女性前盆底重建术的临床解剖研究
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摘要
目的明确女性前盆底重建术治疗女性阴道前壁脱垂的穿刺路径,降低术中并发症的发生率。方法应用红色乳胶分别对3具新鲜女性尸体标本进行桡动脉血管灌注,5 d后对标本进行手术穿刺和路径解剖,同时测量穿刺针与相关血管、神经和处女膜之间的距离。结果所有穿刺均未发生副损伤,1号穿刺针与闭孔神经后支、闭孔动脉前支、闭孔动脉后支、闭膜管、阴部内血管神经、处女膜的距离分别是(2. 6±0. 2) cm、(2. 1±0. 3) cm、(1. 4±0. 1) cm、(2. 1±0. 2) cm、(1. 2±0. 2) cm和(2. 0±0. 2) cm;2号穿刺针与闭孔神经后支、闭孔动脉前支、闭孔动脉后支、闭膜管、阴部内血管神经、处女膜的距离分别是(3. 0±0. 3) cm、(2. 9±0. 2) cm、(0. 6±0. 2) cm、(2. 5±0. 3) cm、(0. 8±0. 2) cm和(6. 1±0. 4) cm。结论女性前盆底重建术通过加强女性盆底Ⅰ和Ⅱ水平的支撑作用来治疗阴道前壁脱垂,术中取膀胱截石位,大腿充分外展,选择恰当的进针点进行由外向内的穿刺,能够大大降低术中损伤重要血管神经的风险。
Objective To identify the route of the female anterior pelvic floor reconstruction which is applied to treat anterior vaginal wall prolapse( AVWP),and to decrease the complication of procedure. Methods Three fresh cadavers were injected colored latex into radial artery. After 5 days,the anterior pelvic floor reconstruction were performed respectively when lactoprene had solidified. The distances between the trocars and related vascular,nerves and hymen were measured. Results There was no complication during all procedures. The distances between No. 1 needle and the posterior branch of the obturator nerve,anterior branch of the obturator artery,posterior branch of the obturator artery,obturator canal,internal pudendal vessels and nerves,and hymen were( 2. 6 ± 0. 2) cm,( 2. 1 ± 0. 3) cm,( 1. 4 ± 0. 1) cm,( 2. 1 ±0. 2) cm,( 1. 2 ± 0. 2) cm and( 2. 0 ± 0. 2) cm respectively. The distances between No. 2 needle and the posterior branch of the obturator nerve,anterior branch of the obturator artery,posterior branch of the obturator artery,obturator canal,internal pudendal vessels and nerves,and hymen were( 3. 0 ± 0. 3) cm,( 2. 9 ± 0. 2) cm,( 0. 6 ± 0. 2) cm,( 2. 5 ± 0. 3) cm,( 0. 8 ± 0. 2) cm and( 6. 1 ± 0. 4) cm respectively. Conclusion The AVWP can be treated with female anterior pelvic floor reconstruction by enhancing the supporting functions of level Ⅰ and Ⅱ.In order to reduce the injury of important vascular and nerve,the patients should be placed in lithotomy position and fully abduct thighs,and the appropriate position to insert and perform outside-in procedure should be selected.
