女性盆底功能障碍性疾病全盆底重建手术的解剖学、影像学及临床治疗研究

发布时间：2018-05-28 04:07

本文选题：盆底功能障碍性疾病 + 全盆底重建手术　；参考：《中国协和医科大学》2009年博士论文

【摘要】： 目的:明确针对中国女性的Prolift~(TM)和改良Prolift两种全盆底重建手术穿刺路径周围的血管神经解剖,提出两种手术的安全性路径操作建议。从临床解剖学、动态MRI影像学和临床治疗效果三方面对比研究Prolift~(TM)和改良Prolift两种全盆底重建手术的差异,以指导安全的Prolift~(TM)和改良Prolift手术路径,进而降低两种手术方式的手术并发症。同时将为改良Prolift手术路径在国内的推广应用提供良好的理论支持依据。方法:采用前瞻随机对照方式确定选取的12具国人成年女性新鲜尸体标本的手术穿刺方式(Prolift~(TM)手术路径6具和改良Prolift手术路径6具),解剖测量两种手术路径穿刺针与周围血管神经和重要脏器的距离,同时确立穿刺针的安全穿刺角度。运用动态MRI技术对同时期手术的20例POP-Q分度确定为Ⅲ度及以上盆腔器官脱垂的患者进行手术前后影像学检查,客观评价两种手术方式影像学治疗的差异。同时前瞻性对比研究我院168名全盆底重建手术患者(Prolift~(TM)手术16例,改良Prolift手术152例)的临床治疗效果。结果: 1、12具尸体解剖研究发现,在闭孔区Prolift~(TM)和改良Prolift两种全盆底重建手术阴道前壁浅带和深带穿刺针均在低于阴蒂水平线的区域穿过闭孔。Prolift~(TM)和改良Prolift两种手术方式阴道前壁深带穿经闭孔膜的穿刺点距离闭孔动静脉后支的距离分别为0.60±0.36cm和0.78±0.10cm小于阴道前壁浅带穿经闭孔膜的穿刺点距离闭孔动静脉前支的距离(1.58±0.05cm和1.58±0.05cm),两组分别比较P均＞0.05。 2、Prolift~(TM)和改良Prolift两种手术方式阴道前壁浅带穿经闭孔外肌的穿刺点距离闭孔神经前支的距离分别为3.23±1.03cm和3.18±0.61cm,距离闭孔神经后支的距离为3.28±0.63cm和2.95±0.63cm;Prolift~(TM)和改良Prolift两种手术方式阴道前壁深带穿经闭孔外肌的穿刺点距离闭孔神经前支的距离分别为3.35±0.59cm和3.16±1.04cm,距离闭孔神经后支的距离为2.68±0.57cm和2.86±0.87cm;两种手术方式比较P值均＞0.05. 3、Prolift~(TM)阴道前壁深带穿入阴道内长度(5.63±0.15cm)大于改良Prolift手术(4.83±0.05cm),(P＜0.01)。Prolift~(TM)阴道后壁穿刺针穿入阴道内长度(7.38±0.15cm)大于改良Prolift手术(5.88±0.23cm),(P＜0.01)。 4、Prolift~(TM)阴道后壁穿刺针与尾动脉的距离为(0.88±0.10cm),短于改良Prolift手术与尾动脉的距离(2.95±0.09cm),(P＜0.01)。Prolift~(TM)阴道后壁穿刺针与阴部内动脉的距离为(1.59±0.36cm),短于改良Prolift手术与阴部内动脉的距离(3.40±0.36cm),(P＜0.01)。Prolift~(TM)阴道后壁穿刺针与直肠的距离和为(0.88±0.10cm),改良Prolift手术与直肠的距离分别为1.05±0.89cm和0.86±0.62cm,两组比较无明显统计学差异,(P＞0.05)。 5、骶棘韧带起于平第4骶孔的骶骨至第1尾骨的侧缘,向外侧延伸止于坐骨棘盆侧的骨面。骶结节韧带由致密结缔组织组成,起于平第3骶孔的骶骨至第1尾骨的侧缘,向外下方延伸止于坐骨体背侧的骨面。骶结节韧带下缘低于骶棘韧带下缘。在距离坐骨棘内侧1.30±0.12cm以内骶结节韧带与骶棘韧带重叠融合,形成骶棘骶结节韧带复合体。 6、Prolift~(TM)组阴道后壁穿刺针穿过骶棘骶结节韧带复合体的比例为66.7%,明显高于改良Prolift组16.7%;穿过髂尾肌的比例为25%,明显低于改良Prolift组75%,两组分别比较均有显著统计学差异(P均＜0.05)。 7、Prolift~(TM)手术穿刺路径的安全区域:阴道前壁浅带穿刺针向上轴向旋转的方向与矢状面的角度大于25°或阴道前壁深带穿刺针向上轴向旋转的方向与矢状面的角度为大于30°,进入盆腔后未改变穿刺方向,可损伤膀胱、尿道或穿入腹壁。在穿入肛门旁切口处时穿刺针向坐骨结节方向偏斜大于5°即可损伤阴部管内的血管和神经;向内侧肛门方向倾斜15°可损伤直肠。 8、改良Prolift手术穿刺路径的安全区域:穿刺阴道前壁浅带时穿刺平面与尿道矢状面成45°角,缝合针手柄轴向水平面移动范围为15°～35°,垂直平面移动范围为40°～90°为盆底韧带缝合针穿刺阴道前壁浅带经闭孔区的安全路径。穿刺阴道前壁深带时穿刺平面与尿道矢状面成45°角,缝合针手柄轴向垂直平面范围为40°～60°,水平面范围为10°～15°,为盆底韧带缝合针穿刺阴道前壁深带经闭孔区的安全路径。改良Prolift术行阴道后壁穿刺时,注意穿刺时将阴道尽量向后顶至骶棘韧带附近,避免后壁穿刺针进入坐骨直肠窝后向外侧旋转或侧偏,同时在阴道内手指指引下内旋穿刺针穿过盆膈进入阴道。 