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1、盆腔器官脱垂诊治盆腔器官脱垂诊治相关问题相关问题 北京大学人民医院妇科北京大学人民医院妇科 王建六王建六1 1Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu盆腔器官脱垂评估方法有哪些POP-Q分期如何实施传统手术方法是否真的存在问题如何正确评判新的盆底重建手术2 2Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-L
2、iu盆腔器官脱垂评估方法盆腔器官脱垂评估方法3 3Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu外阴情况的评估外阴状态，阴裂长度,会阴体长度正常会阴体长度为2-4cm正常经产妇阴道外口长约4-6cm阴道口宽大表明会阴浅横肌撕裂4 4Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu会阴体移动度检查用一手指放在阴
3、道或直肠内，向检查者方向轻拉会阴体，同时评估会阴体厚度 会阴体移动性大于1cm， 为移动度过大直肠阴道膈有裂伤和分离5 5Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu阴道检查用标准的双叶窥器检查阴道和宫颈用单叶窥器置入阴道下压后壁，检查前壁的最大脱垂。单叶窥器下压前壁检查阴道后壁情况注意阴道侧壁及顶端下降的程度同时用子宫探针或直尺测量相应数据6 6Peking University Peoples Peking University Peoples
4、 Hospital Wang Jian-LiuHospital Wang Jian-Liu7 7Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu8 8Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu确定阴道旁缺陷、中央型缺陷用环形钳撑开阴道侧沟屏气用力而没有出现阴道壁膨出，而两侧阴道侧壁向中央膨隆，提示存在阴道
5、旁缺陷。阴道旁缺陷常有正常阴道皱襞。屏气用力时撑开阴道侧沟，阴道前壁仍膨出，提示中央缺陷。出现中央型缺陷时，正常阴道壁的皱襞消失，阴道前壁呈平滑、光亮的外观。9 9Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu1010Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu1111Peking University
6、Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu评价盆底的收缩力手指位于阴道口内约5cm处5点及7点部位的耻骨直肠肌和耻骨尾骨肌让患者收缩肛提肌及阴道，阴道内手指感受收缩力。检查者将另一只手放在患者的腹部以检测患者是否收缩了腹肌。盆底肌收缩持续时间也反映盆底肌肌力。1212Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu检查耻骨宫颈筋膜膀胱膨出说
7、明有阴道筋膜撕裂。检查时将卵圆钳放置于阴道顶部，相当于耻骨宫颈筋膜白线的位置如放置后脱垂消失，为白线处筋膜损伤如膨出仍存在，说明为中线处筋膜损伤1313Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu1414Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu肛门和直肠检查 评估会阴体完整性及肛门括约肌张力评估会阴
8、体完整性及肛门括约肌张力检查方法为将一食指置于阴道内，另一只手的食指置于直肠内，两手指对合并慢慢向会阴体滑出，可检查直肠膨出。高位触诊可检查肠疝。1515Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu直肠阴道膈触诊高位触诊RectoceleEnterocele1616Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-
9、Liu如何评判疾病程度，选择适宜的治疗如何评判疾病程度，选择适宜的治疗1717Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu老师言传身教1818Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu国内标准-子宫脱垂目前国内所用的分期是根据1981年全国部分省、自治区“两病”科研协作组的意见进行分期。子宫脱垂：以坐
10、骨棘水平为标准进行分度1919Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-LiuI度 轻：宫颈最低点达坐骨棘以下 重：宫颈最低点达处女膜缘II度 轻：宫颈脱出阴道口外 重：宫颈和部分宫体脱出阴道口外III度：宫颈和宫体全部脱出阴道口外2020Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu膀胱脱垂、直肠脱垂的分度
11、以患者平卧时用力屏气时阴道前后壁膨出的程度分度I度：阴道壁达处女膜缘，但未膨出于阴道外II度：部分阴道壁已膨出阴道外III度：阴道壁已全部膨出于阴道外 2121Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu存在问题I度：轻重之间？II度：轻重之间？II度和III度之间？2222Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang
12、Jian-Liu盆腔器官脱垂量化分期法（POP-Q）POP-QPOP-Q（pelvic organ pelvic organ prolapseprolapse quantitationquantitation）是）是19951995年年美国妇产科学会制定。美国妇产科学会制定。19961996年被美国妇科泌尿学协会年被美国妇科泌尿学协会(American (American UrogynecologyUrogynecology Society, AUGS)Society, AUGS)认可、接纳并认可、接纳并推荐在临床、科研中使用推荐在临床、科研中使用推荐在临床、科研中使用推荐在临床、科研中使用，
13、至今已成为至今已成为国外应用最广泛国外应用最广泛国外应用最广泛国外应用最广泛的脱垂评价体系。的脱垂评价体系。20042004年国内人民卫生出版社出版的年国内人民卫生出版社出版的妇产科学妇产科学妇产科学妇产科学第六版第六版第六版第六版已已将将POP-QPOP-QPOP-QPOP-Q编入编入编入编入教材。教材。2323Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-LiuPOP-QPOP-Q特点特点用阴道前、后壁及顶端上的各2个解剖点与处女膜平面关系界定阴道前后