Objective To identify the route of the female anterior pelvic floor reconstruction which is applied to treat anterior vaginal wall prolapse( AVWP),and to decrease the complication of procedure. Methods Three fresh cadavers were injected colored latex into radial artery. After 5 days,the anterior pelvic floor reconstruction were performed respectively when lactoprene had solidified. The distances between the trocars and related vascular,nerves and hymen were measured. Results There was no complication during all procedures. The distances between No. 1 needle and the posterior branch of the obturator nerve,anterior branch of the obturator artery,posterior branch of the obturator artery,obturator canal,internal pudendal vessels and nerves,and hymen were( 2. 6 ± 0. 2) cm,( 2. 1 ± 0. 3) cm,( 1. 4 ± 0. 1) cm,( 2. 1 ±0. 2) cm,( 1. 2 ± 0. 2) cm and( 2. 0 ± 0. 2) cm respectively. The distances between No. 2 needle and the posterior branch of the obturator nerve,anterior branch of the obturator artery,posterior branch of the obturator artery,obturator canal,internal pudendal vessels and nerves,and hymen were( 3. 0 ± 0. 3) cm,( 2. 9 ± 0. 2) cm,( 0. 6 ± 0. 2) cm,( 2. 5 ± 0. 3) cm,( 0. 8 ± 0. 2) cm and( 6. 1 ± 0. 4) cm respectively. Conclusion The AVWP can be treated with female anterior pelvic floor reconstruction by enhancing the supporting functions of level Ⅰ and Ⅱ.In order to reduce the injury of important vascular and nerve,the patients should be placed in lithotomy position and fully abduct thighs,and the appropriate position to insert and perform outside-in procedure should be selected.
引文
[1]Marschke J,Hengst L,Schwertner-Tiepelmann N,et al. Transvaginal single-incision mesh reconstruction for recurrent or advanced anterior vaginal wall prolapse[J]. Arch Gynecol Obstet,2015,291(5):1081-1087. doi:10. 1007/s00404-014-3497-9.
[2]Maher C,Feiner B,Baessler K,et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse[J]. Cochrane Database Syst Rev,2016,2:CD012079. doi:10. 1002/14651858.CD012079.
[3]Caquant F,Collinet P,Debodinance P,et al. Safety of trans vaginal mesh procedure:retrospective study of 684 patients[J]. J Obstet Gynaecol Res,2008,34(4):449-456. doi:10. 1111/j. 1447-0756. 2008.00820. x.
[4]吴伟英.前盆重建术对阴道前壁脱垂患者生活质量的影响[J].中国妇幼保健,2015,33(30):5920-5922. doi:10. 7620/zgfybj. j.issn. 1001-4411. 2015. 33. 75.
[5] Giarenis I,Robinson D. Prevention and management of pelvic organ prolapse[J]. F1000Prime Rep,2014,6:77. doi:10. 12703/P6-77.
[6]Delroy CA,Castro Rde A,Dias MM,et al. The use of transvaginal synthetic mesh for anterior vaginal wall prolapse repair:a randomized controlled trial[J]. Int Urogynecol J,2013,24(11):1899-1907. doi:10. 1007/s00192-013-2092-0.
[7]Jelovsek JE. Predicting urinary incontinence after surgery for pelvic organ prolapse[J]. Curr Opin Obstet Gynecol,2016,28(5):399-406. doi:10. 1097/GCO. 0000000000000308.
[8]De Lancey JO. Anatomic aspects of vaginal eversion after hysterectomy[J]. Am J Obstet Gynecol,1992,166(6 Pt 1):1717-1728.
[9]Palma PCR,Monteiro MVC,Ledesma MA,et al. Treatment of anterior vaginal wall prolapse using transvaginal anterior mesh with apical fixation:a prospective multicenter study with up to 2 years of follow-up[J].Int Neurourol J,2018,22(3):177-184. doi:10. 5213/inj. 1836036.018.
[10]Tamanini JT,de Oliveira Souza Castro RC,Tamanini JM,et al. A prospective,randomized,controlled trial of the treatment of anterior vaginal wall prolapse:medium term followup[J]. J Urol,2015,193(4):1298-1304. doi:10. 1016/j. juro. 2014. 10. 003.
[11]Mac Donald S,Terlecki R,Costantini E,et al. Complications of transvaginal mesh for pelvic organ prolapse and stress urinary incontinence:tips for prevention,recognition,and management[J]. Eur Urol Focus,2016,2(3):260-267. doi:10. 1016/j. euf. 2016. 06. 016.
[12]Juliato CR,Santos Júnior LC,Haddad JM,et al. Mesh surgery for anterior vaginal wall prolapse:a meta-analysis[J]. Rev Bras Ginecol Obstet,2016,38(7):356-364. doi:10. 1055/s-0036-1585074.
