子宫内膜异位症单纯腹腔镜治疗与术后应用GnRHa疗效的Meta分析

目的：评价单纯腹腔镜手术治疗与腹腔镜手术后应用促性腺激素释放激素激动剂（GnRHa）治疗子宫内膜异位症的疗效。方法：依据循证医学原则,用Cochrane系统评价方法,检索2000—2011年期间Cochrane图书馆,PUBMED,CNKI,CBM,万方和重庆维普数据库等。纳入单纯腹腔镜手术治疗与腹腔镜手术后联合应用GnRHa治疗子宫内膜异位症的随机对照试验（RCT）,采用RevMan 5.0软件行Meta分析。结果：①共纳入8篇符合要求的RCT文献,共计862例患者。②所纳入的研究根据随机方法、分配隐藏、盲法、失访、基线比较和等级描述等对所纳入的研究行质量评估,结果质量均达B级。Meta分析结果：术后应用GnRHa组随访1年症状缓解率比单纯腹腔镜组高（OR=4.30,95%CI：2.86~6.47,P＜0.01）;术后联合应用GnRHa组复发率比单纯腹腔镜组低（OR=0.18,95%CI：0.13~0.26,P＜0.01）;术后联合应用GnRHa组妊娠率比单纯腹腔镜组高（OR=4.98,95%CI：3.43~7.23,P＜0.01）。结论：腹腔镜手术后应用GnRHa治疗子宫内膜异位症的总体疗效优于单纯腹腔镜手术治疗。     

腹腔镜内凝热—色试验用于诊断盆腔子宫内膜异位症

目的：评估内凝热－色试验（ＨＣＴ）作为一种诊断盆腔子宫内膜异位症（ＥＭ）方法的临床价值。方法：对８３例不育症患者在腹腔镜下行ＨＣＴ，以诊断ＥＭ。１００℃内凝器探查盆腹膜，棕黑色为ＥＭ阳性。检查结果与直观法和活体组织检查结果进行对照。结果：直观法：８３例中诊断为ＥＭ３５例，未发现ＥＭ４８例。ＨＣＴ法：直观法诊断的３５例ＥＭ可见病灶，ＨＣＴ法检查均为阳性；直观法未发现ＥＭ的４８例中，２０例经ＨＣＴ检查发现无色素的ＥＭ阳性病灶。无色素病损的外观表现包括腹膜充血（７０．９％）、环状腹膜缺损（１２．７％）、半透明水泡样赘生（１０．９％）、白色斑块（１０．９％）、外观正常（５．４％）。其中，１３例共２５处无色素病损经活体组织检查，ＥＭ阳性率为６４．０％（１６／２５）。结论：ＨＣＴ可检测无色素的ＥＭ病灶，核实直观法对盆腔粘连的病因诊断和提高ＥＭ的ＦＩＧＯ分期准确性，是一种可靠、敏感且能准确定位的诊断ＥＭ的新方法，克服了直观法和活体组织检查诊断ＥＭ的多种漏诊因素。     

深部浸润型子宫内膜异位症手术治疗进展

手术治疗是深部浸润型子宫内膜异位症(DIE)的主要治疗方式。腹腔镜下完整切除DIE病灶具有高疼痛缓解率和低复发率的特点,目前已成为首选治疗方法,但完整DIE病灶切除后导致膀胱和直肠等功能障碍日益受到关注。最近的研究发现,保留盆腔自主神经的DIE手术可避免术后膀胱、直肠以及性功能紊乱。综述近年有关保留盆腔自主神经的DIE手术的治疗进展。     

LNG-IUS治疗子宫内膜异位症术后的临床观察

目的:探讨左炔诺孕酮宫内缓释系统(LNG-IUS)用于子宫内膜异位症(EMs)腹腔镜保守性手术后巩固治疗的临床疗效和不良反应.方法:选择主诉痛经的EMs患者70例,行腹腔镜保守性手术后分为2组,LNG-IUS组35例,促性腺激素释放激素激动剂(GnRHa)组35例.另选取33例术后给予非甾体抗炎药治疗的患者作为对照组....     

