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。     

腹腔镜阴道骶骨固定术治疗盆腔器官脱垂的疗效评价

目的:评价腹腔镜阴道骶骨固定术(LSC)治疗盆腔器官脱垂的临床疗效。方法:2009年1月至2015年5月对100例中盆腔缺陷为主的盆腔器官脱垂患者行LSC,分离右侧盆腔后腹膜,将网片远端固定于阴道前后壁、阴道穹隆;近端网片固定于骶前纵韧带,网片无张力置于腹膜后。采用手术成功、手术并发症及盆底功能障碍问卷(pelvic floor distress inventory-short form 20,PFDI-20)评价疗效。结果:手术时间165.7±48.0分钟,术中出血量119.5±108.5 ml。术后留置尿管时间4.3±2.4天,排便时间4.7±1.3天,住院9.6±3.6天。手术均成功,无复发病例,新发尿失禁17例。术后并发症共12例,包括暂时性尿潴留1例,肠梗阻3例,发热1例,术后网片侵蚀6例,术后右下腹坠痛再次手术网片取出术1例。100例随访31.9±17.6月。PFDI-20术后评分较术前有显著性差异(3.46±3.56分vs 17.98±8.24分,P0.001)。结论:LSC治疗中盆腔缺陷为主的盆腔器官脱垂,安全,效果好,能显著改善患者盆底功能障碍症状。     

Laparoscopic Dissection of the Pelvic Ureter: Rules of Engagement

Study Objective

To point out the relevant anatomy of the ureter and to demonstrate its rules of dissection.

Laparoscopic Neuronavigation for Deep Lateral Pelvic Endometriosis: Clinical and Surgical Implications

Study Objective

To evaluate the clinical presentation and surgical outcome in patients with deep lateral pelvic endometriosis (dLPE).

腹腔镜髂耻韧带悬吊术在治疗盆腔器官脱垂中的研究进展

在中老年女性日常生活中,盆腔器官脱垂（pelvic organ prolapse,POP）的负面影响越来越严重,其发病率也在逐年增高。由中盆腔缺陷导致的子宫或穹窿的脱垂在POP中并不少见,其手术后复发率与术中修复是否达到标准密切相关。腹腔镜手术及植入性网片的应用,使手术更趋向微创及生理解剖结构重建,降低了术后复发率及并发症发生率。目前,腹腔镜阴道骶骨固定术（LSC）或腹腔镜子宫骶骨固定术（LSH）是中盆腔脱垂治疗的金标准术式,但对于盆腔空间狭小（肥胖或者粘连等导致）的患者此手术实施起来比较困难,排便问题（尤其是便秘）是最常见的并发症。许多外科医生改进了该术式,将网片固定在骶岬顶端,但此部位的固定导致腹壁方向发生改变。而应用腹腔镜髂耻韧带悬吊术的术后主观满意度高、复发率极低,能够恢复盆底生理解剖结构,具有较好的临床效果。     

Medium-Term Anatomical and Functional Results of Isolated Laparoscopic Sacrocolpopexy for Female Pelvic Organ Prolapse during the Early Learning Curve

BackgroundLaparoscopic repair of female pelvic organ prolapse is a technically challenging surgery, especially for the beginners.MethodsWe performed a follow-up study of women who underwent laparoscopic sacrocolpopexy or sacrohysteropexy (LSCP/LSHP) for pelvic organ prolapse between January 2015 and October 2019. We analysed anatomical and subjective success rates, peri-operative complications and medium-term complications.ResultsTwenty women underwent LSCP/LSHP with average follow-up of 16 months. Anatomical success rate was 95%, and subjective success rate was 90%. Blood loss averaged at 24 ml. Majority of women (90%) reported improvement in their symptoms and 10% reported no change in symptoms. There were no mesh complications.ConclusionLaparoscopic sacrocolpopexy is an effective and safe surgery for female pelvic organ prolapse even by beginners.     

Pelvic organ descent and symptoms of pelvic floor disorders

OBJECTIVE: This study evaluates the relationship between symptoms of pelvic floor disorders, and measurement of pelvic organ prolapse. STUDY DESIGN: This retrospective cross-sectional study assessed prolapse in 905 women in an academic urogynecologic practice using the Pelvic Organ Prolapse Quantification exam. Symptoms were assessed with a Likert symptom questionnaire and the Urogenital Distress Inventory. Relationships between symptoms and prolapse were analyzed using Spearman's correlation. RESULTS: Symptoms of "bulging" correlated moderately to the greatest extent of prolapse (r=0.4, P<.001). Frequency of bother progressively increases when the leading edge descends from -3 and 0. Between +1 and +5, 90% of women report bother. Symptoms typically attributed to anterior or posterior wall prolapse did not correlate with descent of the respective compartment. CONCLUSION: "Bulging" is the principle symptom that correlates with prolapse severity. We found no discrete anatomic position that discriminates between prolapse as a disease state and normal anatomic variation.     

