磁共振成像在盆腔器官脱垂诊治中的价值

doi:10.12280/gjfckx.20020733

摘要/Abstract

摘要：

盆腔器官脱垂（pelvic organ prolapse，POP）疾病发生、发展的研究多基于大体解剖和体格检查，对患者的研究不够深入，在疾病诊疗及手术方案的制定和实施过程中过分依赖术者经验及其主观判断结果，缺乏客观数据作为支撑。磁共振成像（magnetic resonance imaging，MRI）具有对盆底结构高分辨率的独特优势，可以分辨出盆底器官各个支持结构并且对其进行定量分析，根据其测量结果研究POP患者阴道不同水平的支持结构，判断盆底力量的薄弱部位，进而针对薄弱部位制定个体化手术方案，对提高盆底重建手术的指向性及降低术后复发率有深刻的意义，从而有助于实现盆底重建手术微创、解剖复位及功能恢复，显著减少手术并发症的发生。此外，行盆底重建手术术前、术后完善MRI，可以评估手术质量，预测手术后复发。

关键词: 磁共振成像, 盆腔器官脱垂, 病理学, 生理学, 骨盆底

Abstract:

Studies on the occurrence and development of pelvic organ prolapse (POP) was mostly based on gross anatomy and physical examination, but studies on patients are not thorough enough. In the process of disease diagnosis and treatment, surgeons′ experience and subjective judgment results played an important role on the development and implementation of surgical program, which lacked objective data as support. Magnetic resonance imaging (MRI) has the unique advantage of high-resolution pelvic floor structure, which can distinguish various support structures of pelvic floor organs and quantitatively analyze. Different levels of vaginal support structures of POP patients are studied according to the results. The weak parts of pelvic floor are judged. And then, an individualized surgical plan for the weak parts is made. It is of great significance to improve the orientation of pelvic floor reconstruction surgery and reduce the recurrence rate. We can realize the desire of minimally invasive surgery, anatomical reduction and functional recovery and minimize the occurrence of surgical complications. In addition, MRI can evaluate the quality of surgery and predict the recurrence of surgery.

Key words: Magnetic resonance imaging, Pelvic organ prolapse, Pathology, Physiology, Pelvic floor

王树瑜, 王温馨, 赵烨. 磁共振成像在盆腔器官脱垂诊治中的价值[J]. 国际妇产科学杂志, 2023, 50(1): 116-120.

WANG Shu-yu, WANG Wen-xin, ZHAO Ye. Value of Magnetic Resonance Imaging in the Diagnosis and Treatment of Pelvic Organ Prolapsed[J]. Journal of International Obstetrics and Gynecology, 2023, 50(1): 116-120.