Can Narrowband Imaging Improve the Laparoscopic Identification of Superficial Endometriosis? A Prospective Cohort Trial

Study Objective

To assess the usefulness of narrowband imaging (NBI) to detect additional areas of endometriosis not identified by standard white light in patients undergoing laparoscopy for the investigation of pelvic pain.

Endometriosis and infertility Surgery and ART: An integrated approach for successful management

OBJECTIVES: Laparoscopy is considered the gold standard for treatment of endometriosis. In vitro fertilization and embryo transfer (IVF-ET) is often used to treat women with infertility associated with endometriosis. The objective of the study was to evaluate the pregnancy rate after surgical treatment and to assess whether a combined approach with laparoscopic surgery followed by IVF-ET can improve the "overall" pregnancy rate. STUDY DESIGN: A retrospective observational study was carried out on 107 infertile patients who underwent laparoscopic surgery for endometriosis and came at follow-up for a period of time between 1 and 11 years. Sixty-seven patients who did not become pregnant after surgery subsequently underwent IVF-ET. RESULTS: The pregnancy rate achieved after the integrated laparoscopy-IVF approach was 56.1%. The pregnancy rate after surgery, was significantly lower (37.4%). The fecundity rate for spontaneous conceptions within 6 months of laparoscopy (23.2%) was significantly higher (P<0.05) than for the following intervals. The cumulative fecundity in women older than 35 years was significantly lower than in younger women. CONCLUSIONS: In patients with endometriosis-associated infertility, surgery followed by IVF-ET is more effective than surgery alone. When patients fail to conceive spontaneously, after a maximum of 1 year from laparoscopic surgery, IVF should be suggested.     

The Role of Ovarian Suspension in Endometriosis Surgery: A Randomized Controlled Trial

Study ObjectiveA very high percentage of patients with severe pelvic endometriosis develop adhesions after laparoscopic surgery. The objective of this trial was to evaluate the role of ovarian suspension performed during surgery for severe endometriosis on ovarian adhesions and postoperative pelvic pain.DesignA randomized controlled trial (Canadian Task Force classification I).SettingThe tertiary care University Hospital of Bologna, Bologna, Italy.PatientsEighty patients with ovarian and posterior deep infiltrating endometriosis were included in the study.InterventionsPatients underwent laparoscopic surgery for endometriosis and were randomized sequentially into 2 groups: transient ovarian suspension was performed in the treatment group (n = 40), whereas in the control group (n = 40) ovaries were left free in the pelvis. Symptom intensity (dysmenorrhea, chronic pelvic pain, dyspareunia, dyschezia, and dysuria) were ranked using a visual analog scale. Postsurgical ovarian adhesions were evaluated using transvaginal ultrasonographic scans performed by an ultrasound operator who was blinded to the details of the operative procedure and women's randomization allocation. Complications, lesion localization, endometrioma diameter, and surgery time were recorded.Measurements and Main ResultsAt follow-up, a significantly lower rate of ultrasound-detectable ovarian adhesions with the uterus and the bowel was observed in the treatment group, respectively (46.7% vs 77.3%, p = .003 and 26.7% vs 68.2%, p < .0005). Patients in the control group showed a higher percentage of fixed ovaries with moderate and severe adhesions than the treatment group, respectively (56.8% vs 28.9%, p = .003 and 20.5% vs 8.9%, p = .110). No differences between the 2 groups were found regarding complications and pelvic pain.ConclusionOvarian suspension seems to be an additional effective surgical procedure associated with an increased ovarian mobility in women treated for severe endometriosis. Moreover, it is feasible, safe, simple, and fast. Hence, it should be routinely used during laparoscopic surgery for endometriosis.     

