Clinical Study On Surgical Treatment Of Pelvic Organ Prolapse

Background:Pelvic organ prolapse(hereafter referred as POP)is a serious social and life problem with high incidence rate and incurs heavy financial burdens.The treatment of POP can be either surgical or non-surgical.For light POP non-surgical treatment should be undertaken in the first place.Only when the treatment is invalid,should surgical treatment be undertaken.The surgical treatment of POP dates back to long time ago and boasts a great variety,the most typical of which is transvaginal hysterectomy(herafter referred as TVH)plus repair of vaginal anterior and posterior wall.With the further anatomic understanding of the pelvic floor,the improvement of surgical instruments as well as the invention and application of new repair materials, many new surgical methods evolved.Transvaginal Mesh,TVM began to be used on POP patients in surgical treatment.As a new surgical technique,TVM can better repair the defects and realize the structural reconstruction and tissue replacement.The recurrence rate of TVM surgery is lower.The short-term and mid-term effect are stable and the long-term effect need further observation.ObjectiveTo investigate the clinical significance of TVM and TVH plus repair of vaginal anterior and posterior wall on the treatment of POP.Materials and MethodsSubjects:sixty patients with POP who have undergone operation at QiLu Hospital from June 2005 to February 2008 was selected.Among whom 42 cases are uterine prolapse,3 cases are fundus of vaginal prolapse,43 cases are vaginae anterior prolapse,35 cases are vaginae posterior prolapse.36 cases accompaned old perineal laceration And all their POP-Q stage wereⅡ～Ⅳ.The ages of the patients range from 36 to 86,with the average of 55.32 years.None of the patients have smoking and excessive drinking.None of the patients received hormone replacement therapy.The patients were randomly divided into two groups:the study group and the control group.In each group there are respectively 30 patients.In the study group,all patients received TVM,among which 20 received TVH+TVM as study group 1 and 4 received TVM routine surgery as study group 2 and 6 received TVM routine surgery as study group 3.In the control group 30 were given routine traditional vaginal hysterectomy plus repair of anterior and posterior wall of the vagina.Methods:1.Operation indication:1.1 TVH+ante-pelvicTVM:(1)uterine prolapse,＞POP-QⅡ.(2)vaginae anterior prolapse,＞POP-QⅡ.(3)age:over fifty years old,who requires hysterectomy.1.2 TVH+whole pelvic TVM:(1)uterine prolapse,＞POP-QⅡ.(2)vaginae anterior prolapse,＞POP-QⅡ.(3)vaginae posterior prolapse,＞POP-QⅡ.(4)age:over fifty years old,who requires hysterectomy.1.3 Ante-pelvic TVM without hysterectomy:(1)uterine prolapse,Ⅰ～Ⅱ.(2) vaginae anterior prolapse,＞POP-QⅡ.(3)young and requiring to keep uterus;(4) senior patients who can not withstand an operation of a large range.1.4 Whole pelvic TVM without hysterectomy:(1)uterine prolapse,POP-QⅠ～Ⅱ.(2)vaginae anterior prolapse,＞POP-QⅡ.(3)vaginae posterior prolapse,＞POP-QⅡ.(4)young and requiring to keep uterus;(5)senior patients who can not withstand an operation of a large range.1.5 Ante-pelvic TVM after hysterectomy:(1)fornix of vaginal prolapse,＞POP-QⅡ.(2)vaginae anterior prolapse,＞POP-QⅡ.1.6 Whole pelvic TVM after hysterectomy:(1)fornix of vaginal prolapse,＞POP-QⅡ.(2)vaginae anterior prolapse,＞POP-QⅡ.(3)vaginae posterior prolapse,＞POP-QⅡ. 1.7.TVH plus repair of vaginal anterior and posterior wall:(1)POP,＞POP-QⅡ. (2)without reproductive need.(3)without maglignant diseases.2.Surgical methods:In study group 1,7 patients received TVH+ante-pelvic TVM,13 received TVH+whole pelvic TVM.In study group 2,4 were given TVM without hysterectomy,among whom 2 were given ante-pelvic TVM surgery,1 was given whole pelvic TVM surgery,1 was given Prolift surgery.In study group 3,6 received TVM surgery,among whom 1 received ante-pelvicTVM surgery and 5 received whole pelvic TVM surgery.3.Medical examination before operation:including regular health examination, obstetrics check,POP-Q,sonography and TCT.4.Relevant information on the operation:All the parameters during the operation have been recorded,such as bleeding volume,operating time.The parameters during recovery after the operation were also recorded,such as the indwelling catheter time, mean in-hospital period and complications.The POP-Q values and the length of the vagina were measured before and after the surgery.5.Follow-up:Each patient was followed up every 3 months during the first year after the operation and during the second year after the operation was followed up every half year.The follow-up includes questions as to whether there was recurrence and whether sexual life was affected.SPSS 11.0 was used for statistical analysis.T-test