發(fā)布時(shí)間：2018-06-01 14:48

  本文選題：重度盆腔器官脫垂 + 盆底重建��； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景:盆腔器官脫垂(pelvic organ prolapse,POP)是指由于盆底支持組織缺損或松弛而引起的盆腔臟器脫離正常的解剖位置,子宮脫垂是指子宮從正常位置沿陰道下降,宮頸外口達(dá)坐骨棘水平以下,美國國立研究院(National Institutes of Health,NIH)指出,POP是指任何陰道節(jié)段的前緣達(dá)到或超過處女膜緣外1cm以上。手術(shù)治療可有效地緩解因盆腔器官脫垂引起的不適癥狀,并能有效地提高患者的生活質(zhì)量。手術(shù)治療的目的:1.解剖學(xué)組織復(fù)位;2.恢復(fù)或者保持正常的膀胱功能;3.恢復(fù)或者保持正常的直腸功能;4.恢復(fù)或者保持正常性功能。手術(shù)治療盆腔臟器脫垂的方法有:傳統(tǒng)的經(jīng)陰道子宮切除術(shù)和前、后壁修補(bǔ)術(shù);陰道封閉術(shù);曼氏手術(shù);骶棘韌帶固定術(shù)等[1]。傳統(tǒng)手術(shù)為應(yīng)用自體筋膜進(jìn)行盆地重建,文獻(xiàn)報(bào)道復(fù)發(fā)率30%,部分重度POP的患者難以達(dá)到解剖學(xué)復(fù)位,并且隨著時(shí)間進(jìn)展,復(fù)發(fā)率更高。人工合成網(wǎng)片在治療盆腔臟器脫垂中應(yīng)用,能同時(shí)糾正中央缺陷以及側(cè)方缺陷,降低POP的復(fù)發(fā),提高患者生活質(zhì)量。本研究通過對(duì)齊魯醫(yī)院經(jīng)陰道植入網(wǎng)片盆底重建術(shù)的患者的長期隨訪,分析經(jīng)陰道植入網(wǎng)片盆底重建術(shù)的遠(yuǎn)期療效。目的:探討經(jīng)陰道植入網(wǎng)片盆底重建術(shù)治療重度盆腔器官脫垂的遠(yuǎn)期療效方法:采用回顧性研究的方法,對(duì)2008年1月到2015年12月之間,在山東大學(xué)齊魯醫(yī)院行經(jīng)陰道植入網(wǎng)片的盆底重建術(shù)(TVM)105例的重度POP病例進(jìn)行術(shù)后隨訪調(diào)查,手術(shù)方法為經(jīng)陰道植入前路網(wǎng)片前盆重建術(shù),經(jīng)陰道后路植入網(wǎng)片后盆重建術(shù),經(jīng)陰道植入全盆網(wǎng)片的全盆重建術(shù)。通過對(duì)患者臨床資料的分析,評(píng)估經(jīng)陰道植入盆底重建術(shù)手術(shù)相關(guān)指標(biāo)及圍手術(shù)期并發(fā)癥;通過門診復(fù)查,行婦科檢查,用盆腔器官定量分期法(POP-Q)量化脫垂嚴(yán)重程度,并將盆底重建術(shù)術(shù)前和術(shù)后進(jìn)行統(tǒng)計(jì)學(xué)對(duì)比分析,評(píng)估經(jīng)陰道植入網(wǎng)片盆底重建術(shù)的客觀臨床療效;根據(jù)盆底障礙影響簡易問卷-7(PFIQ-7)、盆底功能障礙問卷(PFDI-20)和盆腔器官脫垂性功能問卷(PSIQ-12)得分,通過對(duì)術(shù)前及術(shù)后患者問卷得分進(jìn)行統(tǒng)計(jì)學(xué)比較,評(píng)估經(jīng)陰道植入網(wǎng)片盆底重建術(shù)后患者的主觀臨床療效;通過規(guī)律隨訪以及定期復(fù)查,評(píng)估經(jīng)陰道植入網(wǎng)片盆底重建術(shù)術(shù)后盆腔器官脫垂復(fù)發(fā)情況以及術(shù)后遠(yuǎn)期并發(fā)癥的情況。統(tǒng)計(jì)學(xué)分析:采用SPSS16.0進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)數(shù)資料以頻數(shù)或者比率表示,計(jì)量資料以均數(shù)士標(biāo)準(zhǔn)差表示,采用配對(duì)t檢驗(yàn)進(jìn)行比較,以P0.05視為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果：1.經(jīng)陰道植入網(wǎng)片盆底重建術(shù)治愈率:1.1根據(jù)ICS標(biāo)準(zhǔn)1年、3年、5年治愈率分別為94.7%、87.1%、80.4%;1.2根據(jù)復(fù)合標(biāo)準(zhǔn)1年、3年、5年治愈率分別為94.7%,91.4%、88.2%。2.經(jīng)陰道植入網(wǎng)片盆底重建術(shù)患者臨床資料及一般情況:2.1經(jīng)陰道植入網(wǎng)片盆底重建術(shù)術(shù)后共隨訪患者105例,有效隨訪患者95例,有效隨訪率為90.5%(95/105)。2.2患者平均年齡為63.9±10.5歲,產(chǎn)次為1.8±0.7次,BMI為29.5±9.8kg/m2,難產(chǎn)病史患者占30.5%(29/95),既往子宮切除史患者占24.25%(24.25),絕經(jīng)后患者占87.0%(83/95),慢性腹壓增加患者占48.4%(46/95)。2.3經(jīng)陰道植入網(wǎng)片盆底重建術(shù)患者術(shù)前POP-Q分期:術(shù)前POP-Q分期Ⅲ-Ⅳ期的患者為95例,其中,盆底前腔室Ⅲ-Ⅳ期脫垂患者為55例,占57.9%,盆底中腔室Ⅲ-Ⅳ期患者為47例,占49.5%,盆底后腔室Ⅲ-Ⅳ期脫垂患者18例,占18.9%。3.經(jīng)陰道植入網(wǎng)片盆底重建術(shù)手術(shù)相關(guān)指標(biāo)及圍手術(shù)期并發(fā)癥3.1經(jīng)陰道植入網(wǎng)片盆底重建術(shù)手術(shù)相關(guān)指標(biāo):手術(shù)平均時(shí)間為79± 11mmin,手術(shù)術(shù)中出血量為90.3±50mL,手術(shù)后平均尿管留置時(shí)間為6±1天,手術(shù)后平均住院時(shí)間為5±1天。3.2經(jīng)陰道植入網(wǎng)片盆底重建手術(shù)圍手術(shù)期并發(fā)癥:手術(shù)中膀胱損傷1例(1.1%),手術(shù)后泌尿系感染2例(2.1%),手術(shù)后尿潴留3例(3.2%),手術(shù)后下肢靜脈血栓形成3例(3.2%)。4.經(jīng)陰道植入網(wǎng)片盆底重建手術(shù)治療重度POP臨床療效4.1客觀臨床療效:應(yīng)用國際統(tǒng)一評(píng)價(jià)體系POP-Q分期進(jìn)行評(píng)估:經(jīng)陰道植入網(wǎng)片盆底重建手術(shù)患者1年后復(fù)查POP-Q分期中的Aa,Ba,Ap,Bp以及C點(diǎn)與術(shù)前相應(yīng)位置對(duì)比分析有顯著療效(P0.005),手術(shù)前及手術(shù)后陰道總長度差異無統(tǒng)計(jì)學(xué)意義(P=0.012);4.2主觀臨床療效:4.2.1完成盆底障礙影響簡易問卷(PFIQ-7)調(diào)查的患者95例,術(shù)后隨訪得分與術(shù)前得分對(duì)比顯示術(shù)后患者生活質(zhì)量提高(P0.005);4.2.2完成盆底障礙影響簡易問卷(PFIQ-7)調(diào)查的患者95例,術(shù)后隨訪得分與術(shù)前得分對(duì)比顯示術(shù)后患者生活質(zhì)量提高(P0.005);4.2.3完成盆腔器官脫垂性功能問卷(PSIQ-12)調(diào)查的患者65例,術(shù)后隨訪得分與術(shù)前得分對(duì)比,顯示術(shù)后性生活質(zhì)量有改善(P0.005)。