Urinary Tract Injuries in Laparoscopic Hysterectomy: A Systematic Review

The aim of this review was to estimate the incidence of urinary tract injuries associated with laparoscopic hysterectomy and describe the long-term sequelae of these injuries and the impact of early recognition. Studies were identified by searching the PubMed database, spanning the last 10 years. The key words “ureter” or “ureteral” or “urethra” or “urethral” or “bladder” or “urinary tract” and “injury” and “laparoscopy” or “robotic” and “gynecology” were used. Additionally, a separate search was done for “routine cystoscopy” and “gynecology.” The inclusion criteria were published articles of original research referring to urologic injuries occurring during either laparoscopic or robotic surgery for gynecologic indications. Only English language articles from the past 10 years were included. Studies with less than 100 patients and no injuries reported were excluded. No robotic series met these criteria. A primary search of the database yielded 104 articles, and secondary cross-reference yielded 6 articles. After reviewing the abstracts, 40 articles met inclusion criteria and were reviewed in their entirety. Of those 40 articles, 3 were excluded because of an inability to extract urinary tract injuries from total injuries. Statistical analysis was performed using a generalized linear mixed effects model. The overall urinary tract injury rate for laparoscopic hysterectomy was 0.73%. The bladder injury rate ranged from 0.05% to 0.66% across procedure types, and the ureteral injury rate ranged from 0.02% to 0.4% across procedure type. In contrast to earlier publications, which cited unacceptably high urinary tract injury rates, laparoscopic hysterectomy appears to be safe regarding the bladder and ureter.     

全子宫切除术手术途径的发展现状

子宫切除术是妇科最常见的手术方法，随着医学理念及医疗器械领域的不断进步，各种手术方式层出不穷，目前采用的术式包括经腹子宫切除术（TAH）、经阴道子宫切除术（TVH）、经腹腔镜子宫切除术（TLH）以及单孔腹腔镜手术（LESS）、经阴道自然腔道内镜手术（v-NOTES）、机器人辅助腹腔镜手术（robotic assisted laparoscopy）进行子宫切除等。对于手术医师而言，应根据具体情况，在保证患者安全的前提下，合理地选择手术方式，制定规范化、人性化、个体化的治疗方案，以实现患者利益的最大化，这是每位医生的工作宗旨。通过查阅近年国内外相关文献，并结合临床实践经验，对每种子宫切除手术途径的安全性、可行性、优势以及局限性进行了全面系统的阐述，旨在通过对各种方式子宫切除术的比较，为临床医生更好地选择适合的子宫切除手术途径提供参考。     

Minimally Invasive Radical Hysterectomy for Cervical Cancer: A Systematic Review and Meta-analysis

ObjectiveTo compare recurrence rate, progression-free survival (PFS), and overall survival for early-stage cervical cancer after minimally invasive (MIS) vs abdominal radical hysterectomy.Data SourcesMEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Library databases.Methods of Study SelectionWe identified studies from 1990 to 2020 that included women with stage I or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or PFS and overall survival with MIS vs abdominal radical hysterectomy. (The review protocol was registered with the International Prospective Register of Systematic Reviews: CRD4202173600).Tabulation, Integration, and ResultsWe performed random-effects meta-analyses overall and by length of follow-up. Fifty articles on 40 cohort studies and 1 randomized controlled trial that included 22 593 women with cervical cancer met the inclusion criteria. Twenty percent of the studies had <36 months of follow-up, and 24% had more than 60 months of follow-up. The odds of PFS were worse for women undergoing MIS radical hysterectomy (odds ratio 1.54; 95% CI [confidence interval], 1.24–1.94; 14 studies). When limited to studies with longer follow-up, the odds of PFS were progressively worse with MIS radical hysterectomy (HR [hazard ratio] 1.48 for >36 months; 95% CI, 1.21–1.82; 10 studies; HR 1.69 for >48 months; 95% CI, 1.26–2.27; 5 studies; and HR 2.020 for >60 months; 95% CI, 1.36–3.001; 3 studies). For overall survival, the odds were not significantly different for MIS vs abdominal hysterectomy (odds ratio 0.94; 95% CI, 0.66–1.35; 14 studies) (HR 0.99 for >36 months; 95% CI, 0.66–1.48; 9 studies; HR 1.05 for >48 months; 95% CI, 0.57–1.94; 4 studies; and HR 1.35 for >60 months; 95% CI, 0.73–2.51; 3 studies).ConclusionIn our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse PFS than open radical hysterectomy for early-stage cervical cancer. The emergence of this finding with longer follow-up highlights the importance of long-term, high-quality studies to guide cancer and surgical treatments.     

