腹腔镜下经髂前上棘旁隧道式悬吊术或联合经肛吻合器直肠切除术治疗合并出口梗阻型便秘症状的盆腔脏器脱垂疗效分析

Efficacy of laparoscopic tunnel-like peri-anterior superior iliac spine suspension or combined with stapled transanal rectal resection in the treatment of pelvic organ prolapse with outlet obstruction constipation

目的探讨腹腔镜下经髂前上棘旁隧道式悬吊术（L-TASISS）或联合经肛吻合器直肠切除术治疗合并出口梗阻型便秘（OOC）症状的盆腔脏器脱垂（POP）的有效性和安全性。方法2010年8月至2015年1月间，郑州大学第一附属医院采用L-TASISS或联合经肛吻合器直肠切除术（STARR）治疗了119例合并OOC的POP患者，经POP评价系统（POP-Q）评分均为Ⅱ～Ⅳ度。回顾性总结分析这组病例的临床资料，比较手术前后症状的改善情况。结果全组患者有51例（42.9%）单纯行L-TASISS ，68例（57.1%）行L-TASISS联合STARR。均顺利完成手术，无中转开腹的患者。手术时间（67.8±10.9）min，出血量（10.3±3.8）ml，留置尿管时间（3.6±1.1）d，住院时间（5.1±1.8）d。术后1个月，主诉腹壁疼痛或牵张感者15例（12.6%），其中3例经局部注射封闭、1例行切口缝线松解术后缓解，其余11例均在3个月内自行缓解；均未见输尿管狭窄或积水、髂内血管血栓形成以及其他补片相关并发症的发生。术后1年，全组患者均获随访，93例（78.2%）OOC症状缓解（满意76例，非常满意17例），仅1例（0.8%）压力性尿失禁未缓解，15例（12.6%）性交痛或性交不快未缓解，但未见新增性交痛或性交不快患者；症状复发11例（9.2%），其中排粪不尽感9例（7.6%）；术后POP-Q分度Ⅱ度2例（1.7%），Ⅲ度1例（0.8%）；便秘罗马Ⅲ评分（1.4±0.9）分[术前为（7.8±3.6）分]。术前有53例（44.5%）发生肠疝，术后仅有1例（0.8%）（χ^2= 64.77，P= 0.000）；术前有106例（86.6%）排粪困难，87例（73.1%）排粪不尽感，术后明显改善，分别只有7例（5.9%）和9例（7.6%）症状未完全缓解（χ^2= 155.78 ，P= 0.000）；术前有3例（2.5％）排粪失禁，经手术后均得到改善。结论L-TASISS或联合STARR术对于合并OCC的POP患者具有良好的近期疗效，且术式安全可行。

Objective To explore the efficacy and safety of laparoscopic tunnel-like peri-anterior superior iliac spine suspension（L-TASISS） or combined with stapled transanal rectal resection （STARR） in the treatment of pelvic organ prolapse （POP） with outlet obstructive constipation （OOC）. Methods A total of 119 POP patients complicated with OOC（ Ⅱ to Ⅳ stage evaluated by POP-Q） received L-TASISS or combined with STARR in the First Affiliated Hospital of Zhengzhou University from August 2010 to January 2015. Clinical and follow-up data of these patients were analyzed retrospectively and compared before and after operation. Results Among 119 cases, 51 cases （42.9%） underwent L-TASISS alone, and 68 cases （57.1%） received L-TASISS combined with STARR. All the 119 patients were successfully operated without conversion to open surgery. The operation time was（67.8 ± 10.9） minutes, the intra-operative blood loss was （10.3 ±3.8） ml, the indwelling catheter time was （3.6 ± 1.1） days, and hospital stay was （5.1±1.8） days. One month after operation, abdominal wall pain or stress occurred in 15 cases, of whom 3 cases were improved by local block injection, 1 case by incision stitches release, the rest ameliorated spontaneously within 3 months after surgery. No potential ureterostenosis, hydroureterosis, internal iliac vascular thrombosis resulting from compression of the mesh and other complications related to the mesh were found. One year after operation, all the patients were followed up. The OOC remission rate was 78.2%（93/119）, of whom 76 cases were satisfied and 17 patients were completely satisfied. One case（0.8%） with stress urinary incontinence did not improve. Fifteen cases（12.6%） with algopareunia or dyspareunia did not achieve remission, but there was no new algopareunia or dyspareunia case. Eleven patients （9.2%） presented recurrence of symptoms, of whom 9 cases（7.6%） complained of sensation of incomplete evacuation. Two cases（1.7%） were graded as POP- Q Ⅱ, and 1 case （0.8%） as POP-Q Ⅲ after surgery. Constipation Score of all the patients was 1.4 ±0.9 （compared to 7.8 ±3.6 preoperatively） according to Rome Ⅲ criteria. Enterocele occurred in 53 cases （44.5%） preoperatively corresponded with only 1 case （0.8%） after operation （χ^2= 64.77, P = 0.000）. One hundred and six cases （86.6%） with defecation difficulties and 87 cases （73.1%） with sensation of incomplete evacuation before operation were significantly improved after surgery, corresponding with 7（5.9%） and 9 （7.6%） symptomatic cases respectively （χ^2= 155.78, P = 0.000）. Three cases （2.5%） with preoperative fecal incontinence symptoms were improved after operation as well. Conclusion The procedure of L-TASISS or combined with STARR for POP patients with OCC has good short-term efficacy, and is safe and feasible.