盆腔脏器廓清术在妇科恶性肿瘤中的应用进展

盆腔脏器切除术在妇科恶性肿瘤中弥补了放疗、化疗等姑息性治疗的不足,为缓解复发或晚期患者的症状提供了可能,特别是盆腔内中央性扩散,不宜进行小范围部分切除且不适合放疗的晚期或复发妇科恶性肿瘤患者提供了最后的治疗机会。但由于手术范围广泛,手术并发症及死亡率高。正确掌握手术适应证,提高手术技巧,正确处理术前术后可降低手术并发症,提高生存率。     

盆腔廓清术治疗妇科恶性肿瘤50例临床分析

目的:探讨行盆腔廓清术的妇科恶性肿瘤患者的围术期情况及预后。方法:选择北京大学人民医院2015年10月至2020年12月于妇科行盆腔廓清术的50例患者进行研究,回顾性分析患者一般情况、肿瘤类型、手术时间、出血量、住院时间、并发症及预后等。结果:(1)50例患者的中位年龄为51岁(27～68岁),45例(90.0%)为复发性盆腔恶性肿瘤,以复发性子宫颈癌(35例,70.0%)为主;5例(10.0%)为初治局部晚期恶性肿瘤。(2)50例中行前盆廓清术、后盆廓清术、全盆廓清术的患者分别为17例、2例、31例。平均住院时间为31.7±18.1天,平均术中出血量2769.0±1929.3 ml,平均手术时间482.9±160.5分钟,平均住院费用115786.0±64485.1元。(3)34例(68.0%)出现早期并发症,主要为术后发热(64.0%);28例(56.0%)出现晚期并发症,主要为泌尿系感染(48.0%)。接受盆底功能重建的有8例患者中仅1例(12.5%)术后出现盆腹腔感染(并发症ClavienDindoⅡ级);未接受重建手术的患者42例,术后发生空盆腔综合征15例(37.5%)。(4)50例患者中失访6例,中位随访时间37.4个月(1～63个月),中位生存时间28.2个月(1～63个月),中位无瘤生存时间17.1个月(1～63个月)。随访期内11例术后复发(7例,29.2%)或未控(4例,16.7%),手术切缘均为阳性;11例死亡,手术切缘阳性9例(81.8%)。结论:盆腔廓清术多应用于复发性子宫颈癌,并发症较多但可控,盆底功能重建可能有助于降低术后空盆腔综合征的发生,切缘阳性可能是影响患者预后的因素之一。盆腔廓清术的临床价值和预后相关因素有待于进一步多中心、大样本研究。     

盆腔脏器清除术相关的解剖要点和手术技巧

盆腔脏器清除术手术范围广,涉及腹外科、妇科和泌尿外科.该文对盆腔脏器清除术相关的盆腔局部解剖和手术技巧进行了分析论述.     

妇科恶性肿瘤盆腔淋巴清扫后淋巴囊肿处理

淋巴囊肿是妇科恶性肿瘤盆腔淋巴清扫术后常见的并发症。为了预防淋巴囊肿形成可采用开放盆腔腹膜、大网膜成型术、使用奥曲肽等方法,但是,术后放置盆腔引流管并不会降低淋巴囊肿发生率。如果淋巴囊肿压迫周围脏器,影响患者生活质量或者发生感染,则需要治疗。超声或CT引导下经皮穿刺引流可能是一种简单有效的治疗方法,有时还会加用无水乙醇或碘伏等硬化剂治疗。腹腔镜手术在淋巴囊肿治疗中也显示了较好的应用前景。但是,具体手术方式应结合临床情况、治疗经过和手术医生的经验综合分析、个体化治疗。     

81例妇科恶性肿瘤妇女术后性生活分析

目的了解妇科恶性肿瘤妇女术后性生活的情况.方法选取我院妇科1994年1月至1998年12月诊治的81例恶性肿瘤术后的妇女,采用调查问卷方式进行逐一面对面调查,并将卵巢癌、子宫内膜癌、宫颈癌的患者分为三组,比较术后性生活的情况.结果81例患者有33例(40.7%)术后有性生活,其中有60.7%(20/33)表现为性欲下降.卵巢癌、子宫内膜癌、宫颈癌三组妇女在性生活恢复时间、性生活频度以及性生活满意度等方面并无显著性差异(P＞0.05).81例患者对性方面问题的处理,有15人(18.5%)咨询过医生.71例(87.7%)患者希望医生在性问题上给予帮助,并表示希望开设此类门诊.结论手术范围不是决定术后性功能状态的唯一因素,心理上的压抑与恐惧常常是导致术后性功能异常的重要方面.因此,重视妇科恶性肿瘤患者的心理状态,将对改善这些妇女术后的性功能有重要帮助.     

