盆底超声联合剪切波弹性成像预测子宫全切术后盆底功能障碍性疾病的临床价值

Clinical value of pelvic floor ultrasound combined with shear wave elastography in predicting pelvic floor dysfunction after total hysterectomy

目的探讨盆底超声联合剪切波弹性成像(SWE)预测子宫全切术患者发生盆底功能障碍性疾病(PFD)的临床价值。方法前瞻性选取因子宫良性疾病行子宫全切术患者47例为病例组,以及同期未行子宫切除术的已婚已育女性70例为对照组,应用盆底超声测量静息状态及最大Valsalva动作下两侧肛提肌厚度、肛提肌裂孔前后径、膀胱颈距参考线距离,计算膀胱颈移动度;应用SWE测量静息状态及最大Valsalva动作下肛提肌附于耻骨下支处、肌腹及尾侧杨氏模量最大值(Emax)、最小值(Emin)、平均值(Emean),并计算其差值(ΔEmax、ΔEmin、ΔEmean),比较两组上述参数的差异。采用多因素Logistic回归分析筛选PFD的独立影响因素;绘制受试者工作特征(ROC)曲线分析盆底超声联合SWE预测子宫全切术后PFD的诊断效能。结果病例组PFD的发生率高于对照组(59.6%vs.42.9%),差异有统计学意义(P=0.005)。病例组最大Valsalva动作下膀胱颈距参考线距离、膀胱颈移动度均较对照组增大,差异均有统计学意义(均P<0.05);病例组静息状态及最大Valsalva动作下左、右侧肛提肌厚度均较对照组减小,肛提肌裂孔前后径均较对照组增大,差异均有统计学意义(均P<0.05)。病例组静息状态及最大Valsalva动作下肛提肌附于耻骨下支处、肌腹及尾侧Emax、Emin、Emean均较对照组增大,ΔEmax、ΔEmin及ΔEmean均较对照组减小,差异均有统计学意义(均P<0.05)。多因素Logistic回归分析显示,最大Valsalva动作下肛提肌裂孔前后径、最大Valsalva动作下左侧肛提肌肌腹Emax及左侧肛提肌肌腹ΔEmax、ΔEmean均为PFD的独立影响因素(均P<0.05)。ROC曲线分析显示,最大Valsalva动作下肛提肌裂孔前后径、最大Valsalva动作下左侧肛提肌肌腹Emax及左侧肛提肌肌腹ΔEmax、ΔEmean单独及联合应用预测子宫全切术后PFD的曲线下面积分别为0.776、0.721、0.625、0.860、0.964,以联合诊断的曲线下面积最高,对应的灵敏度为97.4%,特异度为80.0%。结论盆底超声联合SWE可用于预测子宫全切术患者PFD发生风险,有一定的临床应用价值。

Objective To explore the clinical value of pelvic floor ultrasound combined with shear wave elastography(SWE)in predicting pelvic floor dysfunction(PFD)in patients after total hysterectomy.Methods Forty-seven women who underwent total hysterectomy for benign uterine diseases were prospectively included as the case group,and 70 married and fertile women who did not underwent hysterectomy during the same period were included as the control group.Pelvic floor ultrasound was used to measure the thickness of levator ani muscle on both sides,the anteroposterior diameter of levator hiatus,and the distance from the bladder neck to the reference line under resting state and maximum Valsalva maneuver,and the bladder neck mobility was calculated.SWE was used to measure the maximum,minimum and mean of Young’s(Emax,Emin,Emean)modulus of the levator ani muscle attached to the inferior pubic branch,the muscle belly and the tail under the resting state and the maximum Valsalva maneuver,and the difference value(ΔEmax,ΔEmin,ΔEmean)were calculated,and the differences of the above parameters between the two groups were compared.Multivariate Logistic regression analysis was used to screen the independent influencing factors of PFD.Receiver operating characteristic(ROC)curve was drawn to analyze the diagnostic efficacy of pelvic floor ultrasound combined with SWE in predicting PFD after total hysterectomy.Results The incidence of PFD in the case group was higher than that in the control group(59.6%vs.42.9%),and the difference was statistically significant(P=0.005).The distance from the bladder neck to the reference line under the maximum Valsalva maneuver,the mobility of the bladder neck in the case group were significantly higher than those in the control group(all P<0.05).The thickness of levator ani muscle on both sides in the case group were lower than those in the control group at resting state and maximum Valsalva maneuver,and the anteroposterior diameter of levator hiatus was higher than that in the control group,with statistically significant differences(all P<0.05).The Emax,Emin and Emean of the levator ani muscle attached to the inferior pubic branch,the muscle belly and the tail side in the case group were higher than those in the control group at resting state and maximum Valsalva maneuver,andΔEmax,ΔEmin andΔEmean were lower than those in the control group,with statistically significant differences(all P<0.05).Multivariate Logistic regression analysis showed that the anteroposterior diameter of levator hiatus under maximum Valsalva maneuver,Emax of the left levator anal muscle under maximum Valsalva maneuver,ΔEmax andΔEmean of the left levator anal muscle were independent risk factors for PFD(all P<0.05).ROC curve analysis showed that the areas under the curve for diagnosing PFD after total hysterectomy using the anteroposterior diameter of levator hiatus during maximum Valsalva maneuver,the Emax of the left levator ani muscle belly during maximum Valsalva maneuver,and theΔEmax andΔEmean of the left levator ani muscle belly,both individually and combined,were 0.776,0.721,0.625,0.860 and 0.964,respectively.The area under the curve of combined diagnosis was the highest,the corresponding sensitivity was 97.4%,and the specificity was 80.0%.Conclusion Pelvic floor ultrasound combined with SWE can accurately predict PFD in patients after total hysterectomy,and has certain clinical application value.