阴道封闭术治疗老年性重度盆腔器官脱垂的临床疗效

目的 探讨阴道封闭术治疗老年性重度盆腔器官脱垂(POP)的临床主、客观疗效.方法 2005年10月至2010年2月,采用阴道全封闭术及阴道部分封闭术(LeFort术)治疗老年性重度POP患者63例,患者采用POP定量分度(POP-Q)法分期均为Ⅲ～Ⅳ期,平均年龄(75±6)岁(59～87岁),其中58例(92%)伴有1种以上的内科合并症.63例患者中,子宫脱垂53例,宫颈脱垂1例,阴道穹隆脱垂9例;既往POP修补术后复发7例;合并排尿困难23例(36%),排便困难11例(17%),大便失禁3例(5%);尿失禁及脱垂前有尿失禁史28例(44%).63例患者中,48例(76%)行阴道全封闭术,15例(24%)行阴道部分封闭术;58例(92%)同时行肛提肌+会阴体修补术,20例(32%)同时行抗尿失禁术.分别于术后2个月及1年进行随访,观察手术效果,测量POP-Q分期及阴道、阴裂及会阴体长度,并采用非正式的自身形象和满意度问卷评价手术的主观效果.结果 63例患者的平均手术时间为(105±48)min,其中阴道全封闭术及阴道部分封闭术分别为(128±58)和(82±26)min,两者比较,差异有统计学意义(P<0.05);平均术中出血量为(187±128)ml(50～600 ml),其中阴道全封闭术及阴道部分封闭术分别为(232±159)和(101±54)ml,两者比较,差异也有统计学意义(P<0.05).无手术副损伤及死亡者,术后并发症的发生率为5%(3/63).63例患者术后POP-Q分期均≤Ⅰ期,无一例复发.患者术后1年时的平均阴道长度、阴裂长度分别为(3.4±1.1)、(2,3±0.5)cm,均明显小于术前[分别为(7.7±1.1)、(5.5±1.5)cm,P<0.01];会阴体长度为(3.5±0.9)cm,明显大于术前[(2.6±0.9)cm,P<0.01].63例患者中,3例(5%)术后发生轻度尿失禁.术前23例有排尿困难者平均残余尿量为(110±38)ml(50～235 ml),术后拔除尿管后减至12 ml.11例术前有排便困难者,术后6例(54%)好转;3例有大便失禁者,术后2例(2/3)好转.术后1年时,共52例(82%)患者完成了自身形象和满意度问卷,其中对手术很满意及满意者49例(94%),不满意及很不满意者3例(6%).结论 阴道封闭术治疗老年性重度POP的并发症发生率、复发率较低,主、客观成功率较高,对于老年体弱、无阴道性交要求者是一种安全、能缓解排尿及排便困难、疗效持久和满意度高的良好术式.

Colpocleisis in elderly patients with severe pelvic organ prolapse

Objective To study the objective and subjective therapeutic effect of total and partial (LeFort) colpocleisis in treatment of severe pelvic organ prolapsed ( POP) in selected elderly patients.Methods From Oct 2005 to Feb.2010,63 severe POP patients[59-87 years,median age (75 ±6) years]with stage Ⅲ and Ⅳ by POP-Q system underwent total and partial colpocleisis.The mean age was (75 ±6)years (59-87 years).Fifty-eight patients(58/63,92% )present more than one kind of medical disease.There were 53 cases with uterus prolapse,1 case with cervix prolapse and 9 cases with vaginal vault prolapse.Seven patients were recurrent POP from previous surgery.Twenty-three patients(36% ) presentedvoiding difficulty.Seven patients (17%) presented obstructive bowel symptom.Three patients (5%) presented fecal incontinence,and 28 patients(44% )presented either had urinary incontinence or history of that Among 63 patients,48 patients (76% ) underwent total colpoclesis,and 15 (24% ) patients partial colpoclesis.Meanwhile,58 (92% ) patients underwent levator myorrhaphy plus perineorrhaphy and 20 (32% ) patients underwent anti-urinary incontinence procedure ( TVT-0 ),respectively.Patients were followed up to evaluate therapeutic effect at 2 months and 1 year after surgery.Objective evaluation included the POP-Q and the length of vagina,genital hiatus,perineal body.A nonvalidated Body Image and Satisfaction Questionnaire was completed for subjective evaluation.Results The mean operating time of 63 patients was (105 ±48) minutes,which was (128 ±58) in total and (82 ±26) minutes partial procedures,which exhibited significant difference(P<0.05).The mean blood loss was (187 ± 128) ml (50-600 ml),total and partial procedures caused (232 ± 159) and (101 ±54) ml,respectively,which also showed significant difference ( P < 0.05 ).No intraoperative injury or death occurred.The rate of postoperative complications was 5% (3/63).Mean follow-up time of 63 patients was 22.5 months (1-51 months).All patients had POP-Q staging score ≤Ⅰ.No recurrent patient was observed.At 1 year after operation,the mean preoperative total vaginal length (TVL) and genital hiatus (GH) of (7.7 ± 1.1) and (5.5 ± 1.5)cm were decreased to (3.4 ± 1'.l)and (2.3 ±0.5) cm (P<0.01) ;and perineal body (PB) measurements was increased from (2.6±0.9) to (3.4 ±0.9)cm(P <0.01).Three (5%,3/63) patients had mild urinary incontinence after the operation.Twenty-three patients with voiding difficulty presenting the mean postvoid residual volumes (110 ± 38) ml(50-235 ml) were decreased to 12 ml after the operation.Obstructive bowel symptom was improved in 6(54%,6/11) patients,and fecal incontinence improved in 2(2/3).One year after the operation,52 ( 82% ) patients completed the nonvalidated Body Image and Satisfaction Questionnaire.49 (94% ) patients said either 'very satisfied' or 'satisfied' with the outcome of their surgery,while 3 ( 6% ) reported unsatisfied or not at all satisfied.Conclusions The objective and subjective curative rates of colpocleisis in treatment of severe POP are high with lower morbidity and recurrence.Colpocleisis is a safe and effective management in selected elderly patients with severe POP,who no longer desire to maintain vaginal coital function.