机器人辅助腹腔镜骶骨固定术治疗盆腔器官脱垂的疗效

Efficacy and urodynamic analysis of robot assisted laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse

目的探讨机器人辅助腹腔镜骶骨固定术治疗盆腔器官脱垂的有效性与安全性。方法回顾性分析2019年9月至2022年5月于北京医院行机器人辅助腹腔镜骶骨固定术的16例盆腔器官脱垂患者的临床资料。均为女性,年龄(73.5±9.3)岁,术前病程4~240个月,体质指数(24.2±1.7)kg/m^(2),产次(1.7±0.8)次,盆腔器官脱垂定量(POP-Q)分度Ⅲ~Ⅳ度。术前最大尿流率(9.6±3.4)ml/s,排尿期最大逼尿肌压力26(20,32)cmH_(2)O(1cmH_(2)O=0.098kPa),膀胱初感尿意容量(119.1±39.4)ml,膀胱初感尿急容量(253.6±75.7)ml,膀胱最大测压容量(406.0±79.8)ml,残余尿量10(10,28)ml。术前7例(44%)尿动力学检查可见无抑制性收缩波,提示存在逼尿肌过度活动。术前盆底功能障碍性疾病症状问卷(PFDI-20)评分100(70,122)分,盆底障碍影响简易问卷(PFIQ-7)评分107(90,160)分。机器人辅助腹腔镜骶骨固定术中显露骶骨岬右侧区域,分离子宫前后壁,右侧子宫阔韧带分离2cm小孔。将网片裁剪为“Y”形穿过小孔,“Y”形网片前后叶缝合固定于宫颈,另一端固定于骶骨前纵韧带。观察手术时间、术中出血量。通过手术前后影像尿动力学检查结果、POP-Q分度、PFDI-20评分、PFIQ-7评分变化评价手术效果。结果本研究16例手术均顺利完成。术中均未出现尿道、膀胱、直肠及重要血管、神经损伤。手术时间(255.6±56.0)min,出血量(28.8±18.2)ml。术前7例存在逼尿肌过度活动者,术后复查逼尿肌过度活动消失或大幅减少。术后随访3~36个月,随访期间1例出现复发,其余未出现脱垂和排尿症状,术后复查POP-Q分度均降为0~Ⅰ度,患者主观满意率94%(15/16)。术后患者PFDI-20评分为13(8,24)分,PFIQ-7评分为11(6,15)分,均较术前显著降低(P<0.001);膀胱初感尿急容量为(272.5±88.5)ml,较术前显著增加(P=0.038);膀胱最大测压容量为(427.2±79.2)ml,较术前显著增加(P=0.006)。影像尿动力学检查示,患者术后基本恢复盆底解剖结构,达到功能复位。结论机器人辅助腹腔镜骶骨固定术治疗盆腔器官脱垂主观效果及客观效果好,复发率较低,并发症较少,其对于膀胱功能的改善尚需更大样本量研究验证。

Objective To explore the efficacy and safety of robot assisted laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse.MethodsThe data of 16 patients who underwent robot assisted laparoscopic sacrocolpopexy in Beijing Hospital from September 2019 to May 2022 were collected.The average age was(73.5±9.3)years,the preoperative course was 4-240 months,the body mass index was(24.2±1.7)kg/m^(2),the number of births was(1.7±0.8),and the quantitative index of pelvic organ prolapse(POP-Q)was grade Ⅱ-Ⅳ.The maximum urine flow rate before operation was(9.6±3.4)ml/s,the maximum detrusor pressure during urination was 26(20,32)cmH,0,the first sense urine volume of the bladder was(119.1±39.4)ml,the first sense urine urgency volume of the bladder was(253.6±75.7)ml,the maximum bladder pressure capacity was(406.0±79.8)ml,and the residual urine volume was 10(10,28)ml.The preoperative PFDI-20 score was 100(70,122)and the PFIQ-7 score was 107(90,160).During the robot assisted laparoscopic sacrocolpopexy,the right area of the sacral promontory was exposed,the anterior and posterior walls of the uterus were separated,and the 2 cm small hole was separated from the right broad ligament of the uterus.The mesh was cut into a "y" shape and passed through the small hole.The anterior and posterior leaves of the Y-shaped mesh were sutured to fix the cervix,and the other end was fixed to the anterior longitudinal ligament of the sacrum.The operation time and intraoperative bleeding were observed.The effect of surgery was evaluated by preoperative and postoperative urodynamic imaging,POP-Q stage,PFDI-20 score and PFIQ-7 score.ResultsAll the 16 operations were successfully completed.No injury of urethra,bladder,rectum,important blood vessels and nerves occurred during the operation.The average operation time was(255.6±56.0)min,and the average amount of bleeding was(28.8±18.2)ml.There was no inhibitory contraction wave in 7 patients(44%)before operation,suggesting that there was detrusor overactivity.After operation,the detrusor overactivity disappeared or significantly decreased in 7 patients.The postoperative follow-up period was 3-36 months.During the follow-up period,one patient had recurrence,and the rest had no prolapse and urination problems.The POP-Q stage was reduced to grade O-I after the operation.The subjective satisfaction rate of patients was 94%.The PFDI-20 score[13(8,24)]and PFIQ-7 score[11(6,15)]after operation were significantly reduced(P<0.001),the initial urgent volume of bladder(272.5±88.5)ml was significantly increased compared with that before operation(P=0.038),and the maximum volume of bladder(427.2±79.2)ml was significantly increased compared with that before operation(P=0.006).Image urodynamics showed that the patient basically recovered the pelvic floor anatomy and achieved functional reduction.ConclusionsRobot assisted laparoscopic sacrocolpopexy has good subjective and objective effects in POP,low recurrence rate and less complications.It needs a larger sample size study for confirming the improvement of bladder function.