5.經(jīng)陰道植入網(wǎng)片盆底重建術(shù)治療重度POP術(shù)后復(fù)發(fā)及遠(yuǎn)期并發(fā)癥5.1經(jīng)陰道植入網(wǎng)片盆底重建術(shù)術(shù)后復(fù)發(fā)率為5.3%(5/95)。其中3例為保留子宮的經(jīng)陰道植入全盆網(wǎng)片的全盆重建術(shù)。在95位患者中,經(jīng)陰道植入全盆網(wǎng)片的全盆重建術(shù)共為5例,該術(shù)式的術(shù)后復(fù)發(fā)率為60%(3/5)。5.2經(jīng)陰道植入網(wǎng)片盆底重建術(shù)術(shù)后晚期并發(fā)癥:網(wǎng)片暴露4例(4.2%),網(wǎng)片侵蝕1例(1.1%),陰道壁潰瘍1例(1.1%),陰道壁肉芽腫2例(2.1%),術(shù)后新發(fā)尿失禁3例(3.2%),術(shù)后頑固性腹股溝疼痛1例(1.1%);5.3經(jīng)陰道植入網(wǎng)片盆底重建術(shù)再次手術(shù)率:因脫垂復(fù)發(fā)再手術(shù)率為3.2%(3/95),因術(shù)后并發(fā)癥在手術(shù)率為6.3%(6/95);結(jié)論:1.經(jīng)陰道植入網(wǎng)片盆底重建術(shù)是治療重度POP的安全、有效的手術(shù)方式,并在解剖學(xué)復(fù)位、提高患者生活質(zhì)量以及提高性生活質(zhì)量指標(biāo)評(píng)估中,療效可得到肯定;2.重度盆腔器官脫垂患者,保留子宮的經(jīng)陰道植入全盆網(wǎng)片全盆重建術(shù)術(shù)后復(fù)發(fā)風(fēng)險(xiǎn)明顯高于伴子宮切除的全盆重建術(shù)。
[Abstract]:Background: pelvic organ prolapse (POP) refers to the dissection of pelvic organs caused by pelvic floor support or relaxation. Uterine prolapse refers to the descent of the uterus from the normal position along the vagina and the level of the cervix to the level of the sciatic spine, the National Institute of the United States (National Institutes of Health,) NIH) pointed out that POP means that the anterior edge of any vaginal segment reaches or exceeds 1cm above the hymen margin. Surgical treatment can effectively relieve the discomfort caused by pelvic organ prolapse and effectively improve the quality of life of the patient. The objective of surgical treatment: 1. anatomic tissue relocations; 2. restoration or maintenance of normal bladder function; 3. recovery Or maintain normal rectal function; 4. restore or maintain normal function. Surgical treatment of pelvic viscera prolapse is: traditional transvaginal hysterectomy and anterior, posterior wall repair; vaginal closure; mansoni surgery; sacral spine ligament fixation and other traditional [1]. operations for the use of autologous fascia for basin reconstruction, the literature reports recurrence rate. 30%, the patients with partial severe POP are difficult to achieve anatomical reduction, and the recurrence rate is higher as time progresses. The application of artificial synthetic mesh in the treatment of pelvic organ prolapse can correct the central defects and lateral defects, reduce the recurrence of POP and improve the quality of life of the patients. This study through the vaginal implantation of the pelvic floor in the Qilu Hospital Long term follow-up of patients with reconstructive surgery, the long-term effect of pelvic floor reconstruction with transvaginal implant was analyzed. Objective: To explore the long-term effect of pelvic floor reconstruction by transvaginal implant surgery for severe pelvic organ prolapse: a retrospective study was performed between January 2008 and December 2015 at Qilu Hospital of Shandong University. After pelvic floor reconstruction (TVM), 105 cases of severe POP cases were followed up. The operation method was the anterior pelvic reconstruction of the