子宫托与盆底重建术治疗老年重度盆腔脏器脱垂的疗效评估

发布时间：2018-04-21 07:58

本文选题：盆腔脏器脱垂 + 硅胶子宫托　；参考：《郑州大学》2017年硕士论文

【摘要】：盆腔器官脱垂(Pelvic organ prolapse,POP)是指因盆底的支持系统作用减弱而致使膀胱、子宫以及直肠等器官组织位置下移。随着人类寿命的延长,盆腔器官脱垂发病率逐年上升,其终生患病率高达30%~50%,脱垂程度达III度以上将严重影响患者的生活质量。目前,脱垂程度III度以上的治疗方式主要包括子宫托治疗以及手术治疗。手术主要包括传统术式及放置网片的盆底重建术。美国妇产科学会将子宫托治疗POP作为其指南中推荐的首选方法,然而目前国内硅胶子宫托只在少数三甲医院被应用,且重度脱垂的治疗仍以手术为主。近些年,国内已有针对硅胶子宫托治疗盆腔脏器脱垂的研究,但仍缺乏针对当前流行的盆腔脏器脱垂治疗策略的对比研究。本研究通过对硅胶子宫托和盆底重建术治疗老年重度POP患者的随访观察对其疗效进行评估,为老年患者治疗方式的选择提供临床依据。目的探讨硅胶子宫托和盆底重建术两种不同方式改善老年女性重度盆腔器官脱垂患者生活质量的差异,并对治疗后满意度及并发症进行分析,旨在为老年POP患者治疗方式的选择提供临床依据。资料与方法1研究对象选取2013年1月至2014年5月就诊于郑州大学第三附属医院的有症状、年龄60岁以上、盆腔器官脱垂定量分度Ⅲ~Ⅳ度的老年患者,经治疗方式的详细咨询(包括硅胶子宫托和盆底重建术治疗的方法、优缺点、可能存在的并发症及费用等),排除对两种治疗均有禁忌症的患者,按其选择进行分组。2研究方法2.1硅胶子宫托:均由美国COOPER公司提供,由于本研究对象均为POP-Q III-IV度,故所用类型为兼备支撑和填充作用的圆形短柄状(Gellhorn型)。2.2手术:所选术式为当前应用较广、适用于重度POP的子宫切除术+阴道置入网片的盆底重建术,或单纯行阴道置入网片的盆底重建术。手术均由我院盆底重建病区资深医生一人进行。2.3资料收集:包括:就诊年龄、体质指数(body mass index,BMI)、经阴道分娩次数、激素补充治疗情况、绝经情况,既往是否行子宫切除术、尿失禁情况,有无慢性咳嗽病史及慢性便秘病史,有无合并糖尿病,精神类疾患等病史。2.4分组:排除禁忌症后按患者选择进行分组,分为硅胶子宫托组和盆底重建术组,共144例纳入本研究。2.5排除标准:(1)因某种合并症(如心、肝、肺、肾等疾病)影响麻醉或手术而只能用子宫托治疗者;(2)子宫托试戴失败或使用子宫托后又改选手术治疗者;(3)合并其它妇科疾病需要手术治疗者。2.6诊断标准:本研究中脱垂分度所应用的标准为盆腔器官脱垂定量分度法(pelvic organ prolapsed quantitation,POP-Q)。2.7临床效果分析:应用盆底功能障碍问卷PFDI-20、盆底障碍简易调查问卷PFIQ-7对患者的治疗前的生活质量进行评分。完善治疗后6个月、2年PFDI-20、PFIQ-7评分。参照Bai等的满意度评估方法对治疗后满意度评分。进行组内治疗前后生活质量评分比较,组间治疗后6个月、2年的生活质量评分及满意度的比较,并对并发症进行分析。2.8随访及统计分析:主要以门诊随访和电话随访为主。完善治疗后6个月、2年的PFDI-20、PFIQ-7评分,详细询问其并发症出现的时间、类型及次数。并对其满意度进行记录分析。所有数据均录入EXCEL表格。录入的数据均使用统计学分析软件SPSS21.0进行分析比较,根据数据类型不同(定量资料、定性资料)及比较范围不同(组内比较、组间比较)应用相应的分析方法进行统计学计算。检验水准取α=0.05,P值0.05为有统计学意义。结果1.硅胶子宫托与盆底重建术治疗6个月和治疗2年PFDI-20、PFIQ-7评分较治疗前均降低(P0.05)。子宫托治疗2年与6个月比较PFDI-20、PFIQ-7评分差异无统计学意义,其P值分别为0.43、0.75。盆底重建术治疗2年与6个月比较PFDI-20、PFIQ-7评分差异有统计学意义,其P值分别为0.04、0.03。2.盆底重建术与硅胶子宫托治疗6个月后生活质量评分比较无明显统计学差异,PFDI-20、PFIQ-7评分P值分别为0.35、0.83。3.盆底重建术2年后治疗效果优于硅胶子宫托,PFDI-20、PFIQ-7的P值分别为0.00、0.02。4.盆底重建术与子宫托治疗后满意度6个月组间差异无统计学意义(P=0.37);治疗后2年手术组满意度高于子宫托组,差异有统计学意义(P=0.04),盆底重建术治疗远期满意度较硅胶子宫托高。5.子宫托并发症主要为:阴道分泌物增多17.02%(8/47),阴道异味10.64%(5/47)。6.盆底重建术围手术期并发症主要为:穿刺点或下肢牵拉痛13.92%(11/79),尿潴留8.86%(7/79);术后远期并发症:网片外露13.92%(11/79),新发尿路症状10.13%(8/79)。结论1.硅胶子宫托与盆底重建术均为治疗老年重度盆腔脏器脱垂的有效方法,疗效确切。2.盆底重建术与硅胶子宫托治疗老年重度盆腔脏器脱垂近期疗效及治疗后满意度无明显差异,但远期疗效及满意度盆底重建术较高。3.对于高龄患者而言盆底重建术围手术期并发症及网片外露发生率较高。4.高龄患者、不能耐受手术或者不接受手术治疗的患者,硅胶子宫托是一种值得推荐的治疗方法。
[Abstract]:Pelvic organ prolapse (POP) refers to the displacement of bladder, uterus and rectum because of the weakening of the support system of the pelvic floor. With the prolongation of human life, the incidence of pelvic organ prolapse is rising year by year, its lifetime prevalence is up to 30%~50%, and the degree of prolapse of more than III will seriously affect the patient. At present, more than III degrees of prolapse are mainly included in the treatment of uterine care and surgical treatment. The operation mainly includes the traditional surgery and the placement of the pelvic floor reconstruction. The American Society of Obstetrics and Gynecology has recommended the treatment of POP as the preferred method in its guide. However, the domestic silicone uterine care is only a few in the country. Three a hospital has been used, and the treatment of severe prolapse is still based on operation. In recent years, there has been a study on the treatment of pelvic viscera prolapse by silicone hysterectomy in