不同术式治疗重度盆腔脏器脱垂的临床疗效分析

Clinical Curative Effects of Three Surgical Procedures in the Treatment of Severe Pelvic Organ Prolapse

目的探讨全盆底重建术、阴式子宫全切除术+阴道前、后壁修补术、阴道不全闭合术治疗重度盆腔脏器脱垂(POP)的疗效及对患者生活质量的影响。方法选择2009年1月至2010年1月,于北京妇产医院接受全盆底重建术[n=22,其中3例合并压力性尿失禁(SUI),同时行经闭孔无张力尿道中段悬吊术(TVT-O)],传统阴式子宫全切除术+阴道前、后壁修补术(n=26,其中6例合并SUI,同时行尿道折叠术手术,阴道不全闭合术(n=11,其中2例合并SUI,同时行尿道折叠术)患者,共计59例为研究对象,分别将其纳入重建组(n=22)、阴宫组(n=26)、闭合组(n=11)。3组患者在孕次、产次、内科合并症等方面比较,差异无统计学意义(P>0.05)(本研究遵循的程序符合北京妇产医院人体试验委员会制定的伦理学标准,得到该委员会批准,分组征得受试对象的知情同意)。比较3组患者的术中出血量、手术时间、术后病率等围手术期指标;术后6,12个月以POP-Q分度和盆底功能影响问卷-短表20(PFIQ-20),作为客观及主观疗效评价指标;比较手术前、后排尿症状改变及性生活改变情况,评价手术对患者排尿及性生活质量的影响。结果①闭合组患者手术时间短于另2组,3组比较,差异有统计学意义(P<0.05);3组患者的术中出血量、住院时间、术后病率比较,差异无统计学意义(P>0.05)。②对重建组患者随访6,12个月的客观治愈率均为100.00%(22/22);阴宫组术后6个月的客观治愈率为90.91%(20/22),12个月为86.36%(19/22);闭合组术后6,12个月的客观治愈率均为88.89%(8/9)。3组术后6,12个月的客观治愈率比较,差异无统计学意义(P>0.05)。③3种术式的术前与术后6,12个月PFIQ-20评分比较,差异有统计学意义(P<0.05)。3组间术前PFIQ-20评分比较,差异无统计学意义(P>0.05);术后6,12个月阴宫组评分高于重建组及闭合组,差异有统计学意义(P<0.05)。④3组术前与术后6,12个月的UDI-6评分比较,差异有统计学意义(P<0.05)。⑤闭合组患者术前均已无性生活1年以上。重建组患者中,7例(31.82%,7/22)术前有性生活,术后5例(22.73%,5/22)有性生活,3例(13.64%,3/22)存在不同程度性交痛。阴宫组患者术前有性生活者为6例,且术后均有性生活,仅2例存在性交痛。结论 3种术式均为治疗重度POP的有效术式,且全盆底重建术在主观、客观治愈率上优于阴式子宫切除+阴道前、后壁修补术。对于无性生活要求的老年重度POP患者,采用阴道不全闭合术疗效肯定,可改善其术后近期的生活质量。

Objective To evaluate the therapeutic effect of total pelvic floor reconstruction （Prolift）, transvaginal hysterectomy （TVH） plus repair of vaginal anterior and posterior wall, and partial colpocieisis on pelvic organ prolapse in the treatment of sever pelvic organ prolapse （POP）. Methods From January 2009 to January 2010, fifty-nine patients with sever POP who were admitted into Beijing Obstetrics and Gynecology Hospital were included into this study. They received different operation methods, 22 cases were cured by total pelvic floor reconstruction （3 patients received TVT-O simultaneously, group A）, 26 cases were cured by TVH plus repair of vaginal anterior and posterior wall （6 patients received plication operation of urethra simultaneously, group B）, and 11 cases were cured by partial eolpocleisis （2 patients received plication operation of urethra simultaneously, group C）. Intra-operative blood loss, operating time and mean hospital stay were compared among three groups. Patients were received objective assessment [according to pelvic organ prolapse quantitative examination （POP-Q） score] and subjective assessment （Pelvic Floor Distress Inventory Short Form, PFDI-20） by followed up at 6 months and 12 months after the operation. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Maternal and Child Care Hospital of Fangshan District of Beijing, and Beijing Gynecology and Obsetrics Hospital. Informed consent was obtained from all participates. There had no significant difference between three groups on gravidity, parity and internal medicine complications, and so on （P〉0. 05）. Results （2） There had significant difference of operation time among three groups （P〈0.05）, but there had no significant difference of intraoperative blood loss, hospital stay and operative morbidity among three groups （P〉0.05）. （2） Objective cure rates of group A, B, C were 100.00% （22/22）, 90.9%（20/22）, 88.89%（8/9）, respectively, in six months after the operation, 100.00% （22/22）, 86.36% （19/22）, and 88.89% （8/9）, respectively, in twelve months after the operation.. There had no significant difference of objectively cure rates among three groups （P）0.05）. （3）Scores of PFDI-20 in three groups at 6 months and twelve months after the operation compared with the preoperative score were significantly different （P〈0.05）. There had no significant difference of PFIQ20 before the operation among three groups （P）0.05）, but after the operation, the score of group B was higher than those of the other two groups （P〈0. 05）.（4） The had significant difference of UDI-6 score before and after the operation in six and twelve months among three groups （P〈0.05）. （5） Patients in group C had no sexual life for over 1 year before operation. In group A, 7 cases （31.82%, 7/22） had sexual life before operation, 5 （22.73%, 5/22） also had sexual life after operation, but 3 （13.64%, 3/22） felt pain in sexual life. In group B, 6 cases had sexual life before operation, 6 cases also had sexual life after operation, 2 felt pain in sexual life. Conclusions Three operation methods are all effective ways in the treatment of sever POP. Prolift is better than transvaginal hysterectomy plus repair of vaginal anterior and posterior wall in objective and subjective cure rate. Partial colpocleisis is a effective way of sever POP for the old patients without sexual life, they can get better quality of life after operation in short period.