参考文献 35

[1]	中华医学会妇产科学分会妇科盆底学组. 盆腔器官脱垂的中国诊治指南(2020年版)[J]. 中华妇产科杂志, 2020, 55(5):300-306. doi: 10.3760/cma.j.cn112141-20200106-00016. doi: 10.3760/cma.j.cn112141-20200106-00016
[2]	梁诗琪, 陈春林, 刘萍, 等. 盆腔器官脱垂患者宫骶韧带与输尿管、直肠解剖关系的MRI三维重建研究[J]. 中华妇产科杂志, 2021, 56(1):27-33. doi: 10.3760/cma.j.cn112141-20200612-00500. doi: 10.3760/cma.j.cn112141-20200612-00500
[3]	Schulten S, Claas-Quax MJ, Weemhoff M, et al. Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis[J]. Am J Obstet Gynecol, 2022, 227(2):192-208. doi: 10.1016/j.ajog.2022.04.046. doi: 10.1016/j.ajog.2022.04.046 pmid: 35500611
[4]	Weintraub AY, Glinter H, Marcus-Braun N. Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse[J]. Int Braz J Urol, 2020, 46(1):5-14. doi: 10.1590/S1677-5538. doi: 10.1590/S1677-5538.IBJU.2018.0581 pmid: 31851453
[5]	Zenebe CB, Chanie WF, Aregawi AB, et al. The effect of women's body mass index on pelvic organ prolapse: a systematic review and meta analysis[J]. Reprod Health, 2021, 18(1):45. doi: 10.1186/s12978-021-01104-z. doi: 10.1186/s12978-021-01104-z pmid: 33608022
[6]	Fitzgerald J, Richter LA. The Role of MRI in the Diagnosis of Pelvic Floor Disorders[J]. Curr Urol Rep, 2020, 21(7):26. doi: 10.1007/s11934-020-00981-4. doi: 10.1007/s11934-020-00981-4 pmid: 32415411
[7]	Zhang H, Wang Z, Xiao X, et al. Dynamic magnetic resonance imaging evaluation before and after operation for pelvic organ prolapse[J]. Abdom Radiol(NY), 2022, 47(2):848-857. doi: 10.1007/s00261-021-03361-9. doi: 10.1007/s00261-021-03361-9
[8]	Stothers L, Locke JA, Abdulaziz M, et al. Standing open magnetic resonance imaging improves detection and staging of pelvic organ prolapse[J]. Can Urol Assoc J, 2021, 16(1):E20-E24. doi: 10.5489/cuaj.7244. doi: 10.5489/cuaj.7244
[9]	Huebner M, DeLancey J. Levels of pelvic floor support: what do they look like on magnetic resonance imaging?[J]. Int Urogynecol J, 2019, 30(9):1593-1595. doi: 10.1007/s00192-019-03986-x. doi: 10.1007/s00192-019-03986-x pmid: 31143979
[10]	Luo J, Betschart C, Chen L, et al. Using stress MRI to analyze the 3D changes in apical ligament geometry from rest to maximal Valsalva: a pilot study[J]. Int Urogynecol J, 2014, 25(2):197-203. doi: 10.1007/s00192-013-2211-y. doi: 10.1007/s00192-013-2211-y pmid: 24008367
[11]	马辛欣, 尚诗瑶, 谢冰, 等. 磁共振成像对女性重度盆腔器官脱垂患者子宫骶主韧带数字化三维重建模型的量化研究[J]. 中国妇产科临床杂志, 2015, 16(4):313-317. doi: 10.13390/j.issn.1672-1861.2015.04.007. doi: 10.13390/j.issn.1672-1861.2015.04.007
[12]	梁诗琪, 陈春林, 刘萍. 宫骶韧带磁共振成像研究及相关盆腔器官脱垂生物力学研究进展[J]. 中国实用妇科与产科杂志, 2021, 37(3):403-405. doi: 10.19538/j.fk2021030130. doi: 10.19538/j.fk2021030130
[13]	Wang X, Wang X, Zhou Y, et al. Mitofusin2 regulates the proliferation and function of fibroblasts: The possible mechanisms underlying pelvic organ prolapse development[J]. Mol Med Rep, 2019, 20(3):2859-2866. doi: 10.3892/mmr.2019.10501. doi: 10.3892/mmr.2019.10501 pmid: 31322173
[14]	Guler Z, Roovers JP. Role of Fibroblasts and Myofibroblasts on the Pathogenesis and Treatment of Pelvic Organ Prolapse[J]. Biomolecules, 2022, 12(1):94. doi: 10.3390/biom12010094. doi: 10.3390/biom12010094
[15]	Handa VL, Blomquist JL, Carroll M, et al. Longitudinal Changes in the Genital Hiatus Preceding the Development of Pelvic Organ Prolapse[J]. Am J Epidemiol, 2019, 188(12):2196-2201. doi: 10.1093/aje/kwz195. doi: 10.1093/aje/kwz195 pmid: 31565742
[16]	Cheng W, Thibault MD, Chen L, et al. Changes in cardinal ligament length and curvature with parity and prolapse and their relation to level III hiatus measures[J]. Int Urogynecol J, 2022, 33(1):107-114. doi: 10.1007/s00192-021-04824-9. doi: 10.1007/s00192-021-04824-9
[17]	Ramanah R, Berger MB, Chen L, et al. See it in 3D!: researchers examined structural links between the cardinal and uterosacral ligaments[J]. Am J Obstet Gynecol, 2012, 207(5):437.e1-e7. doi: 10.1016/j.ajog.2012.08.036. doi: 10.1016/j.ajog.2012.08.036
[18]	谢冰, 尚诗瑶, 武靖, 等. 磁共振成像对盆腔器官脱垂患者子宫骶韧带形态学评估的初步探讨[J]. 中国妇产科临床杂志, 2013, 14(3):245-248. doi: 10.3969/j.issn.1672-1861.2013.03.017. doi: 10.3969/j.issn.1672-1861.2013.03.017
[19]	Kalis V, Kovarova V, Rusavy Z, et al. Trans-obturator cystocele repair of level 2 paravaginal defect[J]. Int Urogynecol J, 2020, 31(11):2435-2438. doi: 10.1007/s00192-020-04337-x. doi: 10.1007/s00192-020-04337-x
