深部浸润型子宫内膜异位症的治疗研究新进展

深部浸润型子宫内膜异位症（deep infiltrating endometriosis,DIE）是子宫内膜异位症（endometriosis,EMs）的一种特殊类型,其特指浸润深度≥5 mm的EMs病灶,可累及盆腔不同部位,主要位于后盆腔,如宫骶韧带、子宫直肠陷凹、阴道直肠隔和结直肠等。疼痛是其主要临床症状,且形式多样,包括痛经、慢性盆腔痛、深部性交痛及泌尿消化系统相关的疼痛等。目前DIE的治疗主要以手术为主,但手术困难、手术安全、术后并发症较难避免等均是非常棘手的问题。研究者据此提出的保留神经功能的病灶切除术,机器人辅助腹腔镜手术等方法正在被探究中。综述DIE的治疗研究新进展。     

腹腔镜治疗深部浸润型子宫内膜异位症临床疗效61例分析

目的探讨腹腔镜手术治疗深部浸润型子宫内膜异位症的疗效和安全性。方法对北京大学第一医院收治的61例深部浸润型子宫内膜异位症患者临床资料进行分析。结果 61例手术均在腹腔镜下完成,无严重手术并发症。随访55例(随访率90.2%),平均随访时间42.7个月(12～74个月)。术后痛经缓解率分别为1年53.1%、2年51.1%、3年66.7%,与术前相比较差异均有统计学意义(P0.001)。但非经期下腹痛、肛门或直肠痛和性交痛与术前相比,差异无统计学意义。29例有生育要求者13例妊娠(44.8%);其中8例合并不孕症者4例妊娠(50%)。结论腹腔镜治疗深部浸润型子宫内膜异位症安全有效。     

深部浸润型子宫内膜异位症的药物治疗

摘要:深部浸润型子宫内膜异位症 (DIE)是指病灶浸润深度≥5mm,可导致痛经、慢性盆腔痛及性交痛等症状。手术是主要的治疗方法,但手术治疗并发症发生率高。药物治疗是重要的辅助治疗措施,可以缓解患者的疼痛症状。术后药物治疗可以延长复发时间。     

深部浸润型子宫内膜异位症诊治进展

深部浸润型子宫内膜异位症(DIE)是指子宫内膜异位病灶在腹膜下浸润深度超过5mm,主要分布于直肠子宫陷凹、子宫骶骨韧带、直肠阴道隔、膀胱及肠道.病史及临床症状仍然是DIE诊断的主要线索;妇科检查是DIE诊断的主要手段;阴道超声、核磁共振成像及直肠超声尤其是内镜直肠超声是DIE诊断和分型的重要辅助检查方法;手术治疗是DIE的主要治疗方法.     

深部浸润型子宫内膜异位症诊治进展

深部浸润型子宫内膜异位症（DIE）是指子宫内膜异位病灶在腹膜下浸润深度超过5mm，主要分布于直肠子宫陷凹、子宫骶骨韧带、直肠阴道隔、膀胱及肠道。病史及临床症状仍然是DIE诊断的主要线索；妇科检查是DIE诊断的主要手段；阴道超声、核磁共振成像及直肠超声尤其是内镜直肠超声是DIE诊断和分型的重要辅助检查方法；手术治疗是DIE的主要治疗方法。     

单孔腹腔镜手术治疗盆腔深部浸润型子宫内膜异位症临床研究

目的 探讨单孔腹腔镜手术治疗盆腔深部浸润型子宫内膜异位症的可行性与安全性。方法 回顾性分析2018年4月至2020年8月南京医科大学附属常州第二人民医院妇科接受单孔腹腔镜盆腔深部浸润型子宫内膜异位症切除术的24例患者的临床资料。分析手术时间、术中出血量、并发症、复发率及术后生育情况。结果 24例患者手术均顺利完成,手术时间（166.25±90.95）min,术中出血量（98.75±63.61）mL;术后无需镇痛类药物。出院后予促性腺激素释放激素激动剂（GnRH-a）注射联合地诺孕素序贯治疗,2例术后自然受孕分娩,1例不孕症患者采用辅助生殖技术后成功分娩。1例复发。结论 如选择合适的病例,单孔腹腔镜手术治疗盆腔深部浸润型子宫内膜异位症可能是安全有效的。     

深部浸润型子宫内膜异位症复发处理

复发是子宫内膜异位症（endometriosis,EM,内异症）临床诊治中常见、难以处理、需管理的一项重要问题。深部浸润型内异症（deeply infiltrating endometriosis,DIE）经彻底切除后很少复发,前次手术残留的病灶被认为是复发的主要原因。复发的患者盆腔粘连严重、病灶侵入深,手术并发症多,为再次手术增加了极大的难度,对于术者的技术水平要求则更高。因此,二次手术必须基于细致的风险、收益评估方可实施。加强术前及术后各个环节治疗方案的评估,强调有计划的终身管理。     

