Women with advanced pelvic organ prolapse and levator ani muscle avulsion would significantly benefit from mesh repair surgery
Women with advanced pelvic organ prolapse and levator ani muscle avulsion would significantly benefit from mesh repair surgery
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DOI：
10.1002/uog.23109
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发表时间：
2021-04-01
影响因子：
7.1
通讯作者：
Chan, S. S. C.
中科院分区：
文献类型：
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作者：
Wong, N. K. L.;Cheung, R. Y. K.;Chan, S. S. C.
目的由于担心盆腔器官脱垂（POP）的并发症，一些国家暂停了补片手术。然而，补片修复已被证明可以降低手术后脱垂复发的风险。鉴于这一争议，我们的目的是评估iii期或iv期POP女性在补片修复手术后与自然组织修复后POP的主观和客观复发发生率。方法：这是一项前瞻性观察研究，研究对象是2013年至2018年期间出现iii期或iv期POP并接受原发性脱垂手术的女性。术前进行经会阴超声检查，离线分析容积以评估提肛肌（LAM）撕脱的存在。所有妇女都被建议进行网状修复或原生组织重建。补片修复组术后随访5年，自体组织修复组术后随访2年。随访时评估脱垂症状和POP量化（POP- q）分期。POP主观复发定义为患者报告的脱垂症状（阴道膨出感或拖拽感）。客观复发定义为POP-Q >= II期。比较使用和未使用补片的妇女主客观脱垂的复发率。采用多因素回归分析确定POP复发的危险因素。结果共招募了154名iii期或iv期脱垂的中国女性。其中，104例（67.5%）进行了补片修复（57例经腹，47例经阴道），50例（32.5%）进行了原生组织修复手术。95例（61.7%）发生LAM撕脱。网片修复组的POP主观复发率（4.8% vs 20.0%, P = 0.003）和客观复发率（20.2% vs 46.0%, P = 0.001）均显著低于原生组织修复组。在多因素logistic回归分析中，补片修复与降低脱垂的主观复发风险（比值比（OR）， 0.20 (95% CI, 0.07-0.63)）和客观复发风险（OR, 0.16 (95% CI, 0.07-0.55)）显著相关。在女性LAM撕脱伤的亚组分析中，补片修复显著降低了POP的主观复发风险（OR, 0.24 (95% CI, 0.07-0.87)）和客观复发风险（OR, 0.23 (95% CI, 0.09-0.57)）。补片相关并发症发生率低，补片暴露可保守治疗或小手术治疗。结论：与原生组织修复相比，补片修复手术与iii期或iv期POP女性脱垂的主观复发风险降低5倍和客观复发风险降低6倍相关。在伴有LAM撕脱的女性中，补片修复手术可使POP的客观和主观复发率降低4倍。补片相关并发症发生率低，补片暴露可保守治疗或小手术治疗。对于这些高危女性来说，网状手术的好处似乎超过了网状并发症的风险，它可能是这类女性的一种治疗选择。(C) 2020年国际妇产科超声学会。
Objectives Mesh repair surgery for pelvic organ prolapse (POP) has been suspended in some countries owing to concerns about its associated complications. However, mesh repair has been shown to reduce the risk of prolapse recurrence after surgery. In view of this controversy, our aim was to assess the incidence of subjective and objective recurrence of POP following mesh repair surgery vs native-tissue repair in women with Stage-III or Stage-IV POP.Methods This was a prospective observational study of women who presented with Stage-III or Stage-IV POP and received primary prolapse surgery between 2013 and 2018. Transperineal ultrasound was performed before the operation and volumes were analyzed offline to assess the presence of levator ani muscle (LAM) avulsion. All women were counseled on either mesh repair or native-tissue reconstruction. The mesh-repair group was followed up for up to 5 years and the native-tissue-repair group for up to 2 years after the operation. Prolapse symptoms and POP quantification (POP-Q) staging were assessed at follow-up. Subjective recurrence of POP was defined as symptoms of prolapse (vaginal bulge sensation or dragging sensation) reported by the patient. Objective recurrence was defined as POP-Q >= Stage II. The subjective and objective recurrences of prolapse were compared between women with and those without mesh use. Multivariate regression analysis was used to identify risk factors for the recurrence of POP.Results A total of 154 Chinese women with Stage-III or Stage-IV prolapse were recruited. Of these, 104 (67.5%) underwent mesh repair (transabdominal in 57 women and transvaginal in 47 women) and 50 (32.5%) had native-tissue repair surgery. Ninety-five (61.7%) women had LAM avulsion. Both the subjective POP recurrence rate (4.8% vs 20.0%; P = 0.003) and the objective recurrence rate (20.2% vs 46.0%; P = 0.001) were significantly lower in the mesh-repair group than in the native-tissue-repair group. On multivariate logistic regression analysis, mesh repair was associated significantly with a reduced risk of subjective recurrence (odds ratio (OR), 0.20 (95% CI, 0.07-0.63)) and of objective recurrence (OR, 0.16 (95% CI, 0.07-0.55)) of prolapse. On subgroup analysis of women with LAM avulsion, mesh repair significantly reduced the risk of subjective recurrence (OR, 0.24 (95% CI, 0.07-0.87)) and objective recurrence (OR, 0.23 (95% CI, 0.09-0.57)) of POP. The incidence of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery.Conclusions Mesh repair surgery, compared with native-tissue repair, was associated with a 5-fold reduction in the risk of subjective recurrence and a 6-fold reduction in the risk of objective recurrence of prolapse in women with Stage-III or Stage-IV POP. In women with concomitant LAM avulsion, mesh repair surgery was associated with a 4-fold reduction in both objective and subjective recurrence of POP. The rate of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery. The benefit of mesh surgery for these high-risk women appears to outweigh the risks of mesh complications, and it could be a treatment option for this group of women. (C) 2020 International Society of Ultrasound in Obstetrics and Gynecology.