Learningcurvefordetectionofpelvicpartsofuretersbytransvaginalsonography:feasibilitystudy經(jīng)陰道超聲探查輸尿管盆腔段的學(xué)習(xí)曲線：可行性研究Introduction-Urinarytractendometriosis介紹-泌尿道子宮內(nèi)膜異位癥Urinarytractendometriosis(UTE)showsaprevalenceof1–5.5%inwomenaffectedbyendometriosis.子宮內(nèi)膜異位癥患者中泌尿道子宮內(nèi)膜異位癥（UTE）的患病率為1-5.5%UTEisassociatedwithmoreadvancedstagesofdeepinfiltratingendometriosis(DIE).UTE合并高分期的深部浸潤(rùn)性內(nèi)異癥（DIE）Ureteralinvolvementandtherebyobstructionmayleadtohydronephrosisandparenchymaldamage.累及輸尿管及繼發(fā)梗阻可導(dǎo)致腎積水及腎實(shí)質(zhì)損傷Symptomsareoftenunspecific(dysmenorrhea,pelvicpain)-only69%ofpatientswithbladderendometriosisexhibiturinarycomplaints.癥狀常無(wú)特異性（痛經(jīng)、盆腔痛）-只有69%的膀胱內(nèi)異癥患者有尿路相關(guān)癥狀SurgicaltreatmentofUTEisregardedasasafeprocedureinexperthandsandwhenperformedinatertiaryreferralsetting.在三級(jí)轉(zhuǎn)診中心由專家手術(shù)治療UTE被認(rèn)為是安全的治療方法

Introduction–RoleofTVSinurinarytractendometriosis

介紹-泌尿道內(nèi)異癥中的經(jīng)陰道超聲作用AccuratepresurgicalstagingofDIEisimportantforadequatepatientcounselingandinplanningamultidisciplinarysurgicalprocedure.手術(shù)前對(duì)DIE正確分期對(duì)于為患者提供充分的咨詢及多學(xué)科手術(shù)治療的準(zhǔn)備很重要Transvaginalsonography(TVS)canbeusedtodiagnosetheanatomicallocationandsizeofaureterallesion.經(jīng)陰道超聲（TVS）可用于診斷輸尿管病灶的解剖位置及大小TVScandiagnoseproximalhydronephrosisuptotheleveloftheuterinearteryandallowsvisualizationofearlystagesofureteralobstruction,evenpriortosonographicdetectionofrenalhydronephrosis.TVS可診斷達(dá)子宮動(dòng)脈水平的近端輸尿管擴(kuò)張，甚至在超聲顯示腎積水之前能探查早期的輸尿管梗阻SeveralstudieshaveproposedthatassessmentoftheuretersshouldbepartoftheTVSexaminationinwomenwithsuspectedDIE.多項(xiàng)研究建議評(píng)價(jià)輸尿管需作為可疑DIE婦女TVS檢查的一部分

ToevaluatethelearningcurveforTVS-baseddetectionofthepelvicpartsoftheuretersinatertiaryreferralsetting.評(píng)價(jià)在一個(gè)三級(jí)轉(zhuǎn)診中心TVS檢測(cè)輸尿管盆腔段的學(xué)習(xí)曲線Aimofthestudy研究目的Methods方法Prospectivestudy.前瞻性研究RecruitedwereconsecutivewomenattendinganoutpatientgynecologicalclinicinatertiaryreferralcenterforendometriosisandpelvicpainbetweenJanuary2017andJune2017.2017年1月到2017年6月，因內(nèi)異癥和盆腔痛就診于一所三級(jí)轉(zhuǎn)診中心婦科門診的患者，連續(xù)入組Thenumberofwomenrecruitedwasdependentonhowmanywererequiredforthetraineestoreachproficiency.Virgins/womenwithprevioushysterectomyorsurgeryforDIEwereexcluded.入組病例數(shù)取決于被培訓(xùn)的醫(yī)生達(dá)到操作熟練所需的病例數(shù)。無(wú)性生活及既往有全子宮切除史及DIE手術(shù)史的婦女被排除ThesonographersparticipatinginthestudywereanexpertexaminerandthreetraineeswhoweregeneralgynecologistswithabasicknowledgeofTVS(eachhadperformedapproximately1000TVSexaminations).參加此項(xiàng)研究的人員包括一名專家及三位受培訓(xùn)醫(yī)生，受培訓(xùn)醫(yī)生具有TVS相關(guān)的基礎(chǔ)知識(shí)（沒(méi)人進(jìn)行過(guò)約1000的TVS檢查）Priortocommencementofthestudy,eachtraineeobserved10routineTVSexaminations,includingscanningoftheureters,performedbytheexpert.研究開始之前，每個(gè)受培訓(xùn)醫(yī)生觀看專家10次常規(guī)TVS檢查，包括輸尿管的掃查