Perioperative Interventions to Minimize Blood Loss at the Time of Hysterectomy for Uterine Leiomyomas: A Systematic Review and Meta-analysis

Study ObjectiveHysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.Data SourcesLibrarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.Methods of Study SelectionIncluded studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.Tabulation, Integration, and ResultsSurgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39–0.79; p < .01) and blood loss (?96.43 mL; 95% CI, ?153.52 to ?39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (?69.07 mL; 95% CI, ?135.20 to ?2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, ?0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (?27.72 mL; 95% CI, ?35.07 to ?20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, ?0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, ?0.15 to 0.20; p = .79) or blood loss (?50.88 mL; 95% CI, ?106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, ?8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.ConclusionPerioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.     

The Use of Barbed Suture for Laparoscopic Hysterectomy and Myomectomy: A Systematic Review and Meta-analysis

We conducted a meta-analysis comparing the efficacy of laparoscopic suturing with or without barbed suture for myomectomy or hysterectomy. We used a systematic electronic search strategy of published literature using the following databases: Cochrane Database of Systematic Reviews, MEDLINE, Embase, and OVID MEDLINE In-Process & Other Non-Indexed Citations databases. The following medical subject heading terms, key words, and their combinations were used: laparoscopy, myomectomy, hysterectomy, and barbed suture. Studies in which women undergoing laparoscopic myomectomy or hysterectomy using barbed suture or conventional suture were selected. The main outcome measures chosen for the current meta-analysis were operative time, suturing time, estimated blood loss or change in hemoglobin level, and degree of suturing difficulty. The results of the meta-analysis studies were expressed as the standardized mean difference (SMD) with 95% confidence intervals (CIs). Compared with the use of conventional suture, the total operative time of laparoscopic myomectomy (SMD = −0.58; 95% CI, −0.88 to −0.28) and the suturing time to close the uterine incision (SMD = −1.38; 95% CI, −1.86 to −0.90) were significantly reduced with the use of barbed suture. Meta-analysis on laparoscopic hysterectomy shows that the time to suture the vaginal vault, the total operative time, and the estimated blood loss were comparable with or without the use of barbed suture. The degree of suturing difficulty was reported in 2 randomized trials. Compared with the use of conventional suture, the degree of suturing difficulty was lower with the use of barbed suture (SMD = −1.39; 95% CI, −1.83 to −0.95). The use of barbed suture facilitates laparoscopic suturing of myomectomy incision and closure of the vaginal vault. Its use is associated with a reduced operative time of laparoscopic myomectomy.     

Comparison of Perioperative Outcomes in Outpatient and Inpatient Laparoscopic Hysterectomy

