***脱に対する腟壁支持補強術式の併用法に関する臨床的検討(<特集>第56回日本産科婦人科学会シンポジウム4 : 安全性および確実性の向上を目指した婦人科手術の工夫)

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INTRODUCTION : In the aging society, genital organ prolapse (POP) such as uterine prolapse, cystocele and vaginal prolapse after hysterectomy has been increasing. POP frequently causes urinary incontinence, defect of fecal evacuation and dyspareunia and consequently affects the quality of life of aging women. Al-though conventional vaginal hysterectomy and anterior/posterior colporrhaphy have been applied for POP in Japan, anatomical defects of pelvic support are different on individual basis and surgical repair for POP should be based on an anatomical diagnosis to be reviewed in each case, not uniform illness. Vaginal supporting mechanism is divided into three levels (Level I , vaginal apex support by uterosacral ligament and cardinal ligament complex ; Level n , upper 2/3 vaginal support by attaching to pelvic side wall ; Level in , a urethral and lower 1/3 vaginal support by fusing perinea! membrane). The lower urinary tract is supported in the shape of a hammock in pelvic viscera by anterior vaginal wall and pubocervical fascia. In this study, I introduced combined reinforcement surgeries for level I and level III vaginal wall support of POP. OPERATIONS AND RESULTS : (1) Combination technique of iliococcygeal fascia colpopexy and the modified McCall culdeplasty for Level I support Thirty three patients with uterine prolapse and cystocele over grade 2 by half-way system (Baden & Walker) underwent the combined surgeries. For control, 20 patients diagnosed as POP with same grade underwent the modified McCall culdeplasty alone for the vaginal apical support. Briefly, conventional vaginal hysterectomy was performed and removed the peritoneum on Douglas pouch which formed an enterocele. Uterosacral ligaments on both sides were palpated and grasp the firm portion by Pean forceps. Vaginal posterior fornix and bilateral uterosacral ligaments were sutured doubly with #1PDS (McCall culdeplasty). Bilateral pararectal space around the ischial spine was exfoliated from vaginal cuff to expose the iliococcygeus fascia. #1 PDS string was penetrated on this fascia by Deschamp ligature carrier and sutured them to vaginal side wall. If necessary, anterior and/or posterior colporrhaphy was added. Operation time, blood loss, postoperative pain, residual urine, hospitalization, and recurrent events of vaginal laxation were carefully followed. The average operation time extended 33min and blood loss increased 120ml by additional iliococcygeus fascia colpopexy. Any significant differences of postoperative pain, residual urine volume, hospitalization in both groups were not observed. Anterior vaginal wall laxation and urethral Hypermobility were observed in 6% of the combined surgery group and in 35% of the group of McCall culdeplasty alone. (2) Combination technique of Tension-free Vaginal Tape (TVT) operation and the anterior colporrhaphy for postoperative stress urinary incontinence (SUI) TVT is designed as a urethral sling operation to cure urethral hypermobility. Postoperative SUI is frequently observed in POP patients. For application of TVT during general anesthesia, we injected saline of 300〜350ml in a bladder under general anaesthesia and measured intravesical pressure by suprapubic abdominal tapping technique. TVT was performed for 11 patients with SUI and POP after vaginal hysterectomy and anterior colporrhaphy. Operation time extended 25min by TVT. No a additional blood loss was recognized. All cases have been continent so far for 13〜24 months, while residual urine volume more than 50ml continued for 10 days in 3 cases. In comparison with 12 cases underwent TVT alone, no significant adverse effect was observed. These results indicate that CONCLUSIONS : (1) Additional iliococcygeus fascia colpopexy with the modified McCall culdeplasty was safe and effective procedure to reinforce the vaginal apical support (Level I) for POP. (2) Adjustment of TVT position was possible under general anesthesia indicating that TVT operation can be performed as an additional operation at the same time of other surgeries for POP to prevent postoperative SUI.
社団法人日本産科婦人科学会の論文
2004-12-01

***脱に対する腟壁支持補強術式の併用法に関する臨床的検討(<特集>第56回日本産科婦人科学会シンポジウム4 : 安全性および確実性の向上を目指した婦人科手術の工夫)

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