14、壁及子宫脱垂程度。解剖上的6个点以厘米计算, 位置精确。 以阴道前壁或后壁膨出替代了膀胱、直肠膨出。2424Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu阴道前壁测量点：阴道前壁测量点：AaAa， BaBaAaAa点：位于阴道前壁中线距尿道外口点：位于阴道前壁中线距尿道外口3cm3cm， AaAa点相对于处女膜的范围从点相对于处女膜的范围从3 3至至3 3BaBa点：从阴道前穹隆的阴道反折至点：从阴道前穹隆的阴道反折至AaAa点的阴点的阴 道前壁上段
15、的任一最远的位点。规定在道前壁上段的任一最远的位点。规定在 无脱垂的情况下无脱垂的情况下BaBa点为点为3 3。2525Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu 阴道后壁测量位点：阴道后壁测量位点：ApAp， BpBpApAp点：位于阴道后壁中线距处女膜点：位于阴道后壁中线距处女膜3cm3cm。规规定定ApAp点相对于处女膜的测量范围从点相对于处女膜的测量范围从3 3至至3cm3cm。BpBp点：从阴道后穹隆的阴道反折至点：从阴道后穹隆的阴道反
16、折至ApAp点的点的阴道后壁上段的任一最远的位点。按定阴道后壁上段的任一最远的位点。按定义，无脱垂的情况时义，无脱垂的情况时BpBp点为点为3cm3cm。2626Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu宫颈或阴道顶端测量位点：宫颈或阴道顶端测量位点：C C， D DC点：表示宫颈最远端或子宫全切术后阴道断端的前边缘。D点：表示有宫颈的妇女的后穹隆的部位。它代表子宫骶韧带附着宫颈后壁的水平。这个测量点可将骶主韧带悬吊功能丧失与宫颈延长鉴别。当宫颈
17、缺如时不测量D点2727Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu三条线：三条线：TVLTVL，GHGH，PBPB阴道全长阴道全长(TVL) ：是当是当C C或或D D处于完全正常位处于完全正常位置时阴道的最大深度（脱垂时将置时阴道的最大深度（脱垂时将C C、D D恢复到恢复到正常位置）正常位置）生殖孔（生殖孔（GHGH）：）：从尿道外口中点量至处女膜从尿道外口中点量至处女膜后缘中线后缘中线会阴体会阴体(PBPB)：从生殖孔的后缘至肛门口中点：从
18、生殖孔的后缘至肛门口中点2828Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu2929Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu图图2. 记录记录POP-Q的的33格表格表anterior wall anterior wall AaAa anterior wallanterior wall BaBa C
19、ervix or cuffCervix or cuff C C genital hiatusgenital hiatus ghgh perinealperineal body body pbpb Total vaginal lengthTotal vaginal length tvltvl posterior wallposterior wall ApAp posterior wallposterior wall Bp Bp Posterior Posterior fornixfornix D D 3030Peking University Peoples Peking University
20、Peoples Hospital Wang Jian-LiuHospital Wang Jian-LiuPOP-QPOP-Q的的3333格表可清楚客观地反映盆腔格表可清楚客观地反映盆腔器官脱垂变化的各个部位的具体数值器官脱垂变化的各个部位的具体数值根据各个数值可画出脱垂的图形。根据各个数值可画出脱垂的图形。像肿瘤像肿瘤TNMTNM分期一样，分期一样，POP-QPOP-Q可将盆腔器可将盆腔器官脱垂按其进展不同程度分为官脱垂按其进展不同程度分为5 5期。期。 3131Peking University Peoples Peking University Peoples Hospital Wang
21、Jian-LiuHospital Wang Jian-Liu 盆腔器官脱垂的量化分期盆腔器官脱垂的量化分期0 0 0 0 期期期期 无脱垂。无脱垂。无脱垂。无脱垂。I I I I期期期期 测量数值与测量数值与测量数值与测量数值与0 0 0 0期不符，测量值期不符，测量值期不符，测量值期不符，测量值 - 1 - 1 - 11cm 1cm 1cm 1cm ，但但但但 少于阴道全长。（即：测量数值少于阴道全长。（即：测量数值少于阴道全长。（即：测量数值少于阴道全长。（即：测量数值+1+1+1+1） IVIVIVIV期期期期 下生殖道完全外翻。脱垂最远的部分至少下生殖道完全外翻。脱垂最远的部分至少下生
22、殖道完全外翻。脱垂最远的部分至少下生殖道完全外翻。脱垂最远的部分至少为后阴道全长的数值。为后阴道全长的数值。为后阴道全长的数值。为后阴道全长的数值。3232Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-LiuPOP-Q分期的不足POP-QPOP-Q分期过于繁琐，分期过于繁琐，不好理解，很难学习和不好理解，很难学习和应用。应用。分期没有提及阴道侧壁分期没有提及阴道侧壁情况。情况。3333Peking University Peoples Peking Uni
23、versity Peoples Hospital Wang Jian-LiuHospital Wang Jian-LiuJIANLIU3434Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu不会则 难会则不难3535Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu3636Peking University Pe
24、oples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu“传统”盆腔器官膨出修复手术存在问题曼式手术阴式子宫切除术阴道前后壁修补术会阴修补术3737Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu国内近年国内近年传统传统手术治疗盆腔器官脱垂报道（手术治疗盆腔器官脱垂报道（1 1）金玲、王建六等金玲、王建六等 20052005年年 盆腔器官脱垂术后盆腔器官脱垂
