经阴道高位宫骶韧带悬吊术治疗复发性盆腔器官脱垂的疗效分析

Effectiveness of vaginal high uterosacral ligament suspension for treatment of recurrent pelvic organ prolapse

目的探讨经阴道高位宫骶韧带悬吊术(HUS)治疗盆底修补手术后复发性盆腔器官脱垂(POP)的适应证及临床效果。方法回顾性分析2005年11月—2018年1月外院盆底修补手术后因POP复发转诊至解放军总医院第四医学中心、采用经阴道HUS再次手术修补的患者共42例的临床资料。前次盆底修补手术术式包括单纯阴道前和(或)后壁修补术30例(71%,30/42),曼氏手术5例(12%,5/42),经阴道网片修补5例(12%,5/42),骶棘韧带固定2例(5%,2/42)。复发的中位时间为9个月(最短1个月,最长216个月);其中复发时间≤3个月者14例(33%,14/42),>3个月者28例(67%,28/42),其中位复发时间分别为2和18个月。脱垂的复发部位(Ⅲ度及以上):前壁33例(79%,33/42),顶端19例(45%,19/42),后壁7例(17%,7/42)。再次手术的指征:(1)主观症状严重影响生命质量;(2)拒绝子宫托治疗,要求手术;(3)脱垂达盆腔器官脱垂定量(POP-Q)分度法Ⅲ度及以上。采用经阴道HUS的手术指征为:(1)要求保留阴道功能者;(2)有顶端悬吊需要者;(3)有阴道手术条件。结果再次手术时采用经阴道HUS,均成功缝合双侧宫骶韧带并悬吊穹隆,同时加用阴道前壁网片25例(60%,25/42),阴道后壁网片3例(7%,3/42),达到了阴道顶端以及前后壁的良好复位。无输尿管、肠管等副损伤发生。经阴道HUS术后中位随访时间为5.3年;术后POP-Q各指示点(Aa、Ba、C、Ap、Bp)均较术前明显上升(P均<0.01),C点由术前+0.3 cm降为-8.2 cm(P<0.01)。客观成功率在穹隆和后壁均为100%(42/42),在前壁为93%(39/42);主观满意度为95%(40/42)。至今无一例要求再次手术或佩戴子宫托者。结论对于要求盆底重建又缺乏顶端牢固悬吊的盆底修补手术后复发性POP患者,经阴道HUS辅以阴道前后壁修补术是1种可选择的有效术式。

Objective To evaluate the indications and clinic outcomes of vaginal high uterosacral ligament suspension (HUS) for treatment of recurrent advanced pelvic organ prolapse (POP). Methods This retrospective study analyzed 42 women with recurrent advanced POP who were referred to Fourth Medical Center of PLA General Hospital and underwent transvaginal HUS between November 2005 and January 2018. Primary surgeries included 30 vaginal colporrhaphy, 5 Manchester operation, 5 transvaginal mesh repair,2 sacrospinous ligament fixation.The median time for recurrence from primary pelvic floor repair surgery was 9 months, including 14 cases (33%, 14/42)≤3 months (median time was 2 months) and 25 cases (67%, 28/42) longer than 3 months (median time was 18 months).The rate of recurrent prolapse in stage Ⅲ or Ⅳ was 79%(33 cases), 45%(19 cases) and 17%(7 cases) in anterior, apical and posterior compartment respectively. Results Transvaginal high bilateral uterosacral ligaments were identified and used for successful vaginal vault suspension after vaginal hysterectomy and residual cervical resection in all 42 consecutive patients. The cases of transvaginal mesh used in anterior wall and posterior wall were 25 (60%, 25/42) and 3 (7%, 3/42) respectively. There was no major intra- and postoperative complications,such as ureter and other pelvic organ injury. The median time of follow-up was 5.3 years after transvaginal HUS. The points of pelvic organ prolapse quantification system reduced significantly and point C improved from +0.3 cm to -8.2 cm after reoperation (P<0.01). The objective cure rate were 100%(42/42) both in apex and posterior compartment,while 93%(39/42) in anterior compartment. None had reoperation or pessary usage for recurrence of prolapse. Conclusion Transvaginal HUS with vaginal wall repair could be as a safety, cost-effective, minimal traumatic and durable procedure for recurrent POP in the most of cases.