子宫颈癌患者广泛性子宫切除术后下泌尿道的尿动力学特点

目的 探讨宫颈癌患者在广泛性子宫切除手术前后下泌尿道的尿动力学特点.方法 选择Ⅰ b～Ⅱa期宫颈癌患者46例,分别于广泛性子宫切除术前及术后进行尿动力学检查.结果 26例(57%)患者术前排尿模式正常但术后需借助于腹压排尿;排尿后残余尿量明显增加,术后为(205±201)ml,而术前为(5±3)ml,两者比较,差异有统计学意义(P＜0.01).术后正常尿意膀胱容量较术前显著增加,分别为(365±108)、(286±84)ml,两者比较,差异有统计学意义(P=0.01);最大膀胱容量较术前显著增加,分别为(670±174)、(402±124)ml,两者比较,差异有统计学意义(P=0.05);膀胱顺应性显著下降[分别为(15±5)、(102±64)ml/cm H2O(1 cm H2O=0.098 kPa),P＜0.01];最大逼尿肌收缩压显著下降[分别为(11±5)、(39±14)cm H2O,P＜0.01];功能性尿道长度缩短[分别为(31±7)、(39±7)mm,P＜0.01].结论 广泛性子宫切除术后下泌尿道功能障碍,其尿动力学特点表现为膀胱感觉功能减退,逼尿肌功能受损,而尿动力学检查有助于早期诊断.     

广泛性子宫切除术后膀胱功能的研究

目的探讨广泛性子宫切除术后尿动力学改变及膀胱功能康复的影响因素。方法220例广泛性子宫切除术后患者分为2组:7d组122例,初次留置尿管7d;14d组98例,初次留置尿管14d。比较两组患者术后尿动力学改变及膀胱功能恢复的时间,并分析其影响因素。结果①广泛性子宫切除术后7d,13·9%的患者膀胱无知觉,平均膀胱容量(256·2±64·9)ml,平均尿流率(7·6±2·9)ml/s;术后14d,2·0%的患者膀胱无知觉,平均膀胱容量(310·4±80·5)ml,平均尿流率(9·2±3·4)ml/s。(P<0·01);②7d组,术后14d、21d膀胱功能恢复的比例分别为86·9%、91·0%;14d组,术后14、21d膀胱功能恢复的比例分别为94·9%、99·0%。(P<0·01);③术后7d,尿路感染(UTI)发生率为37·7%,并发UTI者,膀胱功能康复率为52·2%,无UTI者为81·6%。术后14d,UTI发生率为62·2%;并发UTI者,膀胱功能康复率为91·8%;无UTI者为100·0%。(P<0·01)。结论广泛性子宫切除术后,患者膀胱功能障碍主要为神经源性膀胱,留置尿管14d比留置尿管7天膀胱功能恢复好。随着留置尿管时间的延长,UTI发生率相应地上升。UTI也是影响术后膀胱功能恢复的重要因素之一。     

腹腔镜辅助阴式子宫切除术与阴式子宫切除术适应证的探讨

目的通过比较腹腔镜辅助阴式子宫切除术(LAVH)与阴式子宫切除术(VH)的不同手术适应证及效果,探讨LAVH与VH手术病人的最佳选择。方法回顾性分析上海瑞金医院1999年6月至2002年12月间LAVH与VH手术病例381例,比较两种手术在手术时间、出血量、术后住院日、术中术后并发症及两者的手术适应证,尤其是子宫大小、盆腔粘连等的不同。结果两组手术在术中出血、手术并发症等方面差异无显著性意义,LAVH手术时间较长与患者子宫大、盆腔粘连者多、手术难度大有关。VH组患者均为正常或小于正常大小的子宫、无盆腔粘连、不伴有附件疾病者,手术适应证明显受限制。结论VH与LAVH均为创伤小、恢复快的微创手术,但VH适合于子宫小、无粘连并伴下垂者,而LAVH扩大了VH的适应证,是值得推广的手术。     

