盆底重建术联合无张力尿道中段悬吊术治疗盆腔脏器脱垂合并压力性尿失禁的Meta分析

Combined prolapse and midurethral sling surgery versus prolapse surgery for women with pelvic organ prolapse and stress urinary incontinence：a Meta-analysis

目的 系统评价盆底重建手术联合无张力尿道中段悬吊术治疗盆腔器官脱垂（POP）合并压力性尿失禁（SUI）的术后疗效与临床安全性.方法 计算机检索PubMed、EMbase、The Cochrane Library（2016年第7期）、Web of Knowledge、CNKI、CBM、WanFang Data、VIP等数据库,搜集盆底重建手术联合无张力尿道中段悬吊术治疗POP合并SUI的相关随机对照试验（RCT）,检索时限均从建库至2016年7月31日.由2位评价员独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Rev Man 5.3软件进行Meta分析.结果共纳入4个RCT,共646例患者.Meta分析结果显示：对于POP合并SUI的患者,在术后结局指标方面,盆底重建手术联合无张力尿道中段悬吊术组术后尿失禁[RR=0.57,95%CI（0.46~0.70）,P〈0.000]、术后压力性尿失禁[RR=0.24,95%CI（0.10~0.60）,P=0.002]、术后急迫性尿失禁[RR=0.58,95%CI（0.39~0.85）,P=0.006]、术后治疗压力性尿失禁[RR=0.20,95%CI（0.06~0.67）,P=0.009]、术后因压力性尿失禁再次手术[RR=0.07,95%CI（0.01~0.56）,P=0.010]的发生率低于盆底重建手术组.在并发症方面,盆底重建手术联合无张力尿道中段悬吊术组膀胱穿孔/损伤[RR=9.72,95%CI（1.78~53.01）,P=0.009]、泌尿系感染[RR=1.77,95%CI（1.23~2.54）,P=0.002]、1周内不完全的膀胱排空[RR=1.39,95%CI（1.06~1.81）,P=0.020]的发生率高于盆底重建手术组,而排尿功能障碍、阴道网片侵蚀、大出血/损伤大血管的发生率两组差异无统计学意义.结论 对于POP合并SUI的患者,盆底重建手术联合无张力尿道中段悬吊术组术后尿失禁、术后治疗尿失禁的发生率低于盆底重建手术组,而部分术后并发症的发生率高于盆底重建手术组.受纳入研究数量和质量的限制,上述结论尚需开展更多大样本、高质量的RCT予以验证.

Objective To systematically review the efficacy and safety of prolapse surgery versus combined prolapse and midurethral sling surgery in women with pelvic organ prolapse and stress urinary incontinence.Methods Databases including PubMed,EMbase,the Cochrane Library（Issue 7,2016）,Web of Knowledge,CNKI,CBM,WanFang Data and VIP were searched from inception to July 31th 2016,to collect randomized controlled trial（RCT） of combined prolapse and midurethral sling surgery versus prolapse surgery for pelvic organ prolapse and stress urinary incontinence.Two reviewers independently screened literature,extracted data and assessed the risk of bias of included studies.Then,meta-analysis was performed using RevMan 5.3 software.Results A total of 4 RCT involving 446 patients were included.The results of meta-analysis showed that,for postoperative outcomes,compared with prolapse surgery,the incidence of urinary incontinence,stress urinary incontinence,urgency urinary incontinence,any treatment for SUI,surgery for stress urinary incontinence[RR=0.57,95%CI（0.46~0.70）,P〈0.000;RR=0.24,95%CI（0.10~0.60）,P=0.002;RR=0.58,95%CI（0.39~0.85,P=0.006;RR=0.20,95%CI（0.06~0.67）,P=0.009;RR=0.07,95%CI（0.01~0.56）,P=0.010]were lower in combined prolapse and midurethral sling surgery.For complications,the incidence of bladder perforation or injury,urinary tract infection,incomplete bladder emptying at 1 week[RR=9.72,95%CI（1.78~53.01）,P=0.009;RR=1.77,95%CI（1.23~2.54）,P=0.002;RR=1.39,95%CI（1.06~1.81）,P=0.020]were higher in combined prolapse and midurethral sling surgery,while there were no statistical differences between the two groups in the incidence of voiding dysfunction,vaginal tape erosion,major bleeding or vascular complication.Conclusion For women with pelvic organ prolapse and stress urinary incontinence,compared to prolapse surgery,the incidence of urinary incontinence and treatment of urinary incontinence is lower in combined prolapse and midurethral sling surgery,the incidence of partial complications is higher in combined prolapse and midurethral sling surgery.Due to the limited quality and quantity of the included studies,more high quality studies are needed to verify the above conclusion.