It is a vigorous collaboration between medical professionals from multiple disciplines. But three and a half months after the operation, she first developed urinary tract irritation symptoms such as frequent urination, urgency, and painful urination. Later, she developed difficul

Medicine is never an isolated island

It is the complementation of subjective analysis and objective examination

It is the full cooperation of multidisciplinary medical people

It is the common care and trust between doctors and patients

Together, we build a solid bridge to the other side of health

May 1 An ordinary afternoon

Zhang Ting (pseudonym) sat on the hospital bed anxiously

waiting for her diagnosis result

A few months ago, she did not expect

that she would become the protagonist of this "investigation"

The atmosphere in the ward was quiet and peaceful

But in the nearby gynecological ward classroom

a brainstorming was going on intensely

1 It was unspeakable The patient came to see the doctor

Zhang Ting had a history of two vaginal deliveries, and then gradually developed a sinking feeling and uterine prolapse. In order to improve her discomfort and quality of life, she underwent "minimally invasive" laparoscopic iliopectineal ligament suspension surgery in a hospital 7 months ago, and her postoperative condition was fair.

But three and a half months after the operation, she first developed urinary tract irritation symptoms such as frequent urination, urgency, and painful urination. Later, she developed difficulty urinating. The examination showed bladder obstruction and hydronephrosis in both hands. In desperation, she had to undergo catheterization treatment for 2 months.

After the urinary catheter was removed 2 months later, Zhang Ting was still able to urinate on her own, which brought her temporary joy. However, the problem of difficulty urinating always comes back 10 hours after the urinary catheter is removed. The surgery that was supposed to improve the quality of life has caused great trouble.

has become a luxury for most people to "urinate" smoothly. The process of repeated catheterization treatment brought a lot of pain and inconvenience to Zhang Ting. For the elegant and intellectual Zhang Ting, life has become bleak.

What's more, catheterization is a temporary solution to allow her to urinate, treating the symptoms but not the root cause. She decided to find the root of the problem and solve the stubborn problem completely.

After many setbacks and consultations, Zhang Ting came to the Gynecology Clinic of Peking University People's Hospital and sought help from Director Sun Xiuli, a well-known expert in pelvic floor.

2 Tracing the origin imaging showing off his magical powers

"It's really strange. After the iliopectineal suspension surgery, the lower urinary tract function should have improved, how could urinary retention occur?" This is Zhang Ting's problem, and it is also the problem for most people. people's questions.

In the outpatient clinic, Director Sun Xiuli calmed Zhang Ting's nervousness. After carefully asking about the condition, Director Sun was thoughtful. Through his rich clinical experience and keen professional sense, Director Sun vaguely felt that there seemed to be a thread connecting the two cases.

"Compared with other surgical procedures, iliopectineal suspension has the advantage of less bleeding and faster recovery, but it causes relatively large changes in the original anatomy and mechanical structure of the human body. And structural changes often lead to functional abnormalities."

Uterine iliopectineal suspension Schematic diagram of ligament suspension surgery

Pelvic imaging, as the "perspective eye" of the gynecologist, can often help the gynecologist understand the cause of the patient's condition and assist the doctor in formulating a more appropriate surgical plan.

As expected, Zhang Ting’s pelvic imaging examination results revealed many structural abnormalities.

The results of the pelvic MRI examination showed that the lower segment of the bladder and the cervix were tightly adherent, and the mesh that had been previously surgically placed was closely related to the bilateral triangle area.

Pelvic floor ultrasound showed that during the Valsalva maneuver, the urethra was displaced backward and downward, but the posterior wall of the bladder connected to it did not move, and the distance between the pubic symphysis and the cervix was shortened, compressing the urethra. During the transabdominal ultrasound examination, it was found that in front of the cervix, the mesh placed 7 months ago had adhered the cervix to the lower part of the posterior wall of the bladder, restricting the activity of the bladder.