改良Nathanson术联合阴式广泛性子宫切除术在宫颈癌治疗中的应用

目的:探讨改良腹膜外淋巴结清扫术及阴式广泛性子宫切除术在浸润型宫颈癌治疗中的应用价值.方法:2004年10月至2006年10月,我们对18例Ⅰ A2期至ⅡA期的宫颈癌患者实施了经腹的腹膜外淋巴结清扫术及经阴道广泛子宫切除术.腹部淋巴结清扫的单侧切口长约5 cm.在经阴道的广泛子宫切除术时,无需行Schuchardt切口,而是首先切除宫骶韧带,再游离输尿管.结果:18例手术均获成功,平均手术时间212±20.32分钟,平均出血量530±35.12ml,平均术后肛门排气时间26±4.15小时,平均清扫盆腔淋巴结数目31±2.23个.术后无尿潴留发生.结论:改良腹膜外盆腔淋巴结清扫术及经阴道广泛子宫切除术安全可行;并可先于输尿管游离之前,切除宫骶韧带,有利于充分暴露术野,有利于打开输尿管隧道.     

子宫切除术后膀胱功能障碍患者的尿动力学分析

子宫切除术后，由于支配膀胱的神经损伤和膀胱解剖位置的改变，常常引起膀胱功能的障碍，但因其表现出来的症状如尿频、尿急、排尿困难等与尿路感染非常相似，妇科医师常常将其作为慢性尿路感染反复给予抗感染治疗，不但治疗效果甚微，还延误了膀胱功能的康复治疗。本研究对子宫全切除或广泛切除术后3至8个月，长期存在非感染原因的尿路症状者68例，行自由尿流率和尿动力学检查，并以子宫切除术前无尿路症状者和子宫全切除或广泛切除术后相同时间内的无尿路症状者为对照，以探讨子宫切除术后膀胱功能障碍者尿动力学检查的必要性和异常类型。     

腹腔镜下保留神经的广泛性子宫切除术

宫颈癌是女性第四大恶性肿瘤,经腹广泛性子宫切除术联合盆腔淋巴结清扫术是其经典治疗方案,术后5年生存率可达80%以上。但是,由于术中盆腔自主神经受到损伤,患者术后往往伴随着严重的盆底功能障碍。为改善患者术后生活质量,保留神经的广泛性子宫切除术(nerve-sparing radical hysterectomy,NSRH)自1961年被提出以来历经了一系列演变。随着腹腔镜技术在妇科恶性肿瘤领域的应用,腹腔镜的放大作用等优势更有利于盆腔的精细解剖,从而降低了保留盆腔自主神经的难度,腹腔镜下保留神经的广泛性子宫切除术(laparoscopic nerve-sparing radical hysterectomy,LNSRH)在临床中逐渐被应用,但该术式仍有许多问题亟待解决,而且目前关于腹腔镜治疗宫颈癌的争议不断,仍需多中心、大样本的前瞻性随机对照研究对LNSRH的安全性进行随访探讨。     

浅谈阴式子宫切除术并发症及防治体会

本文通过分析笔者所在医院2009年5月至2010年7月应用106例阴式子宫切除术(TVH)与同时期13例行腹式子宫切除术(TAH)手术并发症的发生情况,以证实TVH安全便利,并通过个人操作体会,探讨TVH的优点、应用推广价值及其并发症防治。     

超声对子宫切除术后下尿路形态学改变的观察研究

目的：利用超声观察子宫切除术后女性膀胱和尿道静态及动态的形态变化,从而评估其解剖结构的改变。方法：收集2012年6月-2013年3月于广东省人民医院进行检查的、因子宫病变行全子宫切除术的术后患者136例,根据手术方式及切除范围将其分为3组：A组为腹腔镜辅助的阴式子宫切除术者29例,B组为开腹子宫切除术者41例,C组为开腹广泛子宫切除术者66例。另将无盆腔或腹部手术史者50例设为对照组。4组均行经腹及经会阴超声检查,测量参数包括静止期及压力期（Valsalva呼吸时）膀胱颈移动度（UVJ-M）、膀胱尿道后角（PUVA）及膀胱残余尿量。结果：C组患者术后膀胱及尿道等下尿路解剖结构发生明显改变,UVJ-M、PUVA-r、PUVA-s等参数与对照组比较差异均有统计学意义（均P＜0.01）。 B组患者术后膀胱及尿道等下尿路解剖结构也发生变化,改变程度较C组小,UVJ-M参数与对照组、C组相比差异有统计学意义（均P＜0.01）,PUVA-r、PUVA-s等参数与对照组相比差异无统计学意义（均P＞0.05）。 A组患者术后膀胱及尿道等下尿路解剖结构无明显改变,UVJ-M、PUVA-r、PUVA-s等参数与对照组比较差异均无统计学意义（均P＞0.05）。结论：①超声可对子宫全切术后女性膀胱及尿道形态学变化进行实时观察、客观评价解剖结构的改变。②子宫切除的3种手术方式中以开腹广泛子宫切除术对女性膀胱及尿道解剖结构改变最大,腹腔镜辅助的阴式子宫切除术则几乎没有影响。     

