Tsar'kov P V, Sandrikov V A, Tulina I A, Darinov A A, Brindar N G, Kartashova O V, Beliaeva L E
Khirurgiia (Mosk). 2012(8):25-33.
The aim of current study was to evaluate in complex the effectiveness of transvaginal mesh implants in women with obstructed defecation (OD) syndrome based on the comparison of preoperative and postoperative results of objective diagnostic tools and quality of life parameters.
from prospectively collected database of patients treated in our department those who were treated for OD by means of transvaginally placed mesh implants were chosen. The comparison of pre- and postoperative results of objective evaluation (prolapse stage according to POP-Q system, X-ray defecography - XR-DG and MRI defecography - MRI-DG) as well quality of life parameters (Wexner constipation score and validated Russian version of King's Health Questionnaire) was undertaken. Treatment effectiveness was evaluated using Сlinical Global Impression - Improvement (CGI-I) и Patient Global Impression - Improvement (PGI-I) scales.
In 2007-2011 40 women (mean age 51.8±10.7 years) underwent transvaginal pelvic floor reconstruction with mesh implants. All of them had ≤3 stage pelvic prolapse (POP-Q) and rectocele. Preoperative XR-DG and MRI-DG helped reveal rectocele >4 cm in 85 and 43% of women respectively, 68% of patients had cystocele and 18% - genital prolapse. In 21 case mesh implants for posterior pelvic floor reinforcement were used, in other cases mesh implants for total pelvic floor repair were placed. At a mean of 19 months after the operation manual examination revealed that 90% of women had 1 stage posterior pelvic proplapse, at XR-DG and MRI-DG significant reduction of rectocele size and depth of pelvic floor descent was noted. Besides that significant decrease in mean values of Wexner constipation score and King's health questionnaire was demonstrated. Though mean values of global treatment effectiveness assessment on CGI-I and PGI-I scales didn't significantly differ (2.13±0.85 и 2.68±1.42, р=0.06), the rate of agreement between these scales measured at each single case was very low (κ-0.154), this reflects that clinician has more positive perception of disease dynamics due to treatment than the patient. When mean values of dynamics in different indexes of King's health questionnaire were compared it was demonstrated that the index of quality of life influence (3.53±0.96) was significantly higher than the indexes of OD influence (2.63±1.08) and mechanical symptoms (2.58±1.04), this suggests that while the manifestations of OD syndrome are significantly improved patient quality of life doesn't change substantially.
XR-DG is more specific than MRI-DG in evaluating the size of rectocele and the depth of pelvic floor descent; the use of mesh implants in surgical treatment of OD syndrome results in significant reduction of rectocele and prolapse stage in 90% of patients; clinical evaluation of treatment effectiveness based on objective examination is more optimistic than subjective perception of treatment results by the patient, this indicates that anatomic correction does not always lead to quality of life improvement.
本研究的目的是通过比较客观诊断工具的术前和术后结果以及生活质量参数，综合评估经阴道网状植入物对排便障碍（OD）综合征女性的有效性。
从我们科室前瞻性收集的患者数据库中，选择那些通过经阴道放置网状植入物治疗OD的患者。对客观评估（根据POP-Q系统的脱垂阶段、X线排粪造影 - XR-DG和磁共振排粪造影 - MRI-DG）以及生活质量参数（韦克斯纳便秘评分和经过验证的俄语版国王健康问卷）的术前和术后结果进行比较。使用临床总体印象 - 改善（CGI-I）和患者总体印象 - 改善（PGI-I）量表评估治疗效果。
2007年至2011年，40名女性（平均年龄51.8±10.7岁）接受了经阴道盆底重建网状植入物手术。她们均有≤3期盆腔器官脱垂（POP-Q）和直肠膨出。术前XR-DG和MRI-DG分别在85%和43%的女性中发现直肠膨出>4 cm，68%的患者有膀胱膨出，18%有生殖器脱垂。21例使用网状植入物进行后盆底加固，其他病例放置网状植入物进行全盆底修复。术后平均19个月的手法检查显示，90%的女性有1期后盆腔器官脱垂，在XR-DG和MRI-DG上，直肠膨出大小和盆底下降深度显著减小。此外，韦克斯纳便秘评分和国王健康问卷的平均值显著降低。虽然CGI-I和PGI-I量表上的总体治疗效果评估平均值无显著差异（2.13±0.85和2.68±1.42，p = 0.06），但在每个病例中这两个量表之间的一致性率非常低（κ = 0.154），这反映出临床医生对治疗后疾病动态的感知比患者更积极。比较国王健康问卷不同指标的动态平均值时发现，生活质量影响指标（3.53±0.96）显著高于OD影响指标（2.63±1.08）和机械症状指标（2.58±1.04），这表明虽然OD综合征的表现显著改善，但患者的生活质量并没有实质性改变。
在评估直肠膨出大小和盆底下降深度方面，XR-DG比MRI-DG更具特异性；在OD综合征的手术治疗中使用网状植入物可使90%的患者直肠膨出和脱垂阶段显著降低；基于客观检查的治疗效果临床评估比患者对治疗结果的主观感知更乐观，这表明解剖学矫正并不总是能带来生活质量的改善。
