腹腔镜下环宫颈子宫骶骨固定术治疗中重度盆腔器官脱垂的临床研究

Clinical Study of Laparoscopic Cerclage Sacrohysteropexy for Treating Moderate to Severe Pelvic Organ Prolapse

背景盆腔器官脱垂(POP)是严重影响妇女正常生活的常见病,手术是首选治疗方案之一,近年腹腔镜下盆底重建术越来越受到关注,许多学者认为腹腔镜下骶骨固定术(LSC)是治疗效果最佳、复发风险最小的手术,但传统的LSC也存在较多的弊端。目的探讨腹腔镜下环宫颈子宫骶骨固定术(LCSH)对中重度POP患者的临床疗效,评估其有效性和安全性。方法选取2016年12月-2018年3月在江西省妇幼保健院因中重度POP需行LSC的患者60例,采用随机数字表法分为传统组(30例)行传统LSC和改良组(30例)行LCSH。采用盆腔器官脱垂定量分期法(POP-Q)进行诊断和分期,记录两组患者的手术时间、术中出血量、住院天数、术后留置尿管天数及术后并发症,术后测量患者POP-Q各指示点数值评价术后盆底功能改善情况,以盆底不适调查简表(PFDI-20)评价手术前后患者生活质量状况,并比较两组间及两组手术前后有无差异。结果两组患者均经腹腔镜顺利完成手术,改良组患者的手术时间、术中出血量均少于传统组(P<0.05)。两组患者的随访时间均为3~14个月,均无失访病例。术后3个月及12个月无复发及手术失败病例,客观治愈率为100%,解剖治愈率为100%。术后改良组阴道前壁中线距处女膜缘3 cm处(Aa)、阴道前穹隆的反摺距离Aa点最远处(Ba)、阴道后壁中线距处女膜缘3 cm处(Ap)、阴道后穹隆的反摺距离Ap点最远处(Bp)点测量值较传统组更接近生理状态(P<0.05);两组术后Aa、Ba、宫颈外口最远处(C)、Ap点测量值较术前更接近生理状态,改良组Bp点测量值较术前更接近生理状态(P<0.05)。术前,改良组的POP困扰量表(POPDI-6)、排尿困扰量表(UDI-6)评分高于传统组(P<0.05)。两组术后PFDI-20、POPDI-6、UDI-6评分低于术前,传统组术后结直肠肛门困扰量表(CRADI-8)评分低于术前(P<0.05)。结论 LCSH与传统LSC均对中重度POP安全有效,LCSH更适用于要求保留子宫者,尤其是年轻女性;LCSH网片放置位置更低,具有手术操作简单、手术时间短、术者学习曲线短、术中出血量少、术后并发症少等优点,术后患者主、客观治愈率高,适宜临床推广。

Background Pelvic organ prolapse is a common disease which seriously affects the normal life of women.Surgery is one of the first choice for treatment.In recent years, laparoscopic pelvic floor reconstruction has been paid more and more attention.Many scholars believe that laparoscopic sacrocolpopexy(LSC) is a gold standard operation with minimal recurrence risk.However, there are many disadvantages in traditional LSC operation. Objective To explore clinical efficacy of laparoscopic cerclage sacrohysteropexy for moderate to severe pelvic organ prolapseon, and to assess its effectiveness and safety. Methods A retrospective analysis was performed on the clinical data, from December 2016 to March 2018 in Jiangxi Maternal and Child Health Hospital, in a total of 60 patients with severe moderate to severe pelvic organ prolapseon who received LSC, with 30 cases received laparoscopic cerclage sacrohysteropexy(modified group) and 30 cases received traditional LSC(traditional group) selected by random number table method.Diagnosis and grading of pelvic organ prolapse were identified by Pelvic Organ Prolapse Quantification System(POP-Q). The operation time, blood loss, hospital stay, days of indwelling catheter and complications of the two groups were compared after the operation, and we measured the POP-Q value at every point to assess postoperative pelvic floor function and evaluated preoperative and postoperative quality of life by using the pelvic floor distress inventory(PFDI-20).The difference between the two groups before and after operation was also compared. Results All procedures were successfully completed by laparoscopic therapy. The operation time,blood loss of the modified group were significantly less than those of the traditional group(P<0.05).The follow-up time were 3-14 months after surgery, none of the cases were lost.None of the women had recurrent uterine prolapse at 3 or 12 months after the treatment, with objective cure rate of 100%, and the anatomical cure rate of 100%. The median line of anterior vaginal wall was 3 cm away from hymen margin(Aa), the reverse fold of anterior vaginal fornix was the farthest from Aa point(Ba), the median line of posterior vaginal wall was 3 cm away from hymen margin(Ap), and the measurement value of the farthest point(Bp)of posterior vaginal fornix in the modified group was closer to the physiological state than that of the traditional group(P<0.05);the POP-Q values at Aa, Ba, the furthest exterior cervical orifice(C), Ap in the two groups and Bp in the modified group after operation were closer to the physiological state than those before operation(P<0.05).Before operation, Pelvic Organ Prolapse Distress Inventory(POPDI-6) and Urinary Distress Inventory 6(UDI-6) scores of the modified group were higher than those of the traditional group(P<0.05). Postoperative PFDI-20, POPDI-6 and UDI-6 scores in the two groups were lower than those before operation, while post-operative Colorectal-anal Distress Inventory 8(CRADI-8)score in the traditional group was lower than that before operation(P<0.05).Conclusion The two types of surgery for uterine prolapse are both effective. The laparoscopic cerclage sacrohysteropexy is suitable for patients with moderate to severe pelvic organ prolapse requiring uterus preservation, especially for young women.The mesh placement is lower, and the operation is simpler, with short operation time, short learning curve, small trauma, less bleeding, and faster recovery.The subjective and objective cure rate for patients is high after operation. It is expected to be promoted in clinic.