经会阴盆底超声检查定量评估子宫全切除术后不同时间段盆底结构及功能变化

Study on the changes of pelvic floor structure in different time after hysterectomy by transperineal ultrasound

目的经会阴盆底超声定量评估子宫全切除术后盆底结构、功能在不同时间段内的变化。方法收集2016年3月至2017年7月子宫全切除术后在兰州大学第二医院超声科复查的女性患者105例。其中40～49岁37例,50～59岁49例,≥60岁19例;术后≤1年29例,术后> 1,≤5年33例,> 5,≤10年28例,> 10年15例。选取同期兰州大学第二医院体检且临床未诊断盆底功能障碍性疾病(PFD)的120名女性志愿者作为健康对照组,均未行子宫全切术及其他盆底手术。所有研究对象均行盆底超声检查,测量静息及Valsalva状态下膀胱颈距耻骨联合下缘距离(X)、尿道倾斜角(α)、膀胱尿道后角(β)、直肠壶腹最低点距耻骨联合后下缘距离(D)、膀胱逼尿肌厚度,计算尿道旋转角(Rα)及膀胱颈下降值(BND)。采用t检验比较子宫全切除术组患者与健康对照组受检者超声定量参数;采用χ~2检验比较不同年龄段子宫全切除术组患者术后不同时间段PFD检出率差异。结果与健康对照组受检者比较,子宫全切除术组患者术后膀胱逼尿肌厚度增大,且差异有统计学意义(t=3.28,P <0.05)。静息状态下,与健康对照组受检者比较,子宫全切除术组患者β增大,X及D减小,且差异均有统计学意义(t=4.56、2.17、4.93,P均<0.05);子宫全切除术组患者α增大,但差异无统计学意义。最大Valsalva状态下,与健康对照组受检者比较,子宫全切除术组患者α、β、Rα、BND均增大,X、D均减小,差异均有统计学意义(t=3.37、3.44、3.36、5.06、5.79、5.76,P均<0.05)。105例子宫全切除术组患者术后PFD检出率为60.0%(63/105),其中压力性尿失禁(SUI)检出率为33.3%(35/105),盆腔脏器脱垂(POP)检出率为36.2%(38/105)。POP中,膀胱脱垂检出率为18.1%(19/105),直肠脱垂检出率为10.5%(11/105),肠疝检出率为6.7%(7/105)。子宫全切术后1年内发生PFD以SUI为主,检出率为48.3%(14/29);术后10年后发生PFD以POP为主,检出率为80.0%(12/15)。各年龄段子宫全切除术组患者术后不同时间段PFD检出率差异无统计学意义,表明术后不同时间段PFD检出率可能与子宫全切除术组患者年龄无密切关系。结论经会阴盆底超声检查能够动态观察子宫全切除术后盆底结构的变化,且可对术后PFD进行定量评估。

ObjectiveTo evaluate the changes of pelvic fioor structure and function quantitatively in different periods after taking total hysterectomy by transperineal pelvic ultrasound. MethodsA total of 105 female patients who underwent ultrasound examination after hysterectomy at the Second Hospital of Lanzhou University from March 2016 to July 2017 were enrolled. Among them, 37 cases were 40-49 years old, 49 cases were 50-59 years old, 19 cases were over 60 years old; 29 cases were less than 1 years after hysterectomy, 33 cases were 〉 1, ≤ 5 years after hysterectomy, 28 cases were 〉 5, ≤ 10 years after hysterectomy, and 15 cases were over 10 years after hysterectomy. A total of 120 female volunteers from theSecond Hospital of Lanzhou University who had not been diagnosed with pelvic fioor dysfunction （PFD） were selected as the healthy control group without total hysterectomy or other pelvic floor surgery. All subjects were examined by pelvic fioor ultrasound. The distance from the bladder neck to the lower edge of pubic symphysis （X）, urethral angle （α）, retrovesical angle （β）, the distance from the lowest point from the rectal ampulla to the lower edge of pubic symphysis （D） and detrusor thickness under resting state and maximal Valsalva state were measured. And the urethral rotation angle （Rα） and bladder neck descent value （BND） were calculated. T test was used to compare the ultrasonic quantitative parameters between the total hysterectomy group and the healthy control group, and the detection rate of PFD was compared by Chi-square test between the patients of different age groups at different time after hysterectomy. ResultsThe thicknessof bladder detrusor in total hysterectomy group was significantly higher than that in healthy control group. The age of patients in the total hysterectomy group was older than that in the healthy control group, and the difference was statistically significant. At rest, compared with the subjects in the healthy control group, the βincreased, the X and D decreased in patients with total hysterectomy. The differences were significant. The α increased after hysterectomy, but the difference was not statistically significant. At maximum Valsalva state, compared with the subjects in the healthy control group, the α, β, Rα and BND all increased in the group of total hysterectomy, and the X and D decreased. The difference was statistically significant. The detection rate of PFD in 105 cases of total hysterectomy group was 60% （63/105）, the detection rate of stress incontinence （SUI） was 33.3% （35/105）, and the detection rate of pelvic organ prolapse （POP） was 36.2% （38/105）. In POP, the detection rate of bladder prolapse, rectal prolapse and intestinal hernia was 18.1% （19/105）, 10.5%（11/105） and 6.7% （7/105）. SUI was the main occurrence of PFD within 1 year after total hysterectomy, and the detection rate was 48.3% （14/29）. 10 years after operation, POP was the predominant occurrence of PFD, and the detection rate was 80.0% （12/15）. There was no significant difference in the detection rate of PFD between different age groups after hysterectomy, indicating that the detection rate of PFD at different times after hysterectomy may not be closely related to the age of patients. ConclusionTransperineal pelvic fioor ultrasonography can dynamically observe the changes of pelvic fioor structure after total hysterectomy, and can evaluate PFD quantitatively after operation.