【摘要】 目的 探讨腹腔镜子宫腺肌症病灶切除术联合促性腺激素释放激素激动剂治疗子宫腺肌症的临床疗效和不良反应。方法采用回顾性分析方法,收集清华大学第一附属医院妇产科2007年6月至2011年9月收治的98例子宫腺肌症患者病历资料,按治疗方法分为药物组(68例)和手术联合药物组(30例)。药物组采用醋酸亮丙瑞林皮下注射,每28天1次,用药3~6个月;手术联合药物组使用腹腔镜子宫腺肌症病灶切除术后常规皮下注射醋酸亮丙瑞林3个月。比较2组患者依从性、失访率、性激素水平、症状体征、复发率、不良反应及妊娠率。结果 手术联合药物组患者较药物组失访率低,差异有统计学意义[17.6%(12/68)比6.7%(2/30),P<0.05];用药结束后,2组患者卵泡刺激素、促黄体素、雌二醇水平与治疗前比较均明显降低,差异有统计学意义[药物组卵泡刺激素:(2.24±0.79)U/L比(6.28±2.00)U/L,促黄体素:(3.5±1.2)U/L比(7.0±1.3)U/L,雌二醇:(146±52)pmol/L比(416±33)pmol/L;手术联合药物组卵泡刺激素:(2.18±0.55)U/L比(6.36±1.99)U/L,促黄体素:(4.1±1.0)U/L比(7.3±1.0)U/L,雌二醇:(158±54)pmol/L比(259±42)pmol/L,均P<0.05],停药2个月后手术联合药物组雌二醇水平与治疗前比较差异有统计学意义[(167±67)pmol/L比(259±42)pmol/L,P<0.05],2组其余激素水平与治疗前比较差异无统计学意义[药物组卵泡刺激素:(6.20±1.39)U/L比(6.28±2.00)U/L,促黄体素:(7.3±1.3)U/L比(7.0±1.3)U/L,雌二醇:(439±48)pmol/L比(416±33)pmol/L;手术联合药物组卵泡刺激素:(5.89±0.16)U/L比(6.36±1.99)U/L,促黄体素:(7.1±2.2)U/L比(7.3±1.0)U/L,均P>0.05];用药结束后2组患者痛经程度、月经量、子宫体积、糖类抗原125水平与治疗前比较均明显降低,差异有统计学意义[药物组痛经程度:(0.46±0.16)分比(2.85±0.32)分,月经量:(19±7)ml比(284±46)ml,子宫体积:(108±14)cm~3比(196±10)cm~3,糖类抗原125:(35±13)U/L比(46±26)U/L;手术联合药物组痛经程度:(0.27±0.12)分比(3.58±0.25)分,月经量:(17±7)ml比(338±52)ml,子宫体积:(97±19)cm~3比(237±9)cm~3,糖类抗原125:(29±8)U/L比(73±22)U/L,均P<0.05],停药2个月后药物组患者月经量与糖类抗原125水平与治疗前比较差异无统计学意义[月经量:(290±48)ml比(284±46)ml,糖类抗原125:(57±12)U/L比(46±26)U/L,均P>0.05];药物组患者复发率高于手术联合药物组,差异有统计学意义[月经过多复发率:73.9%(34/46)比10.0%(3/30),痛经加剧复发率:84.8%(39/46)比6.7%(2/30),子宫增大复发率:87.0%(40/46)比3.3%(1/30),糖类抗原125>35 U/L复发率:84.8%(39/46)比16.7%(5/30),均P<0.05];手术未发生并发症,用药期间2组患者均出现更年期样不良反应;手术联合药物组随访期间妊娠率高于药物组,差异有统计学意义[64.3%(18/28)比15.2%(7/46),P<0.05]。结论 腹腔镜子宫腺肌症病灶切除术联合醋酸亮丙瑞林治疗,可在巩固疗效的同时,增加患者依从性,降低失访率,减少复发,增加妊娠率,是治疗子宫腺肌症较理想的方案。更多还原

【Abstract】 Objective To explore both the curative and side effects of combined laparoscopic resection of uterine adenomyosis lesions and gonadotrophin releasing hormone analogue（GnRHa） treatment.Methods A retrospective method was adopted;patients with uterine adenomyosis were recruited and divided into drug group（68 patients） and combined surgery and drug group（30 patients） from June 2007 to September2011.The drug group was treated with GnRHa（leuprolide acetate） subcutaneously every 28 days,lasting for3-6 months;the combined surgery and drug group accepted the laparoscopic resection of uterine adenomyosis lesions and adjunctive GnRHa treatment for 3 months.Compliance,lost follow-up rate,sex hormone levels,symptoms and signs,recurrence rate,adverse reaction and pregnancy rate among patients of two groups were compared.Results There was a better compliance and lower rate of lost during follow-ups in the combined surgery and drug group[comparison of rate of lost to follow-up:17.6%（12/68） vs 6.7%（2/30）,P <0.05].After treatment,the level of follicle stimulating hormone（FSH）,luteinizing hormone（LH） and estradiol were all decreased significantly compared with pre-treatment in both groups[drug group FSH:（2.24 ±0.79） U/L vs（6.28±2.00）U/L,LH:（3.5 ± 1.2） U/L vs（7.0 ± 1.3） U/L,estradiol;（146 ±52）pmol/L vs（416 ±33）pmol/L;combined surgery and drug group FSH:（2.18 ±0.55） U/L vs（6.36 ± 1.99） U/L,LH:（4.1 ±1.0）U/Lvs（7.3 ±1.0）U/L,estradiol:（158 ±54）pmol/L vs（259 ±42）pmol/L,all P <0.05];compared to that before treatment,there was a statistically significant difference in the estradiol level[（167 ± 67） pmol/L vs（259 ±42） pmol/L,P < 0.05];however,other hormones restored and there had no significant difference level[drug group FSH:（6.20 ± 1.39） U/L vs（6.28 ±2.00） U/L,LH:（7.3 ± 1.3） U/L vs（7.0 ±1.3） U/L,estradiol:（439 ± 48） pmol/L vs（416 ± 33） pmol/L;combined surgery and drug group FSH;（5.89 ±0.16） U/L vs（6.36 ± 1.99） U/L,LH;（7.1 ±2.2） U/L vs（7.3 ± 1.0） U/L,all P>0.05].Compared to those before treatment,the degree of dysmenorrhea,menstrual volume,uterine size and level of carcinoma antigen 125(CA₁₂₅) were all significantly reduced after treatment[drug group score of dysmenorrhea;（0.46 ±0.16） vs（2.85 ±0.32）.menstrual volume;（19 ±7） ml vs（284 ±46） ml,uterine size;（108 ±14）cm³ vs（196 ± 10）cm³,CA₁₂₅:（35 ± 13）U/L vs（46 ±26）U/L;combined surgery and drug group score of dysmenorrhea;（0.27 ±0.12） vs（3.58 ± 0.25）,menstrual volume:（17 ± 7） ml vs（338 ±52） ml,uterine size;（97 ±19） cm³ vs（237 ±9） cm³,CA₁₂₅:（29 ±8）U/L vs（73 ±22） U/L,all P <0.05].However,at 2-month post-treatment,the menstrual volume and CA₁₂₅ of the drug group were bounced without significant difference compared to pre-treatment[menstrual volume:（290 ± 48） ml vs（284 ± 46） ml,CA₁₂₅:（57 ± 12） U/L vs（46 ±26） U/L,all P>0.05];the recurrence rate was higher in the drug group and the difference was significant[recurrence rate of heavy menstrual bleeding;73.9%（34/46） vs 10.0%（3/30）,recurrence rate of dysmenorrhea;84.8%（39/46） vs 6.7%（2/30）,recurrence rate of enlarged uterine size;87.0%（40/46） vs3.3%（1/30）.recurrence rate of CA₁₂₅ >35 U/ml:84.8%（39/46） vs 16.7%（5/30）.all P <0.05];all the patients in the surgery group had no severe complications.The menopause symptoms appeared in both groups during treatment;there was a significantly higher pregnancy rate in the combined surgery and drug group[15.2%（7/46） vs 64.3%（18/28）,P<0.05].Conclusion The combined surgery and drug treatment of laparoscopic resection of uterine adenomyosis lesions with adjunctive GnRHa therapy can improve curative effect,compliance,pregnancy rate and decrease the rates of lost during follow-ups.更多还原