应用常规手术器械行骶棘韧带固定术治疗Ⅲ～Ⅳ度盆腔器官脱垂的前瞻性研究

Prospective cohort study on the outcomes of sacrospinous ligament fixation using conventional instruments in treating stage Ⅲ-Ⅳ pelvic organ prolapse

目的评价应用常规手术器械进行骶棘韧带固定术（SSLF）治疗Ⅲ～Ⅳ度盆腔器官脱垂（POP）患者的中长期疗效并评估其安全性。方法前瞻性纳入55例2007年5月至2015年6月在北京协和医院妇产科接受SSLF的Ⅲ～Ⅳ度POP患者。记录并分析所有最终接受SSLF患者的基本信息、围手术期指标和并发症情况，并随访其术后的临床表现和阴道检查情况，以POP定量分度法（POP-Q）评估手术的成功率（术后3个月）、客观治愈率（术后1年），在术后1年时以盆底不适调查表简表（PFDI-20）、盆底功能影响问卷简表（PFIQ-7）评估患者的主观满意度（评分较术前改善视为患者主观满意）。结果55例POP患者中有52例（95％，52，55）应用常规手术器械完成了SSLF，另外3例因暴露骶棘韧带困难而改行坐骨棘筋膜固定术。52例最终接受了SSLF手术的患者，中位术中出血量为100ml（20～300ml），中位手术时间为60min（20～165min）。有2例患者在术后2d发现直径分别为5、7cm的盆腔血肿，经过保守治疗后均痊愈。所有患者术后均能自主排尿。1例患者术后主诉大腿部疼痛，术后3个月随访时仍存在，物理治疗后好转。术后3个月随访时的POP-Q评估结果显示，手术成功率为100％（52/52）。中位随访23．7个月，客观治愈率为98％（51／52），手术复发率为2％（1／52），主观满意度为94％（49／52）。有6％（3／52）的患者术后新发尿失禁。结论绝大部分POP患者可应用常规手术器械实施SSLF，本术式对于骨盆较小的亚洲女性是1种可行、经济而有效的纠正中盆腔缺陷的手术方式。

Objective To evaluate the medium and long term safety and efficacy of sacrospinous ligament fixation （SSLF） performed with conventional instruments in treating stage Ⅲ-Ⅳ pelvic organ prolapse （POP）. Methods A prospective cohort analysis was conducted in the Peking Union Medical College Hospital, between May 2007 and June 2015, enrolling 55 women with stage Ⅲ-Ⅳ POP who intended to receive SSLF. Primary end points were objective success rates using pelvic organ prolapse quantitation system （POP-Q） and subjective satisfaction rates with questionnaires after surgery according to vaginal examination and related questionnaires for all patients who received SSLF eventually. Exploratory outcomes included perioperative parameters and complications. Results Of these 55 POP patients enrolled, 52 （95%, 52/55） received SSLF using conventional surgical instruments, the other 3 cases converted to ischial spinous fascia fixation due to difficulty exposing. Medium blood Loss during operation was 100 ml （20-300 ml） and operative time 60 minutes （20-165 minutes）. Pelvic hematoma with diameters of 5 cm and 7 cm were observed in two patients, both recovered fully with conservative methods. All patients were able to micturate spontaneously after catheter withdrawal. One patient reported right thigh pain after operation which remained till 3-month follow-up and relieved after physiotherapy. The objective success rate was 100% （52/52） at 3 months. With a medium follow-up time of 23.7 months, the objective success rate was 98% （51/52）, the recurrence rate was 2% （1/52） and the satisfactory rate was 94% （49/52）. De novo urinary incontinence occurred in 6% （3/52） of patients. Conclusion Most POP could be corrected with SSLF using conventional instruments which is a feasible, economic and effective procedure for Asian patients with medium compartment prolapse.