卵巢子宫内膜异位囊肿粘连程度及相关因素分析

目的 探讨卵巢子宫内膜异位囊肿(内异症囊肿)粘连程度与患者的临床特点、手术情况及术后复发的关系.方法 对2003年1月至2008年3月就诊于北京协和医院并进行了腹腔镜手术的662例卵巢内异症囊肿患者的临床资料及手术情况进行分析,按术中所见卵巢内异症囊肿与周围组织的粘连情况分为无粘连组31例,轻度粘连(卵巢周围膜状透明粘连,可钝性分离,无血管)组123例,中度粘连(卵巢内异症囊肿被包裹的范围＜1/2,粘连致密,需锐性分离,或者卵巢内异症囊肿被包裹的范围＞1/2,周围疏松粘连,可钝性分离)组310例,重度粘连(卵巢内异症囊肿被包裹的范围＞1/2,多累及卵巢周围脏器和组织,并且粘连致密,需锐性分离,可见血管生成)组198例.比较各组患者疼痛程度、疼痛性质、疼痛时间等临床特点及实验室检查结果、手术情况和术后复发情况,并进行相关危险度和多因素分析.结果 (1)临床特点:中、重度粘连组患者痛经、性交痛、肛门坠胀感、慢性盆腔痛以及CA125异常(>35 kU/L)比例较无粘连、轻度粘连组高,差异有统计学意义(P=0.000、0.000、0.001、0.006、0.000);重度粘连组中不孕患者占15.7%(31/198),高于无粘连组的3.2%(1/31)、轻度粘连组的11.4%(14/123)和中度粘连组的9.7%(30/310),分别比较,差异均有统计学意义(OR=1.728,P<0.05).(2)手术时间及出血量:手术时间无粘连组为(37±15)min,轻度粘连组为(42±19)min,中度粘连组为(50±20)min,重度粘连组为(63±22)min;术中出血量无粘连组为(23±12)ml,轻度粘连组为(31±27)ml,中度粘连组为(40±32)ml,重度粘连组为(70±67)ml.(3)合并其他部位内异症及腺肌病:中、重度粘连组患者中合并子宫腺肌病和(或)深部浸润型内异症患者比例更高(OR=3.466,P=0.000).(4)术后复发:我们将术后复发分为痛经复发和囊肿复发,粘连程度与卵巢内异症囊肿术后复发无明显相关性,但痛经的复发与粘连程度有关(OR=1.685,P=0.046).结论 卵巢内异症囊肿粘连程度越重,疼痛症状越明显,手术时间越长,出血量越多;中、重度粘连患者术后疼痛症状复发率高;粘连程度与囊肿复发率无关.

Study on incidence and associated factors of different degree endometrioma adhesions

Objective To investigate the relationship between degree of endometrioma adhesions and clinical feature, surgical treatment and postoperative recurrence. Methods From Jan 2003 to Mar 2008, 662 patients with endometrioma undergoing laparoscopic ovarian endometrioma excision in Peking Union Medical College Hospital were studied retrospectively. All patients were classified into four groups according to the extent of adhesions: 31 cases in none adhesions group, 123 cases in mild adhesions group (filmy thickness, avascular, easily separated adhesions), 310 cases in moderate adhesions group (less than a half of ovary was adjacent to dense thickness adhesions which was difficult to separate, or above a half of ovary were adjacent to filmy thickness adhesions) and 198 cases in severe adhesions group (above a half of ovary was adjacent to dense thickness, well vascularized adhesions which was difficult to separate, and always involved the other pelvic organs, observed angiogenesis). The comparison of degree, characteristics, period of pain, lab test, surgical management and postoperative recurrence was performed among those above groups. In the mean time, risk factors and multinomial logistic regression were analyzed. Results (1)Clinical characteristics: The incidence of patients with dysmenorrhea, dyspareunia, straining feeling in anus, chronic pelvic pain and the level of CA125 (>35 kU/L) was remarkably higher in moderate-to-severe adhesion groups than in none-to-mild adhesions groups (P=0.000, 0.000, 0.001, 0.006 and 0.000, respectively). Infertility rate were significantly higher in severe adhesions group(15.7%,31/198) than none adhesions group(3.2%,1/31), mild adhesions group(11.4%,14/123) and moderate adhesions group(9.7%,30/310, OR=1.728, P<0.05).(2)Operating time and blood loss: Operating time of each groups was as followed: (37±15) min in none adhesions group, (42±19) min in mild adhesions group, (50±20) min in moderate adhesions group and (63±22) min in severe adhesion group. Blood loss was (23±12) ml in none adhesion group, (31±27) ml in mild adhesion group, (40±32) ml in moderate adhesion group and (70±67) ml in severe adhesions group. Thicker adhesions result in longer operation time and more blood loss. (3)Combined with other disease: The ratio of patients who combined with adenomyosis or deeply infiltrating endometriosis in moderate-to-severer adhesion groups was higher than patients in none-to-mild adhesions groups (OR=3.466, P=0.000). (4) Postoperative recurrence: It was categorized into recurrence of pain and cyst. Moderate-to-severe adhesions was related to higher recurrence rate of pain (OR=1.685,P=0.046), but was irrelevant to recurrence of cyst. Conclusion The more extent of endometrioma adhesions was related to severer pelvic pain symptoms, longer operating time and more blood loss. Postoperative pain recurrence rate was observed in moderate-to-severe adhesion group. Extent of adhesions was irrelevant to cyst recurrence.