本文選題：盆底功能障礙性疾病 + 全盆底重建手術(shù)��； 參考：《中國(guó)協(xié)和醫(yī)科大學(xué)》2009年博士論文

【摘要】： 目的:明確針對(duì)中國(guó)女性的Prolift~(TM)和改良Prolift兩種全盆底重建手術(shù)穿刺路徑周圍的血管神經(jīng)解剖,提出兩種手術(shù)的安全性路徑操作建議。從臨床解剖學(xué)、動(dòng)態(tài)MRI影像學(xué)和臨床治療效果三方面對(duì)比研究Prolift~(TM)和改良Prolift兩種全盆底重建手術(shù)的差異,以指導(dǎo)安全的Prolift~(TM)和改良Prolift手術(shù)路徑,進(jìn)而降低兩種手術(shù)方式的手術(shù)并發(fā)癥。同時(shí)將為改良Prolift手術(shù)路徑在國(guó)內(nèi)的推廣應(yīng)用提供良好的理論支持依據(jù)。 方法:采用前瞻隨機(jī)對(duì)照方式確定選取的12具國(guó)人成年女性新鮮尸體標(biāo)本的手術(shù)穿刺方式(Prolift~(TM)手術(shù)路徑6具和改良Prolift手術(shù)路徑6具),解剖測(cè)量?jī)煞N手術(shù)路徑穿刺針與周圍血管神經(jīng)和重要臟器的距離,同時(shí)確立穿刺針的安全穿刺角度。運(yùn)用動(dòng)態(tài)MRI技術(shù)對(duì)同時(shí)期手術(shù)的20例POP-Q分度確定為Ⅲ度及以上盆腔器官脫垂的患者進(jìn)行手術(shù)前后影像學(xué)檢查,客觀評(píng)價(jià)兩種手術(shù)方式影像學(xué)治療的差異。同時(shí)前瞻性對(duì)比研究我院168名全盆底重建手術(shù)患者(Prolift~(TM)手術(shù)16例,改良Prolift手術(shù)152例)的臨床治療效果。 結(jié)果: 1、12具尸體解剖研究發(fā)現(xiàn),在閉孔區(qū)Prolift~(TM)和改良Prolift兩種全盆底重建手術(shù)陰道前壁淺帶和深帶穿刺針均在低于陰蒂水平線的區(qū)域穿過(guò)閉孔。Prolift~(TM)和改良Prolift兩種手術(shù)方式陰道前壁深帶穿經(jīng)閉孔膜的穿刺點(diǎn)距離閉孔動(dòng)靜脈后支的距離分別為0.60±0.36cm和0.78±0.10cm小于陰道前壁淺帶穿經(jīng)閉孔膜的穿刺點(diǎn)距離閉孔動(dòng)靜脈前支的距離(1.58±0.05cm和1.58±0.05cm),兩組分別比較P均＞0.05。 2、Prolift~(TM)和改良Prolift兩種手術(shù)方式陰道前壁淺帶穿經(jīng)閉孔外肌的穿刺點(diǎn)距離閉孔神經(jīng)前支的距離分別為3.23±1.03cm和3.18±0.61cm,距離閉孔神經(jīng)后支的距離為3.28±0.63cm和2.95±0.63cm;Prolift~(TM)和改良Prolift兩種手術(shù)方式陰道前壁深帶穿經(jīng)閉孔外肌的穿刺點(diǎn)距離閉孔神經(jīng)前支的距離分別為3.35±0.59cm和3.16±1.04cm,距離閉孔神經(jīng)后支的距離為2.68±0.57cm和2.86±0.87cm;兩種手術(shù)方式比較P值均＞0.05. 3、Prolift~(TM)陰道前壁深帶穿入陰道內(nèi)長(zhǎng)度(5.63±0.15cm)大于改良Prolift手術(shù)(4.83±0.05cm),(P＜0.01)。Prolift~(TM)陰道后壁穿刺針穿入陰道內(nèi)長(zhǎng)度(7.38±0.15cm)大于改良Prolift手術(shù)(5.88±0.23cm),(P＜0.01)。 4、Prolift~(TM)陰道后壁穿刺針與尾動(dòng)脈的距離為(0.88±0.10cm),短于改良Prolift手術(shù)與尾動(dòng)脈的距離(2.95±0.09cm),(P＜0.01)。Prolift~(TM)陰道后壁穿刺針與陰部?jī)?nèi)動(dòng)脈的距離為(1.59±0.36cm),短于改良Prolift手術(shù)與陰部?jī)?nèi)動(dòng)脈的距離(3.40±0.36cm),(P＜0.01)。Prolift~(TM)陰道后壁穿刺針與直腸的距離和為(0.88±0.10cm),改良Prolift手術(shù)與直腸的距離分別為1.05±0.89cm和0.86±0.62cm,兩組比較無(wú)明顯統(tǒng)計(jì)學(xué)差異,(P＞0.05)。 5、骶棘韌帶起于平第4骶孔的骶骨至第1尾骨的側(cè)緣,向外側(cè)延伸止于坐骨棘盆側(cè)的骨面。骶結(jié)節(jié)韌帶由致密結(jié)締組織組成,起于平第3骶孔的骶骨至第1尾骨的側(cè)緣,向外下方延伸止于坐骨體背側(cè)的骨面。