全盆腔悬吊术治疗盆腔脏器脱垂的临床分析

目的探讨应用全盆腔悬吊术治疗盆腔脏器脱垂,并同时进行盆底重建的可行性和有效性.方法对16例具有不同缺陷的盆腔脏器脱垂患者进行全盆腔悬吊术.结果平均手术时间65分钟,平均出血150 ml,盆腔脏器脱垂全部得到纠正,随访期间未发现有阴道缩短、扭曲等症状,性生活不受影响.1例出现宫颈延长,1例出现网片排异,余无异常.结论全盆腔悬吊术对 盆腔脏器脱垂患者在保留子宫同时进行盆底重建,简化了手术治疗的过程,手术方法简单易掌握,短期疗效肯定,长期疗效有待进一步观察和随访,值得临床进一步研究.     

腹腔盆腔淋巴清扫术3例报告

1991年Querleu等报道腹腔镜盆腔淋巴清扫术^[1]。国外许多文献相继报道腹腔镜手术应用于妇科恶性肿瘤^[2-4],我院在开展近千例腹腔镜手术基础上进行腹腔镜盆腔淋巴清扫术的初步研究,报告如下。     

46例老年妇女盆腔脏器脱垂手术治疗的临床分析

<正>盆腔脏器脱垂是老年妇女的常见疾病之一,严重影响患者的生活质量,目前治疗手术方式有多种,经阴子宫全切加阴道前后壁修补是主要治疗方法,但术后治愈率低、复发率高。现回顾性分析2005年1月～2009年1月收治的46例盆腔脏器脱垂患者的临床资料,报道如下。     

盆腔脏器脱垂经阴道改良术式临床应用探讨

目的：探讨老年患者盆腔脏器脱垂经阴道子宫切除加阴道壁修补术中,行阴道顶端圆韧带悬吊。预防术后阴道顶端脱垂及阴道壁脱垂复发的可行性及安全性。方法：对2008年1月一2009年12月,我院收治的24例60岁以上子宫脱垂伴阴道壁脱垂患者,经阴道手术中进行阴道顶端圆韧带悬吊术,观察其临床疗效,并进行2年的随访研究。结果：所有患者均成功进行该术式,无一例发生术中脏器损伤及术后出血,24例患者术后均恢复好;术后1、3、6、12、18、24个月随访,所有患者的阴部膨出、下坠感消失,尿失禁消失,性生活质量明显改善,术后无一例阴道顶端脱垂及阴道壁脱垂复发。结论：对子宫脱垂伴阴道壁脱垂的患者,经阴道子宫切除加阴道壁修补术中将阴道顶端悬吊于圆韧带,预防阴道顶端及阴道壁脱垂是一种安全、简单、有效的治疗方法,术后复发率低,少有并发症,值得在基层医院临床应用。     

Robotic-Assisted Total Laparoscopic Supralevator Pelvic Exenteration: Steps in Excising the Pelvic Viscera

Study ObjectiveTo illustrate the key steps involved in performing a supralevator pelvic exenteration robotically.DesignPresentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration.SettingTertiary care academic center.PatientsA patient undergoing pelvic exenteration for uterine leiomyosarcoma.InterventionsRobotic total supralevator pelvic exenteration.Measurements and Main ResultsIn this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL.ConclusionTotal pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks.     

贝伐单抗治疗晚期妇科恶性肿瘤

随着临床对恶性肿瘤研究的深入,分子靶向治疗成为继手术、放疗、化疗后的第4种用于治疗恶性肿瘤的新方法,因其具有特异性强、提高抗肿瘤作用、延长患者生存期的优点备受肿瘤研究者的关注。抗血管内皮生长因子（VEGF）抗体的靶向治疗越来越受重视,而贝伐单抗成为关注的焦点,其是一种重组人源化抗VEGF的单克隆抗体,可与肿瘤细胞上的VEGF特异性结合,而VEGF是肿瘤血管生长的关键调节因子,因此贝伐单抗可以抑制肿瘤血管的生长从而抑制肿瘤细胞的生长。目前,贝伐单抗已被美国食品和药物管理局批准用于卵巢癌、复发或转移性宫颈癌、结直肠癌、肺癌及肾癌的一线治疗。近年来,越来越多研究关注贝伐单抗作为一种新型治疗方法用于晚期妇科恶性肿瘤的治疗,就贝伐单抗在晚期妇科恶性肿瘤中的研究进展进行综述。     