子宫内膜异位症合并不孕患者腹腔镜术后药物治疗妊娠结局分析

目的:探讨子宫内膜异位症(EMT)合并不孕患者腹腔镜术后联合药物治疗对妊娠结局的影响。方法:回顾性分析2006年1月至2011年6月在北京朝阳医院妇产科行腹腔镜手术且随访资料完整的230例EMT合并不孕患者的临床资料,采用方差分析EMT术前r-AFS分期(Ⅰ~Ⅳ期)与术后是否行药物治疗(孕三烯酮组、GnRHa组与未用药组)对各种妊娠结局及不同性质的妊娠结局(良好结局与不良结局)的影响。结果:1术后妊娠135例,妊娠率为58.7%。230例患者中术前4种r-AFS分期的妊娠率比较,差异无统计学意义(P0.05)。135例妊娠患者术前4种r-AFS分期间不同妊娠结局的比较,差异无统计学意义(P0.05)。有妊娠结局的126例患者术前4种r-AFS分期在良好或不良妊娠结局之间比较,差异无统计学意义(P0.05)。2230例患者中,GnRHa组与孕三烯酮组、未用药组相比,其发生的不同妊娠结局比较,差异有统计学意义(P0.05)。有妊娠结局的患者中GnRHa组与未用药组相比,良好结局与不良结局的比较,差异有统计学意义(P0.05),而孕三烯酮组与未用药组相比,差异无统计学意义(P0.05)。结论:术前r-AFS分期对于腹腔镜术后妊娠率及妊娠结局无影响。术后使用GnRHa对于导致不同的妊娠结局有一定的影响,对良好妊娠结局的影响有作用,而孕三烯酮作用不明显。     

Co-Existence of Uterine Myomas and Endometriosis in Women Undergoing Laparoscopic Myomectomy: Risk Factors and Surgical Implications

Study ObjectiveTo investigate the prevalence of and explore risk factors for the coexistence of uterine myomas and endometriosis and to assess operative outcomes during laparoscopic myomectomy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary referral center in London, England.PatientsTwo hundred twelve women undergoing laparoscopic myomectomy to treat symptomatic uterine myomas.InterventionLaparoscopic myomectomy.Measurements and Main ResultsCoexisting myomas and endometriosis were identified in 21.2% of patients. Endometriosis was more common in those with subfertility (44% vs 25.7%; p = .02) and less common in those with bleeding disorders (20% vs 45%; p = .003). Parity, location of myoma, and race/ethnicity affected risk of endometriosis, whereas size and number of myomas did not. Of patients with endometriosis, 42% underwent surgical treatment of endometriosis during myomectomy. Significantly more patients with endometriosis also underwent ovarian cystectomy than did those without endometriosis (15.6% vs 3%; p = .004). Operative time was similar in both groups (109.6 minutes vs 116.4 minutes; p = .83), as was estimated blood loss (271 mL vs 327 mL; p = .16).ConclusionsA diagnosis of concomitant endometriosis should be considered, in particular in patients with subfertility and pain. This enables optimal preoperative counseling and consent for potential additional procedures such as treatment of endometriosis or ovarian cystectomy.     

Long-Term Outcomes on Quality of Life in Women Submitted to Laparoscopic Treatment for Bowel Endometriosis

Study ObjectiveTo evaluate the long-term effects of laparoscopic surgery on quality of life in women with bowel endometriosis.DesignObservational prospective cohort study (Canadian Task Force classification II).SettingCentral Hospital of Santa Casa, Sao Paulo, Brazil.PatientsForty-five patients answered a short-form, 36-item, quality-of-life questionnaire (SF-36) at 3 different times.InterventionsBetween June 2007 and September 2008, patients underwent laparoscopic surgery to treat deep infiltrative endometriosis, with colorectal resection.Measurements and Main ResultsForty-five patients with bowel endometriosis were followed up from 2007 to 2012. Before surgery, all patients exhibited signs suggestive of bowel endometriosis at magnetic resonance imaging and transrectal ultrasound. The patients underwent laparoscopic surgery for resection of the endometriosis lesions, including colorectal resection. The patients completed the questionnaire before surgery (T0), at 12 (T12) and 48 (T48) months after surgery. The 8 items of the SF-36 questionnaire at the different time points of application were compared. For each domain attribute, a score of 0 to 100 was assigned, where 0 signified the worst quality of life, and 100 the best. Statistical analysis was performed using analysis of variance. If differences were detected, multiple comparisons were performed using the Tukey test. Analysis of each domain revealed improved quality of life when comparing the period before surgery with 12 and 48 months after surgery. There was a significant increase (p < .001) in the scores in all of the SF-36 domains when comparing T0 vs T12 and T0 vs T48, with higher average scores at T48 corresponding to the domains of physical functioning, role physical, and social functioning (scores of 85.56, 75.69, and 73.61, respectively).ConclusionLaparoscopic treatment of bowel endometriosis improved the long-term quality of life of patients.     

