腹腔镜下系统保留盆腔自主神经的根治性子宫切除术

在20世纪60年代,日本学者提出在根治性子宫切除术中保留神经尤其是膀胱神经,以避免术后膀胱功能的过度损伤[1-2].     

宫颈癌保留盆腔神经的广泛子宫切除术

广泛子宫切除术是治疗早期宫颈癌的经典术式,100多年前由Wertheim最先提出,1950年Meigs进行改良推广后一直沿用至今。然而其术后并发症较多,尤其是膀胱功能障碍发生率达70%～85%[1],影响患者生活质量。盆腔神经损伤是造成盆腔脏器功能障碍的主要原因。1921年Okaba-yashi最早提出盆腔神经保留手术。随后该技术主要用于直肠癌、前列腺癌根治术,且已有大量临床资料证实该技术可成功保留膀胱功能和性功能且不影响手术效果[2]。近10年来,妇产科学者开始重视该技术并逐渐用于临床。现对该技术用于广泛子宫切除术治疗宫颈癌的进展作一综述。     

系统保留盆腔自主神经广泛性子宫切除术的临床观察

目的:探索系统保留盆腔自主神经的广泛性子宫切除术(systematic nerve sparing radical hysterectomy,SNSRH)对术后膀胱、直肠及性功能的保护作用。方法:选取2007年11月~2009年4月宁夏医科大学附属医院收治的44例宫颈癌及子宫内膜癌患者,A组24例行SNSRH,B组20例行传统根治性子宫切除术,观察SNSRH成功率,两组术后膀胱、直肠和性功能情况。结果:(1)A、B两组严格遵循Ⅲ型子宫切除术标准,手术切除范围无差异;(2)30例行SNSRH,成功保留盆腔自主神经(PAN)24例,失败6例,成功率80%;(3)A、B组平均手术时间、术中出血量差异无统计学意义;A、B组平均留置尿管时间、术后残余尿量、排气排便时间差异有统计学意义(P0.05);(4)A组术后性功能障碍发生率明显低于B组,差异有统计学意义(P0.05)。结论:系统保留PAN的广泛性子宫切除术对术后膀胱、直肠及性功能的恢复有一定的保护作用。     

系统保留盆腔自主神经的广泛性子宫切除术中神经确认与术后膀胱功能评估

文章就盆腔自主神经的走行、系统保留盆腔自主神经的广泛性子宫切除术中神经确认及术后膀胱功能评估进行阐述,重点介绍术中电刺激确认神经技术和术后应用尿动力学评估膀胱功能的方法.     

经腹全子宫切除手术对盆底功能的影响

经腹全子宫切除手术包括经腹全子宫切除术(TAH)和扩大子宫切除术(临床常采用筋膜外子宫切除术、次广泛子宫切除术和广泛性子宫切除术)。术后妇女常出现尿失禁、便秘、性功能障碍等症状,或是原有症状加重。这是由于骨盆底解剖的破坏和盆腔自主神经的损伤,影响其他盆底器官功能所致。妇科医生应对术式有更深入的了解,更好地解决临床遇到的问题。     

经腹全子宫切除手术对盆底功能的影响

经腹全子宫切除手术包括经腹全子宫切除术(TAH)和扩大子宫切除术(临床常采用筋膜外子宫切除术、次广泛子宫切除术和广泛性子宫切除术).术后妇女常出现尿失禁、便秘、性功能障碍等症状,或是原有症状加重.这是由于骨盆底解剖的破坏和盆腔自主神经的损伤,影响其他盆底器官功能所致.妇科医生应对术式有更深入的了解,更好地解决临床遇到的问题.     

在保留神经的广泛全子宫切除术中电刺激盆腔脏器神经

目前早期宫颈癌多行保留神经的广泛全子宫切除术．尽管该手术有利于膀胱功能恢复．但许多患者术后仍有不同程度的排尿障碍。为确定传统的保留神经广泛全子宫切除术中行电刺激盆腔脏器神经并监测膀胱收缩．是否有助于术后膀胱功能恢复,选择Ib及Ⅱa期宫颈癌患者17例，平均年龄49（27～70）岁。患者均行传统的保留神经的广泛全子宫切除术，其中8例术后接受辅助化疗，1例接受放疗。     

深部浸润型子宫内膜异位症保留神经的腹腔镜手术治疗

子宫内膜异位症是严重影响妇女身心健康的一种妇科良性疾病.目前,按其发生机制及临床特点将其分为腹膜型、卵巢型及深部结节浸润型(deep infiltrating endometriosis,DIE)3种类型.DIE是子宫内膜异位症的一种特殊类型,疼痛是该型的特征性临床症状,手术治疗是该型的主要治疗方式.腹腔镜下手术完整切除DIE病灶可消除或减轻患者的临床疼痛症状,且复发率低,是目前DIE手术治疗的首选治疗方式.但由于DIE病灶主要分布在子宫直肠陷凹和子宫骶骨韧带处,因此,完全完整切除DIE病灶常可损伤或切除位于子宫骶骨韧带内或者侧方的下腹下神经丛,导致类似根治性宫颈癌术后直肠、膀胱以及性功能紊乱的并发症,提示保留下腹下神经的DIE手术可以消除或减少术后直肠、膀胱以及性功能紊乱的并发症.     