MethodsThescan:Time2-Time1=timeforidentificationofthepelvicpartsoftheureters.時(shí)間點(diǎn)2-時(shí)間點(diǎn)1=辨認(rèn)輸尿管盆腔段所需時(shí)間Uterus,ovaries,bladderbowel.子宮、卵巢、膀胱、腸管Urinarybladderandurethra-longitudinal,midsagittalsection.膀胱及尿道-縱切面、正中矢狀切面“Time1”時(shí)間點(diǎn)1Distal,intramuralpartoftheureter,includingtheureteralorificeinproximitytothebladdertrigone.輸尿管遠(yuǎn)段、壁內(nèi)段，包括膀胱三角區(qū)輸尿管開口Ureteruptothecrossingoftheuterinearteriesandcommoniliacvessels,whichwerevisualizedusingDopplersonography.顯示輸尿管，達(dá)子宮動(dòng)脈和髂總血管交叉處，血管用多普勒超聲顯示“Time2”時(shí)間點(diǎn)2Ureteraldiameterforbothsidesatrestandduringdilatation.靜息和擴(kuò)張時(shí)雙側(cè)輸尿管直徑**=leftureter.++=uterineartery*Bladderapex.Methods方法Eachwomanwasexaminedfirstbytheexpertaloneandthenbyoneofthethreetrainees.所有婦女先由專家檢查，再由三個(gè)受培訓(xùn)醫(yī)生中的一個(gè)醫(yī)生檢查Incasesofdiscrepancyorifthetraineedidnotvisualizebothureterssuccessfully,thewomanwasre-examinedbytheexpertinthepresenceofthetraineeandtheresultswereexplained.如差異顯著或受培訓(xùn)醫(yī)生未找到雙側(cè)輸尿管，由專家來(lái)重新檢查并解釋結(jié)果，此時(shí)受培訓(xùn)醫(yī)師在場(chǎng)Mainoutcomemeasure-thecorrelationofdetectionatTVSofbothuretersbyTrainee1,2or3,comparedwiththegoldstandardexpertexamination.