Combined Transvaginal/Transabdominal Pelvic Ultrasonography Accurately Predicts the 3 Dimensions of Deep Infiltrating Bowel Endometriosis Measured after Surgery: A Prospective Study in a Specialized Center

Study Objective

To assess the sensitivity and accuracy of combined transvaginal/ transabdominal ultrasonography (TV/TA US) for evaluation of deep infiltrating bowel endometriosis nodules measured after surgery.

A Multicenter International Temporal and External Validation Study of the Ultrasound-based Endometriosis Staging System

Study ObjectiveThe aim of this study was to validate temporally and externally the ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis.DesignA multicenter, international, retrospective, diagnostic accuracy study was carried out between January 2016 and April 2018 on women with suspected pelvic endometriosis.SettingFour different centers with advanced ultrasound and laparoscopic services were recruited (1 for temporal validation and 3 for external validation).PatientsWomen with pelvic pain and suspected endometriosis.InterventionsAll women underwent a systematic transvaginal ultrasound and were staged according to the UBESS system, followed by classification of laparoscopic level of complexity according to the Royal College of Obstetricians and Gynaecologists (RCOG) levels 1 to 3.Measurements and Main ResultsUBESS I, II, and III were then correlated with RCOG levels 1, 2, and 3, respectively. A comparison between temporal and external sites (skipping “A”) and between each site was performed in terms of the diagnostic accuracy of UBESS to predict RCOG laparoscopic skill level.A total of 317 consecutive women who underwent laparoscopy with suspected endometriosis were included. Complete transvaginal ultrasound and laparoscopic surgical outcomes were available for 293/317 (92.4%). At the temporal site, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of UBESS I to predict RCOG level 1 were 80.0%,73.8%, 94.9%, 97.2%, 60.2%, 14.5%, and 0.3%, respectively; of UBESS II to predict RCOG level 2 were 81.0%, 70.6%, 82.0%, 26.7%, 96.8%, 3.9%, and 0.3%, respectively; of UBESS III to predict RCOG level 3 were 91.0%, 85.7%, 92.4%, 75.0%, 96.1%, 11.3%, and 0.2%, respectively. At the external sites, the results of UBESS I to predict RCOG level 1 were 90.3%, 92.0%, 88.4%, 90.2%, 90.5%, 7.9%, and 0.1% respectively; UBESS II to predict RCOG level 2 were 89.2%, 100.0%, 88.5%, 37.5%, 100.0%, 8.7%, and 0.0%, respectively; and UBESS III to predict RCOG level 3 were 86.0%, 67.6%, 98.2%, 96.2%, 82.1%, 37.8%, and 0.3%, respectively.When patients requiring ureterolysis (i.e., RCOG level 3) in the absence of bowel endometriosis were excluded (n = 54), the sensitivity of UBESS III to correctly classify RCOG level 3 increased from 85.7% to 96.7% at the temporal site (n = 42) and from 67.6% to 96.0% at the external sites (n = 12) (p <.005).ConclusionThe results from this external validation study suggest that UBESS in its current form is not generalizable unless there is either or both bowel deep endometriosis and cul-de-sac obliteration present. The major limitation appears to be the misclassification of women who require surgical ureterolysis in the absence of bowel endometriosis.     