保留盆腔植物神经的广泛性子宫切除术治疗子宫颈癌的初步研究

目的 探讨保留盆腔植物神经的广泛性子宫切除术(NSRH)治疗宫颈癌的可行性,并评估其改善术后膀胱功能的效果.方法 选择接受手术治疗的临床分期为Ⅰ b1～Ⅱa期的宫颈癌患者44例,分为两组.研究组22例患者接受NSRH手术,术中在处理主韧带、宫骶韧带、深层的膀胱宫颈韧带及阴道旁组织时,保留盆腔内脏神经、腹下神经、下腹下神经丛及其膀胱支;对照组22例患者接受经典的广泛性子宫切除手术(即Piver Ⅲ类子宫切除术).对比两组患者的术中及术后并发症发生情况.结果 研究组术中出血量为(550±241)ml,对照组为(475±284)ml,两组比较,差异无统计学意义(P>0.05);研究组手术时间为(329±43)min,对照组为(272±56)min,两组比较,差异有统计学意义(P<0.01).术后第8天,研究组及对照组中残余尿量<100 ml的患者比例分别为68%及18%,两组比较,差异有统计学意义(P<0.01);研究组留置尿管时间(8～23 d,中位时间8 d)与对照组(8～32 d,中位时间20 d)比较,差异有统计学意义(P<0.01).两组患者均无严重的手术相关性损伤及病理切缘不净的情况发生.结论 NSRH治疗早期子宫颈癌安全、可行,且能明显改善患者术后的膀胱功能.     

广泛性子宫切除术后留置尿管时间与膀胱功能恢复的关系

广泛性子宫切除是治疗子宫颈癌和子宫内膜癌的经典手术，常同时进行盆腔淋巴结清扫。由于该手术对盆腔交感和副交感神经的损伤，术后常并发膀胱功能障碍。因此，广泛性子宫切除术后应留置尿管多长时间是妇科医生经常面临的问题。为此，我们对220例进行广泛性子宫切除手术的病人，分组对照研究术后留置尿管的时间与膀胱功能恢复的关系，并分析其影响因素。     

Urodynamic study on postsurgical bladder function in cervical cancer treated with systematic nerve-sparing radical hysterectomy

The objective of this study was to assess the postsurgical bladder function by urodynamic study in patients with cervical cancer treated with nerve-sparing radical hysterectomy. A total of 27 consecutive patients were included in the study. Of the 27 patients, autonomic nerves had been completely preserved at least on one side in 22 patients (group A), and autonomic nerves could not be successfully preserved in five patients (group B). In group A, there was no significant difference in compliance at the moment of strong desire to void, maximum flow rate, and residual urine volume between before the operation and at 12 months after the operation. However, abdominal pressure at maximum flow had significantly increased in patients of group B than of group A. Detrusor contraction pressure at maximum flow had significantly decreased in patients of group B than of group A. Bladder sensation was diminished in three cases (60%) of group B but preserved in all the patients of group A. Although it is still preliminary, our surgical technique described in this report is thought to be effective for preservation of bladder function. For further evaluation of the efficacy of nerve-sparing radical hysterectomy in terms of quality of life and survival of patients, a prospective randomized trial needs to be performed.     

A systematic nerve-sparing radical hysterectomy technique in invasive cervical cancer for preserving postsurgical bladder function