This information has become an important clue to solving the mystery and relieving the patient's pain.

"The posterior wall of the bladder is adhered and fixed, but the urethra is displaced backward and downward. Therefore, the bending and folding of the urethra may form a certain angle, which hinders urination." Ultrasound expert Geng Jing put forward speculation based on what he saw. The dynamic ultrasound video provided by

shows that the upper posterior wall of the bladder is adherent to the cervix and has limited movement and does not move together with other parts, which further supports this speculation.

3 Clearing the clouds and seeing the sun Difficult symptoms are beginning to appear

Clear imaging results provide doctors with clearer ideas. But soon there was a new question: This could not explain a phenomenon - Zhang Ting's urinary retention was delayed!

If the compression factor was the only cause, then Zhang Ting's urinary retention should have started from the moment the urinary catheter was pulled out, but Zhang Ting was able to urinate smoothly in the first few hours after the urinary catheter was pulled out.

There must be other potential factors influencing this.

"Imaging provides us with a very intuitive reference, but it also has its own limitations. It can only see the current performance. As clinicians, we need to pay attention to the longer-term and more dynamic process and cannot rely entirely on auxiliary services. Check."

Director Sun picked up the pen and drew on the paper a nearly empty bladder that was able to urinate normally when the urinary catheter was just removed, and then drew a "dejected" bladder that was like a heavy rice plant and was unable to urinate. The bladder thus retains urine.

"In the few hours after Zhang Ting's urinary catheter was removed, the amount of urine accumulated in the bladder was small, the shape changed little, and she could urinate normally. However, after a long time, the large amount of urine accumulated in the bladder pushed the front wall of the bladder downward. And the back of the bladder Due to adhesion, the lower section of the wall cannot deform harmoniously and share the pressure of the front wall, causing the front wall to excessively deform and form an approximately acute angle with the urethra, so urine is stored in the formed recess, leading to urinary retention." After listening to Director Sun's explanation. , everyone suddenly became enlightened.

This internal discussion among the pelvic floor team was very productive. Combining the clinical history, physical examination, and imaging examination, the doctors were able to find a reasonable explanation for Zhang Ting's "strange disease." At the same time, Director Sun and Deputy Chief Physician Xie Bing discussed the possible impact of mesh on the ureter based on high-resolution pelvic floor 3D stress MRI images, and used this to study Zhang Ting's further treatment options.

4 Find the cause, diagnose carefully, and improve the identification.

However, has the real cause been revealed? As long as the adhesion of the mesh is solved, will all the problems be solved?

Professional doctors with mature clinical thinking will not ignore any possibility. Conducting a complete differential diagnosis is a necessary process to trace the real crux.

Picture: Zhang Ting’s urodynamic examination

In addition to imaging examinations, urodynamic test results also need attention. On the pressure-flow rate detection image, the weak, short, and gentle Pdet curve indicates that Zhang Ting has bladder detrusor weakness. As the "propeller" of the urinary system, detrusor dysfunction may also cause difficulty in urinating. If this is the cause of Zhang Ting's urinary retention, then the treatment ideas and plans will be completely different.

After careful consideration, a major discussion on multidisciplinary diagnosis and treatment (MDT) involving obstetrics and gynecology, urology, ultrasound, anesthesiology and other departments was officially launched.

Although the pelvic floor team has reasonable assumptions and examination basis, for every patient, people's doctors will go all out to make the most adequate preparations to maximize the efficacy and minimize the risks.

5 Multidisciplinary joint diagnosis and treatment to explore the truth

Multidisciplinary joint diagnosis and treatment (MDT) has always been the feature and tradition of Peking University People's Hospital. Only by breaking down disciplinary barriers can we maximize the advantages of a general hospital.

Therefore, Professor Xu Kexin, an expert in urology, was invited to the gynecology demonstration classroom to participate in this powerful ward round. Stones from other mountains can be used to attack jade. The participation of urology experts has brought richer experience support to everyone, and also provided a new vision and perspective.

