全盆底重建术后新发压力性尿失禁临床分析

Analysis of de novo stress urinany incontinence after pelvic floor reconstructive surgery

目的通过对盆底重建手术后新发压力性尿失禁(de novo SUI)或SUI加重病例进行回顾性分析,探讨de novo SUI的高危因素。方法回顾性分析2007年1月至2011年2月间因Ⅲ期及以上盆腔器官脱垂(POP)在北京大学人民医院妇科接受Prolift系统全盆底重建术并按时随访的患者140例。根据患者术前、术后SUI的情况将患者分为3组:POP合并SUI组(29例):术前POP合并SUI患者,其中19例行Kelly手术,10例行TVT-O术;de novo SUI组(27例):术前没有尿失禁,术后新发压力性尿失禁患者;对照组(84例):术前、术后均无客观SUI。比较各组POP-Q值及尿动力学参数,logistic回归分析高危因素。结果 ①de novo SUI发生率为24.32%(27/111),其中9例术前合并主观SUI。术前有主观SUI患者术后出现客观SUI的比例是56.25%(9/16),明显高于术前无主观SUI患者(14.88%,18/121;P<0.05);②POP合并SUI组、de novo SUI组的Aa点平均值高于对照组(P<0.01);de novo SUI组的Ba点平均值(4.91)明显高于POP合并SUI组(2.34)和对照组(2.88,P<0.05);③POP合并SUI组的最大尿流率(Qmax)明显高于对照组(P<0.01),de novo SUI组Qmax虽也高于对照组,但差异无统计学意义(P>0.05)。POP合并SUI组和de novo SUI组最大尿道闭合压(MUPP)均显著低于对照组(P<0.01)。④Kelly组中SUI复发率(42.11%,8/19)高于TVT-O组(20.00%,2/10;P<0.05)。⑤logistic回归结果显示,术前主观SUI(P=0.00,OR4.33～7.52),Aa点≥2(P=0.01,OR1.46～1.98),MUPP≤38cmH2O(P=0.00,OR1.73～3.08)为de novo SUI的高危因素。结论①Aa位置低是SUI的高危因素,而当Ba值大即膀胱脱垂明显时,可能掩盖SUI症状,有可能出现术后新发尿失禁;②术前有主观尿失禁症状,MUPP≤38cmH2O是de novo SUI的高危因素;③Kelly术抗尿失禁效果欠佳,建议选择TVT-O术治疗或预防尿失禁。

d Objective The purpose of this study is to detect the risk factors for de novo SUI through retrospectively cases analysis. Methods Data of 140 patients with POP who underwent pelvic floor reconstructive surgery with Prolift system in Peking University People＇s hospital from January 2007 to February 2011 were analyzed retrospectively. Patients were divided into 3 groups according to SUI symptoms., group 1, POP concomitant with SUI： totally 29 cases, including 19 patients with type 1 SUI who underwent Kelly procedure and 10 patients with moder- ate or severe SUI underwent TVT-O surgery; group 2, De novo SUI, totally 27 cases;group 3, Control group, those who had no SUI pre - or post- operation. Results ① There were 20. 71~ （29/140） POP patients accompany with SUI, and the de novo SUI rate after pelvic floor reconstructive surgery was 24. 32% （27/111）. De novo SIAl rate in subject SUI patients was 56.25%, which significantly higher than those had no subject SUI （14. 88%） （ P〈0. 05） ; ②The Aa points of group 1 and group 2 were significantly higher than group 3 （P〈0. 05）, and Ba point of group 2 significantly higher than group 1 and 3 （P（0. 05）. ③ Qraax of group 1 was significantly higher than group 3 （P〈0.01）, also was that in group 2 compared with group 3, hut with no statistic significant （p〉0. 05）. The MUPP in group 1 and 2 was lower than that in group 3 （P〈0. 01）. ④ The relapse rate of SUI in Kelly group was much higher than that in TVT- O group （42. 11% vs 20. 00%, P〈（0. 05）. ⑤ Logstic analysis showed thatpreoperative subject SUI （P= 0. 00, OR 4. 33 -7. 52）, Aa≥2 （P = 0. 01, OR 1.46 - 1.98） and MUPP≤38 cmHzO （P-=0. 00, OR 1.73~3. 08） were risk factors for de novo SUI. Coadasions ~ Preoperative subject SUI, Aa≥2 and MUPP≤38 cmH20 are risk factors for de novo SUI. ② POP patients with objective SUI should underwent anti - SUI surgery accompany with pelvic floor reconstructive surgery. ③TVT- O is better than Kelly for SUI patients.