9、本研究中发现动态MRI对临床诊断为前盆腔器官膨出的患者的符合率达到了95%(19/20),临床诊断为中盆腔器官脱垂的患者的符合率达到了70%(14/20),但对于临床诊断为后盆腔器官膨出的患者的符合率仅达到了25%(5/20)。 10、本研究中发现动态MRI检查Prolift~(TM)手术对泌尿生殖窦增大(H线的改变)和盆底下降(M线的改变)引起的盆底松弛均较术前明显减轻。改良Prolift手术对泌尿生殖窦增大(H线的改变)引起的盆底松弛较术前明显改善,但盆底下降(M线的改变)引起的盆底松弛较术前无显著变化。 11、对20例行不同手术的患者手术前后动态MRI的对比分析发现,临床诊断为治愈患者术后采用MNI HMO系统分度仍发现存在3例轻度盆腔器官脱垂患者,其中Prolift~(TM)手术1例,改良Prolift手术2例。 12、临床研究发现168名患者中(Prolift~(TM)组16例,改良Prolift组152例)Prolift~(TM)组15例,改良Prolift组119例病例完成随访,随访率为80%。手术后平均随访12个月(Prolift~(TM)组4个月,改良Prolift组12个月)手术治愈率分别为100%和94.1%。两种手术方式均未发生严重的并发症。结论 1、经闭孔区行穿刺吊带手术,穿刺针的穿刺范围控制在阴蒂水平以下,无损伤闭孔神经的风险。按照规范手术路径行穿刺手术可避免进入会阴深隙或浅隙,避免损伤会阴区的神经血管。 2、与阴道前壁浅带闭孔区穿刺路径相比,阴道前壁深带经闭孔区穿刺路径更容易损伤闭孔静脉后支,偶尔可损伤闭孔动脉后支,但很少引起严重的闭孔区出血或血肿。 3、文献对于Prolift~(TM)方法后盆腔穿刺损伤尾动脉的报道较少,本研究发现Prolift~(TM)手术较改良Prolift手术更容易损伤尾动脉。 4、本研究发现Prolift~(TM)手术较改良Prolift手术阴道穿刺长度深,但临床研究发现,两种术式的解剖学差异并未对临床治疗效果产生明显影响。 5、本研究首次提出了骶棘骶结节韧带复合体的概念,并提出了Prolift~(TM)阴道后壁穿刺所经过的盆膈结构多为骶结节韧带或骶棘骶结节韧带复合体的新的观点。 6、按照规范的手术路径完成全盆底重建盲针穿刺手术损伤盆腔内重要血管神经的风险小。 7、首次采用动态MRI及其分度方法评价临床POP,并发现动态MRI检查对前盆腔器官膨出的诊断符合率优于对后盆腔器官膨出的诊断符合率。 8、本研究认为不论Prolift~(TM)还是改良Prolift手术均可缩小POP患者泌尿生殖窦大小,Prolift~(TM)手术改善盆底下降程度的治疗效果是否优于改良Prolift手术尚需进一步扩大病例研究。两种手术方式均可有效治疗POP。 9、本研究认为动态MRI较临床诊断盆腔器官脱垂病例更加客观、全面。由于动态MRI费用较高,是否在临床推行PFD的动态MRI检查还需要进一步的循证分析。 10、临床研究发现Prolift~(TM)和改良Prolift两种手术方式均可安全有效治疗重度盆腔器官脱垂性疾病。 11、Prolift~(TM)医疗耗材贵,在现阶段我国特殊的国情和医疗环境下还不能得到普及和迅速发展。改良Prolift手术设计研究适合我国国情,是有效治疗盆底功能障碍性疾病的微创盆底重建手术方式。
[Abstract]:Objective: to clarify the vascular neuroanatomy around the two types of total pelvic floor reconstruction of Chinese women with Prolift~ (TM) and modified Prolift, and to propose the safety path of the two operations. The comparison of the three aspects of clinical anatomy, dynamic MRI imaging and clinical therapeutic effects is to study the Prolift~ (TM) and the improved Prolift two whole basins. The difference between the bottom reconstructive surgery is to guide the safe Prolift~ (TM) and improve the Prolift operation path, and then reduce the complications of the two surgical methods. Meanwhile, it will provide a good theoretical support for the improvement of the Prolift operation path in China.
