盆底重建手术后聚丙烯网片或吊带暴露并发症的处理及结局分析

Clinical management of 110 cases of polypropylene mesh and sling exposure after reconstructive pelvic floor surgery

目的 探讨盆底重建手术后聚丙烯网片或吊带暴露的临床评估、处理方法、结局和疗效分析.方法 回顾性分析解放军总医院第一附属医院2002年1月—2017年10月期间收治的盆底重建手术后发生聚丙烯网片或吊带暴露的110例患者的临床资料,随访时间从盆底手术后1个月至术后10年.对随访中发现网片或吊带暴露者先进行网片暴露的类别、时间和部位（CTS）分类,再按暴露程度、是否伴有感染和疼痛程度等决定处理方式,分为门诊处理组（包括观察期待、局部涂抹雌激素、剪除暴露的网片或吊带）和入院手术组（入院后麻醉下进行手术治疗）,随访两组患者的主、客观疗效,客观检查采用妇科检查确定暴露部位的愈合情况,采用患者整体印象改善评分量表（PGI-I）评估主观满意度.结果 110例盆底重建手术后发生聚丙烯网片或吊带暴露的患者中,门诊处理组74例、入院手术组36例;前次盆底重建手术为经阴道网片手术95例,抗尿失禁吊带手术5例,骶骨阴道穹隆固定术10例.门诊处理组74例患者均为CTS分类1～3类,经门诊处理后均愈合,愈合时间为（3.0±1.8）个月.入院手术组36例患者中,29例为阴道网片暴露CTS分类1～3类患者,其中21例1次手术后愈合,5例手术后再次出现暴露后经保守处理后愈合,2例2次手术后愈合,1例3次手术后愈合;5例为吊带暴露患者,其中2例行吊带部分切除术后愈合,2例为吊带侧方穿出阴道经切开放回后愈合,1例尿道中段吊带暴露将吊带埋入缝合后再次暴露,局部剪除暴露吊带后愈合;1例为术后1年膀胱网片暴露经膀胱切除暴露网片后愈合;1例为网片后路吊带的穿刺路径导致疼痛,去除暴露的网片后疼痛症状缓解.门诊处理组74例患者中,PGI-I评估结果为非常好、很好者分别为65例（87.8％）、9例（12.2％）;入院手术组36例患者中,PGI-I评估结果为非常好、很好者分别为30例（83.3％）、6例（16.7％）.结论 盆底重建手术后,约2/3的网片或吊带暴露属于CTS分类1～3类的轻度患者,可经门诊处理;约1/3属于CTS分类4～6类的重度患者或复杂患者,需要入院手术处理.盆底重建手术后一旦发生网片或吊带暴露应积极处理,绝大多数患者的结局较好,因而不影响原手术效果.

Objective To explore the clinical management and outcomes of polypropylene mesh and sling exposure after reconstructive pelvic surgery（RPS）. Methods A total of 110 cases of mesh and sling exposure after RPS were analyzed, who admitted between Jan. 2002 and Oct. 2017 in First Affiliated Hospital of PLA General Hospital, in which 3 cases were referred from other hospitals. Mesh and sling exposures were identified in the outpatient clinic and categorized and managed according to International Continence Society and International Urogynecology Association（ICS-IUGA）classification about category, time and site（CTS）of mesh complication. Outpatient management included observation, topical estrogen use and mesh removal. Management in hospital included surgical removal of exposed mesh and repair of the＆nbsp;resulting defects under the anesthesia. Seventy-four cases were managed in the outpatient setting, and 36 cases required inpatient management. Follow-up was consecutively performed from 1 month to 10 years. Objective outcome included the surgeon′s assessment of the healing state of the vaginal mucosa. Subjective outcome was evaluated with patient global impression of improvement questionnaire（PGI-I）. Results One hundred and ten patients with mesh exposure were classified according to the different RPS underwent. There were 95 cases from transvaginal mesh surgery, 5 cases from anti-stress urinary incontinence sling surgery, and 10 cases from sacrocolpopxy. The outpatient group healed at an average of（3.0 ± 1.8）months. Of the 36 patients who required inpatient management, 21 cases healed completely at an average of 7 days after one surgery. The remaining 8 cases required either two or three times surgeries or conservative management. In the outpatient group, the PGI-I scale very much better was found in 65 cases（87.8％）and much better in 9 cases（12.2％）. In the inpatient surgery group, the scale was very much better in 30 cases （83.3％）, and much better in 6 cases（16.7％）. Conclusions Among patients with mesh exposure after mesh-augmented RPS, 2/3 of patients with a CTS classification 1-3 could be managed in the office,and remaining 1/3 with CTS classification 4-6 need operation under anesthesia in hospital. If the mesh and sling exposure could be scientifically classified, according to the size, site and accompany symptoms, as well as pain, most of the mesh complications after explosure could be resolved. Using the pelvic floor repair and polypropylene mesh sling, the majority of the patients could get a better outcome, without affecting the effect of the original operation.