広汎子宮全摘術における尿管および膀胱神経温存と下腿浮腫の予防を安全確実に行う方法について(<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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[Objective] I reviewed about the nerve to be distributed over urinary tract, and the method of nerve sparing radical hysterectomy type III. And also I reviewed about the pelvic lymph-node and pelvic lymph-vessels, and the method to reduce the lymph-cyst and the edema of the lower limb after pelvic lymphadnectomy. [Methods] 1. Prevention of bladder paralysis : I recognized that all nerves which distribute to urinary tract (hypogastric nerve/pelvic plexus/bladder branch of pelvic plexus/ureter branch of pelvic plexus) are almost in the membrane which also contains the ureter. The uterine nerves, which distributes to the uterus and vagina, are distributed from pelvic plexus. When the uterine nerves were cut, the nerves which distribute to urinary tract can be shifted laterally. Then the para-colpium will be denuded and be cut widely without cutting the bladder nerves. 2. Prevention of a lymph-cyst and a lymph-edema of lower limbs : A lymph-flow from the lower limbs to the pelvic cavity are distributed to superior femoral node and to a obturator node. These two parts are origins of lymph-cysts. To prevent the lymph-cyst at the part of superior femoral node, superior femoral nodes are reserved to be connected to the big lymph-vessels on the psoas muscle intentionally. Then the lymph flow passes through the big lymph-vessel to the para-aortic area. And also to prevent the lymph-cyst at the part of a obtulator node, the dexon mesh (coarse) are sutured on the pelvic peritoneum, then the lymph flow are passed through the dexon mesh to the peritoneal cavity. [Results] "The urinary tract nerve preservation" 1. The urinary tract nerve preservation : (1) The ureter movement just after operation : A-group (perfect nerve preservation group, 31 cases) : All cases were preserved, B-group (a part nerve preservation group : 22 cases)/C-group (original type ID radical hysterectomy) : all the cases became hydro-ureter. (2) Urinary function test (self urination within 3 weeks after operation) : A-group ; All the cases established the self urination. B-group : Establishment of the self urination were 21/22 (95.5%). This result shows that the preservation of the nerves was not complete in bladder nerve by incision of the para-cervical fascia, which contains the bladder nerve. C-group : Establishment of the self urination 17/21 (81.0%). In C-group, about 20% urinary disturbance were continued. 2. The cutting area of the para-colpium, and the range of the lymph-adnectomy : (1) The para-colpium will be cut very widely in A-group as well as B & C-groups. (2) The area of lymph-adnectomy will be wider in A group than B and C groups. "A pelvic lymphcyst and lymph-edema of lower limbs" 1. The eruption/persistence of lymph-cyst of D-group (peritoneal suture group) : 15/21 : 6/21 (71%/29%) , E-group (with superior femoral node) : 38/60 : 14/60 (63%/23%) , F-group (without superior femoral node) : 1/18 : 0/18 (5.6%/0%). There were lower eruption (p< 0.001). /persistence (p< 0,05) of lymph-cyst in F-group than in D & E-groups. 2. The eruption/persistence of lymph-edema of D-group : 2/21 : 2/21 (9.5%/9.5%) , E-group : 9/60 : 1/60 (15.0%/1.8%) , F-group : 1/18 : 0/18 (5.6%/0%). There were lower eruption(p< 0.05) of lymph-edema in F-group than in D and E-groups. There are no persistence of lymph-edema in F-group. 3. The postoperative ileus is in D-group : 2/21 (9.5%) , E & F-groups(with dexon mesh) : no case. This result show that the dexon mesh can protect the ileus [Conclusions] I showed that the new nerve-sparing method and the nethod of preserving the co-lateral lymph vessel in radical hysterectomy can reduce the side effects of radical hysterectomy.
社団法人日本産科婦人科学会の論文
2004-12-01

著者

吉田信隆
広島市立広島市民病院

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