无气腹腹腔镜下改良环形电切术病灶切除联合药物治疗子宫腺肌病疗效研究

Clinical effects of gasless laparoscopic adenomyosis resection with loop electrosurgical excision procedure combined with drug therapy

目的探讨无气腹腹腔镜下改良环形电切术(LEEP)切除子宫腺肌病病灶,并联合应用促性腺激素释放激素类似物(Gn RHa)和左炔诺孕酮宫内释放系统(LNG-IUS)治疗子宫腺肌病保留子宫的临床效果。方法 2010年8月至2013年7月对上海市闸北区中心医院和上海交通大学医学院附属第九人民医院收治的子宫腺肌病患者60例进行前瞻性研究。首先在无气腹腹腔镜下应用改良LEEP术切除子宫腺肌病病灶,同时应用Gn RHa治疗6个月,然后宫内放置LNG-IUS。观察治疗前后患者临床表现和检查指标的变化。结果 60例患者均完成手术和Gn RHa治疗,58例患者宫内放置LNG-IUS。手术后6个月和12个月子宫体积显著减小,术后18个月子宫体积有所增大,但仍显著小于手术前。手术前血红蛋白(88.8±11.7)g/L,术后3个月即恢复正常。手术前CA125升高41例,术后3个月均降至正常,术后18个月仍在正常水平。55例术前月经过多患者均放置LNG-IUS,手术后12个月和18个月月经量均达到或接近正常。术前共43例痛经者中42例放置LNG-IUS,手术后12和18个月痛经VAS评分均显著低于手术前(P<0.01),术后18个月痛经评分有所增加,但与术后12个月差异无统计学意义(P>0.05)。结论无气腹腹腔镜下改良LEEP术可较满意地切除子宫腺肌病病灶,联合Gn RHa治疗可显著减小子宫体积,改善临床症状,LNG-IUS的应用可进一步巩固治疗效果。

Objective To explore the effects of gasless laparoscopic procedure and LEEP combined with GnRHa and le- vonorgestrel intrauterine system （LNG-IUS） in the treatment of uterine adenomyosis to reserve the uterus of patients. Methods Sixty patients with adenomyosis severe enough for hysterectomy were prospectively studied from August 2010 to July 2012.The patients were all consent-informed to receive gasless laparoscopic adenomyosis resection with LEEP and then GnRHa injection for 6 months, and then to have LNG-IUS insertion in the uterus.The items such as uterine volume, tlemoglobin and serum CA125 levels before and after treatment were observed and compared.The menstrual bleed- ing and dysmenorrhea were also observed and compared between pre-treatment and after menstrual recovery.Results All 60 patients of adenomyosis successfully underwent surgical procedure and GnRHa treatment, and 58 patients had LNG-IUS insertion. The mean uterine volume decreased more significantly after surgery.The mean uterine volumes in- creased lightly at 12th month and at 18th month after surgery, either of which was still significantly far smaller than that before surgery （P〈0.05）.The level of hemoglobin returned to normal from 88.8±11.7g/L before surgelT at the 3rd month after surgery.41 patients were found with high serum CA125 level （66.5 ± 22.6）kU/L before surgery.The mean serum CA 125 level reduced to normal at the 3rd month after surgery, and remained still normal at the 18th month.All the 55 cases with heavy menstrual bleeding had LNG-IUS inserted. The follow-up results showed that the menstrual bleeding turned to normal at the 1st menstrual period after recovery, and remained nearly normal both at the 12th and the 18th month.There were 43 cases with dysmenorrhea among 60 subjects, and 42 had LNG-IUS insertion.The mean visual analogue scale （VAS） scores of dysmenorrhea in the 42 cases were significantly lower at 12th month or at 18th month than that before treatment （P〈0.01）.The VAS score was not significantly different at 18th month from that at 12th month （P〉0.05）.Conclusion The gasless laparoscopic procedure with LEEP could be effective in the resection of the uterine adenomyosis to reserve the uterus with severe adenomyosis.The surgery combined with treatment of GnRHa could effectively decrease the uterine size and improve the symptoms. And the LNG-IUS insertion could maintain the curative effects.