Methods: a prospective randomized controlled method was used to determine the surgical puncture method of 12 Chinese adult female fresh cadavers (6 Prolift~ (TM) and 6 modified Prolift). The distance between the two kinds of surgical puncture needles and the peripheral vascular nerve and the heavy viscera was anatomically measured. At the same time, the puncture needle was punctured safely. Angle. Dynamic MRI technique was used to examine the image of 20 patients with POP-Q degree and more pelvic organ prolapse in the same period operation. The difference between the two surgical methods was objectively evaluated. At the same time, 16 cases of Prolift~ (TM) surgery in 168 patients in our hospital were prospectively compared. Clinical treatment effect of 152 cases with good Prolift operation.
Result:
The 1,12 autopsy study found that the superficial and deep puncture needles of the anterior wall of the vagina in the two types of total pelvic floor reconstruction in the obturator area Prolift~ (TM) and modified Prolift were all below the clitoris horizontal line through the obturator.Prolift~ (TM) and the modified Prolift in the two surgical methods of the anterior wall of the vagina and the punctures of the anterior wall of the vagina were closed to the closed orifice of the obturator. The distance of the branches was 0.60 + 0.36cm and 0.78 + 0.10cm, respectively, and the distance between the punctures of the anterior vaginal wall and the anterior branch of the closed orifice was (1.58 + 0.05cm and 1.58 + 0.05cm). The two groups were all P > 0.05., respectively.
2, Prolift~ (TM) and modified Prolift, the distance between the puncture points of the superficial anterior vaginal wall of the vagina and the anterior branch of the obturator nerve was 3.23 + 1.03cm and 3.18 + 0.61cm respectively. The distance from the posterior branch of the obturator nerve was 3.28 + 0.63cm and 2.95 + 0.63cm; Prolift~ (TM) and modified Prolift two types of anterior wall of the vagina The distance from the occult punctures to the anterior branches of the obturator nerve was 3.35 0.59cm and 3.16 1.04cm respectively, the distance from the posterior branch of the obturator nerve was 2.68 + 0.57cm and 2.86 + 0.87cm, and the two kinds of surgical methods were all more than 0.05..