骶結(jié)節(jié)韌帶下緣低于骶棘韌帶下緣。在距離坐骨棘內(nèi)側(cè)1.30±0.12cm以內(nèi)骶結(jié)節(jié)韌帶與骶棘韌帶重疊融合,形成骶棘骶結(jié)節(jié)韌帶復(fù)合體。 6、Prolift~(TM)組陰道后壁穿刺針穿過(guò)骶棘骶結(jié)節(jié)韌帶復(fù)合體的比例為66.7%,明顯高于改良Prolift組16.7%;穿過(guò)髂尾肌的比例為25%,明顯低于改良Prolift組75%,兩組分別比較均有顯著統(tǒng)計(jì)學(xué)差異(P均＜0.05)。 7、Prolift~(TM)手術(shù)穿刺路徑的安全區(qū)域:陰道前壁淺帶穿刺針向上軸向旋轉(zhuǎn)的方向與矢狀面的角度大于25°或陰道前壁深帶穿刺針向上軸向旋轉(zhuǎn)的方向與矢狀面的角度為大于30°,進(jìn)入盆腔后未改變穿刺方向,可損傷膀胱、尿道或穿入腹壁。在穿入肛門旁切口處時(shí)穿刺針向坐骨結(jié)節(jié)方向偏斜大于5°即可損傷陰部管內(nèi)的血管和神經(jīng);向內(nèi)側(cè)肛門方向傾斜15°可損傷直腸。 8、改良Prolift手術(shù)穿刺路徑的安全區(qū)域:穿刺陰道前壁淺帶時(shí)穿刺平面與尿道矢狀面成45°角,縫合針手柄軸向水平面移動(dòng)范圍為15°～35°,垂直平面移動(dòng)范圍為40°～90°為盆底韌帶縫合針穿刺陰道前壁淺帶經(jīng)閉孔區(qū)的安全路徑。穿刺陰道前壁深帶時(shí)穿刺平面與尿道矢狀面成45°角,縫合針手柄軸向垂直平面范圍為40°～60°,水平面范圍為10°～15°,為盆底韌帶縫合針穿刺陰道前壁深帶經(jīng)閉孔區(qū)的安全路徑。改良Prolift術(shù)行陰道后壁穿刺時(shí),注意穿刺時(shí)將陰道盡量向后頂至骶棘韌帶附近,避免后壁穿刺針進(jìn)入坐骨直腸窩后向外側(cè)旋轉(zhuǎn)或側(cè)偏,同時(shí)在陰道內(nèi)手指指引下內(nèi)旋穿刺針穿過(guò)盆膈進(jìn)入陰道。 9、本研究中發(fā)現(xiàn)動(dòng)態(tài)MRI對(duì)臨床診斷為前盆腔器官膨出的患者的符合率達(dá)到了95%(19/20),臨床診斷為中盆腔器官脫垂的患者的符合率達(dá)到了70%(14/20),但對(duì)于臨床診斷為后盆腔器官膨出的患者的符合率僅達(dá)到了25%(5/20)。 10、本研究中發(fā)現(xiàn)動(dòng)態(tài)MRI檢查Prolift~(TM)手術(shù)對(duì)泌尿生殖竇增大(H線的改變)和盆底下降(M線的改變)引起的盆底松弛均較術(shù)前明顯減輕。改良Prolift手術(shù)對(duì)泌尿生殖竇增大(H線的改變)引起的盆底松弛較術(shù)前明顯改善,但盆底下降(M線的改變)引起的盆底松弛較術(shù)前無(wú)顯著變化。 11、對(duì)20例行不同手術(shù)的患者手術(shù)前后動(dòng)態(tài)MRI的對(duì)比分析發(fā)現(xiàn),臨床診斷為治愈患者術(shù)后采用MNI HMO系統(tǒng)分度仍發(fā)現(xiàn)存在3例輕度盆腔器官脫垂患者,其中Prolift~(TM)手術(shù)1例,改良Prolift手術(shù)2例。 12、臨床研究發(fā)現(xiàn)168名患者中(Prolift~(TM)組16例,改良Prolift組152例)Prolift~(TM)組15例,改良Prolift組119例病例完成隨訪,隨訪率為80%。手術(shù)后平均隨訪12個(gè)月(Prolift~(TM)組4個(gè)月,改良Prolift組12個(gè)月)手術(shù)治愈率分別為100%和94.1%。兩種手術(shù)方式均未發(fā)生嚴(yán)重的并發(fā)癥。 結(jié)論 1、經(jīng)閉孔區(qū)行穿刺吊帶手術(shù),穿刺針的穿刺范圍控制在陰蒂水平以下,無(wú)損傷閉孔神經(jīng)的風(fēng)險(xiǎn)。按照規(guī)范手術(shù)路徑行穿刺手術(shù)可避免進(jìn)入會(huì)陰深隙或淺隙,避免損傷會(huì)陰區(qū)的神經(jīng)血管。 2、與陰道前壁淺帶閉孔區(qū)穿刺路徑相比,陰道前壁深帶經(jīng)閉孔區(qū)穿刺路徑更容易損傷閉孔靜脈后支,偶爾可損傷閉孔動(dòng)脈后支,但很少引起嚴(yán)重的閉孔區(qū)出血或血腫。 3、文獻(xiàn)對(duì)于Prolift~(TM)方法后盆腔穿刺損傷尾動(dòng)脈的報(bào)道較少,本研究發(fā)現(xiàn)Prolift~(TM)手術(shù)較改良Prolift手術(shù)更容易損傷尾動(dòng)脈。 4、本研究發(fā)現(xiàn)Prolift~(TM)手術(shù)較改良Prolift手術(shù)陰道穿刺長(zhǎng)度深,但臨床研究發(fā)現(xiàn),兩種術(shù)式的解剖學(xué)差異并未對(duì)臨床治療效果產(chǎn)生明顯影響。 