输尿管子宫内膜异位症的诊断和治疗

目的 探讨输尿管子宫内膜异位症(内异症)的诊断和治疗策略.方法 1983年至2010年在北京协和医院住院且经手术证实为输尿管内异症的46例患者,分析其临床表现、辅助检查、手术方式、手术发现、病理结果、术后药物治疗、复发的处理及相关因素.结果 46例患者在本院接受了 1～2次的手术治疗,其中48%(22/46)的患者术前没有能够诊断输尿管内异症,46%(21/46)的患者没有症状或仅有痛经表现.输尿管粘连松解术和开腹手术是最主要的手术类型和手术路径,分别为72%(33/46)和63%(29/46).64%(25/39)的患者仅左侧输尿管受累,80%(37/46)为外生型输尿管内异症.87%(40/46)的患者合并盆腔内异症和子宫腺肌病.总计15%(7/46)的患者复发,术后至复发时间的中位数为24个月(13～49个月);复发后均接受再次手术治疗.仅术后是否使用促性腺激素释放激素激动剂与复发有显著相关性,与术后用药的患者相比,术后没有用药的患者复发的OR值为23.2(95%CI为2.4～221.7,P=0.002).结论 输尿管内异症与生殖道内异症关系密切,发病隐匿,早期诊断困难.手术切除后盆腔深部内异症及处理卵巢子宫内膜异位囊肿,对预防内异症进一步累及输尿管有意义.术后积极治疗盆腔内异症是防止复发的关键.

Abstract：

Objective To investigate strategies of diagnosis and treatment of ureter endometriosis. Methods From 1983 to 2010, the cases registered in Peking Union Medical College Hospital and confirmed as ureter endometriosis by surgery were enrolled in this study. Clinical manifestatios, preoperative examinations, surgical categories and routes, surgical and pathological findings, post-operative medical treatment, relapse and relating factors were collected and studied. Results Totally 46 patieuts with ureter endometriosis underwent one or two surgeries. Forty-eight per cent (22/46) of patients were not be diagnosed with ureter endometriosis pre-operatively, and 46% (21/46) only presented dysmenorrhea or even no symptoms. Ureterolysis (72%, 33/46) and laparotomy (63%, 29/46 ) were the most common surgical category and surgical approach. There were 64% (25/39) of patients had left ureter involved and 80% (37/46) had extrinsic ureter endometriosis. Fifteen per cent (7/46) of patients had relapsed disease with median recurrent time of 24 months (13 -49 months), and they all received second surgeries. Logistic regression analysis showed that only gonadotropin releasing hormone analogue agents were related with recurrence when compared with those patients without medical treatment post-operatively significantly ( OR =23.2, 95% CI:2. 4 -221.7, P =0. 002). Conclusions Ureter endometriosis was related with reproductive tract endometriosis. It has insidious process resulting in difficulty for early diagnosis. It's important to treat pelvic deep infiltrating endometriosis and ovarian endometrioma to prevent ureter from further involvement. Post-operative treatment of pelvic endometriosis is the key point of preventing relapse of ureter endometriosis.     

肠道子宫内膜异位症诊断及治疗

摘要：肠道子宫内膜异位症是指子宫内膜异位症病灶侵入或生长于部分或全部肠壁的浆肌层,主要表现是痛经、性交痛、排便痛。肠道子宫内膜异位症可以位于整个消化道的许多部位,但以乙状结肠和直肠交界处最常见。直肠气钡双重造影、经阴道超声、直肠内镜超声、磁共振成像(MRI)、多层螺旋CT等有助于明确诊断。药物治疗可以暂时控制症状,但不能使患者长期获益。根治性子宫内膜异位症病灶切除,包括肠道子宫内膜异位症病灶切除,是治疗肠道子宫内膜异位症的有效方法。肠道子宫内膜异位结节切除方法有表面病灶切除术,病灶碟形切除术和肠管节段性切除吻合术。尽管手术切除肠道子宫内膜异位症病灶还存在争议,但是越来越多的研究显示创伤性的手术改善了肠道子宫内膜异位症患者的症状及生存质量,增加了患者受孕机会。     