Study ObjectiveTo compare 30-day postoperative outcomes in outpatient and inpatient laparoscopic hysterectomy procedures.DesignRetrospective observational study (Canadian Task Force classification II-2).SettingMore than 250 hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program.PatientsWomen undergoing laparoscopic hysterectomy between 2006 and 2010.InterventionOf 8846 patients, 3564 underwent treatment as outpatients, as defined by hospital billing.Measurements and Main ResultsOverall morbidity was low in both cohorts; however, significantly fewer 30-day complications were observed in outpatients (4.5%) than inpatients (7.2%) (p < .001). Individual medical and wound complications were also rare and were less common in outpatients whenever a significant difference existed. After adjusting for demographic and operative variables, multivariate regression models found outpatients to be at significantly lower risk for overall perioperative morbidity (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53–0.78). Outpatients were less likely to experience wound complications (OR, 0.63; 95% CI, 0.46–0.87) and were at lower risk of medical complications (adjusted OR, 0.61; 95% CI, 0.49–0.77) and deep vein thrombosis (adjusted odds ratio, 0.61; 95% CI, 0.47–0.80). Outpatient designation was not a significant predictor for repeat operation (p = .09).ConclusionsOutpatient laparoscopic hysterectomy procedures are not associated with increased risk of 30-day postoperative complications.     

1983-2009年北京协和医院子宫内膜异位症手术治疗的特点及发展趋势

目的 探讨1983-2009年北京协和医院子宫内膜异位症(内异症)手术治疗的特点及发展趋势.方法 通过查阅1983年1月至2009年6月于本院就诊、经手术证实为内异症的病例,比较不同手术方式(开腹手术和腹腔镜手术)、不同手术类型(保守性手术、根治或半根治性手术)的例数及构成差异,分析手术方式及手术类型的变化趋势.结果 资料完整的内异症手术病例共13 972例,占同期所有妇科手术的24.974%(13 972/55 945).其中,腹腔镜手术占内异症手术的59.490%(8312/13 972),显著高于腹腔镜手术在其他疾病相关手术中所占比例[37.700%(15 824/41 973),P<0.01];2005-2009年,内异症腹腔镜手术所占比例上升至68.23%(947/1388),显著高于2000-2004年[56.04%(510/910),P<0.01].盆腔内异症手术中,保留子宫及卵巢的保守性手术占64.014%(8663/13 533);2005-2009年,保守性手术所占的比例上升至66.24%(4176/6304).在盆腔内异症保守性手术及根治或半根治性手术中,腹腔镜手术所占的比例存在显著差异[分别为81.10%(7026/8663)和26.30%(1281/4870),P<0.01].与1983-1999年及2000-2004年比较,2005-2009年内异症手术的年平均手术例数、腹腔镜手术的年平均手术例数及其在内异症手术中所占比例、保守性手术的年平均手术例数及其在盆腔内异症手术中所占比例均显著升高(P均<0.01).内异症相关手术的严重并发症发生率为0.351%(49/13 972).结论 内异症手术治疗是本院妇科手术的重要构成,保守性手术是内异症主要的手术类型,而腹腔镜是主要的手术方式.     

Effect of Hysterectomy due to Benign Diseases on Female Sexual Function: A Systematic Review and Meta-analysis

ObjectiveDetermination of the effect of hysterectomy caused by benign diseases on female sexual function.Data SourcesA search was performed on Scopus, PubMed, Science Direct, ProQuest, ISI Web of Knowledge, and Embase databases. The keywords included hysterectomy (as exposure) and female sexual function (as outcome). Original English observational studies, including cohort, case-control, and cross-sectional studies published as of February 2021, which reported an association between any type of hysterectomy caused by benign female disease and sexual function as an outcome, were included in the study. Studies in participants who received hormone replacement therapy and had sex other than heterosexuals were not included. There was no limit to the initial search period, and articles published by February 2021 were searched.Methods of Study SelectionThe search process resulted in the retrieval of 5587 potentially related articles. After removing duplicated studies, the title and abstract were reviewed and 77 articles remained with the removal of unrelated items. The full text of 14 articles was published in non-English languages, and 52 articles were removed because they did not meet the inclusion criteria, and finally, 11 articles were included in the final analysis.Tabulation, Integration, and ResultsThe Newcastle-Ottawa scale was used to assess the methodological quality of included studies. The evidence was synthesized using meta-analysis via random-effect model with the Der Simonian and Laird weighted method. Publication bias was assessed using the funnel plot and Begg's and Egger's tests. The pooled standardized mean difference for sexual function in hysterectomy vs nonhysterectomy group was 0.08 (95% confidence interval, ?0.38 to 0.55; I² = 96.8%; χ² = 307.94; p <.001; τ² = 0.59). Publication bias and small study effects were not detected. The results of the subgroup analysis showed that the possible sources of heterogeneity are the World Bank countries classification and type of hysterectomy (in some studies, the type of hysterectomy was not specified separately for the study groups; because of this, comparisons were made between Total and supracervical/total). Pooled standardized mean difference was affected by the type of sexual function scale, World Bank countries classification, type of hysterectomy, ovary status, and reproductive status. The results of meta-regression analysis also showed that for each month of distance from hysterectomy, women's sexual function score increases by 0.18.ConclusionThe results of this study showed that hysterectomy caused by benign diseases does not change the sexual function significantly.     

Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis

ObjectiveVaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy.Data SourcesPubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered.Methods of Study SelectionThe Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence.Tabulation, Integration, and ResultsA total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11–0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13–1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00–3.88).ConclusionThere is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.     

阴道闭锁16例临床分析

目的　分析阴道闭锁的临床特点 ,探讨其分型在诊断与治疗中的意义。方法　回顾分析我院近 16年收治的 16例阴道闭锁患者的临床资料。阴道闭锁按解剖学特点分为两型 :Ⅰ型指阴道下段闭锁 ,10例 ;Ⅱ型指阴道完全闭锁 ,6例。结果　Ⅰ、Ⅱ型阴道闭锁平均发病年龄分别为(13 0± 1 1)岁及 (15 5± 3 4 )岁 ,盆腔包块直径分别为 (7 7± 3 0 )cm及 (5 3± 1 0 )cm ,两者比较 ,差异有极显著性 (P <0 0 1) ;平均病程分别为 (3 5± 2 4 )个月及 2 4 0个月 (中位数 )。Ⅰ型阴道闭锁者盆腔包块位置较低 ,而Ⅱ型阴道闭锁者盆腔包块较高或位于盆腔一侧。Ⅰ型阴道闭锁者均行切开术 ,术后置阴道模型 ,随诊 1～ 16 8个月 ,中位数为 2 1 0个月 ,月经均正常 ,其中 4例出现阴道狭窄行阴道扩张术。已婚的 2例中 ,1例足月妊娠剖宫产分娩。Ⅱ型阴道闭锁合并子宫内膜异位症 (内异症 )、输卵管积血、双子宫者各 1例 ,合并双子宫及内异症者 1例 ;3例行子宫切除术 ,3例行保守性手术即阴道成形、宫颈成形及阴道子宫接通术 ,仅 1例术后有月经但伴痛经 ,于术后 6年因内异症手术治疗。结论　Ⅰ型阴道闭锁手术效果好 ;Ⅱ型阴道闭锁多合并内异症或子宫畸形 ,保守性手术治疗效果较差。     

The Fragility of Statistically Significant Results in Gynaecologic Surgery: A Systematic Review

ObjectiveTo use the fragility index (FI) to evaluate the robustness of gynaecologic surgery trials that report statistically significant results. The FI defines the minimum number of patients who must have an alternative outcome to alter statistical significance.Data SourcesWe searched MEDLINE, Web of Science, Embase, and ClinicalTrials.gov from 2011 to 2021 to identify gynaecologic surgery randomized controlled trials (RCTs).Study SelectionA total of 4775 trials were screened for eligibility. All included studies evaluated benign gynaecologic surgery interventions or peri-operative medical interventions. Only 2-arm RCTs with statistically significant dichotomous primary outcomes were included. Ninety-three trials were ultimately included for analysis.Data Extraction and SynthesisData from the included studies, including sample size, loss to follow-up, and number of events, were recorded. The FI of each study was calculated using a predefined technique. The overall FI and FIs by subgroup (clinical subspecialty, country of origin, and statistical test used) are reported as medians alongside their interquartile ranges (IQRs). The Kruskal-Wallis test was applied to find possible statistically significant relationships between FI and the nominal subgroups. Among this cohort, the median FI was 3 (IQR 1–7). The FI was 0 in 13 trials (14%), and in 39 trials (42%), the number of patients lost to follow-up was greater than the FI. The median FI within clinical subspecialty groups (general gynaecology, anaesthesia, urogynaecology, and fertility) did not differ (P = 0.122).ConclusionStatistically significant results of RCTs in gynaecologic surgery are fragile, suggesting that clinicians should interpret results with caution. This is particularly true when the number of patients lost to follow-up is greater than the FI. The FI serves as a quality metric that can be used to evaluate robustness of results when applying the outcomes of RCTs to clinical practice or guideline development.     

