腹腔镜下子宫/阴道-骶骨固定术与阴道网片全盆底重建术治疗盆腔器官脱垂的疗效比较

Comparison the role of laparoscopic sacral hysteropexy/sacrocolpopexy and total vaginal mesh in severe pelvi corgan prolapse

目的探讨腹腔镜下子宫/阴道-骶骨固定术（LSC）与全盆底重建术（TVM）治疗盆腔器官脱垂（POP）的疗效。方法采用回顾性分析方法对2011年1月至2013年12月在四川大学华西第二医院接受LSC的157例患者和经阴道植入网片的160例TVM患者的临床资料进行相关研究。按照接受手术治疗方法的不同,将其分别纳入LSC组（n=157）与TVM组（n=160）。根据POP定量评分法（POP-Q）比较患者术后客观满意度;根据主观症状改善评分（PGI-C）比较患者的主观满意度;比较手术时间、出血量、术中及术后并发症发生率;采用盆底生活质量问卷（PFDI-20,PFIQ-7）及性生活质量问卷（PISQ-12）比较两组患者术前、术后生活质量及性生活质量评分。本研究遵循的程序符合本院人体试验委员会所制定的伦理学标准,得到该委员会批准,分组征得受试对象本人的知情同意,并与之签署临床研究知情同意书。结果 1两组患者病程、体质指数与原发性高血压、糖尿病、支气管炎、排便及排尿困难、尿失禁、合并妇科疾病、宫颈延长发生率,以及既往盆底手术率等比较,差异均无统计学意义（P〉0.05）;但两组患者年龄及术前绝经率比较,差异均有统计学意义（P〈0.05）。2TVM组手术时间较LSC组显著缩短,但TVM组术中出血量却较LSC组显著增加,两组手术时间及术中出血量比较,差异均有统计学意义（P〈0.05）。两组患者术后住院时间及留置尿管时间与联合行其他术式,如子宫切除术率、宫颈延长部分切除术率、TVT-O率、会阴重建术率比较,差异均无统计学意义（P〉0.05）。3对两组患者随访10~44个月,中位随访时间为26个月,LSC组与TVM组患者的客观满意度[分别为94.9%（149/157）与91.9%（147/160）]比较,差异均无统计学意义（P〉0.05）。LSC组患者的PGI-C评分、主观满意度均优于TVM组,且差异均有统计学意义（P〈0.01）;两组患者术后PFDI-20、PFIQ-7评分均较术前显著改善,差异均有统计学意义（P〈0.01）;但两组术后PFDI-20、PFIQ-7问卷评分比较,差异无统计学意义（P〉0.05）;LSC组患者术后PISQ-12评分优于TVM组,且差异有统计学意义（P〈0.01）。4两组患者术后6个月时Aa、Ba、C、Bp和Ap点长度组内比较,均较术前显著改善,差异均有统计学意义（P〈0.01）;两组患者术前及术后6个月组内阴道总长度（TVL）比较,差异均无统计学意义（P〉0.05）。5两组术中均无直肠损伤发生,但TVM组患者术中膀胱损伤率显著高于LSC组,并且差异有统计学意义（P〈0.01）。TVM组术后会阴部疼痛不适率显著高于LSC组,并且差异有统计学意义（P〈0.01）,术中及术后其他并发症发生率比较,差异均无统计学意义（P〉0.05）。结论与TVM比较,LSC具有术中出血量少,术后性生活满意度较高和手术满意度较高的优势,但具体术式还应结合患者意愿和具体情况进行选择。

Objective To compare the efficacy and long term results of laparoscopic sacral hysteropexy/sacrocolpopexy （LSC） and total vaginal mesh （TVM） in severe pelvic organ prolapse （POP）. Methods Retrospectively reviewed the clinical data and follow up results of severe POP patients who had either LSC （n= 157） or TVM （n= 160） in West China Second University Hospital during January 2011 to December 2013. The results of POP quantification（POP-Q） scores, Patient Global Impression of Change （PGI-C）, Pelvic Floor Distress Inventory 20 （PFDI-20）, Pelvic Floor Impact Questionnaire 7 （PFIQ-7） and POP/Urinary Incontinence Sexual Questionnaire 12 （PISQ-12） for quality of life evaluation before and after operation between two groups were compared, as well as the perioperative complications. This study meet the requirement of human experimentation ethics committee and consent form was signed by each patients. Results ① There were no significance differences between two groups among the course of disease, body mass index and morbidity rates of primary hypertension, diabetes, bronchitis, defecation and urination difficulty, urinary incontinence, gynecological diseases, and cervical extension, and previous pelvic operation rate （P〉 0. 05）, respectively. There were significant differences between two groups between age and morbidity rate of menopause preoperative （P 〈 0. 05）. ② Operation duration in TVM group was much shorter than that in LSC group, intraoperative blood loss volume in TVM group was more than that in LSC group. There were significant differences between two groups between operation duration and intraoperative blood loss volume （P 〈 0. 05）. There were no significance differences between two groups among postoperative hospitalization time, and rates of the combination of other operations, such as hysterectomy, partial resection of cervical extension, TVT-O, perineal reconstruction （P〉0. 05）, respectively. ③All the patients were followed-up 10-44 months （median followed-up 26 months）. The objective satisfaction rates between two groups were comparable （94. 90% vs 91.88%, P〉0.05）. The postoperative PGLC scores and the subjective satisfaction rate of LSC group were better than those of TVM group （P 〈 0. 01 ）. The postoperative PFDI-20, PFIQ-7 scores were significantly improved in both groups, but without obvious differences （P〉0.05）. The postoperative PISQ-12 scores of LSC group was significantly better than that of TVM group （P〈0.01）. ④ After postoperative six months, the length of Aa, Ba, C, Bp and Ap were all better than those of preoperative in two groups （P〈0. 01）. There were no significant differences within two groups of TVL at preoperative and in six months （P〉0.05）. ⑤There was no damage of rectal injury duration operation. The damage rate of bladder in TVM group was higher than that in LSC group, and there were significant difference （P〈0.01）. The rate of perineal pain in TVM group was much higher than that in LSC group, and there was significant difference （P〈 0. 01）. There were no significance differences between two groups in the incidence of other complications intraoperative and postoperative （P〉 0.05）. Conclusions Compared with TVM, LSC has the advantages in intraoperative blood loss, postoperative sexual life satisfaction rate and operation subjective satisfaction rate. However, the choice of an ideal operation means still relays on the will and the detailed circumstances of a patient.