vagina implantation, the posterior pelvic reconstruction through the vagina, and the whole basin reconstruction of the whole pelvis through the vagina. The pelvic floor weight was evaluated through the analysis of the patient's clinical data and the pelvic floor weight was evaluated by vaginal implantation. The related indicators and perioperative complications were established. Through the outpatient review, gynecologic examination, the pelvic organ quantitative staging (POP-Q) was used to quantify the severity of prolapse, and the preoperative and postoperative statistical analysis of pelvic floor reconstruction was carried out to evaluate the objective clinical efficacy of the reconstruction of the pelvic floor of the transvaginal implant. The score of simple questionnaire -7 (PFIQ-7), pelvic floor dysfunction questionnaire (PFDI-20) and pelvic organ prolapse function questionnaire (PSIQ-12) was used to evaluate the subjective clinical effect of the patients after pelvic floor reconstruction by vaginal implantation, and to evaluate the vagina through regular follow-up and periodic reexamination. Recurrence of pelvic organ prolapse after pelvic floor reconstruction and postoperative long-term complications. Statistical analysis: statistical analysis was carried out by SPSS16.0. Count data were expressed in frequency or ratio, measured data were represented by the standard deviation of the number of men, compared with paired t tests, and P0.05 was regarded as a statistical difference. Results: 1. the cure rate of pelvic floor reconstruction by transvaginal mesh: 1.1 according to the ICS standard 1 years, 3 years, 5 years cure rate is 94.7%, 87.1%, 80.4%; 1.2 according to the compound standard 1 years, 3, 5 year cure rate respectively is 94.7%, 91.4%, 88.2%.2. transvaginal implantation of pelvic floor reconstruction of patients with clinical data and general situation: vaginal implantation net pelvic 105 cases were followed up and 95 cases were followed up effectively. The average age of the effective follow-up was 90.5% (95/105).2.2, the average age of the patients was 63.9 + 10.5 years, the birth time was 1.8 + 0.7 times, the BMI was 29.5 + 9.8kg/m2, the patients with the history of dystocia accounted for 30.5% (29/95), 24.25% (24.25), postmenopause patients accounted for 87% (83/95), and chronic abdominal pressure. Preoperative POP-Q staging of patients with 48.4% (46/95).2.3 via vaginal implant pelvic floor reconstruction: 95 cases of pre operation POP-Q stage III IV stage, of which 55 cases were in the anterior chamber of pelvic floor, 55 cases, 57.9%, 47 patients in the pelvic floor cavity and 49.5%, 18 patients with stage III IV prolapse in pelvic floor posterior chamber, accounting for 18.9%.. 