青春期子宫内膜异位症43例临床分析

目的探讨青春期子宫内膜异位症的临床特征、诊断和治疗方法。方法对1990～2003年中山大学附属第一、二、三医院及广东省人民医院收治的43例青春期子宫内膜异位症患者的临床资料进行回顾性分析。结果青春期子宫内膜异位症患者诊断时,距离初潮年龄平均间隔时间为4．6年,发病距离就诊时间平均为1年。就诊时的主要症状为盆腔包块18例,占42％;痛经15例,占35％;慢性腹痛10例,占23％;急性腹痛4例,占9％。根据1985年美国生育协会修订的子宫内膜异位症分期(ASF-r)标准,23例(53％)为Ⅲ期,8例(19％)为Ⅰ期,3例(7％)为Ⅱ期,9例(21％)为Ⅳ期。其中9例伴有生殖道畸形,占21％;12例(28％)患者进行了腹腔镜诊断和治疗。结论青春期子宫内膜异位症多发生于初潮后的5年内,主要症状为盆腔包块和痛经。青春期子宫内膜异位症患者的临床症状与成年人相似,腹腔镜是子宫内膜异位症的确诊手段,手术仍是其主要治疗手段。     

泌尿系统子宫内膜异位症的处理

摘要：泌尿系统子宫内膜异位症已有较多报道,其往往与深部浸润型子宫内膜异位症有关。泌尿系统子宫内膜异位症多伴有严重的泌尿系统症状。泌尿系统的症状往往伴随有子宫内膜异位症的妇科症状。该疾病的诊疗往往需要妇科与泌尿科医师的通力合作。药物治疗仅适用小部分患者,且有一定缺陷。手术治疗能达到病灶切除的满意效果,且患者预后较好,不易复发。     

胸腔子宫内膜异位综合征诊治特点

肺和胸膜子宫内膜异位症是一种非常少见的盆腔外子宫内膜异位症,被合称为胸腔子宫内膜异位综合征.临床特点具有月经相关的周期性特点,可以表现为经期咯血、气胸、血性胸腔积液等.病理诊断具有一定困难性,通常依靠临床诊断,需要除外其他引起气胸、咯血、胸腔积液的常见原因.促性腺激素释放激素激动剂(GnRH-a)试验性治疗有助于诊断....     

Diagnosis and treatment of rectovaginal endometriosis: an overview

Rectovaginal endometriosis can be a cause of severe pain, dyspareunia and intestinal problems. A thorough examination is needed and should include diagnostic imaging, such as transvaginal or transrectal ultrasound or magnetic resonance imaging. Medical therapies, such as oral contraceptives, progestins and levonorgestrel-releasing intrauterine devices, all seem to reduce pain and should always be considered. Surgical treatment is challenging and implies a risk of severe complications. It is preferable to treat endometriotic lesions with superficial infiltration into the rectal wall by local laparoscopic excision, while segmental rectal resection is needed in the case of severe intestinal infiltration. This review describes available diagnostic tools, the possibilities for medical treatment and the alternative surgical approaches.     

Diagnosis and management of intestinal endometriosis. A report of five cases

Five cases of intestinal endometriosis presented with infertility and pelvic pain. Rectal bleeding occurred in two patients and diarrhea in one. A diagnosis was achieved with a barium enema study and colonoscopy. All the patients had pelvic endometriosis as documented by laparoscopy. Endometriosis was present in the sigmoid colon in three patients and in the cecum in one; it was pericecal in the fifth. Bowel resection and pathologic study are necessary to relieve the symptoms and avoid neglecting a malignant tumor or other lesions.     