5、本研究首次提出了骶棘骶結(jié)節(jié)韌帶復(fù)合體的概念,并提出了Prolift~(TM)陰道后壁穿刺所經(jīng)過(guò)的盆膈結(jié)構(gòu)多為骶結(jié)節(jié)韌帶或骶棘骶結(jié)節(jié)韌帶復(fù)合體的新的觀點(diǎn)。 6、按照規(guī)范的手術(shù)路徑完成全盆底重建盲針穿刺手術(shù)損傷盆腔內(nèi)重要血管神經(jīng)的風(fēng)險(xiǎn)小。 7、首次采用動(dòng)態(tài)MRI及其分度方法評(píng)價(jià)臨床POP,并發(fā)現(xiàn)動(dòng)態(tài)MRI檢查對(duì)前盆腔器官膨出的診斷符合率優(yōu)于對(duì)后盆腔器官膨出的診斷符合率。 8、本研究認(rèn)為不論P(yáng)rolift~(TM)還是改良Prolift手術(shù)均可縮小POP患者泌尿生殖竇大小,Prolift~(TM)手術(shù)改善盆底下降程度的治療效果是否優(yōu)于改良Prolift手術(shù)尚需進(jìn)一步擴(kuò)大病例研究。兩種手術(shù)方式均可有效治療POP。 9、本研究認(rèn)為動(dòng)態(tài)MRI較臨床診斷盆腔器官脫垂病例更加客觀、全面。由于動(dòng)態(tài)MRI費(fèi)用較高,是否在臨床推行PFD的動(dòng)態(tài)MRI檢查還需要進(jìn)一步的循證分析。 10、臨床研究發(fā)現(xiàn)Prolift~(TM)和改良Prolift兩種手術(shù)方式均可安全有效治療重度盆腔器官脫垂性疾病。 11、Prolift~(TM)醫(yī)療耗材貴,在現(xiàn)階段我國(guó)特殊的國(guó)情和醫(yī)療環(huán)境下還不能得到普及和迅速發(fā)展。改良Prolift手術(shù)設(shè)計(jì)研究適合我國(guó)國(guó)情,是有效治療盆底功能障礙性疾病的微創(chuàng)盆底重建手術(shù)方式。
[Abstract]:Objective: to clarify the vascular neuroanatomy around the two types of total pelvic floor reconstruction of Chinese women with Prolift~ (TM) and modified Prolift, and to propose the safety path of the two operations. The comparison of the three aspects of clinical anatomy, dynamic MRI imaging and clinical therapeutic effects is to study the Prolift~ (TM) and the improved Prolift two whole basins. The difference between the bottom reconstructive surgery is to guide the safe Prolift~ (TM) and improve the Prolift operation path, and then reduce the complications of the two surgical methods. Meanwhile, it will provide a good theoretical support for the improvement of the Prolift operation path in China.
Methods: a prospective randomized controlled method was used to determine the surgical puncture method of 12 Chinese adult female fresh cadavers (6 Prolift~ (TM) and 6 modified Prolift). The distance between the two kinds of surgical puncture needles and the peripheral vascular nerve and the heavy viscera was anatomically measured. At the same time, the puncture needle was punctured safely. Angle. Dynamic MRI technique was used to examine the image of 20 patients with POP-Q degree and more pelvic organ prolapse in the same period operation. The difference between the two surgical methods was objectively evaluated. At the same time, 16 cases of Prolift~ (TM) surgery in 168 patients in our hospital were prospectively compared. Clinical treatment effect of 152 cases with good Prolift operation.