[13]Gyang AN,Feranec JB,Patel RC,et al. Managing chronic pelvic pain following reconstructive pelvic surgery with transvaginal mesh[J]. Int Urogynecol J,2014,25(3):313-318. doi:10. 1007/s00192-013-2256-y.
[14]Adamakis I,Katafigiotis I,Tyritzis SI,et al. Treating anterior vaginal wall prolapse with polypropylene mesh via the transoburator route minimizing the complications with the use of preventing measures. A prospective study with 2-year follow-up[J]. Minerva Ginecol,2015,67(3):231-238.
[2]Maher C,Feiner B,Baessler K,et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse[J]. Cochrane Database Syst Rev,2016,2:CD012079. doi:10. 1002/14651858.CD012079.
[3]Caquant F,Collinet P,Debodinance P,et al. Safety of trans vaginal mesh procedure:retrospective study of 684 patients[J]. J Obstet Gynaecol Res,2008,34(4):449-456. doi:10. 1111/j. 1447-0756. 2008.00820. x.
[4]吴伟英.前盆重建术对阴道前壁脱垂患者生活质量的影响[J].中国妇幼保健,2015,33(30):5920-5922. doi:10. 7620/zgfybj. j.issn. 1001-4411. 2015. 33. 75.
[5] Giarenis I,Robinson D. Prevention and management of pelvic organ prolapse[J]. F1000Prime Rep,2014,6:77. doi:10. 12703/P6-77.
[6]Delroy CA,Castro Rde A,Dias MM,et al. The use of transvaginal synthetic mesh for anterior vaginal wall prolapse repair:a randomized controlled trial[J]. Int Urogynecol J,2013,24(11):1899-1907. doi:10. 1007/s00192-013-2092-0.
[7]Jelovsek JE. Predicting urinary incontinence after surgery for pelvic organ prolapse[J]. Curr Opin Obstet Gynecol,2016,28(5):399-406. doi:10. 1097/GCO. 0000000000000308.
[8]De Lancey JO. Anatomic aspects of vaginal eversion after hysterectomy[J]. Am J Obstet Gynecol,1992,166(6 Pt 1):1717-1728.
[9]Palma PCR,Monteiro MVC,Ledesma MA,et al. Treatment of anterior vaginal wall prolapse using transvaginal anterior mesh with apical fixation:a prospective multicenter study with up to 2 years of follow-up[J].Int Neurourol J,2018,22(3):177-184. doi:10. 5213/inj. 1836036.018.
[10]Tamanini JT,de Oliveira Souza Castro RC,Tamanini JM,et al. A prospective,randomized,controlled trial of the treatment of anterior vaginal wall prolapse:medium term followup[J]. J Urol,2015,193(4):1298-1304. doi:10. 1016/j. juro. 2014. 10. 003.
[11]Mac Donald S,Terlecki R,Costantini E,et al. Complications of transvaginal mesh for pelvic organ prolapse and stress urinary incontinence:tips for prevention,recognition,and management[J]. Eur Urol Focus,2016,2(3):260-267. doi:10. 1016/j. euf. 2016. 06. 016.
[12]Juliato CR,Santos Júnior LC,Haddad JM,et al. Mesh surgery for anterior vaginal wall prolapse:a meta-analysis[J]. Rev Bras Ginecol Obstet,2016,38(7):356-364. doi:10. 1055/s-0036-1585074.
[13]Gyang AN,Feranec JB,Patel RC,et al. Managing chronic pelvic pain following reconstructive pelvic surgery with transvaginal mesh[J]. Int Urogynecol J,2014,25(3):313-318. doi:10. 1007/s00192-013-2256-y.
[14]Adamakis I,Katafigiotis I,Tyritzis SI,et al. Treating anterior vaginal wall prolapse with polypropylene mesh via the transoburator route minimizing the complications with the use of preventing measures. A prospective study with 2-year follow-up[J]. Minerva Ginecol,2015,67(3):231-238.