Diagnosis of endometriosis

Endometriosis is a common disorder of women of reproductive age, yet diagnosis of this condition is often problematic. The most frequent clinical presentations of endometriosis include dysmenorrhea, pelvic pain, dyspareunia, infertility, and pelvic mass. However, the correlation between these symptoms and the stage of endometriosis is poor. Currently available laboratory markers are of limited value. At present, the best marker, serum CA-125, is usually elevated only in advanced stages and therefore not suitable for routine screening. Transvaginal ultrasound and magnetic resonance imaging are often helpful, particularly in detection of endometriotic cysts. Recently, transrectal ultrasound and magnetic resonance imaging were shown to be valuable in detection of deep infiltrating lesions, especially in the rectovaginal septum. Although direct assessment of endometriotic foci at laparoscopy may be viewed as a "gold standard" for identifying endometriosis, the correlation of laparoscopic observations with histological findings is often low. Ultimately, diagnosis of endometriosis requires a careful clinical evaluation in combination with judicious use and critical interpretation of laboratory tests, imaging techniques, and, in most instances, surgical staging combined with histological examination of excised lesions.     

Inguinal endometriosis: A systematic review

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.     

深部浸润型子宫内膜异位症的诊断

摘要:深部浸润型子宫内膜异位症表现为子宫内膜异位病灶浸润深度≥5 mm,常与其他类型子宫内膜异位症并存。常见于骶子宫韧带﹑子宫直肠陷窝﹑阴道穹窿﹑直肠阴道隔等处。主要症状是疼痛和不孕。其诊断主要依靠超声、磁共振及CT,并结合临床表现和妇科检查。     

Diagnosis and laparoscopic treatment of an unusual case of advanced extragenital endometriosis

Endometriosis is considered to be a benign gynaecological disorder, although several pathophysiological aspects of endometrial lesions resemble the behaviour of malignant tissue: similar to carcinomas, endometriotic cells are able to invade and destroy surrounding anatomical structures. Although the medical treatment of endometriotic lesions, including the use of GnRH analogues or gestagens, show temporary effectiveness and have been reported to cause a regression of disease, they rarely provide long-term relief of symptoms in advanced stages of endometriosis involving extragenital organs, such as the rectum or the urinary system. We here describe the diagnosis and minimally invasive surgical treatment of an unusually advanced case of endometriosis involving the rectosigmoid, the urinary bladder and the ureter, leading to secondary hydronephrosis and loss of renal function.     

Diagnosis of endometriosis and pelvic pain

Both the American and the Royal Colleges of Obstetricians and Gynecologists have produced guidelines that recommend patients with chronic pelvic pain, including those suspected of having endometriosis, should receive empirical medical therapy without a preliminary diagnostic laparoscopy. This paper reviews the implications of this approach.     

Innovations in conservative endometriosis treatment: an updated review

Endometriosis is a common, benign and chronic gynecological disorder. It is also an estrogen-dependent disorder that can result in intractable dysmenorrhea, heavy and/or irregular periods, painful bowel movements and urination during menstruation and infertility and ultimatively in repeated surgeries. Although surgery to remove endometriotic lesions is effective in relieving endometriosis-associated pain, recurrence rates are high and many women require continuous medical therapy to control symptoms. Symptom relief with palliation of pain and optimization of the quality of life should be the main aim of the medical therapy. Different pharmacologic treatment options are currently available. The most widely exerted medical therapy for endometriosis involves gonadotropin-releasing hormone (GnRH) agonists and oral contraceptives. Also progestogens and androgen derivates are used. New treatment options that are currently under investigation are selective progestogen receptor modulators (SPRMs), aromatase inhibitors (AI), GnRH- antagonists, cyclooxygenase (COX)-2 inhibitors, angiogenesis disruptor's und immune modulators. Although these new agents are promising, further confirmation in randomized clinical trials is required.     

Diagnosis and clinical presentation of endometriosis

Despite advances in diagnostic techniques, endometriosis remains an enigmatic condition. Clinical symptoms and signs often do not correlate with the anatomic stage of the disease, and morphologic characteristics very widely. A definitive diagnosis can be established only by direct visualization, usually by laparoscopy. In some cases biopsy may be necessary to confirm the presence of disease.