Determining the Fertility Benefit of Controlled Ovarian Hyperstimulation With Intrauterine Insemination After Operative Laparoscopy in Patients With Endometriosis

Study ObjectiveTo determine the fertility benefit of controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI) in surgically treated endometriosis.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingCleveland Clinic Foundation, tertiary care center.PatientsNinety-six women of reproductive age who underwent operative laparoscopy to treat endometriosis-related infertility (endometriosis stage I/II n = 67; stage III/IV n = 29) from 2001 to 2011 at the Cleveland Clinic Foundation.InterventionsCOH via letrozole, clomiphene, or gonadotropins, with or without IUI.Measurements and Main ResultsKaplan-Meier estimations of cumulative pregnancy rates were compared by stage between COH/IUI and spontaneous cycles. Patients with stage I/II endometriosis attempted spontaneous pregnancy for 669 months and 216 COH + IUI cycles, and patients with stage III/IV endometriosis attempted spontaneous pregnancy for 379 months and 74 COH + IUI cycles. Crude pregnancy rates were 45.7% in stage I/II and 40.5% in stage III/IV. Twelve-month cumulative pregnancy rates in stage I/II were 45% for spontaneous attempts and 42% for COH + IUI, and in stage III/IV were 20% for spontaneous attempts and 10% for COH + IUI (not significant). Cumulative pregnancy rates for COH/IUI in stage I/II were significantly higher than in stage III/IV. Monthly fecundity rates were 3.81% for stage I/II spontaneous, 4.59% for COH/IUI, 3.05% for stage III/IV spontaneous, and 1.68% for COH/IUI (not significant).ConclusionsCOH + IUI did not improve pregnancy rates in any stage of endometriosis. In stage III/IV we recommend postoperative in vitro fertilization.     

Laparoscopic surgical staging of locally advanced cervix cancer (IB2 to IVA): initial experience

Introduction and objectives

Cervical cancer incidence worldwide is about 500,000 new cases per year with most of them being detected at a locally advanced stage. Many studies have shown the need to look for extra-pelvic disease when planning appropriate therapy. We performed surgical staging by laparoscopy in 43 cases of cervical cancer at stages IB2 to IVa and evaluated our initial results.

Materials and methods

Between February 2008 and May 2010, we selected 43 patients with histologically confirmed cervical cancer at stages IB2 to IVA with a Karnosfsky index > 70. We classified the tumors according to the FIGO (International Federation of Gynecology and Obstetrics) stage and performed tomographic evaluations of the abdomen to select patients without signs of peritoneal or para-aortic tumor spread. We performed a laparoscopic evaluation of the peritoneal cavity and para-aortic lymph nodes by an extra-peritoneal route. We did not use tweezers or disposable energy seals.

Results

The mean surgical time was 130.8 min. The mean blood loss was 111.5 ml. There was no conversion to laparotomy for any case. We describe a case with peritoneal implants that was classified as IVB.We removed an average of 16.4 lymph nodes; nine cases had para-aortic lymph node metastases.

Conclusion

Laparoscopic surgical staging diagnosed 23.3% of cases with peritoneal spread of the tumor or extra-pelvic lymph node metastases. In this study, we could better define the lymph node status through laparoscopic surgical staging and could therefore recommend more suitable adjuvant therapy for patients with locally advanced cervical cancer.     

机器人系统在早期卵巢癌全面分期手术中的应用进展

早期卵巢癌以手术治疗为主,早期诊断、规范化的治疗可显著提高患者的5年生存率。机器人辅助腹腔镜手术打破了传统腹腔镜手术的局限,具有3D立体视野、高清及稳定的镜头、7个具有自由度的灵活内腕和改进的人体工程学特点,能够在深而窄的手术空间进行精细操作,并具有术中出血量少、术后并发症少和恢复快等优势,在复杂手术中的效果优于传统腹腔镜手术。近年来关于机器人辅助腹腔镜在早期卵巢癌的全面分期手术中的应用研究逐渐增多,微创手术的发展尤其是机器人手术系统的应用为早期卵巢癌的治疗提供了新的方向,选择合适的手术方式对于治疗早期卵巢癌有重要意义。综述机器人系统应用于早期卵巢癌手术的充分性、可行性及安全性。     

Laparoscopic Repair of a Post-Myomectomy Spontaneous Uterine Perforation Accompanied by a Bizarre Tumor Resembling Polypoid Endometriosis

