Raz S, Nitti V W, Bregg K J
Division of Urology, University of California School of Medicine, Los Angeles.
J Urol. 1993 Apr;149(4):724-30. doi: 10.1016/s0022-5347(17)36193-1.
The urologist actively involved in the treatment of female genitourinary disease must to be able to recognize and treat various forms of pelvic prolapse. Enterocele is commonly seen in conjunction with stress urinary incontinence and cystocele or it may result from surgery to correct these problems. Many techniques to correct enterocele have been developed, including transvaginal repairs as well as intra-abdominal procedures such as the Moschcowitz technique or colpofixation to the sacrum for enterocele with vault prolapse. Surgical management of enterocele must take into account several factors, including the presence of stress urinary incontinence, rectocele, vaginal vault prolapse, prior hysterectomy and the desire to maintain sexual activity. Based on these considerations we discuss our approach to the transvaginal repair of enterocele. In patients without vault prolapse a simple enterocele repair is performed. If vault prolapse is present, then the condition of the anterior vaginal wall is considered. In patients with a cystocele a vault suspension procedure is performed, which involves simultaneous suspension of the uterosacral-cardinal ligament complex and vaginal vault along with the bladder neck and bladder. There are 2 modifications of this technique depending on the degree of cystocele: the 4-corner vault suspension for grades 2 and 3 cystocele, and the vault suspension with grade 4 cystocele repair. Patients with vault prolapse and no cystocele undergo sacrospinous ligament fixation. In elderly patients who are not sexually active, especially if they are in poor medical condition, partial colpocleisis is considered. In these patients partial colpocleisis was not performed as a primary procedure but it was done later in 3 who failed an initial attempt at repair. All coexisting vaginal pathology is fixed at the time of enterocele repair. A total of 83 patients underwent enterocele repair according to this protocol and 81 were available for followup. Mean followup was 15 months (range 3 to 70). Overall a successful result (no recurrence) was achieved in 70 patients (86%). Success for individual procedures was 40 of 49 (82%) for simple repair, 24 of 25 (96%) for vault suspension and 6 of 7 (86%) for sacrospinous fixation. In all cases vault suspension or sacrospinous fixation was able to restore vaginal depth and axis with minimal or no vaginal shortening.
积极参与女性泌尿生殖系统疾病治疗的泌尿科医生必须能够识别和治疗各种形式的盆腔脏器脱垂。肠膨出常与压力性尿失禁和膀胱膨出同时出现，也可能是纠正这些问题的手术所致。目前已开发出多种纠正肠膨出的技术，包括经阴道修复以及腹腔内手术，如Moschcowitz技术或针对伴有穹窿脱垂的肠膨出进行的骶骨阴道固定术。肠膨出的手术治疗必须考虑几个因素，包括压力性尿失禁、直肠膨出、阴道穹窿脱垂、既往子宫切除术以及维持性活动的意愿。基于这些考虑，我们讨论了经阴道修复肠膨出的方法。对于无穹窿脱垂的患者，进行简单的肠膨出修复。如果存在穹窿脱垂，则考虑阴道前壁的情况。对于伴有膀胱膨出的患者，进行穹窿悬吊手术，该手术包括同时悬吊子宫骶骨 - 主韧带复合体、阴道穹窿以及膀胱颈和膀胱。根据膀胱膨出的程度，该技术有两种改良方法：2级和3级膀胱膨出采用四角穹窿悬吊术，4级膀胱膨出采用穹窿悬吊术并修复膀胱膨出。有穹窿脱垂但无膀胱膨出的患者接受骶棘韧带固定术。对于无性生活的老年患者，尤其是身体状况较差的患者，考虑进行部分阴道闭合术。在这些患者中，部分阴道闭合术并非作为主要手术进行，而是在3例初次修复失败的患者中后来实施的。在肠膨出修复时，所有并存的阴道病变均得到修复。共有83例患者按照该方案接受了肠膨出修复，其中81例可供随访。平均随访时间为15个月（范围3至70个月）。总体而言，70例患者（86%）取得了成功结果（无复发）。简单修复的成功率为49例中的40例（82%），穹窿悬吊术为25例中的24例（96%），骶棘固定术为7例中的6例（86%）。在所有病例中，穹窿悬吊术或骶棘固定术能够以最小程度或无阴道缩短的方式恢复阴道深度和轴线。
