and fine anatomy of the female pelvic floor. Therefore, it is necessary to optimize the relevant indicators on the basis of the original study and find new research methods to improve the anatomy of the female pelvic floor. MRI has a high soft tissue resolution and can carry out the pelvic floor structure in many directions. Scanning has been used more and more in the study of pelvic floor structure and the diagnosis of POP; MRI is non-invasive, non-radiation, with high soft tissue resolution, dynamic and static functions and multi-plane imaging characteristics, can be used to evaluate the pelvic organ prolapse and pelvic floor morphology, is undoubtedly a better means to study pelvic floor anatomy [9,10]. The color of the image is gray scale, and it is difficult to identify the details of anatomical structure, especially the boundary of soft tissue is blurred. The quality of the two-dimensional scanning image is easy to be affected by location, respiration, intestinal peristalsis and so on. Therefore, it can not reflect the precise anatomy and adjacent relationship of the female pelvic floor most truly and accurately. Visible human (CVH) dataset images are true color, high resolution, small deformation, thin thickness and high registration between images. With the development of digital medicine, it has a broad application prospect in many fields [11,12]. In this study, we intend to use the CVH pelvic segment data set, combined with the thin-slice MRI scan images of the normal female volunteers, to dissect the cervical periphery of the normal female by laparoscope radical hysterectomy (LRH). Surrounding structure is reconstructed in three-dimensional, which provides powerful morphological basis for gynecological surgery, especially RH and PFR surgery simulation teaching and imaging diagnosis, and provides three-dimensional visualization model for gynecological clinical and anatomical basic teaching; meanwhile, using the sagittal MRI image of the pelvic floor of patients with uterine prolapse, the three-dimensional visualization model of the POP pelvic floor structure is established, and the discussion is made. Three-dimensional MRI features and clinical diagnostic significance of pelvic floor in patients with uterine prolapse can truly realize the precise study of female pelvic floor structure and lay a foundation for gynecological clinical diagnosis and treatment. The uterosacral ligament, the main uterine ligament, the pericervical ring, pelvic vessels, mesorectal, bladder lateral space, rectal lateral space and adjacent structures were identified, segmented and reconstructed in three dimensions. Pictures were compared. 2. 30 patients with uterine prolapse from September 2013 to June 2014 were selected as the study group, 20 healthy women as the control group, pelvic floor MRI scanning was performed in resting position and Valsalva movement; the image was measured and 3D modeled by Amira software, and the parameters were compared. 3. Statistical analysis: SPSS 19.0 was used for data processing. Results: 1. Based on CVH, the female pelvis, pelvic organs, bladder and cervical ligaments, uterosacral ligaments, main uterine ligaments, cervical ligaments were reconstructed with Amira 5.2.2 software. The three-dimensional visualization model of the peripheral ring, pelvic vessels, mesorectal, bladder lateral space, rectal lateral space and adjacent structures shows the structure around the cervix and its adjacent relationship. 2. Based on the three-dimensional model, the length, width and thickness of the bladder cervical ligament, uterosacral ligament, main uterine ligament, and the surrounding ring of the cervix are calculated. Quantification and segmentation.3. Based on MRI TSE T2WI sequence and Amira 5.2.2 commercial software, three-dimensional visualization models of pelvic floor structure in prolapsed group and control group were established. PCL line, G1 angle, G2 angle, H line, M line, cervical length, C line, B line and other parameters were quantified by 3D measuring instrument.4. Two phases of prolapsed group and control group were compared respectively: PCL, H line, G1 angle, G2 line. Angle, cervical length had no significant difference (p? 0.05), M line, C line had significant difference (P 0.05), B line had no significant difference at rest (p? 0.05), Valsalva action had significant difference (P 0.05); two phase difference between the two groups: there was no significant difference in PCL between the two groups (p? 0.05), M line, G1 angle, G2 angle, B line, C line had significant difference (P 0.05), H line control group had significant difference (P 0.05). Conclusion: 1. The Chinese Visual Human Data Set (CVH) provides complete and accurate data. Using this database, we reconstructed the female pelvis, pelvic organs, cervical pericervical structures and their importance by comparing LRH-related anatomy with thin-slice MRI images of female pelvis in vivo. The length, width and thickness of the bladder cervical ligament, uterosacral ligament, main uterine ligament and pericervical ring were quantified and segmented on the basis of the three-dimensional model. MRI TSE T2WI sequence can clearly show the pelvic floor structure and the measurement indexes are accurate. It is a good method for diagnosis and treatment decision of pelvic organ prolapse. 4. The three-dimensional visualization reconstruction model of pelvic floor can clearly show the relationship between the structures. Defining the exact location of pelvic floor defect is a good way to simulate pelvic floor surgery, which can provide support for anatomy teaching and further mechanical research.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R711

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