盆底功能障碍性疾病盆底解剖学静动态磁共振成像研究

目的:通过静动态磁共振成像(MRI)检查,比较女性盆底功能障碍性疾病(PFD)患者及正常女性盆底解剖结构改变,探讨盆底特定解剖学异常是否与PFD有关,为盆底重建手术提供客观依据。方法:选择2008年1月至2009年3月确诊为PFD患者46例为研究对象(PFD组),其中盆腔器官脱垂(POP)24例,压力性尿失禁(SUI)10例,POP合并SUI12例;同期选取正常女性14例为对照组。采用静动态MRI进行盆底扫描。比较两组髂尾肌、耻尾肌及耻直肌静动态面积、肛提肌裂孔静动态宽度、膀胱尿道后角、LH线及M线长度、肛提肌角等参数值的变化。结果:PFD组患者静态髂尾肌、耻尾肌、耻直肌的面积大于动态,肛提肌裂孔宽度在静态时小于动态(P<0.05)。而对照组以上参数值在静动态下无明显改变(P>0.05)。PFD组患者膀胱尿道后角、LH线、M线均大于对照组,肛提肌角小于对照组(P<0.05)。结论:MRI能清楚显示盆底解剖结构及功能,肛提肌的形态及功能异常与PFD有关。     

Pelvic Pain and Patient Satisfaction After Laparoscopic Supracervical Hysterectomy: Prospective Trial

Study ObjectiveTo evaluate the occurrence and intensity of cyclic pelvic pain and patient satisfaction after laparoscopic supracervical hysterectomy and to explore the effect of the procedure on pelvic pain relief in women with perioperative detection of endometriosis and in women with histologic confirmation of adenomyosis.DesignProspective observational study with 12-month follow-up after laparoscopic supracervical hysterectomy (Canadian Task Force classification II-2).SettingUniversity teaching hospital in Norway.PatientsOne hundred thirteen premenopausal women with preoperative cyclic pelvic pain treated via laparoscopic supracervical hysterectomy.InterventionsStudy participants underwent laparoscopic supracervical hysterectomy and were followed up at the outpatient clinic at 12 months after the procedure.Measurements and Main ResultsThe main outcomes were occurrence, intensity, and reduction of cyclic pelvic pain and patient satisfaction measured using an ordinal and a visual analog scale at 12 months after the procedure. Of the 113 women included in the study, 8 were lost to follow-up. Consequently, 105 women (92.9%) were followed up at 12 months after surgery. All women had cyclic pelvic pain preoperatively, but only 34 (32.4%) experienced this pain at 12 months after the procedure. The intensity of pelvic pain was reduced from a mean (SD) of 5.5 (2.4) preoperatively to 0.7 (1.5) at 12 months after the procedure on a visual analog scale of 0 to 10 (p < .01). Endometriosis was diagnosed perioperatively in 14 women (12.4 %), and adenomyosis was confirmed at histologic analysis in 19 (18.1%). In women with perioperative detection of endometriosis or histologic confirmation of adenomyosis, there were no significant differences in main outcomes at 12 months after laparoscopic supracervical hysterectomy when compared with women without these diagnoses.ConclusionLaparoscopic supracervical hysterectomy is associated with high patient satisfaction and reduces cyclic pelvic pain to a minimum by 12 months after the procedure.     

Development and Validation of a Laparoscopic Sacrocolpopexy Simulation Model for Surgical Training