Result:
The 1,12 autopsy study found that the superficial and deep puncture needles of the anterior wall of the vagina in the two types of total pelvic floor reconstruction in the obturator area Prolift~ (TM) and modified Prolift were all below the clitoris horizontal line through the obturator.Prolift~ (TM) and the modified Prolift in the two surgical methods of the anterior wall of the vagina and the punctures of the anterior wall of the vagina were closed to the closed orifice of the obturator. The distance of the branches was 0.60 + 0.36cm and 0.78 + 0.10cm, respectively, and the distance between the punctures of the anterior vaginal wall and the anterior branch of the closed orifice was (1.58 + 0.05cm and 1.58 + 0.05cm). The two groups were all P > 0.05., respectively.
2, Prolift~ (TM) and modified Prolift, the distance between the puncture points of the superficial anterior vaginal wall of the vagina and the anterior branch of the obturator nerve was 3.23 + 1.03cm and 3.18 + 0.61cm respectively. The distance from the posterior branch of the obturator nerve was 3.28 + 0.63cm and 2.95 + 0.63cm; Prolift~ (TM) and modified Prolift two types of anterior wall of the vagina The distance from the occult punctures to the anterior branches of the obturator nerve was 3.35 0.59cm and 3.16 1.04cm respectively, the distance from the posterior branch of the obturator nerve was 2.68 + 0.57cm and 2.86 + 0.87cm, and the two kinds of surgical methods were all more than 0.05..
3, Prolift~ (TM) the length of the deep vaginal wall into the vagina (5.63 + 0.15cm) was greater than that of the modified Prolift operation (4.83 + 0.05cm), (P < 0.01).Prolift~ (TM).Prolift~ (TM) transvaginal puncture needle penetrated into the vagina (7.38 + 0.15cm) greater than the modified Prolift operation (5.88 + 0.23cm), (P < 0.01).
