经阴道单孔腹腔镜与经脐单孔腹腔镜子宫全切术近期疗效及术后盆底功能障碍的高危因素分析

Analysis of short-term efficacy and risk factors of pelvic floor dysfunction after total hysterectomy by transvaginal and transumbilical single-hole laparoscopy

摘要:

目的 探讨经阴道单孔腹腔镜（v-NOTES）与经脐单孔腹腔镜（u-LESS）子宫全切术近期疗效并分析术后盆底功能障碍（PFD）发生的影响因素。方法 回顾性分析2021年3月—2023年3月徐州市妇幼保健院156例行子宫全切术的患者的临床资料，按照手术方法分为v-NOTES组（94例）和u-LESS组（62例），按照是否发生PFD分为发生PFD组（21例）与未发生PFD组（135例）。收集记录所有患者的年龄、体质量指数（BMI）、绝经、人工流产史、孕产次、术后初次负重时间、术后初次性生活时间等一般资料。观察并记录所有患者的手术时间、术中出血量、留置尿管时间、肛门排气时间、住院时间等围手术期指标。采用视觉模拟评分法（VAS）评价患者术后疼痛情况，比较两组患者近期疗效、术后PFD发生情况及不同临床因素的差异。采用多因素一般Logistics回归模型分析PFD发生的危险因素。结果 v-NOTES组手术时间、留置尿管时间和肛门排气时间均短于u-LESS组（P <0.05）。u-LESS组与v-NOTES组术后6、12、24 h静息状态下VAS评分比较，结果 ①不同时间点的VAS评分比较，差异有统计学意义（P <0.05）；②u-LESS组与v-NOTES组VAS评分比较，差异有统计学意义（P <0.05），v-NOTES组VAS评分较低，相对镇痛效果较好；③v-NOTES组与u-LESS组VAS评分的变化趋势比较，差异无统计学意义（P >0.05）。v-NOTES组治疗总有效率高于u-LESS组（P <0.05）。u-LESS组与v-NOTES组术后PFD总发生率比较，差异无统计学意义（P >0.05）。发生PFD组与未发生PFD组年龄、BMI、孕产次和术后初次负重时间构成比较，差异均有统计学意义（P <0.05）。年龄大［O^R =1.191（95% CI：1.036，1.369）］、BMI高［O^R =1.196（95% CI：1.059，1.351）］、孕产次多［O^R =1.198（95% CI：1.057，1.359）］、术后初次负重时间≤3个月［O^R =1.372（95% CI：1.082，1.739）］均是子宫全切术后发生PFD的危险因素（P <0.05）。多因素一般Logistic回归模型预测的曲线下面积为0.877，敏感性为80.56%（95% CI：0.763，0.845），特异性为82.58%（95% CI：0.732，0.886）。结论 子宫全切术后PFD发生受患者年龄、BMI、孕产次、术后初次负重时间影响，基于Logistic回归构建的预测模型对子宫全切术后PFD的发生有一定预测价值，v-NOTES及u-LESS不影响术后PFD发生率，但采用v-NOTES可降低患者疼痛、疗效更好。

Abstract:

Objective To investigate the short-term efficacy of transvaginal laparoendoscopic single-site hysterectomy (v-NOTES) and transumbilical laparoendoscopic single-site hysterectomy (u-LESS), and to analyze the influencing factors of postoperative pelvic floor dysfunction (PFD).Methods A total of 156 patients who needed total hysterectomy in our hospital from March, 2021 to March, 2023 were retrospectively selected and divided into u-LESS group (n = 62) and v-NOTES group (n = 94) according to the surgical method. The general data of all patients, such as age, body mass index (BMI), menopause, induced abortion history, gravidity and parity, the first time of postoperative weight-bearing and the first time of postoperative sexual life, were collected and recorded. The operation time, intraoperative blood loss, indwelling catheter time, anal exhaust time, hospital stay and other perioperative indicators were recorded. Visual analogue scale (VAS) was used to evaluate the postoperative pain, and the short-term efficacy and the incidence of PFD were compared between the two groups. Logistic regression was used to analyze the risk factors of PFD.Results The operation time, indwelling catheter time and anal exhaust time in the v-NOTES group were all shorter than those in the u-LESS group (P < 0.05). (1)There were statistically significant differences in the VAS scores at rest at 6 h, 12 h and 24 h after surgery between the u-LESS group and the v-NOTES group (F = 219.021, P = 0.000). (2)There were also statistically significant differences in the VAS scores at rest between the u-LESS group and the v-NOTES group (F = 40.000, P = 0.000). The VAS score at rest in the v-NOTES group was lower than that in the u-LESS group, indicating a better analgesic effect. (3)There wasn't a statistically significant difference in the total effective rate between the u-LESS group and the v-NOTES group (F = 0.444， P = 0.642), and the total effective rate in the v-NOTES group was higher than that in the u-LESS group (P 0.05). There was no statistically significant difference in the total incidence of PFD between the u-LESS group and the v-NOTES group (P < 0.05). There were statistically significant differences in age, BMI, parity and the time of first postoperative weight-bearing between the PFD group and the non-PFD group (P < 0.05). Advanced age [O^R = 1.191(95% CI:1.036, 1.369) ], high BMI [O^R = 1.196(95% CI: 1.059, 1.351) ], multiple pregnancies and deliveries [O^R = 1.198(95% CI: 1.057, 1.359) ], and the time of first postoperative weight-bearing ≤ 3 months [O^R = 1.372(95% CI: 1.082, 1.739) ] were all risk factors for PFD after total hysterectomy (P < 0.05). The area under the curve of the logistic regression model was 0.877, with a sensitivity of 80.56% (95% CI: 0.763, 0.845) and a specificity of 82.58% (95% CI: 0.732, 0.886).Conclusions The incidence of PFD after total hysterectomy is affected by the patient's age, BMI, gravidity, parity and the time of first weight-bearing after operation. The prediction model based on logistic regression has certain predictive value for the occurrence of PFD after total hysterectomy. v-NOTES and u-LESS do not affect the incidence of postoperative PFD. However, v-NOTES can reduce the pain of patients and has better curative effect.