Study ObjectiveTo develop a valid laparoscopic sacrocolpopexy simulation model for use as an assessment and learning tool for performing this procedure.DesignSimulation study (Canadian Task Force classification II-2).SettingTwo tertiary academic centers.InterventionA training model was developed to simulate performance of a laparoscopic sacrocolpopexy. Construct validity was measured by comparing observed masked performances on the model between experienced Female Pelvic Medicine and Reconstructive Surgeons (experts) and upper level trainees. All videotaped performances were scored by 2 surgeons who were masked to subject identity and using the valid and reliable Global Operative Assessment of Laparoscopic Skills scale.Measurements and Main ResultsThe expert group included Female Pelvic Medicine and Reconstructive Surgeons (n = 5) experienced in laparoscopic sacrocolpopexy, and the trainee group (n = 15) included fourth-year gynecology residents (n = 5) and fellows in Female Pelvic Medicine and Reconstructive Surgery and in Minimally Invasive Gynecologic Surgery (n = 10). The experts performed significantly better than the trainees in total score and in every domain of the Global Operative Assessment of Laparoscopic Skills scale (median [range] score: expert group, 33 [30.5–39] vs trainee group, 20.5 [13.5–30.5]; p = .002). Previous surgical experience had a strong association with performance on the model (rho > 0.75). Most subjects “agreed” or “strongly agreed” that the model was authentic to the live procedure and a useful training tool. There was strong agreement between masked raters (interclass correlation coefficient 0.84).ConclusionThis simulation model is valid and reliable for assessing performance of laparoscopic sacrocolpopexy and may be used for practicing key steps of the procedure.     

Laparoscopic surgical repair of pelvic organ prolapse and female stress urinary incontinence

Pelvic organ prolapse (POP) occurs in a relatively big population of women which is continuously increasing and is associated with a variety of urinary bowel and sexual symptoms. As this problem magnifies, the need for surgical repair is increasing relatively. The main goals of surgical repair for POP include: no anatomic prolapse, no functional symptoms, patient satisfaction and avoidance of complications, goals that cannot always be fully achieved. The decision for the type of surgery depends of various factors such as patient characteristics and prolapsed compartment but also by the surgeon expertise. The laparoscopic approach is already the gold standard procedure for many urologic procedures and can also be used for the treatment of POP and stress urinary incontinence. Herein, we review the literature about the available data concerning laparoscopic surgery techniques for treating POP.     

Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures

Study Objective: To clarify the relationship of hypogastric nerves (HNs) with several pelvic anatomic landmarks and to assess any anatomic differences between the 2 sides of the pelvis, both in cadaveric and in vivo dissections.Design: Prospective observational study.Setting: An anatomic theater for cadaveric dissections and a university hospital for in vivo laparoscopy.Patients: Five nulliparous female cadavers underwent laparotomic dissection; 10 nulliparous patients underwent laparoscopic surgery for rectosigmoid endometriosis without posterolateral parametrial infiltration.Interventions: Measurements of the closest distance between HNs and ureters, the midsagittal plane, the midcervical plane, and uterosacral ligaments on both hemipelvises. A comparison of anatomic data of the 2 hemipelvises was conducted.Measurements and Main Results: The right and left HNs were identified in all specimens, both on cadavers and in vivo dissections. A wide anatomic variability was reported. Regarding the differences between the 2 hemipelvises, we found that the right HN was significantly (p <.001) farther to the ureter (mean = 14.5 mm; range, 10–25 mm) than the left one (mean = 8.6 mm; range, 7–12 mm). The HN was closer to the midsagittal plane on the right side (mean = 14.6 mm; range, 12–17 mm) than on the left side (mean = 21.6 mm; range, 19–25 mm). The midcervical plane was found 2.7 mm (range, 2–4 mm) to the left of the midsagittal one. The right HN was found to be nonsignificantly closer to the midcervical plane and the uterosacral ligament on the right side than on the left side (p >.05).Conclusions: Despite a wide anatomic variability of position and appearance, the HNs are reproducibly identifiable using an “interfascial” technique and considering the ureters and uterosacral ligaments as anatomic landmarks.     

腹腔镜下自裁Artisyn-Y型网片同时纠正中盆腔及后盆腔缺陷的术式报道

随着腹腔镜技术的发展,其在妇科盆底功能障碍性疾病诊治方面的作用越来越重要,在解决中盆腔和前盆腔缺陷方面效果确切,而对于后盆腔缺陷的腹腔镜诊治较少报道,且通过腹腔镜手术治疗中盆腔缺陷的同时诊治后盆腔缺陷更是鲜有文献描述。对1例盆腔器官脱垂定量分度法(POP-Q)评分:Aa-3,Ba-3,C+2,Ap+3,Bp+3,D+1,考虑子宫脱垂Ⅲ度合并直肠膨出Ⅲ度的患者,重庆市妇幼保健院妇科盆底与肿瘤科针对中盆腔合并后盆腔缺陷的患者设计一种新术式,可在纠正中盆腔缺陷的同时纠正后盆腔缺陷,且能够达到网片平铺、可调等优点,该术式即应用自裁Artisyn-Y型网片固定宫颈和悬吊子宫纠正中盆腔缺陷,同时加固阴道直肠筋膜从而纠正后盆腔缺陷。     