3, Prolift~ (TM) the length of the deep vaginal wall into the vagina (5.63 + 0.15cm) was greater than that of the modified Prolift operation (4.83 + 0.05cm), (P < 0.01).Prolift~ (TM).Prolift~ (TM) transvaginal puncture needle penetrated into the vagina (7.38 + 0.15cm) greater than the modified Prolift operation (5.88 + 0.23cm), (P < 0.01).
4, the distance between the posterior wall puncture needle of Prolift~ (TM) and the tail artery was (0.88 + 0.10cm), shorter than the distance between the modified Prolift operation and the tail artery (2.95 + 0.09cm), (P < 0.01).Prolift~ (TM).Prolift~ (TM) the distance between the puncture needle of the vagina and the inner part of the pudendal artery (1.59 + 0.36cm), shorter than the distance between the modified Prolift operation and the internal pudendal artery (3.40 + 0.36cm), (P < 0). 1) the distance between the puncture needle of the posterior wall of the vagina.Prolift~ (TM) and the distance from the rectum was (0.88 + 0.10cm). The distance between the improved Prolift operation and the rectum was 1.05 + 0.89cm and 0.86 + 0.62cm respectively. There was no significant difference between the two groups (P > 0.05).
5, the sacrospinous ligament begins with the sacrum of the fourth sacral hole to the lateral margin of the first caudal bone and extends to the lateral bone surface of the sciatic spine. The sacral tubercle ligament is composed of the dense connective tissue, which begins at the lateral margin of the third sacral hole to the first caudal bone, and extends outwards to the bone surface on the dorsal side of the sciatic body. The inferior edge of the sacral tubercle is lower than the lower margin of the sacral spine ligament. In the distance from the inside of the spine to 1.30 + 0.12cm, the sacrotuberous ligament and sacrospinous ligament overlap and form the sacrospinous, sacral tubercle ligament complex.
6, the proportion of the posterior vaginal wall puncture needle through the sacral tuberous ligament complex in the Prolift~ (TM) group was 66.7%, obviously higher than that of the modified Prolift group (16.7%), and the ratio of passing through the iliac caudal muscle was 25%, obviously lower than that of the modified Prolift group (75%), and the two groups were significantly different (P < 0.05).
7, the safe area of the Prolift~ (TM) surgery puncture path: the direction of the anterior vaginal puncture needle and the angle of the sagittal plane is greater than 25 degrees or the direction of the puncture needle of the anterior wall of the vagina is more than 30 degrees, and the angle of the sagittal plane is greater than 30 degrees, and the puncture direction is not changed after entering the pelvic cavity, and the bladder, urethra, or the abdominal wall can be damaged. The blood vessels and nerves in the pudendal canal can be damaged when the puncture needle deviates from the direction of the sciatic tubercle is greater than 5 degrees, and the incline to the medial anus can damage the rectum by 15 degrees to the medial anus.
8, the safe area of the improved Prolift puncture path: the puncture plane and the urethral sagittal plane were 45 degrees angle when the anterior vaginal wall was punctured. The moving range of the axial horizontal surface of the stitch handle was 15 to 35 degrees, and the vertical plane movement range was 40 to 90 degrees as the safe path of the puncture of the superficial anterior wall of the vaginal canal with the pelvic ligament suture needle. The puncture plane and the urethral sagittal plane were 45 degrees angle, the axial vertical plane range of the stitch handle was 40 to 60 degrees, the level of the horizontal plane was 10 to 15 degrees. It was the safe path of the deep zone of the anterior vaginal wall with the pelvic ligament suture needle. When the posterior wall of the vagina was punctured by modified Prolift, the vagina should be put back as far as possible to the top. In the vicinity of the sacrospinous ligament, avoid the posterior wall puncture needle to enter the lateral or lateral side of the rectal fossa, while the internal rotation puncture needle is guided through the diaphragm into the vagina at the same time in the vagina.