recent years, but there is still a lack of comparative study on the current popular treatment strategies for pelvic viscera prolapse. This study was carried out in the treatment of elderly severe POP patients by silica gel subuterine palaces and pelvic floor reconstruction. To evaluate the curative effect of the elderly patients and provide clinical basis for the treatment of elderly patients. Objective to explore the difference in the quality of life of the elderly women with severe pelvic organ prolapse by two different ways to improve the quality of life of the elderly women with severe pelvic organ prolapse, and to analyze the degree of satisfaction and complications after the treatment. The purpose of this study is to develop the elderly patients with POP. The selection of treatment methods provided clinical basis. Data and methods 1 subjects were selected from January 2013 to May 2014 at the Third Affiliated Hospital of Zhengzhou University, the elderly patients aged 60 years and above, with the quantitative degree of pelvic organ prolapse grade III ~ IV, and the detailed and detailed counseling (including silica gel and pelvic floor reconstruction) Methods of treatment, advantages and disadvantages, possible complications and costs, excluding those with contraindications to two treatments, according to the choice of the group.2 study method 2.1 silica gel: all of which were provided by COOPER company in the United States, because the subjects of this study were all POP-Q III-IV degrees, so the type used for both support and filling of the circular short. The Gellhorn type (type).2.2 operation: the selected operation is widely used for the current application of the pelvic floor reconstruction with severe POP hysterectomy plus the vaginal insertion mesh, or the pelvic floor reconstruction with a simple vaginal insertion mesh. The operation is collected by a senior doctor in the pelvic floor reconstruction area of our hospital for a.2.3 data collection, including the age of treatment, body mass index (Bo Dy mass index, BMI), the number of vaginal delivery, hormone supplement treatment, menopause, previous hysterectomy, urinary incontinence, chronic cough history and chronic constipation history, or without diabetes, psychiatric disorders, such as the history of the.2.4 group: after exclusion of contraindications to the patients selected for grouping, divided into silicone uterine care group A total of 144 cases of pelvic floor reconstruction were included in the.2.5 exclusion criteria in this study: (1) patients who had a certain complication (such as heart, liver, lung, kidney and other diseases) could only use uterine care for anesthesia or surgery; (2) the uterine care failed to wear or after the use of the uterus to be reelected, and (3) other gynecologic diseases needed surgical treatment. In this study, the criteria used for the prolapse score were the analysis of the clinical effect of the pelvic organ prolapsed quantitation (POP-Q).2.7: the pelvic floor dysfunction questionnaire PFDI-20 and the simple questionnaire PFIQ-7 for the pelvic floor disorder (PFIQ-7) to score the quality of life before the treatment. 