腹腔镜下子宫悬吊术与阴式全子宫切除合并骶棘韧带悬吊术治疗盆腔器官脱垂的术后疗效比较

目的:探讨盆腔器官脱垂(POP)患者在接受腹腔镜下子宫悬吊术(LUS)或阴式全子宫切除术合并骶棘韧带悬吊术(TVH-SSLF)后的疗效。方法:共纳入符合条件接受手术的POP患者共86例,43例接受LUS术(LUS组),43例接受TVH-SSLF术(TVH-SSLF组);对比分析两组手术时间、术中出血量、住院时间、生活质量评分。采用PFIQ-7量表及PFDI-20量表进行评估调查。结果:所有患者手术顺利完成。LUS组患者失血量(47.44±29.12 ml)显著低于TVH-SSLF组(62.33±22.34 ml)(P<0.05);两组手术时间[75(65,90)分钟vs 75(65,80)分钟]、住院时间[6(6,7)天vs 6(5,7)天]差异无统计学意义(P>0.05)。PFDI-20术前与术后各分值比较差异有统计学意义(P<0.05)。两组PFDI-20问卷仅术后3个月的POPDI-6中LUS组得分均值(0.047±0.138分)显著高于TVH-SSLF组(0.004±0.025分)(P<0.05)。除此之外,两组术前、术后1个月、3个月、6个月的其他各分类项及总分比较,差异均无统计学意义(P>0.05)。PFIQ-7问卷除了第7个问题“挫折感”的肠道直肠症状TVH-SSLF组得分显著高于LUS组(0.090±0.294分vs 0.000±0.000分,P<0.05)外,其他各分类项以及总评分比较,差异均无统计学意义(P>0.05)。结论:LUS在术后恢复和症状改善上与TVH-SSLF无明显差异,对于有子宫保留意愿、无妇科恶性肿瘤的患者是一个安全、更优的选择。     

Laparoscopic Diagnosis and Treatment of Obturator Nerve Entrapment Because of a Deep Infiltrating Endometriotic Nodule: A Case Report

Deep infiltrating endometriosis (DIE) is a particular form of endometriosis causing a variety of severe pelvic pain in women. The involvement of peripheral nerves by DIE implants is very rare. The most common involved site is the sacral plexus. There are few reported cases of involvement of the obturator nerve by DIE. To our knowledge, only 6 cases of symptomatic obturator nerve involvement by DIE have been described (according to PubMed database search in July 2018), and 3 of them were treated laparoscopically. We report a rare case of a deep infiltrating endometriotic nodule entrapping the right obturator nerve. Unlike the previously reported cases, patient history, clinical and laboratory data, and missed findings in previous imaging studies made our case difficult to diagnose. We successfully diagnosed the case and treated the patient with laparoscopic surgery. A video showing the surgery is also included. The recent follow-up in July 2018 (18 months after the operation was performed in January 2017) showed no signs or symptoms of recurrence or any other new complaints. The 18-month follow-up for this case is the longest follow-up data reported in the literature.     

A New Technique of Laparoscopic Implantation of Stimulation Electrode to the Pudendal Nerve for Treatment of Refractory Fecal Incontinence and/or Overactive Bladder With Urinary Incontinence

Study ObjectiveTo show a new technique of laparoscopic implantation of electrodes for stimulation of the pudendal nerve for treatment of fecal incontinence and/or overactive bladder with urinary incontinence.DesignStep-by-step explanation of the technique using videos and pictures (educative video).SettingHyperactivity of the bladder with urinary incontinence, in particular the non-neurogenic form of the condition, but also fecal incontinence may affect millions of women worldwide without any comorbidities and in particular without any neurologic disorders or prolapsed organs. First-line conservative treatments do not always result in sufficient improvement of symptoms and are often associated with disabling adverse effects leading to treatment failure. Electrical stimulation of the pelvic nerves has emerged as an alternative and attractive treatment in refractory cases. A novel technique of implantation of an electrode to the pudendal nerve has been developed for treatment of fecal incontinence and of hyperactivity of the bladder with urinary incontinence. The laparoscopic approach is the only technique that enables placement of an electrode in direct contact with the endopelvic portion of the pudendal nerve within the protection of the pelvis.InterventionLaparoscopic transperitoneal implantation of a stimulation electrode to the endopelvic portion of the pudendal nerve.ConclusionThis technique of transperitoneal placement of an electrode to the endopelvic portion of the pudendal nerve is an effective, safe, and reproducible day procedure for treatment of intractable hyperactive bladder, urinary incontinence, fecal incontinence, and a combination of both forms of incontinence.