4, the distance between the posterior wall puncture needle of Prolift~ (TM) and the tail artery was (0.88 + 0.10cm), shorter than the distance between the modified Prolift operation and the tail artery (2.95 + 0.09cm), (P < 0.01).Prolift~ (TM).Prolift~ (TM) the distance between the puncture needle of the vagina and the inner part of the pudendal artery (1.59 + 0.36cm), shorter than the distance between the modified Prolift operation and the internal pudendal artery (3.40 + 0.36cm), (P < 0). 1) the distance between the puncture needle of the posterior wall of the vagina.Prolift~ (TM) and the distance from the rectum was (0.88 + 0.10cm). The distance between the improved Prolift operation and the rectum was 1.05 + 0.89cm and 0.86 + 0.62cm respectively. There was no significant difference between the two groups (P > 0.05).
5, the sacrospinous ligament begins with the sacrum of the fourth sacral hole to the lateral margin of the first caudal bone and extends to the lateral bone surface of the sciatic spine. The sacral tubercle ligament is composed of the dense connective tissue, which begins at the lateral margin of the third sacral hole to the first caudal bone, and extends outwards to the bone surface on the dorsal side of the sciatic body. The inferior edge of the sacral tubercle is lower than the lower margin of the sacral spine ligament. In the distance from the inside of the spine to 1.30 + 0.12cm, the sacrotuberous ligament and sacrospinous ligament overlap and form the sacrospinous, sacral tubercle ligament complex.
6, the proportion of the posterior vaginal wall puncture needle through the sacral tuberous ligament complex in the Prolift~ (TM) group was 66.7%, obviously higher than that of the modified Prolift group (16.7%), and the ratio of passing through the iliac caudal muscle was 25%, obviously lower than that of the modified Prolift group (75%), and the two groups were significantly different (P < 0.05).
7, the safe area of the Prolift~ (TM) surgery puncture path: the direction of the anterior vaginal puncture needle and the angle of the sagittal plane is greater than 25 degrees or the direction of the puncture needle of the anterior wall of the vagina is more than 30 degrees, and the angle of the sagittal plane is greater than 30 degrees, and the puncture direction is not changed after entering the pelvic cavity, and the bladder, urethra, or the abdominal wall can be damaged. The blood vessels and nerves in the pudendal canal can be damaged when the puncture needle deviates from the direction of the sciatic tubercle is greater than 5 degrees, and the incline to the medial anus can damage the rectum by 15 degrees to the medial anus.
8, the safe area of the improved Prolift puncture path: the puncture plane and the urethral sagittal plane were 45 degrees angle when the anterior vaginal wall was punctured. The moving range of the axial horizontal surface of the stitch handle was 15 to 35 degrees, and the vertical plane movement range was 40 to 90 degrees as the safe path of the puncture of the superficial anterior wall of the vaginal canal with the pelvic ligament suture needle. The puncture plane and the urethral sagittal plane were 45 degrees angle, the axial vertical plane range of the stitch handle was 40 to 60 degrees, the level of the horizontal plane was 10 to 15 degrees. It was the safe path of the deep zone of the anterior vaginal wall with the pelvic ligament suture needle. When the posterior wall of the vagina was punctured by modified Prolift, the vagina should be put back as far as possible to the top. In the vicinity of the sacrospinous ligament, avoid the posterior wall puncture needle to enter the lateral or lateral side of the rectal fossa, while the internal rotation puncture needle is guided through the diaphragm into the vagina at the same time in the vagina.
9, in this study, the coincidence rate of dynamic MRI for patients with anterior pelvic organ expansion was 95% (19/20). The coincidence rate of patients diagnosed with pelvic organ prolapse was 70% (14/20), but the coincidence rate of patients diagnosed as posterior pelvic organ expansion was only 25% (5/20).
10, in this study, we found that dynamic MRI examination of Prolift~ (TM) operation on genitourinary Dou Zengda (H line change) and pelvic floor decline (the change of the M line) significantly reduced the pelvic floor relaxation than before the operation. The improved Prolift operation was significantly improved for the pelvic floor relaxation caused by the urogenital Dou Zengda (the H line change), but the pelvic floor decreased (the change of the M line). No significant changes in pelvic floor relaxation were observed before the operation.