Let’s analyze the possibility of the two causes, the corresponding clinical evidence and auxiliary examinations, restore the occurrence and development process of the disease as much as possible, and give specific treatment suggestions. The different thinking and experience of multiple disciplines make diagnosis and treatment plans more complete.

Based on the medical history, imaging, and urodynamic test results, it was considered that Zhang Ting's urination difficulty was likely related to surgery, so she decided to perform laparoscopic mesh release + removal to loosen the fixed posterior wall of the bladder and relieve the lower bladder. obstruction.Because the magnetic resonance showed that the mesh is closely related to the trigone area of ​​the bladder, it was decided to first loosen the mesh from the cervix, cut it from the iliopectineal ligament fixed on the lateral pelvic wall, and then carefully peel the mesh from the posterior wall of the bladder. , dissociate carefully around the triangle area to avoid damaging the ureter. These measures ensure greater surgical safety.

But the problem comes again. If the mesh is cut from the fixed end of the iliopectineal ligament, the uterus will fall down again, causing the recurrence of uterine prolapse. Moreover, the patient itself also has problems with posterior vaginal wall prolapse and old perineal lacerations. There are also some differences on whether to perform prolapse repair surgery at the same time.

"This will indeed make the operation more complicated, and the operation time and difficulty will be significantly increased. However, the patient overcame many difficulties before coming to the People's Hospital from other places. Two operations will have a greater impact on the patient's body, psychology, and economy. It’s a huge burden. As the second clinical medical school of Peking University, we need to show enough responsibility and care to be worthy of the patient’s trust.”

In the end, the obstetrics and gynecology team decided to perform the surgery at the same time and solve Zhang Ting’s problem at once. All troubles. In order to minimize the trauma of the secondary operation, the operation adopts a "minimally invasive" laparoscopic combined with transvaginal surgical approach.

During the operation, it was indeed found that the bladder and cervix were fixed together. Director Sun patiently and carefully separated and protected the important tissues and organs. He cut the mesh and carefully removed it from the sides of the bilateral pelvic walls and the ventral side with great tension. A mesh covered with inflammatory adhesion material was used, and the pelvic floor support structure was reconstructed.

Picture: Intraoperative photos of laparoscopic mesh release

During the operation, it was found that the bladder and cervix were fixed together. Director Sun patiently separated and protected the important tissues and organs, and carefully removed the mesh covered with inflammatory adhesions. X-rays were taken and the pelvic floor structure was repaired.

Under the protection of the anesthesiology department, the operation went smoothly, but the doctors and nurses were still undecided. Can they help Zhang Ting completely get rid of the urinary catheter this time?

6 The stubborn disease was cured Many efforts led to a happy ending

On the fourth day after the operation, the nurse helped Zhang Ting remove the urinary catheter. The observation time seemed extremely long. After 2 hours, the patient urinated successfully. Everyone breathed a sigh of relief, but still did not dare to relax completely. Director Sun asked the night shift doctor to observe closely to avoid overfilling of the bladder.

During the ward rounds the next morning, Zhang Ting excitedly told everyone that her urination was smooth and she did not feel any discomfort. The medical team breathed a sigh of relief. During the 3 days of follow-up observation, Zhang Ting maintained normal urinary function.

The dust settled and Zhang Ting was discharged from the hospital successfully one week after the operation.

This touching and ups and downs story about "difficulty urinating" finally has a happy ending.

"Thank you! You have put my life back on track and allowed me to bathe in the sunshine of health again." Zhang Ting expressed her gratitude to the obstetrics and gynecology pelvic floor team, ultrasound team, urology department, radiology department , etc. for their help. The multidisciplinary team expressed their sincere gratitude.