Minimally Invasive Pelvic Exenteration for Gynecologic Malignancies: A Multi-Institutional Case Series and Review of the Literature

Study ObjectiveTo assess the feasibility and efficacy of minimally invasive pelvic exenteration (MIPE) in a multi-institutional Italian case series of women with gynecologic cancer and a review of the literature.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingThree Italian university/teaching hospitals: “Agostino Gemelli” Foundation University Hospital in Rome, "ARNAS Civico Di Cristina Benfratelli” Hospital in Palermo, and “Maggiore della Carità” Hospital in Novara.PatientsWe reviewed all consecutive cases with gynecologic malignancies in this multi-institutional setting recorded between March 2014 and June 2017. Women with primary or central recurrent/persistent gynecologic cancer considered suitable for exenterative surgery after multidisciplinary tumor board discussion were included. Clinicopathological, perioperative, and survival data were retrieved from the institutional electronic database (STAR center).InterventionsAll patients underwent total or anterior MIPE with a laparoscopic or robotic approach.Measurements and Main ResultsTwenty-three patients underwent MIPE during the study period, including 12 (52.1%) by a laparoscopic approach and 11 (47.9%) by a robotic approach. All but 1 woman underwent MIPE for recurrent disease. The overall median operative time was 540 minutes (range, 310–720 minutes) with laparoscopy, slightly longer than with the robotic approach (p = .04). Median estimated blood loss was 400 mL (range, 200–600 mL). R0 resection was achieved in 17 of 23 patients (73.9%). There were no perioperative deaths. Early major postoperative complications occurred in 2 patients (8.7%). The median duration of hospitalization was 10 days (range, 6–33 days). With a median follow-up of 15 months, 11 patients (47.8%) developed recurrence. The median disease-free survival was 11 months (range, 5–18 months). To date, 155 MIPEs for gynecologic cancers have been reported in the literature. Among these, 12.6% had major postoperative complications, and overall postoperative mortality was 0.6%.ConclusionMIPE is a feasible procedure with low rate of intraoperative and postoperative complications. Careful patient selection is crucial to balance perioperative risks and potential survival benefits and to achieve complete tumor resection.     

Pelvic Exenteration: Effects of Surgery on Quality of Life and Body Image—A Prospective Longitudinal Study

Objectives. The goal of this study was to evaluate the impact of reconstructive and nonreconstructive surgical procedures on quality of life and body image for women who undergo pelvic exenteration.Methods. Twenty-eight patients were assessed in a prospective study with a preoperative semistructured interview and an objective assessment (T1). Interviews and questionnaires were repeated 4 (T2) and 12 (T3) months postoperatively. The women were divided into groups with two, one, or no ostomies. A separate comparison was made of women with and without vaginal capacity. Quality of life was defined in terms of five categories according to the definition of health proposed by the World Health Organization: physical and psychosocial health; marital and sexual status; medical interactions.Results. At all points in time, the patients' quality of life was affected most significantly by worries about the progression of the tumor. Twelve months postoperatively, patients with two ostomies reported a significantly lower quality of life (P= 0.008) and poorer body image (P= 0.002) than patients with no ostomy. At T3, patients with vaginal capacity reported fewer problems in all categories related to quality of life and significantly (P= 0.015) fewer sexual problems.Conclusion. An evaluation of quality of life and body image demonstrates the benefits of newer techniques for organ reconstruction. Thus, organ reconstruction should be performed whenever possible in patients with pelvic exenteration.     

Pelvic Exenteration for Malignant Melanomas of the Vagina or Urethra with over 3 mm of Invasion

Pelvic exenteration has usually been employed as salvage treatment for gynecologic malignancies which have failed primary radiotherapy. The therapeutic mainstay for vulvar melanomas has become wide local excision with or without concurrent regional node dissection. Patients with primary melanoma of the vagina who undergo exenteration as primary therapy may experience 50% 5-year survival if the pelvic nodes are free of metastases. However, the overall 5-year survival for vaginal melanoma is 15%. In our patient population, there have been four patients with vaginal or urethral melanomas treated primarily with pelvic exenteration. The purpose of this study was to report that patients with vaginal or urethral melanomas over 3 mm in thickness may benefit from primary pelvic exenteration. Four patients underwent pelvic exenteration at Indiana University Medical Center for malignant melanoma of the vagina or urethra between 1986 and 1992. The pathologic specimens of all patients were analyzed for thickness, growth pattern, and nodal metastases. Patient age ranged from 50 to 71. Thickness of the melanomas ranged from >3 to 12 mm. All four patients underwent exenterations, three total and one anterior. All patients had negative pelvic and inguinal nodes at the time of surgery. None of the patients has experienced a recurrence. Three of four patients are alive without evidence of disease at 31 to 97 months following their exenteration. One patient died postoperatively of cardiopulmonary complications. Patients with melanomas of the vagina and female urethra, greater than 3 mm in thickness, may benefit from primary pelvic exenteration.     