保留盆腔自主神经的广泛性子宫切除术应用于宫颈癌的研究进展

宫颈癌患者的广泛性子宫切除术对宫旁组织及阴道的大范围切除,可导致盆腔自主神经结构的损伤,引起相应器官的功能障碍,以膀胱功能障碍最为突出.近年来多项研究对盆腔自主神经结构进行重新认识,并在此基础上开展了保留盆腔自主神经的广泛性子宫切除术(NSRH).术中通过对盆腔自主神经的精细分离,系统保留其具体结构,但其手术复杂,缺乏...     

妊娠合并肺动脉高压患者不同程度肺动脉高压与妊娠结局临床分析#br#

目的了解子宫颈癌根治性子宫切除术后患者下尿路症状患病情况及其相关因素。方法选择2012年1月至2015年3月在全国13家研究中心接受PiverⅢ型子宫切除的690例宫颈癌患者,并按照年龄和体质指数匹配妇科门诊无手术史良性疾病患者690例作为对照组,采用女性下尿路症状国际尿失禁标准问卷(ICIQFLUTS)和膀胱过度活动症评分(overactive bladder symptom score, OABSS)对两组患者进行问卷调查。结果宫颈癌组下尿路症状患病率(78.3%, 540/690)与对照组(78.7%, 543/690)相似(P0.05)。宫颈癌组储尿期症状患病率(66.2%, 457/690)低于对照组(75.5%, 521/690)(P 0.05),而排尿期症状(52.3%, 361/690)和膀胱过度活动症(overactive bladder symptom, OAB)(14.5%, 100/690)患病率显著高于对照组(24.1%, 166/690; 8.8%,61/690)(P 0.05)。单因素分析显示,腹腔镜手术、术中切除宫旁长度或阴道长度 3 cm与排尿期症状、OAB患病相关(P 0.05)。Logistic分析显示,腹腔镜手术是排尿期症状(OR=2.380, 95%CI:1.664～3.405)和OAB的危险因素(OR=1.972, 95%CI:1.155～3.367)。结论宫颈癌患者根治性子宫切除术后排尿期症状及OAB患病率升高,可能与切除较多的宫旁和阴道组织有关。     

Ureteric obstruction after radical hysterectomy

Two patients with invasive carcinoma of the cervix treated with radical hysterectomy developed total unilateral ureteric obstruction postoperatively. A temporary percutaneous nephrostomy was inserted. Because both patients needed adjuvant radiotherapy, intended reimplantation of the ureter was postponed. During this period spontaneous passage through the ureter was observed after 5 and 14 weeks, respectively. It is emphasized that a 'wait and see' policy may be justifiable in the case of ureteric obstruction of unclear etiology after radical hysterectomy for at least 3 months, as long as renal function is preserved by percutaneous nephrostomy drainage of the affected kidney side.     

