阴式辅助下腹腔镜骶骨阴道固定术治疗重度盆腔器官脱垂的近期疗效

Short-term Efficiency of Vaginally Assisted Laparoscopic Sacrocolpopexy for Severe Pelvic Organ Prolapse

目的探讨阴式辅助下腹腔镜骶骨阴道固定术（vaginally assisted laparoscopic sacrocolpopexy,VALS）治疗以中盆腔缺陷为主的重度盆腔器官脱垂（pelvic organ prolapse,POP）的临床疗效,评价其有效性和安全性。方法 2014年1月-2015年6月26例POP-Q分期为Ⅲ、Ⅳ期子宫脱垂行阴式辅助下腹腔镜＂Y＂形聚丙烯网片骶骨阴道固定术,合并阴道前、后壁膨出分别于膀胱阴道间隙和直肠阴道间隙增加植入网片的长度,4例（15.4%）合并中度以上压力性尿失禁（stress urinary incontinence,SUI）同期行经闭孔无张尿道中段悬吊术（trans-obturator tape,TOT）,采用POP-Q分期法和盆底症状影响量表-20（PFDI-20）、盆底障碍影响问卷-7（PFIQ-7）、盆腔器官脱垂/尿失禁性功能问卷-12（PISQ-12）分别评价解剖和功能疗效。结果 26例均顺利完成手术,手术时间（146.3±36.6）min,术中出血量（87.3±37.8）ml,术后残余尿量（33.5±13.8）ml。术后POP-Q分期Aa、Ba、C、Ap、Bp各指示点解剖位置中位数分别为-3.0、-3.0、-8.0、-3.0、-3.0 cm,较术前各指示点中位数1.5、3.0、2.0、-2.3、-1.5 cm明显改善（P〈0.05）。术后PFIQ-7评分较术前显著降低[（33.3±3.6）分vs.（55.4±2.8）分,t=-27.321,P=0.000];术后PFDI-20评分较术前显著降低[（35.4±2.7）分vs.（66.4±3.7）分,t=-35.993,P=0.000];术后PISQ-12评分较术前显著升高[（40.8±3.2）分vs.（21.6±3.4）分,t=19.809,P=0.000]。术后26例随访6-25个月,（12.5±6.2）月,无复发、网片侵蚀、性生活不适;2例术后新发SUI,其中1例术后5个月行TOT。术前6例尿失禁,术后3例症状减轻,3例症状加重经功能锻炼后症状减轻。客观治愈率100.0%,功能恢复率80.8%（21/26）。结论 VALS是治疗以中盆腔缺陷为主的重度POP安全、有效的方法,短期疗效确切,但可能诱发或加重尿失禁。

Objective To explore the clinical efficiency and safety of vaginally assisted laparoscopic sacrocolpopexy（ VALS）for treating severe pelvic organ prolapse（ POP） due to middle pelvic compartment defects. Methods We retrospectively analyzed the clinical data of 26 patients with Ⅲ or Ⅳ stage severe uterine prolapse who were given VALS by using Y-shaped polypropylene mesh from January 2014 to June 2015. Patients complicated with anterior and posterior vaginal wall prolapse were given prolonged mesh placement in the vesicovaginal and rectovaginal interspace, and patients complicated with moderate and severe stress urinary incontinence（ SUI） underwent trans-obturator tape（ TOT） surgery. The anatomic and functional recovery was evaluated by the pelvic organ prolapse quantification（ POP-Q）,the pelvic floor distress inventory-20（ PFDI-20）,pelvic floor impact questionnaire-7（ PFIQ-7）,and the pelvic organ prolapse / urinary incontinence sexual questionnaire-12（ PISQ-12）. Results All the operations were accomplished successfully. The operation time was（ 146. 3 ± 36. 6） min,the blood loss was（ 87. 3 ± 37. 8） ml,and the residual urine volume was（ 33. 5 ± 13. 8） ml. The median values were recovered from 1. 5,3. 0,2. 0,- 2. 3,and- 1. 5 cm preoperatively to- 3. 0,- 3. 0,- 8. 0,- 3. 0,and- 3. 0 cm postoperatively at anatomic sites of Aa,Ba,C,Ap,and Bp,respectively. The POPQ examination after operation was significantly improved. The postoperative score of PFIQ-7 was lower than that before the treatment[（ 33. 3 ± 3. 6） points vs.（ 55. 4 ± 2. 8） points,t =- 27. 321,P = 0. 000]. The score of PFDI-20 after the treatment was lower than that before the treatment [（ 35. 4 ± 2. 7） points vs.（ 66. 4 ± 3. 7） points,t =- 35. 993,P = 0. 000]. The score of PISQ-12 after the treatment was higher than that before the treatment [（ 40. 8 ± 3. 2） points vs.（ 21. 6 ± 3. 4） points,t = 19. 809,P = 0. 000]. Thefollow-up duration was（ 12. 5 ± 6. 2） months among 26 cases. All the cases were cured without recurrence. None of them experienced mesh erosion or dyspareunia. Two cases suffered from de novo SUI postoperatively,and one of them was given TOT 5 months after VALS. Out of 6 cases of SUI,symptoms were relieved after opertion in 3 cases and symptoms were more serious after VALS in 3 cases,which were relieved after functional exercise. The objective cure rate was 100% and the functional recovery rate was 80. 8%（ 21 /26）.Conclusions VALS is a kind of safe and effective operation method in the treatment of severe POP due to middle pelvic compartment defects. The short-term curative effect is definite,but may induce or exacerbate urinary incontinence.