25、术后盆腔器官脱垂术后盆腔器官脱垂术后复发相关因素复发相关因素复发相关因素复发相关因素分析分析分析分析 1999199920042004年期间完整资料年期间完整资料 7474例例术式术式 TH 100% AC 88% PC 80%TH 100% AC 88% PC 80%术后随访术后随访 31.431.4月（月（5 56060个月）个月） 复发复发复发复发 54545454（其中（其中（其中（其中I I I I期期期期79%79%79%79%，IIIIIIII期以上期以上期以上期以上21%)21%)21%)21%) 穹隆脱垂穹隆脱垂 2323例，前壁例，前壁 2828例，后壁例，后壁 1111例
26、例3838Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu国内近年国内近年传统传统手术治疗盆腔器官脱垂报道（手术治疗盆腔器官脱垂报道（2 2）20062006年游珂、韩劲松等，年游珂、韩劲松等，传统手术治疗盆腔脏器脱垂术传统手术治疗盆腔脏器脱垂术传统手术治疗盆腔脏器脱垂术传统手术治疗盆腔脏器脱垂术后效果初探后效果初探后效果初探后效果初探 212 212 例中随访例中随访105105（ 49.5% 49.5% ），），14.6%14.6%（31/2123
27、1/212）拒绝随访。）拒绝随访。 34.4% (73/212)34.4% (73/212)完成问卷完成问卷调查以及盆腔检查调查以及盆腔检查POP-Q, POP-Q, 随访时间中位数为随访时间中位数为28.628.6月月主观治愈主观治愈主观治愈主观治愈94.594.594.594.5，客观治愈，客观治愈，客观治愈，客观治愈60.0%60.0%60.0%60.0%术后复发术后复发2828人（人（38.4%)38.4%)（POP-Q II POP-Q II 度度及以上及以上）3939Peking University Peoples Peking University Peoples Hospit
28、al Wang Jian-LiuHospital Wang Jian-Liu过去文献国内1959-1984年 19531953年创刊的年创刊的中华妇产科杂志中华妇产科杂志文献文献 19591959年年19831983年年 术式术式 阴式子宫切除阴式子宫切除+ +阴道壁修补为主阴道壁修补为主 1959 1959 于阑馥于阑馥 阴道壁修补阴道壁修补2323例例 随访随访1717例（例（74%74%）复发）复发4 4例例（23.523.523.523.5) ) ) ) 1980 1980 高瑞英高瑞英 阴式子宫切除阴式子宫切除+ +阴道壁修补阴道壁修补127127例例 随访随访117117（92.1
29、92.1） 随访时间随访时间1 19 9年年 膀胱膨出膀胱膨出3131（26.526.526.526.5） 直肠膨出直肠膨出4 4（3.43.4） 4040Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu国外文献综合文献治愈率：综合文献治愈率：30%-49%术后平均复发时间为术后平均复发时间为25.1525.15 14.114.1个月个月 Gordon D et al. Gordon D et al. NeurourolNeurourol Urodyn
30、,1999 Urodyn,19994141Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu客观评价盆底重建新术式补片在盆底重建中的应用4242Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu4343Peking University Peoples Peking University Peoples Hospi
31、tal Wang Jian-LiuHospital Wang Jian-Liu生物补片生物补片-脱细胞生物组织补片脱细胞生物组织补片4444Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu中盆腔SSLFP-IVS骶前固定术4545Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-LiuSacrospinous Liga
32、ment Suspension（Fixation） The sacrospinous ligament suspension fixation (SSLF) procedure is a less invasive and moderately successful operation for vaginal vault prolapse. 4646Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu4747Peking University People
33、s Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu阴道顶端骶骨固定术阴道顶端骶骨固定术-Straight-in-Straight-in解剖学重建！功能重建？4848Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu 重度膨出患者效果？4949Peking University Peoples Peking University Peoples Hospital
34、Wang Jian-LiuHospital Wang Jian-Liu前盆腔重建不足？中盆腔重建不足？后盆腔重建不足？联合（多部位）缺陷？5050Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu全盆腔重建的概念包括：阴道前壁脱垂（中央型，旁侧缺陷）子宫脱垂（阴道穹隆脱垂）阴道后壁脱垂（直肠脱垂）但不包括：尿道脱垂会阴损伤5151Peking University Peoples Peking University Peoples Hospital Wa
35、ng Jian-LiuHospital Wang Jian-Liu5252Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu改进的全盆底重建12例手术小补片术后随访：3例侵蚀 2例复发李亚兰李亚兰 张晓红张晓红 王建六王建六 等等 中国妇产科临床杂志中国妇产科临床杂志 200820085353Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu5454Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu5555Peking University Peoples Peking University Peoples Hospital Wang Jian-LiuHospital Wang Jian-Liu
