经阴道修补膀胱阴道瘘失败的预后因素:巢式病例对照研究

doi:10.19723/j.issn.1671-167X.2021.04.009

摘要/Abstract

摘要：

目的: 分析影响经阴道修补膀胱阴道瘘(vesicovaginal fistula, VVF)失败的预后因素。方法: 应用回顾性巢式病例对照研究的方法,以2014年1月至2020年12月于北京大学第一医院泌尿外科接受经阴道膀胱阴道瘘修补手术失败的15例患者为病例组,检索同一时间范围内由同一术者进行经阴道膀胱阴道瘘修补成功的患者,按照1:4匹配60例作为对照组。比较病例组与对照组间年龄、体重指数(body mass index, BMI)、膀胱阴道瘘病因、伴随泌尿生殖系统畸形情况、修补次数、瘘口特征、手术过程、术后恢复等因素是否具有差异,分析经阴道修补膀胱阴道瘘失败的影响因素。结果: 病例组BMI(26.3±3.9) kg/m²,阴道内瘘口直径(1.5±0.8) cm,经阴道修补的手术时间(111.8±19.8) min,伴随泌尿生殖系统畸形比例4/15,多次经阴道修补比例13/15,同期接受输尿管再植比例6/15,术后发热比例5/15;对照组BMI(23.9±3.0) kg/m²,阴道内瘘口直径(0.8±0.5) cm,经阴道修补的手术时间(99.9±19.7) min,伴随泌尿生殖系统畸形比例2/60,多次经阴道修补比例18/60,同期接受输尿管再植比例5/60,术后均无发热。与对照组相比,病例组BMI高(P =0.013)、阴道内瘘口直径大(P =0.002)、经阴道修补的手术时间长(P =0.027)、伴随泌尿生殖系统畸形比例高(P =0.013)、多次经阴道修补比例高(P <0.001)、既往初次修复时同期接受输尿管再植比例高(P =0.006)、经阴道修补术后发热比例高(P <0.001)。选取瘘口直径、伴随泌尿生殖系统畸形、经阴道多次修补、既往接受过输尿管再植进行多因素分析,采用后退法进行影响因素筛选。多因素分析显示瘘口直径≥1 cm (OR =10.45,95%CI =1.90~57.56,P =0.007)、经阴道多次修补(OR =16.97, 95%CI =3.17~90.91, P =0.001)是经阴道修补VVF失败的独立预后因素。结论: 瘘口直径≥1 cm、经阴道多次修补是经阴道修补VVF失败的独立预后因素。

关键词: 膀胱阴道瘘, 经阴道修补, 巢式病例对照研究

Abstract:

Objective: To analyze the prognostic factors affecting the failure of transvaginal repair of vesicovaginal fistula (VVF). Methods: A retrospective nested case-control study was conducted. A total of 15 patients who underwent unsuccessful transvaginal vesicovaginal fistula repair in the Department of Urology, Peking University First Hospital from January 2014 to December 2020 were enrolled as the case group. A total of 60 patients receiving transvaginal vesicovaginal fistula repair by the same surgeon within the same time range, were selected as the control group. The age, body mass index (BMI), etiology of vesicovaginal fistula, associated genitourinary malformation, frequency of repair, characteristics of fistula, surgical procedure, postoperative recovery and other factors were compared between the case group and the control group, and the influencing factors of failure were analyzed. Results: The BMI of the case group was (26.3±3.9) kg/m², the diameter of vaginal fistula was (1.5±0.8) cm, and the operative time of transvaginal repair was (111.8±19.8) min. The proportion of the patients with genitourinary malformations was 4/15, the proportion of the patients with multiple vaginal repairs was 13/15, the proportion of the patients with concurrent ureteral reimplantation was 6/15, and the proportion of the patients with postoperative fever was 5/15. In the control group, the BMI was (23.9±3.0) kg/m², the diameter of vaginal fistula was (0.8±0.5) cm, the operative time of transvaginal repair was (99.9±19.7) min, the rate of associated genitourinary malformation was 2/60, the rate of multiple transvaginal repair was 18/60, the rate of concurrent ureteral reimplantation was 5/60, and no postoperative fever was found. Compared with the control group, the case group had higher BMI (P=0.013), bigger vaginal fistula (P=0.002), longer time of operation (P=0.027), higher proportion of genitourinary malformations (P=0.013), higher proportion of repeated transvaginal repair (P<0.001), higher proportion of ureter reimplantation (P=0.006), and higher proportion of postoperative fever (P<0.001). Multivariate analysis showed that fistula diameter ≥1 cm (OR=10.45, 95%CI=1.90-57.56, P=0.007) and repeated transvaginal repair (OR=16.97, 95%CI=3.17-90.91, P=0.001) were independent prognostic factors for VVF failure in transvaginal repair. Conclusion: Fistula diameter ≥1 cm and repeated transvaginal repair are independent prognostic factors of failure in transvaginal repair.

Key words: Vesicovaginal fistula, Transvaginal repair, Nested case-control study

中图分类号:

R694.6

杨洋,陈宇珂,车新艳,吴士良. 经阴道修补膀胱阴道瘘失败的预后因素:巢式病例对照研究[J]. 北京大学学报（医学版）, 2021, 53(4): 675-679.

YANG Yang,CHEN Yu-ke,CHE Xin-yan,WU Shi-liang. Prognostic factors for failure of transvaginal repair of vesicovaginal fistula: A nested case-control study[J]. Journal of Peking University (Health Sciences), 2021, 53(4): 675-679.

图/表 2

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参考文献 18

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Items	Case group (n=15)	Control group (n= 60)	t/χ²	OR (95%CI)	P
BMI/(kg/m²), $\bar{x}±s$	26.3±3.9	23.9±3.0	2.54		0.013
Fistula diameter/cm, $\bar{x}±s$	1.5±0.8	0.8±0.5	3.55		0.002
Operation time/min, $\bar{x}±s$	111.8±19.8	99.9±19.7	2.27		0.027
Associated genitourinary malformation, n	4	2	8.88	8.00 (1.62-39.64)	0.013
Repeated transvaginal repair, n	13	18	15.89	2.89 (1.87-4.46)	<0.001
Ureter reimplantation, n	6	5	9.62	4.80 (1.69-13.63)	0.006
Absence of fever, n	10	60	21.43	0.67 (0.47-0.95)	<0.001
Age/years, $\bar{x}±s$	49.3±8.1	48.7±7.8	0.26		0.793
Follow-up time/months, $\bar{x}±s$	36.5±25.3	36.9±22.5	-0.06		0.950
Depth of fistula/cm, $\bar{x}±s$	6.3±1.4	6.6±1.1	-1.07		0.287
Modified Latzko technique, n	8	39	0.70	0.82 (0.49-1.36)	0.403
With other diseases, n	6	22	0.06	1.09 (0.54-2.20)	0.811
Urine culture positive, n	3	4	2.52	3.00 (0.75-12.00)	0.138
Menopause, n	13	52	0.00	1.00 (0.80-1.25)	>0.999

Items	Partial regression coefficient	Standard error	Wald χ²	OR (95%CI)	P
Fistula diameter≥1 cm	2.35	0.87	7.27	10.45 (1.90-57.56)	0.007
Repeated transvaginal VVF repair	2.83	0.86	10.93	16.97 (3.17-90.91)	0.001
Constant term	-0.50	0.48	1.12	0.60	0.290