阴式筋膜外子宫颈切除术在宫颈上皮内瘤变和宫颈微浸润癌治疗中的临床应用

Application of transvaginal external fascia trachelectomy in the treatment of CIN and micro-invasive cervical cancer

目的探讨阴式筋膜外子宫颈切除术保守性治疗Ia1期宫颈鳞癌及不适于行宫颈锥切术的宫颈上皮内瘤变（GIN）Ⅲ级患者的可行性及安全性。方法选择大面积CINIII（阴道镜下病变面积≥3／4）、CINⅡ～Ⅲ锥切术后或环形电切术（LEEP）术后复发、病变残存或切缘阳性、经LEEP并活检后病理诊断的宫颈鳞癌Ia1期（除外脉管受累）、CINⅢ合并阴道上段上皮内瘤变（VAIN），且要求保留子宫和（或）生育功能的患者，行阴式筋膜外子宫颈切除术治疗，对其临床资料进行分析。结果79例接受阴式筋膜外子宫颈切除术的患者中，Ia1期宫颈鳞癌6例，大面积CINⅢ61例（23例累及腺体），CINⅢ合并VAIN3例，CINⅢLEEP术后病变残存6例、切缘阳性2例，CINII锥切术后复发1例。79例患者的平均手术时间为39min，平均出血量为40ml，平均住院时问为10d。3例CINllI合并VAIN者切除阴道壁2em以上，占3．8％（3／79）。无手术副损伤，无输尿管损伤，无术中、术后大出血。随访未发现术后复发病例，月经异常14例，无性生活影响。5例有生育要求的患者中，1例患者自然流产1次，人工流产1次，现术后第3次妊娠20“周。足月妊娠分娩4例，其中3例为剖宫产，1例为顺产。结论对于Ia1期宫颈鳞癌、大面积CINⅢ、CINⅢ合并VAIN以及CINⅡ—Ⅲ锥切术后复发、病变残存、切缘阳性等不适于行宫颈锥切术患者，阴式筋膜外子宫颈切除术是一种安全有效的保守性治疗术式。

Objective To explore the feasibility and safety of transvaginal external fascia trachelectomy to conservatively treat patients with stage I al squamous carcinoma of the uterine cervix （SCC） and cervical intraepithelial neoplasia （CIN）Ⅲ, who are not suitable to take cold knife conization （CKC）. Methods From July 2002 to September 2010, those patients who had a strong desire to preserve the uterus or fertility but also are confronted with following situations received transvaginal external fascia trachelectomy ： CIN Ⅲ with large area lesion （colposcopically observed lesion area was larger than 3/4 of the cervix）, or patients with CIN Ⅱ -Ⅲ suffered recurrence or had persistent lesion or positive margin after CKC or LEEP, or patients with CIN Ⅱ-Ⅲ upgraded into stage Ial SCC through LEEP and pathological confirmation （except for those with lymphovascular space invasion）, or CIN m patients complicated with upper vaginal intraepithelial neoplasia （VAIN）. Their clinical information and data were reviewed and analyzed. Results Among the 79 cases, who underwent transvaginal external fascia trachelectomy, six were stage Ial SCC, 61 were CINⅢ with a large area lesion （23 cases had glandular involvement）, three were CIN Ⅲ complicated with VAIN, six were CIN Ⅲ with persistent lesion after LEEP, two were CIN Ⅲ with positive margins after LEEP, and one case had recurrence after conization. The median age of these patients was 33 years old, ranging from 23 to 40 years old. The mean operation time was 39 min （rang 20-60 min） , the average amount of bleeding was 40 ml （rang 1-300 ml） and the mean hospital stay was 10 d （ rang 6-17 d）. The CIN Ill patients complicated with VAIN received this surgery with resection of the adjacent vaginal mucosa more than 2 cm in 3.8% （3/79）. The median follow-up time was 49 months （8-85 months） and none of these patients had ureteral injury or large amount of intraoperative or postoperative bleeding or post- operative recurrence. No patient complained any effect on their sexual life. Among the five patients with reproductive desire, one was at her 22 w gestation after one induced abortion and one spontaneous abortion, four patients experienced term birth in which three were cesarean section and one was natural labour. Conclusions Transvaginal external fascia trachelectomy is a safe and effective conservative treatment for stage I al SCC, CIN m with large area lesion, CIN llI complicated with VAIN and CINⅡ-Ⅲ suffering recurrence, persistent lesion or positive margins after CKC and others that are not suitable to take CKC.