深部浸润型子宫内膜异位症与不孕

摘要：深部浸润型子宫内膜异位症(DIE)可导致不孕,具体机制不详。对DIE相关的不孕,单纯药物治疗不能提高妊娠率,反而会延迟受孕时间。手术治疗则可提高妊娠率,但手术的风险较大。DIE导致不孕的妇女推荐先行两个周期的体外受精 胚胎移植术,无效后再考虑手术治疗。     

腹腔镜诊断盆腔深部浸润型子宫内膜异位症的临床价值

目的 探讨盆腔深部浸润型子宫内膜异位症（DIE）病灶分布的特点和腹腔镜诊断的准确性。 方法 收集中山大学附属第一医院2008年8月到2012年5月以DIE为手术指征患者79例,行腹腔镜下子宫内膜异位症根治术,腹腔镜诊断后切除各个部位的DIE病灶。以病理诊断为标准,分别计算腹腔镜诊断不同部位DIE病灶的阳性预测值（PPV）、阴性预测值（NPV）、敏感度（SEN）和特异度（SPE）。结果 取得盆腔DIE病灶组织274份,其中后盆腔242份（88.32%）,左侧（27.73%,76/274）多于右侧（24.45%,67/274）。盆腔DIE病灶以骶韧带最常见（39.42%,108/274）,依次为直肠（16.06%,44/274）、阴道直肠隔（12.04%,33/274）、阴道后穹窿（9.12%,25/274）。腹腔镜诊断DIE的PPV为98.83%（254/257）,SEN为92.70%（254/274）、NPV为45.95%（17/37）、SPE为85%（17/20）。肠壁和阴道后穹窿的诊断符合率最高为100%（47/47和25/25）,阴道直肠隔为96.97%（32/33）,左、右骶韧带分别为83.64%（46/55）和90.56%（48/53）,左、右输尿管分别为83.33%（10/12）和66.67%（4/6）。结论 腹腔镜下诊断盆腔DIE病灶的病理诊断阳性率较高。     

泌尿系合并肠道深部浸润型子宫内膜异位症3例报道

正深部浸润型子宫内膜异位症(deep infiltrating endometriosis,DIE)是一种特殊类型的盆腔子宫内膜异位症,是指病灶浸润深度超过腹膜以下5mm,并出现纤维化和肌性增生~([1])。DIE发生率低,为1%~2%,病灶常分布于子宫骶韧带、肠道、阴道、膀胱、输尿管,其频率分别为52.7%、22.7%、16.2%、6.3%、2.1%,而同时累及肠道、膀胱和输尿管的DIE更为罕见~([2])。手术清除病灶结     

Transvaginal ultrasound for diagnosis of deeply infiltrating endometriosis

Deeply infiltrating endometriosis is the clinical form of the disease that is generally associated with conditions of more intense pain and may require more complex surgical management, consequently resulting in greater risks to the patient. In recent years, various investigators have confirmed the usefulness of methods such as magnetic resonance imaging (MRI), transrectal ultrasound and transvaginal ultrasound (TVUS) for the diagnosis of deep endometriotic lesions. The objectives of the present study are to describe the method used to perform TVUS for the detection of deeply infiltrating endometriosis, and to discuss the clinical benefits that the data obtained may offer clinicians providing care for patients suspected of having this type of endometriosis.     

Clinical pitfalls of pain recurrence in endometriosis arising in the posterior vaginal fornix

Endometriotic nodules in the lower genital tract often cause dysmenorrhea and dyspareunia. We report here a case of posterior vaginal fornix endometriosis that was overlooked for several years. We performed a trans-vaginal resection after the associated pain was not relieved by repetitive gonadotropin-releasing hormone agonist (GnRHa) therapy or abdominal surgery. After the resection, the patient's symptoms disappeared. The patient subsequently conceived and proceeded to a full-term delivery. The pathological diagnosis was 'endometriosis of the vagina.' Immunohistochemical staining revealed that the progesterone receptor-positive cells outnumbered the estrogen receptor-positive cells. We emphasize that the existence of vaginal lesions should be considered in cases in which pain has not improved despite long-term GnRHa administration, or in cases involving dyspareunia. To provide appropriate treatment, attentive evaluation and careful examination of the disease are necessary for a patient with prolonged unsatisfactory progress.     

Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification

Objective

To use the ENZIAN classification for preoperative estimation of laparoscopic operating time in patients with deeply infiltrating endometriosis (DIE).

Study design

Retrospective study of women with DIE (n = 151) who underwent laparoscopic surgery.

Results

151 of 470 patients had DIE (n = 205 lesions) exclusively in compartments A (rectovaginal septum, vagina), B (sacrouterine ligament to the pelvic wall) and C (rectum, sigmoid colon). These laparoscopically treated lesions were used to calculate a model for estimating operating time for DIE, assuming complication-free procedures (overall significance for model's predictive power: P < 0.001). The error of estimation for the operating time prediction is 0 ± 35.35 min (mean ± SD; range −83 to +117 min). The actual operating time for all operations was 109.32 ± 74.38 min (mean ± standard deviation).

Conclusions

Using a model for predicting operating time based on the ENZIAN classification enables resources to be planned more precisely in surgery management. Patients with DIE can also be given more precise information regarding the expected operating time.     

Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating endometriosis

Objective

To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) findings relative to surgical presence of deeply infiltrating endometriosis (DIE).

Methods

This prospective study included 92 women with clinical suspicion of DIE. The MR images were compared with laparoscopy and pathology findings. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for diagnosis of DIE were assessed.

Results

DIE was confirmed at histopathology in 77 of the 92 patients (83.7%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI to diagnose DIE at each of the specific sites evaluated were as follows: retrocervical space (89.4%, 92.3%, 96.7%, 77.4%, 90.2%); rectosigmoid (86.0%, 92.9%, 93.5%, 84.8%, 89.1%); bladder (23.1%, 100%, 100%, 88.8%, 89.1%); ureters (50.0%, 100%, 95.5%, 95.7%); and vagina (72.7%, 100%, 100%, 96.4%, 96.7%).

Conclusion

MRI demonstrates high accuracy in diagnosing DIE in the retrocervical region, rectosigmoid, bladder, ureters, and vagina.     

Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy.

OBJECTIVE: To describe the use of mechanical anastomoses in cases of laparoscopically assisted vaginal rectosigmoidectomy for the treatment of rectosigmoid endometriosis. METHODS: Pilot study evaluating eight patients with rectosigmoid endometriosis referred for surgical treatment. All patients were submitted to laparoscopically assisted vaginal segmental resection of the rectosigmoid with anastomoses performed using linear and circular staplers. RESULTS: The average length of the surgical procedure was 177.5 min and average duration of hospitalization was 4.13 days. There were no intra-operative complications and integrity of the anastomoses was confirmed in all patients. One patient reported partial improvement of symptoms and 7 patients presented complete clinical remission 12 months following surgery. CONCLUSION: Laparoscopically assisted vaginal segmental resection of the sigmoid infiltrated by endometriosis is a feasible surgical procedure. The technique combines transvaginal access with mechanical intestinal anastomoses performed using linear and circular staplers, and achieves good results with low morbidity.     

The impact of deep disease on surgical treatment of endometriosis

Objective

To compare the difficulty of surgery in patients with and without deeply infiltrating endometriosis.

Study design

Prospective cohort study performed in one hospital specialized in the surgical treatment of endometriosis. 193 consecutive patients undergoing excision of all visible endometriosis by laparoscopy (176 patients, 91.2%) or by laparotomy (17 patients, 8.2%). The duration of surgery, the number of operations, the number of day-surgery operations, the need to operate with a surgeon, the ability to perform complete excision during one operation, and the ability to perform operation by laparoscopy were compared in patients with and without deep lesions.

Results

The mean duration of surgery was 192 (SD 96), and 76 (SD 41) min in patients with and without deep lesions (p < 0.001). Ureterolysis (66% vs. 20%, p < 0.001), division of adhesions (92% vs. 69%, p < 0.001), and hysterectomy (32% vs., 8%, p < 0.001), were more often performed on patients with deep lesions. 41 patients (42%) with deep lesions, and 1 patient (1%) without deep lesions were operated with a surgeon (p < 0.001). Day-surgery was less often performed on patients with deep lesions (11% vs. 45%, p < 0.001). Complete excision during one operation was performed on 95% and on 97% of the patients with and without deep lesions (p = 1.0). Complete excision was less often performed by laparoscopy in patients with deep lesions (79% vs. 95%, p < 0.001).

Conclusions

Surgical treatment of deep lesions is more demanding and time-consuming than surgical treatment of other types of endometriosis, and collaboration with a surgeon is often necessary. Complete excision during one operation is a realistic goal for endometriosis surgery, but it is significantly less often achievable by laparoscopy in patients with deep lesions than in patients without deep lesions.