Infectious urinary tract morbidity with prolonged bladder catheterization after radical hysterectomy

OBJECTIVE: This study was undertaken to determine the incidence of catheter-associated infection after radical hysterectomy and to evaluate the role of prophylactic antibiotics in these patients. STUDY DESIGN: A 4-year retrospective review of 102 women undergoing radical hysterectomy for cervical or endometrial cancer was performed. Clinical data were abstracted and analyzed with chi(2) and t tests. RESULTS: Catheter-associated infection was observed in 11% (12 of 102) and was not altered by the administration of prophylactic antibiotics (11.1% vs 11.8%, P=.95). Of the 12 women who had infection, 11 were treated as outpatients, and 1 patient required admission for pyelonephritis. Patient age, comorbid medical conditions, class of radical hysterectomy, perioperative complications, operative time, blood loss, catheter type, duration of catheterization, and length of hospitalization had no effect on the development of catheter-associated infection. CONCLUSION: The incidence of catheter-associated infection in women requiring prolonged catheterization after radical hysterectomy is relatively low. Withholding prophylactic antibiotics from these patients is a reasonable clinical option.     

Sexual dysfunction in Thai women with early-stage cervical cancer after radical hysterectomy

We determined the prevalence of sexual dysfunction in women with early-stage cervical cancer who had undergone radical hysterectomy in three institutions of Thailand. An interview was conducted according to the structured questionnaire composing of seven domains of sexual function: frequency, desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia. From 105 women included in the study, mean age was 45.3 +/- 7.8 years. Seventy-five (71.4%) were in premenopausal period. Eight out of 105 women (7.6%) never resumed their sexual intercourse after radical hysterectomy, 97 women resumed their sexual intercourse during 1-36 months postoperation (median, 4 months). Dyspareunia was increased in approximately 37% of women, while the other six domains of sexual function were decreased, ranging from approximately 40-60%. Of interest, only 10.5% of these cervical cancer women had some information of sexual function from medical or paramedical personnel, 17.1% obtained it from other laymen or public media, and 61.9% had never had it from any resources. Our conclusion is-sexual dysfunction is a common problem after cervical cancer treatment, but it has not been well aware of. These findings may necessitate health care providers to be more considerate on this problem.     

Management of early-stage cervical carcinoma by modified (Type II) radical hysterectomy

OBJECTIVE:. Surgical management of cervical carcinoma by radical hysterectomy has been proven a highly effective method in treating early-stage disease. The purpose of this study was to evaluate the efficacy and safety of modified (Type II) radical hysterectomy for the treatment of early-stage (I-IIA) cervical carcinoma. METHODS: A retrospective analysis of data on 435 patients with cervical carcinoma who were managed by modified radical hysterectomy was performed. In 145 cases a multimodal approach was used due to the presence of one or more risk factors such as lymph node metastasis, CLS involvement, bulky tumor, and exocervical extension of disease. Preoperative irradiation was offered to 62 patients, whereas adjuvant irradiation was offered to 101 patients. RESULTS: The mean age of the patients was 42.5 years. The majority of the patients had squamous cell cancer (81.6%). The patients were clinically staged as IA (3.2%), IB (86.7%), and IIA (10.1%). Positive pelvic lymph nodes were noted in 65 patients (14.9%). Operative morbidity was minimal, whereas adjuvant radiation treatment had no impact on the disease but caused genitourinary morbidity in terms of ureteral stricture and postoperative bladder dysfunction (P < 0.001). The overall 5-year survival was 88.7%. The most significant predictors related to 5-year survival were nodal metastasis (P < 0.001), adenomatous histology (P < 0.001), lesion size (P < 0.001), and CLS involvement (P = 0.004). Adjuvant radiation resulted in better local pelvic control of the disease. CONCLUSION: The results of our study support the concept that less radical procedures could be effectively applied to early-stage cervical carcinoma 4 cm or smaller with optimal surgical margins.     

Pelvic floor dysfunction and radical hysterectomy

Although the survival outcome for treated, early-stage, node-negative cervical cancer is excellent, the operation of radical hysterectomy conveys major morbidity, particularly with respect to bladder and bowel function. There may be some degree of spontaneous recovery, but a significant proportion of postoperative women will have to live with the disabling effects of surgery for decades, and few seek help for their distress. As such, quality of life issues have become highly relevant in the management of this disease, and attention has turned to reducing morbidity, especially to the pelvic viscera. This review presents an overview of the surgical mechanisms presumed to be responsible for pelvic floor denervation and describes subsequent bladder and bowel dysfunction, together with future possibilities for minimizing morbidity, including less radical, more individual surgery, and nerve-sparing techniques.