腹腔镜下骶前固定术治疗盆底功能障碍性疾病18例分析

目的:分析腹腔镜下骶前固定术治疗以中盆腔缺陷为主的盆底功能障碍性疾病的临床疗效,评价骶前固定术的有效性及安全性。方法:18例盆底功能障碍患者采用腹腔镜下骶前固定术,观察术后治愈率及围手术期并发症发生情况。结果:术后治愈率达100%,均未发生术中及术后大出血、膀胱及直肠损伤;术后随访患者解剖结构均得到成功恢复,其阴道断端距离处女膜最远点较术前减小(P0.05);性生活恢复满意度与术前比较差异无统计学意义(P0.05)。结论:腹腔镜下骶前固定术是一种安全有效的治疗以中盆腔缺陷为主的盆底功能障碍疾病的手术方式,短期疗效确切,长期疗效有待进一步观察。     

Urinary Tract Infection in Patients of Gynecological Malignancies Undergoing External Pelvic Radiotherapy

A total of 216 midstream urine (MSU) samples from 36 patients with gynecological malignancies undergoing external pelvic radiotherapy (RT) were studied periodically every week for any evidence of urinary tract infection (UTI). UTI was detected in 33.3% patients of whom 8.3% had infection at the onset of RT and the rest developed UTI during the course of therapy. All three patients who had UTI at the onset of RT underwent cystoscopy as a part of routine pretreatment workup. A higher preponderance of UTI was observed in patients of stage III carcinoma cervix (33.3%) compared to stage II (16.7%) during the course of RT. Half of the patients with UTI had repealed episodes of infection despite appropriate antibiotic treatment. The study emphasizes the importance of conducting periodic MSU examination in patients with gynecological malignancies during RT and its treatment with appropriate antibiotics to minimize the risks of further injury to the already susceptible uroepithelium following radiotherapy.     

无气腹腹腔镜在41例妇科手术的临床应用

目的:探讨无气腹腹腔镜手术治疗妇科疾病的疗效及优势.方法:回顾性分析我院对41例伴有心肺功能异常及中老年患者行悬吊式无气腹腹腔镜手术的,临床资料,并分析其手术情况和术后恢复情况.结果:41例患者在无气腹腹腔镜下顺利完成手术.术前、术中、术后的血气分析、呼吸功能监测情况、循环功能监测情况、心电监护情况比较,差异无统计学意义,P>0.05.术后1例季肋下痛,1例双肩痛,均自愈.结论:无气腹腹腔镜手术对伴有心肺功能异常或中老年患者的妇科疾病,在治疗上有一定优势.     

妇科腹腔内出血175例临床分析

目的 :明确异位妊娠和黄体破裂所致腹腔内出血的临床特征以减少误诊。方法 :对因异位妊娠和黄体破裂所致腹腔内出血急诊入院的 175例患者的临床资料进行回顾性分析。结果 :异位妊娠 134例 ,占 76 .5 7% ,黄体破裂 41例 ,占 2 3.43%。异位妊娠腹腔内出血量为 10 5 1.32± 75 2 .12 ml,2 0 .6 9%患者出血量在 15 0 0 ml以上 ,2 2 .39%有昏厥史 ,停经 (82 .84% )、腹痛 (92 .5 4% )、阴道不规则出血 (76 .12 % )是主要的三联征。黄体破裂腹腔内出血量为 790± 6 39.15 ml,14.6 3%有昏厥史 ,腹痛 (97.5 6 % )是主要症状。内出血量两组比较差异有显著意义 ,P<0 .0 1。本资料 149例经手术止血 ,黄体破裂中 2 6例 (6 3.41% )经保守治疗成功。无一例死亡。结论 :详细询问病史 ,血 HCG检测和阴道 B超检查 ,后穹窿或腹腔穿刺是简便而重要的诊断手段