经阴道子宫骶骨韧带高位悬吊术治疗子宫脱垂的临床探讨

目的探讨经阴道子宫骶骨韧带高位悬吊术（HUS）治疗子宫脱垂的解剖生理基础、适应证、手术技巧、输尿管损伤的预防及临床近、中期疗效。方法2003年6月至2007年9月,采用经阴道HUS悬吊阴道穹隆、重建耻骨宫颈筋膜及直肠阴道筋膜,治疗中、重度子宫脱垂50例。患者平均年龄60．1岁,术后平均随访时间24个月（4～51个月）。同时采用盆腔器官脱垂定量分度（POP-Q）法对子宫脱垂程度及手术后结果进行评价,以术后C点值≤POP-QⅠ度计算成功率。结果术中50例中、重度子宫脱垂患者的宫骶韧带均可在后腹膜坐骨棘内后侧、经长组织钳钳夹牵拉、清楚触及和辨认,并均成功对阴道穹隆进行了悬吊和筋膜重建。术中应根据对输尿管解剖部位和相邻关系的准确认识、术中触摸、掌握缝合进针深度及方向、膀胱镜检查并确认输尿管开口位置等方法避免输尿管损伤。50例中,无一例输尿管损伤。术后平均随访时间24个月,POP-Q法C点值由术前1．5cm降为术后的-7．5cm;主、客观成功率均达100％。结论经阴道HUS悬吊并重建阴道穹隆、耻骨宫颈筋膜、直肠阴道筋膜是利用自身组织作为悬吊点治疗子宫脱垂,符合恢复解剖生理、保留功能及微创原则,主、客观成功率高。

High vaginal uterosacral ligament suspension for treatment of uterine prolapse

OBJECTIVE: To evaluate the physiological and anatomic basis,indications,surgical skills, prevention of ureter injury and clinic outcomes of using high uterosacral ligament suspension (HUS) for correction of advanced uterine prolapse by the vaginal route. METHODS: Fifty women with advanced uterine prolapse underwent transvaginal HUS after vaginal hysterectomy with reconstruction of pubocervical and rectovaginal fascia to correct their uterine prolapse between June 2003 and September 2007. The average age of the women was 60.1 years. The mean follow-up period was 24 months (range 4-51 months). The degree of pelvic organ prolapse preoperatively and anatomic outcomes postoperatively were assessed with pelvic organ prolapse quantification system (POP-Q). RESULTS: The remnants of the uterosacral ligaments were clearly identified and palpated posterior and medial to the ischial spines by traction with a 24 cm long Allis clamp and used for successful vaginal vault suspension and reconstruction in all 50 consecutive advanced uterine prolapse patients. The ureter injury was avoided by complete knowledge of the ureter's course from the cervix/apex toward its insertion in the sacral region and how far outside of the uterosacral ligament, by uteri palpation and by suturing purposefully placed "deep" dorsally and posteriorly toward the sacrum, as well as by cystoscopy examination of the spillage of urine from both ureters. Mean POP-Q point C improved from 1.5 to -7.5 cm with a median follow-up of 24 months. If the successful HUS was defined as point C < or = stage I prolapse, both the objective and subjective cure rates were as high as 100% with a maximum follow-up of 51 months. None of the 50 patients had repeat operation for recurrence of prolapse. There was no major intra-or postoperative complications, such as ureter and other pelvic organ injury. CONCLUSION: HUS with fascial reconstruction seems to be a safe, minimal traumatic, tolerable and highly successful procedure for vaginal repair of advanced uterine prolapse. Because of the use of native tissue as suspension site HUS is more physiologic and cost effective.