手术后口服小剂量米非司酮治疗子宫内膜异位症的近期疗效和副作用的初步观察

目的探讨保留生育功能或保留卵巢功能手术后服用小剂量米非司酮治疗子宫内膜异位症(内异症)的临床疗效、副反应及对生殖激素水平和骨代谢的影响.方法米非司酮组31例,予米非司酮10 mg口服,每日1次;达那唑组30例,予达那唑200 mg口服,每日2～3次,均连续用药3个月.观察两组症状、体征改善情况,用药后的副反应及用药3个月时血清生殖激素水平和骨代谢生化指标的变化.结果两组症状、体征缓解率相似.米非司酮组潮热、阴道出血、腰背疼痛、体重增加、痤疮等副反应发生率显著低于达那唑组(P<0.05).用药3个月时,米非司酮组血清促卵泡激素和黄体生成激素与达那唑组比较,差异无显著性(P>0.05);米非司酮组雌二醇(E2)为(204.9±45.3) pmol/L,保持在卵泡期水平,达那唑组为(94.3±33.0) pmol/L,为绝经后水平,两组比较,差异有极显著性(P<0.01).停药13～15 d,米非司酮组E2水平为(1 221.6±384.2) pmol/L,较用药前排卵期下降,但差异无显著性(P>0.05),达那唑组为(815.1±376.0) pmol/L,明显下降(P<0.05).停药当月黄体高峰期孕酮水平,米非司酮组为(33.1±5.6) nmol/L,与治疗前相似,而达那唑组为(27.4±4.9) nmol/L,显著降低(P<0.01),两组间差异有显著性(P<0.05).用药3个月时,米非司酮组尿脱氧吡啶啉/尿肌酐(UDpd/Cr)、血碱性磷酸酶(AKP)和骨钙素(BGP)与用药前比较,差异均无显著性(P>0.05);达那唑组血AKP为(54.0±10.7) U/L,BGP为(7.7±1.9) μg/L,较用药前明显升高(P<0.01),而UDpd/Cr水平无显著变化(P>0.05).米非司酮组停药后基础体温上升和月经复潮时间较达那唑组为短.结论手术后加用米非司酮可明显改善患者症状和体征,疗效与达那唑类似,但副反应明显减少.10 mg/d米非司酮3个月治疗可使血清E2保持在卵泡期水平,且对骨代谢无明显影响.     