主要結(jié)果的測(cè)量-三個(gè)受培訓(xùn)醫(yī)生TVS顯示雙側(cè)輸尿管，與專家檢測(cè)的金標(biāo)準(zhǔn)的一致性Atimelimitof150sforidentificationofeachureterwassetinordertoevaluatethefeasibilityofincludingthisexaminationstepinclinicalpracticeandworkupprotocols.Anyexaminationtakinglongerthanthiswascountedasafailure.每側(cè)輸尿管檢測(cè)時(shí)間規(guī)定在150秒以內(nèi)，以評(píng)價(jià)把此項(xiàng)檢查納入到臨床實(shí)踐中及檢查規(guī)范中的可行性。超過(guò)這個(gè)時(shí)間的檢查視為失敗Methods方法Thestatisticaltool,learningcurveofcumulativesummation(LC-CUSUM)wasusedtoassessthelearningcurve=thenumberofTVSexaminationsneededtobecapableofdetectingthepelvicpartsoftheureters.統(tǒng)計(jì)學(xué)方法，累積總和學(xué)習(xí)曲線（LC-CUSUM）用于評(píng)價(jià)學(xué)習(xí)曲線=顯示盆腔段輸尿管所需的TVS檢查數(shù)Thismethodwasdesignedtoindicatewhenaprocesshasreachedapredefinedlevelofperformance.此方法設(shè)計(jì)以顯示何時(shí)檢查水平達(dá)到預(yù)先規(guī)定的水平Byevaluatingthenumberofsequentialinterventionsofsuccessesandfailures,thetestallowsmonitoringofindividualperformanceduringthelearningprocessofnewmethodologiesandtechniques.通過(guò)評(píng)價(jià)成功和失敗順序干預(yù)的次數(shù)，這個(gè)試驗(yàn)可以監(jiān)測(cè)新的方法和技術(shù)學(xué)習(xí)過(guò)程中的個(gè)體表現(xiàn)Ascoreiscomputedfromsuccessiveoutcomes,withsuccessesyieldingnegativescoresandfailuresyieldingpositivescores.從連續(xù)的結(jié)果計(jì)算得出評(píng)分-成功分值為負(fù)數(shù)，失敗分值為正數(shù)Results結(jié)果140womenwererecruited>onewasexcludedduetovirginity,twobecauseofahistoryofhysterectomyandtwoduetopriorsurgeryforUTE>135womenwereincludedinthefinalanalysis.140個(gè)婦女入組>排除無(wú)性生活病例1例、既往子宮切除病例2例、UTE手術(shù)史病例2例>最終分析135例婦女NoneofthesewomenexperiencedseverepainduringTVS.所有婦女在TVS過(guò)程中無(wú)嚴(yán)重的疼痛Therewerenocasesofproximalhydroureterdetected.未發(fā)現(xiàn)近段輸尿管擴(kuò)張病例TVS探查輸尿管盆腔段135例基本情況及超聲表現(xiàn)基本情況年齡妊娠次數(shù)激素治療多癥狀痛經(jīng)性交困難大便困難排尿困難異位囊腫深部浸潤(rùn)內(nèi)異癥

腸管陰道/直腸陰道隔膀胱

宮骶韌帶Results結(jié)果Trainees1,2and3reachedthepredefinedlevelofproficiencyforidentificationoftherightureterafter48,34and38patients,respectively.受培訓(xùn)醫(yī)生1、2、3分別在檢查48、34、38例病人后，顯示右側(cè)輸尿管達(dá)到了預(yù)先定好的熟練水平Trainees1,2and3reachedthepredefinedlevelofproficiencyforidentificationoftheleftureterafter47,38and27patients,respectively.受培訓(xùn)醫(yī)生1、2、3分別在檢查47、38、27例病人后，顯示左側(cè)輸尿管達(dá)到了預(yù)先定好的熟練水平圖2.三位受培訓(xùn)醫(yī)生TVS顯示右側(cè)（a）及左側(cè)（b）輸尿管盆腔段LC-CUSUM的測(cè)試評(píng)分。如評(píng)分低于決定界限（灰色實(shí)線）以下時(shí)，受培訓(xùn)醫(yī)生認(rèn)為不熟練，如在之上，受培訓(xùn)醫(yī)生被認(rèn)為熟練顯示輸尿管。受培訓(xùn)醫(yī)生1：實(shí)線；受培訓(xùn)