9, in this study, the coincidence rate of dynamic MRI for patients with anterior pelvic organ expansion was 95% (19/20). The coincidence rate of patients diagnosed with pelvic organ prolapse was 70% (14/20), but the coincidence rate of patients diagnosed as posterior pelvic organ expansion was only 25% (5/20).
10, in this study, we found that dynamic MRI examination of Prolift~ (TM) operation on genitourinary Dou Zengda (H line change) and pelvic floor decline (the change of the M line) significantly reduced the pelvic floor relaxation than before the operation. The improved Prolift operation was significantly improved for the pelvic floor relaxation caused by the urogenital Dou Zengda (the H line change), but the pelvic floor decreased (the change of the M line). No significant changes in pelvic floor relaxation were observed before the operation.
11, the comparative analysis of the dynamic MRI before and after the operation of 20 patients with different operations found that 3 cases of mild pelvic organ prolapse were found in the clinical diagnosis after the operation of the cured patients with MNI HMO system, of which 1 were Prolift~ (TM), and 2 with improved Prolift operation.
12, clinical study found 168 patients (Prolift~ (TM) group 16 cases, improved Prolift group 152 cases) Prolift~ (TM) Group 15 cases, improved Prolift group 119 cases completed follow up, follow up rate was 12 months after 80%. operation (Prolift~ (TM) 4 months, improved Prolift group 12 months) operation cure rate was 100% and 94.1%. two operation respectively was not There is a serious complication.
conclusion
1, the puncture sling operation in the closed orifice area, the puncture needle is controlled under the level of the clitoris, without the risk of injury of the obturator nerve. According to the standard operation route, the puncture operation can avoid the deep or shallow clearance of the perineum, and avoid the damage of the neurovascular in the perineum area.
2, compared with the puncture path of the anterior wall of the vagina, the puncture path of the anterior wall of the vagina is more likely to damage the posterior branch of the obturator vein and occasionally can damage the posterior branch of the obturator artery, but it rarely causes severe obturator hemorrhage or hematoma.
3, there are few reports on the injury of the caudal artery by pelvic puncture after Prolift~ (TM) method. This study found that Prolift~ (TM) surgery is more likely to damage the tail artery than the modified Prolift operation.
4, the study found that the Prolift~ (TM) operation was longer than that of the modified Prolift operation, but the clinical study found that the two types of anatomical differences did not have a significant effect on the effect of the clinical treatment.
5, this study first proposed the concept of sacral tuberous ligament complex for the first time, and proposed a new point of view that the pelvic diaphragm structure of the Prolift~ (TM) posterior wall of the vagina is mostly the sacral nodular ligament or the sacral tuberous ligament complex.
6, according to the standard operation path, the risk of total pelvic floor reconstruction with blind needle puncture is very small.
7, the clinical POP was evaluated by dynamic MRI and its classification method for the first time, and it was found that the diagnostic coincidence rate of dynamic MRI examination for anterior pelvic organ expansion was better than the diagnostic coincidence rate of post pelvic organ expansion.
8, this study believes that both Prolift~ (TM) or improved Prolift surgery can reduce the size of the genitourinary sinus in POP patients. Whether the treatment effect of Prolift~ (TM) operation to improve the pelvic floor decline is better than the modified Prolift operation needs further expansion of the case study. The two surgical methods can effectively treat POP..
9, this study suggests that dynamic MRI is more objective and comprehensive than clinical diagnosis of pelvic organ prolapse. As the dynamic MRI cost is higher, further evidence-based analysis is needed if the dynamic MRI examination of PFD is carried out in clinical practice.
10, clinical studies found that Prolift~ (TM) and modified Prolift two kinds of surgical methods are safe and effective in the treatment of severe pelvic organ prolapse.
11, Prolift~ (TM) medical consumables are expensive and can not be popularized and rapidly developed in the special conditions and medical environment of our country at the present stage. The improved Prolift surgical design study is suitable for the national conditions of our country. It is a minimally invasive pelvic floor reconstruction method for effective treatment of pelvic floor dysfunction.
【学位授予单位】：中国协和医科大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R713;R322

【引证文献】