11, the comparative analysis of the dynamic MRI before and after the operation of 20 patients with different operations found that 3 cases of mild pelvic organ prolapse were found in the clinical diagnosis after the operation of the cured patients with MNI HMO system, of which 1 were Prolift~ (TM), and 2 with improved Prolift operation.
12, clinical study found 168 patients (Prolift~ (TM) group 16 cases, improved Prolift group 152 cases) Prolift~ (TM) Group 15 cases, improved Prolift group 119 cases completed follow up, follow up rate was 12 months after 80%. operation (Prolift~ (TM) 4 months, improved Prolift group 12 months) operation cure rate was 100% and 94.1%. two operation respectively was not There is a serious complication.
conclusion
1, the puncture sling operation in the closed orifice area, the puncture needle is controlled under the level of the clitoris, without the risk of injury of the obturator nerve. According to the standard operation route, the puncture operation can avoid the deep or shallow clearance of the perineum, and avoid the damage of the neurovascular in the perineum area.
2, compared with the puncture path of the anterior wall of the vagina, the puncture path of the anterior wall of the vagina is more likely to damage the posterior branch of the obturator vein and occasionally can damage the posterior branch of the obturator artery, but it rarely causes severe obturator hemorrhage or hematoma.
3, there are few reports on the injury of the caudal artery by pelvic puncture after Prolift~ (TM) method. This study found that Prolift~ (TM) surgery is more likely to damage the tail artery than the modified Prolift operation.
4, the study found that the Prolift~ (TM) operation was longer than that of the modified Prolift operation, but the clinical study found that the two types of anatomical differences did not have a significant effect on the effect of the clinical treatment.
5, this study first proposed the concept of sacral tuberous ligament complex for the first time, and proposed a new point of view that the pelvic diaphragm structure of the Prolift~ (TM) posterior wall of the vagina is mostly the sacral nodular ligament or the sacral tuberous ligament complex.
6, according to the standard operation path, the risk of total pelvic floor reconstruction with blind needle puncture is very small.
7, the clinical POP was evaluated by dynamic MRI and its classification method for the first time, and it was found that the diagnostic coincidence rate of dynamic MRI examination for anterior pelvic organ expansion was better than the diagnostic coincidence rate of post pelvic organ expansion.
8, this study believes that both Prolift~ (TM) or improved Prolift surgery can reduce the size of the genitourinary sinus in POP patients. Whether the treatment effect of Prolift~ (TM) operation to improve the pelvic floor decline is better than the modified Prolift operation needs further expansion of the case study. The two surgical methods can effectively treat POP..
9, this study suggests that dynamic MRI is more objective and comprehensive than clinical diagnosis of pelvic organ prolapse. As the dynamic MRI cost is higher, further evidence-based analysis is needed if the dynamic MRI examination of PFD is carried out in clinical practice.
10, clinical studies found that Prolift~ (TM) and modified Prolift two kinds of surgical methods are safe and effective in the treatment of severe pelvic organ prolapse.
11, Prolift~ (TM) medical consumables are expensive and can not be popularized and rapidly developed in the special conditions and medical environment of our country at the present stage. The improved Prolift surgical design study is suitable for the national conditions of our country. It is a minimally invasive pelvic floor reconstruction method for effective treatment of pelvic floor dysfunction.
【學(xué)位授予單位】：中國(guó)協(xié)和醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2009
【分類號(hào)】：R713;R322

【引證文獻(xiàn)】

相關(guān)博士學(xué)位論文 前1條

1 商曉;女性盆底在體生物力學(xué)研究[D];北京協(xié)和醫(yī)學(xué)院;2011年

相關(guān)碩士學(xué)位論文 前1條

1 陳永連;Prolift盆底重建手術(shù)綜合療效分析及MRI在盆底重建手術(shù)質(zhì)量評(píng)估中的臨床應(yīng)用[D];暨南大學(xué);2011年

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本文編號(hào)：1945199