The objective of this study is to describe a technique for preserving the autonomic nerve systematically, including the hypogastric nerves, pelvic splanchnic nerves, and pelvic plexus and its vesical branches, based on anatomic considerations for the autonomic nerves innervating the urinary bladder, in radical hysterectomies and to assess postsurgical bladder function. A nerve-sparing radical hysterectomy was carried out on 27 consecutive patients with uterine cervical cancer treated between 2000 and 2002. The FIGO stages of the disease consisted of 10 stage Ib1, 6 stage Ib2, 3 stage IIa, and 8 stage IIb. The nerve-sparing procedure was successfully completed in 22 of the 27 patients (81.5%) in the study. At 1 year after the operation, bladder symptoms were significantly improved in the nerve-sparing group compared to the non-nerve-sparing group. Urinary incontinence and abnormal (diminished) bladder sensation were observed in three of the five patients (two patients had both symptoms), for whom the nerve-sparing procedure could not be performed, but none of the 22 patients for whom the nerve-sparing procedure was performed had incontinence, and only two patients had abnormal (increased) bladder sensation (P= 0.0034 for incontinence and P= 0.030 for abnormal bladder sensation). The patients' survival was not adversely affected by the nerve-sparing procedure. Although it is still preliminary, the surgical technique described in this report is thought to be effective for preserving bladder function, and thus, the quality of life could be improved for patients with cervical cancer who are treated with a radical hysterectomy. For further evaluation of the efficacy of nerve-sparing radical hysterectomy, a prospective randomized trial needs to be performed.     

Unilateral or bilateral nerve-sparing radical hysterectomy: a surgical technique to preserve the pelvic autonomic nerves while increasing radicality

We performed unilateral or bilateral nerve-sparing (UNS or BNS) radical hysterectomies combined with a parametrial excision in patients with locally advanced cervical cancer. The parametrial excision technique is characterized by a meticulous sharp dissection of the avascular plane outside the visceral fascia of the uterus and vagina under direct vision, providing an en bloc parametria and ensuring that all regional spread of the disease is contained within negative surgical margins. The aim of this study was to describe this surgical technique and to retrospectively evaluate the feasibility and the impact on early bladder function. From February 2005 to November 2006, 32 patients with FIGO stage IB-IIB cervical cancer, who had the tumor of more than 20 mm in diameter, underwent the UNS surgery or BNS surgery. A parametrial excision was performed in all the patients. The surgical procedure was safely completed in all the patients. Though 14 patients had tumor invasion to the parametria, none of the patients had a positive surgical margin in the parametrium. The bladder function of patients in the UNS group immediately after surgery was more damaged than that in the BNS group. However, all the patients in both groups recovered spontaneous voiding with no need of self-catheterization during the perioperative periods. This preliminary study showed that the surgical technique is feasible and safe. For confirmation of the efficacy of this technique, further large prospective studies are needed.     

Nerve-sparing class III radical hysterectomy: a modified technique to spare the pelvic autonomic nerves without compromising radicality

The objectives were to describe our nerve-sparing class III radical hysterectomy technique and assess the feasibility and safety of the procedure as well as its impact on voiding function. From January to August 2005, 21 consecutive patients with FIGO stage IB-IIA cervical cancer and 1 patient with clinical stage II endometrial cancer underwent nerve-sparing radical hysterectomy with systematic pelvic lymphadenectomy. The transurethral catheter was removed on the seventh postoperative day. Then intermittent self-catheterization was performed and post-void residual urine volume (PVR) was recorded. The nerve-sparing procedure was completed successfully and safely in all of the patients. Eight (36%) and 6 (27%) patients had the PVR of < 100 ml and < 50 ml respectively at the initial removal of the catheter. On the fourteenth day, 82% and 77% of the patients had the PVR of < 100 ml and < 50 ml, respectively. The mean duration before the PVR became < 50 ml was 11.27 (5-26) days. In conclusion, the technique described in this preliminary study appears safe, adequate, and feasible in our population with satisfactory recovery of voiding function. A larger comparative study is needed on long-term urinary, bowel, and sexual function as well as recurrence and survival.     

保留盆腔自主神经对宫颈癌患者术后性生活质量影响的探讨

目的 探讨腹腔镜下保留盆腔自主神经的广泛子宫切除术(laparoscopic nerve sparing radical hysterectomy,LNSRH)对早期宫颈癌患者术后性生活质量的影响。 方法 选取2011年8月至2013年3月因早期子宫颈癌(Ⅰa2～Ⅰb1期)于青岛市市立医院行腹腔镜下广泛子宫切除术的患者,采用随机数字表法将其分为2组,其中LNSRH组29例,行LNSRH+腹腔镜下盆腔淋巴结清扫术（laparoscopic pelvic lymphadenectomy,LPL）,对照组30例,行腹腔镜下广泛子宫切除（laparoscopic radical hysterectomy,LRH）+LPL（LRH组）。术前及术后1年采用女性性功能指标量表(female sexual function index,FSFI)对所有患者进行问卷调查,评价其性生活质量。 结果 术前两组FSFI总评分及各部分得分差异无统计学意义,术后LNSRH组FSFI总评分高于LRH组,差异有统计学意义（P<0.05）。术后各部分评分中性欲望、性唤起、阴道润滑、性高潮、性满意度得分LNSRH组均高于LRH组,差异有统计学意义（P<0.05）;性交痛评分两组之间差异无统计学意义。结论 LNSRH患者较LRH患者术后有较为理想的性生活状态,LNSRH可能对提高早期宫颈癌患者术后性生活质量有效。     