3. the related indexes of pelvic floor reconstruction by transvaginal implantation of net plate and perioperative complications 3.1 through vaginal implantation of pelvic floor reconstruction, the average time of operation was 79 + 11mmin, the amount of bleeding in the operation was 90.3 + 50mL, the average catheter indwelling time after operation was 6 + 1 days after operation, and the average hospital time after operation was 5 + 1 days.3.2 transvaginal. Perioperative complications: 1 cases (1.1%) of bladder injury in operation, 2 cases of urinary tract infection (2.1%) after operation, 3 cases of postoperative urinary retention (3.2%), 3 cases of lower limb venous thrombosis (3.2%) after operation (3.2%).4. transvaginal implantation of pelvic floor reconstruction for severe POP clinical effect of 4.1 objective clinical curative effect: applied international clinical effect: Application International The POP-Q staging of the unified evaluation system was evaluated: 1 years after the pelvic floor reconstruction of the vaginal implant, the Aa, Ba, Ap, Bp and C points were compared with the corresponding position before operation (P0.005), and there was no significant difference between the preoperative and postoperative vaginal length (P=0.012), and the 4.2 subjective clinical efficacy: 4.2.1 completion. 95 cases of simple questionnaire (PFIQ-7) were affected by pelvic floor disorder. The postoperative follow-up scores and preoperative scores showed that the patients' life quality was improved (P0.005); 4.2.2 completed pelvic floor disorders affecting 95 patients with simple questionnaire (PFIQ-7). The postoperative follow-up scores and preoperative scores showed that the quality of life was improved (P0.005) after the operation (P0.005); 4. 2.3 patients who completed the pelvic organ prolapse sexual function questionnaire (PSIQ-12) survey 65 cases, the postoperative follow-up scores and preoperative scores were compared, showing that the postoperative sex life quality was improved (P0.005).5. via vaginal implant pelvic floor reconstruction for the treatment of severe POP recurrence and long-term complications, 5.1 after the vaginal implant pelvic floor reconstructive surgery, the recurrence rate was 5. 3% (5/95). 3 of them underwent full pelvic reconstruction by transvaginal full pelvic mesh for retention of uterus. In 95 patients, total pelvic reconstruction by transvaginal full pelvic mesh was performed in 5 cases. The postoperative recurrence rate was 60% (3/5).5.2 via vaginal implant pelvic floor reconstruction: 4 cases (4.2%) were exposed to mesh and 1 cases (1.). 1%) 1 cases (1.1%) of vaginal wall ulcers, 2 cases of vaginal wall granuloma (2.1%), 3 cases of new urinary incontinence (3.2%) after operation, 1 cases of intractable inguinal pain after operation (1.1%), and 5.3 transvaginal reoperation rate of pelvic floor reconstruction: recurrence rate of recurrent prolapse was 3.2% (3 /95) and postoperative complication was 6.3% (6/95); conclusion: transvaginal implant network Pelvic floor reconstruction is a safe and effective method for the treatment of severe POP, and the curative effect can be affirmed in the anatomic reduction, the improvement of the quality of life and the improvement of the quality of life. 2. patients with severe pelvic organ prolapse, the risk of recurrence after the whole pelvic reconstruction of the uterus by transvaginal implantation of the uterus is obviously higher than that of the whole pelvic reconstructive operation. Total pelvic reconstruction with hysterectomy.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R713

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