醫(yī)生2：虛線；受培訓(xùn)醫(yī)生3：點(diǎn)線Results結(jié)果

專家及受培訓(xùn)醫(yī)生使用TVS成功顯示右側(cè)及左側(cè)輸尿管、靜息和擴(kuò)張時(shí)輸尿管的大小所需的時(shí)間

輸尿管直徑檢查者輸尿管位置時(shí)間靜息擴(kuò)張

受培訓(xùn)醫(yī)生1的患者

專家右

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醫(yī)生1右

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受培訓(xùn)醫(yī)生2的患者

專家右

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醫(yī)生2右

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受培訓(xùn)醫(yī)生3的患者

專家右

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醫(yī)生3右

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數(shù)據(jù)顯示為中位數(shù)（25百分位范圍）。檢查超過(guò)150秒則認(rèn)為是失敗，并未被納入Discussion–Mainfindings討論-主要發(fā)現(xiàn)

Thetrainees,withabasiclevelofcompetenceinTVS,acquiredanadequatelevelofproficiencyinidentifyingtherightureterafteramaximumof48TVSexaminations,andtheleftureterafteramaximumof47TVSexaminations.具備基本TVS操作水平的受培訓(xùn)醫(yī)生在最多48次及47次對(duì)右側(cè)和左側(cè)輸尿管進(jìn)行TVS檢查后達(dá)到了熟練水平Intertraineevariabilitywasobserved,inaccordancewiththeresultsBazotetal.,whoevaluatedlearningcurvesforTVSvisualizationofendometriomas.Thismaybeexplainedbysmalldifferencesinexperienceofthetraineesaswellastechnicalaspects.受培訓(xùn)者之間存在差異，結(jié)果與Bazotetal等的研究一致，他們?cè)u(píng)價(jià)了TVS探查子宮內(nèi)膜異位囊腫的學(xué)習(xí)曲線。這能用受培訓(xùn)人員經(jīng)驗(yàn)及技術(shù)有細(xì)微的差異來(lái)解釋Thenumberofscans(about48)apparentlyrequiredinordertobecomecapableinidentifyingtheuretersshouldbeeasilyincorporatedintotrainingprotocolsforTVSandfeasibleineverydayclinicalteachingpractice.要熟練顯示輸尿管所需的檢查數(shù)約為48次，可較容易結(jié)合到TVS培訓(xùn)方案中，在每日的臨床教學(xué)中也有可行性。Discussion–Limitations討論-局限性Eligiblewomenwererecruitedfromatertiaryreferralsetting,inwhichgynecologistsperformboththeTVSworkupandsurgery-learningcurvemaybedifferentfortraineesinothersettings,inwhichthesedisciplinesareseparate.入組病例是在三級(jí)轉(zhuǎn)診中心所收集，在三級(jí)轉(zhuǎn)診中心中TVS以及手術(shù)均由婦科醫(yī)師來(lái)進(jìn)行-在其他中心，TVS及手術(shù)分開進(jìn)行，受培訓(xùn)醫(yī)生的學(xué)習(xí)曲線可能有所不同AllthreetraineesweregeneralgynecologistswithbasicexperienceinTVS-resultsmaynotbetransferabletogynecologicalresidentsorlessexperiencedgynecologicalstaffperformingTVSwithoutanypriorknowledge.三位受培訓(xùn)醫(yī)生均是普通婦科醫(yī)師，有基礎(chǔ)的TVS操作經(jīng)驗(yàn)-在婦科實(shí)習(xí)醫(yī)師及有較少的TVS經(jīng)驗(yàn)的婦科醫(yī)師中結(jié)果可能不適用Thetimelimitof150stoidentifysuccessfullyeachuretermayhavebeentoolow.However,itwassettoassessthepracticalfeasibilityofincludingexaminationoftheuretersaspartoftheroutineTVSworkupinatertiaryreferralsetting.顯示一側(cè)輸尿管所需時(shí)間限定在150秒，這可能很短。但這樣設(shè)定是為了評(píng)價(jià)三級(jí)轉(zhuǎn)診中心中輸尿管的檢查納入到的常規(guī)TVS檢查中的實(shí)踐可行性Theinteractionbetweenexpertexaminer,patientandtraineemay