A nerve-sparing radical hysterectomy: Guidelines and feasibility in Western patients

Abstract. Trimbos JB, Maas CP, DeRuiter MC, Peters AAW, Kenter GG. A nerve-sparing radical hysterectomy: Guidelines and feasibility in Western patients.
Surgical damage to the pelvic autonomic nerves during radical hysterectomy is thought to be responsible for considerable morbidity, i.e., impaired bladder function, defecation problems, and sexual dysfunction. Previous anatomical studies and detailed study of surgical techniques in various Japanese oncology centers demonstrated that the anatomy of the pelvic autonomic nerve plexus permits a systematic surgical approach to preserve these nerves during radical hysterectomy without compromising radicality. We introduced elements of the Japanese nerve-preserving techniques and carried out a feasibility study in ten consecutive Dutch patients. The technique involved three steps: first, the identification and preservation of the hypogastric nerve in a loose tissue sheath underneath the ureter and lateral to the sacro-uterine ligaments; second, the inferior hypogastric plexus in the parametrium is lateralized and avoided during parametrial transsection; third, the most distal part of the inferior hypogastric plexus is preserved during the dissection of the posterior part of the vesico-uterine ligament. The clinical study showed that the procedure is feasible and safe, except possibly when used with very obese patients and patients with broad, bulky tumors. Surgical preservation of the pelvic autonomic nerves in radical hysterectomy deserves consideration in the quest to improve both cure and quality of life in cervical cancer patients.     

宫颈癌根治手术中输尿管及膀胱保护问题

输尿管和膀胱与女性内生殖器官相毗邻,宫颈癌根治术手术范围广、难度大,所以极易发生输尿管和膀胱的损伤,严重影响患者的生存质量。因此,应了解宫颈癌手术输尿管及膀胱损伤的常见原因,术前充分评估,精确掌握手术区域解剖,正确使用各种能量器械,时刻注意保护输尿管及膀胱,避免发生严重后遗症,改善患者的预后,减少医疗纠纷的发生。     

耻骨上膀胱造瘘术在宫颈癌根治术中的应用

目的探讨耻骨上膀胱造瘘术在宫颈癌根治术中的应用价值。方法采用回顾性对比分析耻骨上膀胱造瘘术和经尿道口留置尿管两种方法对宫颈癌患者术后膀胱功能恢复、尿道感染率和平均住院时间的影响,评价耻骨上膀胱造瘘术在宫颈癌根治术中的应用价值。结果 99例宫颈癌根治术患者,56例采用耻骨上膀胱造瘘术,与43例留置尿管组比较,其膀胱功能恢复时间无明显差异(16.7d和18.4d,P0.05),但尿道感染率明显降低(16.7%和31.8%,P0.01),住院时间明显缩短(18.1d和25.2d,P0.05),可减轻患者的经济负担。结论在宫颈癌根治术中应用耻骨上膀胱造瘘术安全可行,具有良好的临床应用前景。     

机器人辅助广泛性子宫切除术和盆腔淋巴结切除术的初步研究

目的 探讨将机器人手术系统应用于宫颈癌的广泛性子宫切除+盆腔淋巴结切除术的可行性.方法 2008年12月-2009年8月,采用da Vinci机器人手术系统,对5例Ⅰb1～Ⅱ a期宫颈癌患者行机器人辅助广泛性子宫切除+盆腔淋巴结切除术.记录手术时间、术中出血量、术中及术后并发症的发生情况、手术前后血红蛋白含量变化、术后体温及排气时间、术后恢复自主排尿时间、术后住院时间、病理检查结果、盆腔淋巴结切除数等.结果 5例患者全部顺利完成手术,无中转开腹,无术中或术后并发症出现.5例患者的手术时间分别为305、365、275、240和245 min,平均为286 min;术中出血量分别约为200、400、650、300和400 ml,平均为390 ml.5例患者术后最高体温均未超过37.5℃,术后36 h均排气.5例患者术后住院时间分别为11、13、9、12和12 d,平均为11.4 d.5例患者的病理检查结果均为鳞状细胞癌,阴道残端和宫旁切缘均无残留病灶.盆腔淋巴结切除数分别为14、22、16、21和18个,平均为18.2个,淋巴结无转移.结论 机器人手术系统可以应用于宫颈癌的广泛性子宫切除+盆腔淋巴结切除术,这一新方法为宫颈癌的手术治疗提供了一个新的选择.