Alas Alexandriah N, Anger Jennifer T
Department of Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Florida, Weston, FL, USA.
Curr Urol Rep. 2015 May;16(5):33. doi: 10.1007/s11934-015-0498-6.
Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery.
• Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10]. • Pessaries should be managed with regular follow-up care to minimize complications [14•]. • Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•]. • Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•]. • Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy. • Obliterative procedures are effective but are considered definitive surgery [24••]. • The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.
盆腔器官脱垂是一种常见病症，多达12%的女性一生中需要接受手术治疗。本手稿专门综述了顶端脱垂的治疗选择。保守治疗和手术治疗方案都是可以接受的，应根据患者的偏好来选择。子宫托是最常用的保守治疗选择。有指导的盆底肌肉训练比自行进行的凯格尔运动更有益，不过对于高级别或顶端脱垂可能无效。手术治疗选择包括经腹和经阴道途径，经阴道途径可通过开放手术、腹腔镜手术和机器人手术进行。一项系统评价表明，骶骨阴道固定术治疗顶端脱垂的长期成功率高于阴道手术，但阴道手术可被视为一种可接受的替代方案。近期数据显示，子宫骶韧带悬吊术和骶棘韧带悬吊术在1年时疗效相当。迄今为止，两项随机对照试验表明，机器人辅助骶骨阴道固定术和腹腔镜辅助骶骨阴道固定术疗效相当。虽然经腹手术可能具有更高的长期耐久性，但在为患者提供咨询时，外科医生应考虑到与阴道手术相比，这些手术的手术时间更长、疼痛更剧烈且费用更高。
• 由物理治疗师进行盆底物理治疗（PFPT）是顶端脱垂保守治疗的最佳方法[10]。• 应对子宫托进行定期随访护理，以尽量减少并发症[14•]。• 微创骶骨阴道固定术似乎与金标准经腹骶骨阴道固定术（ASC）效果相同[42•]。• 机器人辅助骶骨阴道固定术（RASC）和腹腔镜辅助骶骨阴道固定术（LASC）效果相同，盆底外科医生应根据其腹腔镜技术水平和专业知识来选择使用[44, 45•]。• 子宫骶韧带悬吊术（USLS）和骶棘韧带悬吊术（SSLS）被认为是疗效相当的手术，可与经阴道子宫切除术联合进行。• 闭塞性手术有效，但被视为确定性手术[24••]。• 一些研究表明，就解剖学结果而言，经阴道网片优于自体组织修复，但并发症发生率更高。经阴道网片应保留给受过充分培训的外科医生使用，以便将并发症降至最低。