6 months after the treatment, 2 years PFDI after the treatment was perfected. -20, PFIQ-7 score. According to the satisfaction evaluation method of Bai and so on, the scores of life quality before and after treatment were compared, the quality of life scores and satisfaction were compared 6 months, 2 years after group treatment, and the complications were analyzed by.2.8 follow-up and statistical analysis: the main results were outpatient follow-up and telephone follow-up. 6 months after good treatment, 2 years of PFDI-20, PFIQ-7 score, detailed inquiries about the time, type and number of its complications, and record and analyze their satisfaction. All data are recorded in the EXCEL form. The data recorded are analyzed and compared with the statistical analysis software SPSS21.0, according to the different data types (quantitative data, qualitative data) And the comparison range was different (group comparison, group comparison) to use the corresponding analysis method for statistical calculation. The level of alpha =0.05, P value 0.05 was statistically significant. Results 1. silica gel and pelvic floor reconstruction for 6 months and 2 year PFDI-20, PFIQ-7 scores were lower than before treatment (P0.05). Uterine care 2 years and 6 months ratio. Compared with PFDI-20, the difference of PFIQ-7 score was not statistically significant. The P value of 0.43,0.75. pelvic floor reconstruction was compared with PFDI-20 for 2 years and 6 months, and the difference of PFIQ-7 score was statistically significant. The P value was no significant difference between 0.04,0.03.2. pelvic floor reconstruction and silicone uterine care 6 months after 6 months, PFDI-20, PFIQ-. 7 P value was 0.35,0.83.3. pelvic floor reconstruction after 2 years, the treatment effect was better than that of silica gel. The P value of PFDI-20 and PFIQ-7 had no statistically significant difference between the 6 months after the 0.00,0.02.4. pelvic floor reconstruction and the uterine care (P=0.37), and the degree of satisfaction of the operation group was higher than that of the uterine care group after 2 years of treatment (P=0). .04), the complications of pelvic floor reconstruction for long-term satisfaction compared with silica gel uterine elevation.5. were mainly: vaginal secretions increased by 17.02% (8/47), vagina odor 10.64% (5/47).6. pelvic floor reconstruction, the perioperative complications were mainly: puncture point or lower limb traction pain 13.92% (11/79), urinary retention 8.86% (7/79); postoperative long-term complications: 13. net exposure 13. 92% (11/79), new symptoms of urinary tract 10.13% (8/79). Conclusion 1. silica gel and pelvic floor reconstruction are effective methods for the treatment of severe pelvic viscera prolapse in the elderly. There is no significant difference in the short-term curative effect and satisfaction between the pelvic floor reconstruction and the silicone hysterectomy for the treatment of severe pelvic organ prolapse in the elderly, but the long-term effect and satisfaction are satisfactory. Pelvic floor reconstruction is high.3. for the elderly patients with pelvic floor reconstruction in the perioperative complications and the incidence of mesh exposure is higher in.4. elderly patients, unable to tolerate surgery or not to accept surgical treatment of patients, silica gel uterine care is a recommended treatment.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R713

【参考文献】