[20]	Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect[J]. Obstet Gynecol, 1981, 57(3):357-362. pmid: 7465150
[21]	Arenholt L, Pedersen BG, Glavind K, et al. Prospective evaluation of paravaginal defect repair with and without apical suspension: a 6-month postoperative follow-up with MRI, clinical examination, and questionnaires[J]. Int Urogynecol J, 2019, 30(10):1725-1733. doi: 10.1007/s00192-018-3807-z. doi: 10.1007/s00192-018-3807-z pmid: 30506182
[22]	Huddleston HT, Dunnihoo DR, Huddleston PM 3rd, et al. Magnetic resonance imaging of defects in DeLancey′s vaginal support levels Ⅰ, Ⅱ, and Ⅲ[J]. Am J Obstet Gynecol, 1995, 172(6):1778-1782,discussion 1782-1784. doi: 10.1016/0002-9378(95)91411-0. doi: 10.1016/0002-9378(95)91411-0 pmid: 7778632
[23]	Aronson MP, Bates SM, Jacoby AF, et al. Periurethral and paravaginal anatomy: an endovaginal magnetic resonance imaging study[J]. Am J Obstet Gynecol, 1995, 172(6):1702-1708,discussion 1708-1710. doi: 10.1016/0002-9378(95)90413-1. doi: 10.1016/0002-9378(95)90413-1
[24]	Larson KA, Hsu Y, Chen L, et al. Magnetic resonance imaging-based three-dimensional model of anterior vaginal wall position at rest and maximal strain in women with and without prolapse[J]. Int Urogynecol J, 2010, 21(9):1103-1109. doi: 10.1007/s00192-010-1161-x. doi: 10.1007/s00192-010-1161-x pmid: 20449568
[25]	Larson KA, Luo J, Guire KE, et al. 3D analysis of cystoceles using magnetic resonance imaging assessing midline, paravaginal, and apical defects[J]. Int Urogynecol J, 2012, 23(3):285-293. doi: 10.1007/s00192-011-1586-x. doi: 10.1007/s00192-011-1586-x pmid: 22068322
[26]	DeLancey JO, Kearney R, Chou Q, et al. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery[J]. Obstet Gynecol, 2003, 101(1):46-53. doi: 10.1016/s0029-7844(02)02465-1. doi: 10.1016/s0029-7844(02)02465-1 pmid: 12517644
[27]	DeLancey JO, Morgan DM, Fenner DE, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse[J]. Obstet Gynecol, 2007, 109(2 Pt 1):295-302. doi: 10.1097/01.AOG.0000250901.57095.ba. doi: 10.1097/01.AOG.0000250901.57095.ba pmid: 17267827
[28]	Nandikanti L, Sammarco AG, Kobernik EK, et al. Levator ani defect severity and its association with enlarged hiatus size, levator bowl depth, and prolapse size[J]. Am J Obstet Gynecol, 2018, 218(5):537-539. doi: 10.1016/j.ajog.2018.02.005. doi: S0002-9378(18)30148-0 pmid: 29454870
[29]	Sammarco AG, Nandikanti L, Kobernik EK, et al. Interactions among pelvic organ protrusion, levator ani descent, and hiatal enlargement in women with and without prolapse[J]. Am J Obstet Gynecol, 2017, 217(5):614.e1-614.e7. doi: 10.1016/j.ajog.2017.07.007. doi: 10.1016/j.ajog.2017.07.007
[30]	Faulkner JA, Larkin LM, Claflin DR, et al. Age-related changes in the structure and function of skeletal muscles[J]. Clin Exp Pharmacol Physiol, 2007, 34(11):1091-1096. doi: 10.1111/j.1440-1681.2007.04752.x. doi: 10.1111/j.1440-1681.2007.04752.x
[31]	Swenson CW, Masteling M, DeLancey JO, et al. Aging effects on pelvic floor support: a pilot study comparing young versus older nulliparous women[J]. Int Urogynecol J, 2020, 31(3):535-543. doi: 10.1007/s00192-019-04063-z. doi: 10.1007/s00192-019-04063-z pmid: 31388719
[32]	Nandikanti L, Sammarco AG, Chen L, et al. Levator bowl volume during straining and its relationship to other levator measures[J]. Int Urogynecol J, 2019, 30(9):1457-1463. doi: 10.1007/s00192-019-04006-8. doi: 10.1007/s00192-019-04006-8 pmid: 31222569
[33]	Sammarco AG, Sheyn D, Hong CX, et al. Pelvic cross-sectional area at the level of the levator ani and prolapse[J]. Int Urogynecol J, 2021, 32(4):1007-1013. doi: 10.1007/s00192-020-04546-4. doi: 10.1007/s00192-020-04546-4
[34]	Schmidt P, Chen L, DeLancey JO, et al. Correction to: Preoperative level II/III MRI measures predicting long-term prolapse recurrence after native tissue repair[J]. Int Urogynecol J, 2022, 33(11):3303. doi: 10.1007/s00192-022-05369-1. doi: 10.1007/s00192-022-05369-1
[35]	Chen L, Swenson CW, Xie B, et al. A new 3D stress MRI measurement strategy to quantify surgical correction of prolapse in three support systems[J]. Neurourol Urodyn, 2021, 40(8):1989-1998. doi: 10.1002/nau.24781. doi: 10.1002/nau.24781