子宫内膜异位症手术治疗后复发相关因素的分析

目的探讨子宫内膜异位症(内异症)术后复发的相关因素。方法对356例内异症手术治疗患者随访3年,将其中复发的75例患者的临床资料进行回顾性分析,对可能引起复发的相关因素(年龄、临床病理类型、分期、手术方式、术后是否加用米非司酮)进行分析。结果年龄≤24岁患者的复发率为0,与其余4个年龄段(25~29、30~34、35~39、≥40岁,复发率分别为19·8%、19·8%、31·9%和21·6%)比较,差异有统计学意义(χ2=11·212,P<0·05);年龄与复发率有相关关系(P<0·05)。在临床病理类型中,混合型、深部结节型患者的复发率分别为29·2%、33·3%,前者明显高于卵巢型的17·5%(χ2=4·622,P=0·032);复发率与临床病理类型有相关关系(P<0·05)。复发率随着内异症分期的增高而增加(P<0·05);Ⅰ~Ⅱ、Ⅲ、Ⅳ期患者的复发率分别为12·9%、22·5%、55·6%,Ⅰ~Ⅱ期与Ⅲ、Ⅳ期患者的复发率分别比较,差异均有统计学意义(χ2=5·129,χ2=33·899,P均(0·05)。Ⅲ期内异症患者腹腔镜手术与开腹手术的术后复发率分别为31·3%、11·3%,两者比较,差异有统计学意义(χ2=7·971,P=0·005)。加用米非司酮患者的复发间隔时间为(13±4)个月,未用药患者的复发间隔时间为(7±3)个月,两者比较,差异有统计学意义(t=4·575,P<0·01)。结论内异症的治疗应根据患者年龄、临床病理类型、分期选用创伤小并能较彻底清除病灶的个体化治疗方案。术后短期应用抑制卵巢功能的药物可延长复发间隔时间。     

子宫内膜切除术后妊娠结局的探讨

目的 探讨经宫颈子宫内膜切除术（TCRE）后妊娠的结局及其处理方法。方法 回顾分析我院TCRE后妊娠26例32例次的妊娠情况及其结局。结果 1例次自然流产,27例次人工流产,其中1例次宫腔粘连,狭窄,用宫腔电切镜切开后吸宫,1例次吸出完整胎囊后出血700ml,一般处理无效,行宫腔球囊压迫止血,另1例次右宫角妊娠,吸宫失败,行经腹子宫切除术,1例次宫颈妊娠,大出血;2例输卵管妊娠,1例足月妊娠,胎盘植入,剖宫产分娩一足月小样儿,同时切除子宫。结论 TCRE后仍有妊娠可能,但其困难流产,胎盘植入,胎儿生长受限,第三产程异常等并发症发生率升高,故应视为高危人群,加强监护。     

Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis

ObjectiveThe aim of this systematic review and meta-analysis was to perform an updated analysis of the literature in regard to the surgical management of minimal to mild endometriosis. This study evaluated women of reproductive age with superficial endometriosis to determine if the results of surgical excision compared with those of ablation in improved pain scores postoperatively.Data SourcesThe following databases were searched from inception to May 2020 for relevant studies: Cochrane Central Register of Controlled Trials, PubMed (MEDLINE), Ovid (MEDLINE), Scopus, and Web of Science.Methods of Study SelectionFrom our literature search, a total of 2633 articles were identified and screened. Ultimately, 4 randomized controlled trials were selected and included in our systematic review. The combined total number of subjects was 346 from these 4 studies, with sample sizes ranging from 24 to 170 participants. Data from 3 of the included studies were able to be compared and analyzed for a meta-analysis. The primary outcome was reduction in the visual analog scale (VAS) score for endometriosis-associated pain (dysmenorrhea, dyschezia, and dyspareunia), with follow-up time ranging from 6 to 60 months postoperatively.Tabulation, Integration, and ResultsData extracted from each study included the mean reduction in the VAS score from baseline. A random-effects model was used owing to significant heterogeneity across the studies. Statistical analyses were performed using Review Manager 5.3 software (Cochrane Collaboration, London, United Kingdom). The meta-analyses showed no significant differences between the excision and ablation groups in the mean reduction in VAS scores from baseline to 12 months postoperatively for dysmenorrhea (mean difference [MD] –0.03; 95% confidence interval [CI], –1.27 to 1.22; p = .97), dyschezia (MD 0.46; 95% CI, –1.09 to 2.02; p = .56), and dyspareunia (MD 0.10; 95% CI, –2.36 to 2.56; p = .94). In addition, there were no significant differences between the excision and ablation groups in mean VAS scores at the 12-month follow-up and beyond for dysmenorrhea (MD –0.11; 95% CI, –2.14 to 1.93; p = .92), dyschezia (MD 0.01; 95% CI, –0.70 to 0.72; p = .99), and dyspareunia (MD 0.34; 95% CI, –1.61 to 2.30; p = .73).ConclusionOn the basis of the data from our systematic review and pooled meta-analysis, no significant difference between laparoscopic excision and ablation was noted in regard to improving pain from minimal to mild endometriosis. However, to make definitive conclusions on this topic, larger randomized controlled trials are needed with longer follow-up.     

Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis

ObjectiveTo identify the most effective analgesia for women undergoing office hysteroscopy.Data SourcesWe searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception until August 2019 for studies that investigated the effect of different analgesics on pain control in office hysteroscopy.Methods of Study SelectionWe included randomized controlled trials that investigated the effect of analgesics on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting compared with the control group.Tabulation, Integration, and ResultsThe literature search returned 561 records. Twenty-two studies were selected for a systematic review, of which 16 were suitable for meta-analysis. There was a statistically significant reduction in pain during office hysteroscopy associated with preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) (standardized mean difference [SMD] –0.72; 95% confidence interval [CI] –1.27 to –0.16), opioids (SMD –0.50; 95% CI –0.97 to –0.03), and antispasmodics (SMD –1.48; 95% CI –1.82 to –1.13), as well as with the use of transcutaneous electrical nerve stimulation (TENS) (SMD –0.99; 95% CI –1.67 to –0.31), compared with the control group. Moreover, similar reduction in pain was observed after office hysteroscopy: NSAIDs (SMD –0.55; 95% CI –0.97 to –0.13), opioids (SMD –0.73; 95% CI –1.07 to –0.39), antispasmodics (SMD –1.02; 95% CI –1.34 to –0.69), and TENS (SMD –0.54; 95% CI –0.95 to –0.12). Significantly reduced pain scores with oral NSAID administration during (SMD –0.87; 95% CI –1.59 to –0.15) and after (SMD –0.56; 95% CI –1.02 to –0.10) office hysteroscopy were seen in contrast to other routes. Significantly more adverse effects were reported with the use of opioids (p <.001) and antispasmodics (p <.001) when compared with the control group, in contrast to NSAIDs (p = .97) and TENS (p = .63).ConclusionWomen without contraindications should be advised to take oral NSAIDs before undergoing office hysteroscopy to reduce pain during and after the procedure. TENS should be considered as an alternative analgesic in women with contraindications to NSAIDs.     

Outpatient Vaginal Hysterectomy: A Pilot Project

a pilot project was undertaken at the Woodstock General Hospital to determine the feasibility and cost-effectiveness of completing vaginal hysterectomies as outpatient procedures. Nineteen women voluntarily participated in this project between October 1998 and June 1999. There were no complications reported for seventeen of the women but two women required triage assistance. No hospital admissions were required. Compared to the control group there were no differences in complication rates. The cost to the hospital was significantly lower for the outpatient procedure. Given the early success of this project, outpatient vaginal hysterectomies will continue to be offered at the Woodstock General Hospital.     

腹腔弥漫型平滑肌瘤病一例

腹腔弥漫型平滑肌瘤病是一种罕见的特殊类型子宫平滑肌瘤,目前,其发病机制尚不明确,发病率极低,误诊率较高。报道山东大学附属省立医院2021年收治的1例腹腔弥漫型平滑肌瘤病患者,该患者以月经频发伴经量增多为首发症状,术前未明确诊断为腹腔弥漫型平滑肌瘤病,相关辅助检查也无明确指征,术中探查可见多枚平滑肌瘤样结节弥漫生长于腹腔。腹腔弥漫型平滑肌瘤病的病灶可弥漫分布于盆腹腔多器官表面,肉眼较难与腹膜转移癌或胃肠道间质肿瘤相鉴别。另外,在临床表现上,症状多与病灶种植位置有关,无特异性表现。在实际临床实践中,术前检出率极低,为降低误诊率,应对有多次子宫平滑肌瘤复发病史、腹腔镜碎瘤史的患者提高警惕,必要时行盆腹腔磁共振成像完善术前检查。