The obstetrics and gynecology pelvic floor team looks at the big picture and starts at the small, improving multiple examinations such as pelvic floor imaging and urodynamics, and conducting comprehensive and comprehensive preoperative evaluations, only to provide patients with accurate and individualized treatment. . Brother departments provide timely help and support, collaborate to participate in MDT, and jointly formulate and implement more scientific treatment plans.

Helping hands with care and patience

That’s it

Peking University People’s Hospital

Multidisciplinary experts collaborate in diagnosis and treatment to fight the disease together

Helping patients regain the warmth of life

and the power of health

Introduction to the discipline

Obstetrics and Gynecology

Peking University People’s Hospital Obstetrics and Gynecology The department was founded in April 1942 by Professor Lin Qiaozhi, a famous expert in obstetrics and gynecology. Under the leadership of several generations of academic leaders, it is currently a key clinical specialty of the National Health Commission, a key discipline of the Ministry of Education, and the Department of Obstetrics and Gynecology of the Ministry of Science and Technology. Disease Clinical Research Center, National Pelvic Floor Disease Quality Control Center and Diagnosis and Treatment Center.The Department of Obstetrics and Gynecology focuses on gynecological tumors, pelvic floor diseases, cervical lesions, gynecological endocrinology, high-risk pregnancy, fetal medicine, reproductive surgery and assisted reproduction. It treats more than 310,000 outpatients annually and inpatients annually. There are nearly 10,000 visits, and patients from other places account for more than 1/3. It has established a gynecological tumor center, a pelvic floor disease diagnosis and treatment center, a prenatal diagnosis center, and a reproductive medicine center. The clinical and scientific research work in related fields ranks among the best in the country.

Department of Urology

The Department of Urology at Peking University People’s Hospital consists of wards, outpatient clinics and laboratories. In recent years, based on the main diseases of the Department of Urology, the basic setting of subspecialties has been completed: urinary tract stones group, laparoscopic treatment group of urinary tumors, prostate disease group; urinary continence and pelvic floor group, andrology group, The transplantation team, outpatient clinic and extracorporeal shock wave lithotripsy team maintain the leading position in the country in the diagnosis and treatment of urinary tract stones and the academic level of functional urology. At the same time, the minimally invasive technology of andrology and laparoscopy has also reached the domestic advanced level.

Department of Radiology

The Department of Radiology of Peking University People’s Hospital has experienced nearly a century of development and has become a fully digital, modern imaging examination, diagnosis and treatment department with a full range of services, providing digital X-ray photography, contrast examination, CT, MRI, and various Interventional examination and treatment services use more advanced diagnosis and treatment equipment and more professional diagnosis and treatment technology to serve the majority of patients.

Peking University People's Hospital was founded in 1918. After more than a century of development, the hospital has now become a modern comprehensive tertiary-level hospital integrating medical treatment, teaching, scientific research and health care. The comprehensive strength ranks first in the country. It has three academician teams: hematology , thoracic and minimally invasive surgery, and severe trauma treatment. The team leader of the project to improve disease diagnosis and treatment capabilities has become an important engine for national medical progress.

In order to continuously improve the hospital's ability to diagnose and treat difficult diseases, Peking University People's Hospital will promote multidisciplinary joint diagnosis and treatment as a key medical task and encourage greater cooperation between disciplines. The Medical Office assists various disciplines in establishing multidisciplinary joint diagnosis and treatment teams to carry out multiple The joint-discipline diagnosis and treatment model realizes multi-disciplinary collaboration and information sharing mechanisms, integrates the team advantages of professional skills from various disciplines, and efficiently carries out clinical work, breaking the traditional "one-on-one" diagnosis and treatment model and providing patients with "one-stop" comprehensive services. , promote the development of multidisciplinary regional medicine and provide high-quality medical services to more patients.

END

Feed | Edited by Obstetrics and Gynecology, Medical Department

| Yu Xian, Shi Yu

Statement | If reprinted, please indicate the source "Peking University People's Hospital" (WeChat ID: rmyy 1918)

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