Among various long-term complications after previous myomectomy, increasing risk of uterine rupture or dehiscence during pregnancy, and in particular during labor, has been widely recognized. In contrast, the world literature includes no case report of spontaneous uterine perforation or rupture after myomectomy in a nonpregnant woman, and only 1 case of iatrogenic uterine perforation after uterine artery embolization has been reported. Recently, we encountered an extremely rare case of spontaneous uterine perforation after previous myomectomy accompanied by a bizarre tumor resembling polypoid endometriosis, which was successfully treated via laparoscopic surgery. The patient reported genital bleeding and lower abdominal pain. Preoperative magnetic resonance imaging and intraoperative findings clearly demonstrated the presence of a uterine wall defect and a multicystic tumor that had developed from the perforated portion of the uterus. The patient underwent successful laparoscopic surgery for repair of the perforated uterus and resection of the tumor. The clinicopathologic diagnosis of the tumor was tentatively confirmed as an endometriosis-like lesion resembling polypoid endometriosis. We speculate that the cause of the tumor was retrograde menstruation, as in the pathogenesis of endometriosis.     

In Vitro Fertilization Success Rates after Surgically Treated Endometriosis and Effect of Time Interval between Surgery and In Vitro Fertilization

Study Objective

To evaluate the impact of endometriosis staging and endometriomas on in vitro fertilization (IVF) outcome and to assess the optimal time interval between laparoscopy and IVF.

GnRHa联合反加疗法用于腹腔镜术后子宫内膜异位症的临床观察

目的:探讨促性腺激素释放激素激动剂(GnRHa)联合结合型雌激素(CEE)及醋酸甲羟孕酮(MPA)用于子宫内膜异位症手术后巩固治疗的临床效果及安全性。方法:将96例腹腔镜术后子宫内膜异位症患者随机分成3组:单药组(33例):于术后皮下注射曲普瑞林3.75 mg,每28 d 1次,连用6个周期;反加组(32例)于术后皮下注射曲普瑞林3.75 mg,每28 d 1次,连用6个周期,自用药第4个周期起开始反加疗法,即加用结合型雌激素0.625 mg/d,醋酸甲羟孕酮5 mg/d,连用3个周期;对照组(31例):术后拒用药物治疗(因价格昂贵)。结果:单药组、反加组临床症状完全缓解率分别为90.9%和93.8%,均高于对照组(48.4%,P<0.01);单药组、反加组累计复发率分别为3.0%和6.2%,均低于对照组的(33.3%,P<0.01);治疗后单药组与反加组患者的血清雌二醇(E2)、卵泡刺激素(FSH)、黄体生成激素(LH)均低于对照组,差异有统计学意义(P<0.05),治疗后单药组患者的E2水平明显低于反加组(P<0.05),差异有统计学意义。结论:GnRHa联合结合型雌激素及醋酸甲羟孕酮反加疗法对控制低雌激素症状安全有效。反加疗法能减少GnRHa的不良反应且不影响其疗效。     

子宫内膜异位症分型的思考、建议及意义

子宫内膜异位症(EMs)是一类常见却复杂多样的妇科良性疾病,严重地影响妇女的健康和生活质量。改良的美国生育协会EMs分期评分法(r-AFS)是近30年来世界范围内应用最广泛的EMs分期系统,但其评分具有随机性和主观性。ENZIAN系统一定程度补充了r-AFS在深部浸润型EMs(DIE)评价上的不足。EMs生育指数(EFI)可预测合并不孕的EMs患者手术后的非体外受精(non-IVF)生育结局。新的姚氏分型将子宫直肠陷凹病变作为基本病变之根本所在,通过标准化的记录分析系统,反映疾病的整体病变范围,有利于规范化分析临床表现与分期、分型之间的关系,对患者的治疗采取标准的手术范围。     

Laparoscopic staging in advanced cervical cancer: the pros and cons of an oncological concept

In this paper, the concept of laparoscopic pretreatment staging in women with advanced cervical cancer is surveyed. While a number of authors have demonstrated the potential advantages of surgical staging for optimum individual treatment planning, clear definition of the radiation field, and potential avoidance of radical hysterectomy, an additional operation including para-aortic lymphadenectomy with considerable learning curve must also be considered. In one study, the negative effect of surgical staging on the survival of patients with cervical cancer has been reported. A positive effect of surgical staging on the prognosis of patients with advanced cervical cancer has not yet been shown. In conclusion, this concept must be further evaluated in specialized centers until a clear recommendation can be made.