was used to process the data of the two patient groups,and the result is measured by mean+standard deviation.The contrast between the groups in surgical cure rate,the recurrence rate,and postoperative complications is measued by X~2 test.Statistical analysis is undertaken with a=0.05 as the test standard.Results1.Analysis of clinical information:There were no significant difference between the four groups in the aspects such as the degree of POP,and general situation of the patient,for example,age,body mass index,delivery ways,reproductive history, menopause,as well as whether there was constipation(p＞0.05).2.Information on the operation: Operation time:The average operation time of study group 1 was 72.50±21.32 minutes,and the average operation time of study group 2 was 51.12±11.73 minutes, and the average operation time of study group 3 was 53.47±10.61 minutes,while the average operation time of the control group was 75.52±20.65 minutes.There was no significant difference of operation time between study group 1 and the control group,.p＞0.05.There was significant difference between study group 2,study group 3 and the control group respectively,p＜0.05.The average operation time of study group 2 and study group 3 is significantly shorter than the other two groups.Bleeding during the operation:For study group 1 the average amount of bleeding was 75.31±23.52ml,for study group 2 the average amount of bleeding was 29.67±10.52ml,for study group 3 the average amount of bleeding was 31.33±10.66ml and for the control group the average amount of bleeding was 81.12±25.73ml.There was no significant difference between study group 1 and the control group(p＞0.05). The amount of bleeding of study group 2 and study group 3 was significantly different from the control group respectively(p＜0.05).Indwelling catheter time:No significant difference was found(p＞0.05).Mean in-hospital time:For study group 1 it was 9.82±1.73 days,for study group 2 was 6.02±0.57 days,for study group 3 was 6.11±0.78 days and for the control group it was 10.26±2.15 days.Study group 2 and study group 3 is significantly shorter than the control groups(p＜0.05),while there is no significant difference between study group 1 and the control group(p＞0.05).As to the rate of complications after the operation there is no significant difference among the four groups(p＞0.05).3.Clinical evaluation after operation:Examination result of POP-Q:The POP-Q degrees of the four groups are all at the cured level 0 orⅠ.The comparison of vaginal length:the average vaginal lengths before and after operation are 6.81±0.92cm,6.78±1.07cm for study group 1,6.83±0.95cm, 7.05±0.51 cm for study group 2,6.76±0.89cm,6.69±0.67cm for study group 3 and 6.92±1.17cm,5.27+0.94cm for the control group.There are no statistically significant difference among the four groups in terms of vaginal length before the operation (p＞0.05).After operation,the vaginal length of the control group is significantly shorter than the vaginal length before the operation.The vaginal length of study group 1 and study group 2 and study group 3 did not show significant change after the operation,and compared with the control group,there was significant difference respectively(p＜0.05).4.Follow-up:The maximum follow-up was up to two and half years,and the average of the follow-up was eight months.The rate of follow-up for the study group is 100%while the rate of follow-up for the control group is 96.67%as one patient was lost.Recurrence rate:In the study group,there was one case of recurrence rate;the cure rate is 96.67%,and the recurrence rate is 3.33%.In the control group there were 5 cases of recurrence;the cure rate is 83.33%and the recurrence is 16.67%.In the study group there was one case of the erosion of the mesh,and the occurrence rate is 3.33%.There is significant difference between the study group and the control group in the recurrence rate(p＜0.05)with the figure of the study significantly lower than the control group.The impact on the quality of sexual life:In the study group there were 3 cases of pain in sexual life and in the control group there were 7 cases of complaint about the lowering of the quality of sexual life.There was significant differece between the study group and the control group in terms of sexual life(p＜0.05).The impact on the study group is significantly smaller than the impact on the control group.Conclusion1.Transvaginal hysterectomy plus repair of vaginal anterior and posterior wall of POP and TVM are both effective ways in the treatment of POP.2.As a new surgical technique,TVM can better repair the defects and realize the structural reconstruction and tissue replacement.The recurrence rate of TVM surgery is lower.The short-term and mid-term effect are stable and the long-term effect need further observation.