多种微创保守性术式治疗子宫腺肌病及术后生殖预后的临床观察

Long-Term Clinical Observation of Various Minimal Invasive Conservative Surgical Procedures for Adenomyosis and Analysis of Factors Influencing Postoperative Reproductive Prognosis

目的探讨多种微创保守性术式治疗子宫腺肌病(AM)的长期疗效,以及子宫腺肌病患者术后生殖预后的影响因素。方法收集2010年1月至2014年1月诊断为子宫腺肌病且有意愿保留子宫或生育要求的患者共93例,根据手术方式的不同分为:子宫动脉阻断术(uterine artery blockage)组(A组,n=32),病灶切除术(lesion resection surgery)组(B组,n=33),子宫动脉阻断联合病灶切除术组(C组,n=28),比较3组间的随访指标;对7个可能影响术后生殖预后的因素进行单因素和多因素Logistic回归分析。结果与术前相比,3组患者术后各阶段的月经量均明显减少、痛经评分下降、子宫体积明显缩小(P<0.05);3组术后相应指标(月经量、痛经评分、子宫大小)在术后12月均降至最低,随后有上升趋势;术后12月起C组月经量、痛经评分、子宫大小分别与同期A、B组比较,差异有统计学意义(P<0.05)。单因素分析发现1年内妊娠率与年龄、子宫内膜-肌层交界区(JZ)厚度、合并子宫内膜异位症(EM)情况、术后规范用药情况及接受助孕、辅助生殖技术情况等因素有关,差异有统计学意义(P<0.05);进一步多因素Logistic回归分析显示,独立危险因素包括年龄≥35岁、JZ厚度>12 mm,而当JZ厚度<10mm、术后常规用药则是保护性因素。(OR分别为2.327、3.025、0.328、0.357,P<0.05)。结论 3种术式治疗AM的远期疗效良好,其中以子宫动脉阻断联合病灶切除术的疗效更佳;术后生殖预后与多个因素有关。

Objective To explore the long-termeffects of various minimal invasive conservative surgical procedures on adenomyosis （AM）, and to investigate the factors influencing postoperative reproductive prognosis. Methods Clinical data of 93 patients who were diagnosed with AM and had willingness to retain uterus or requirement for fertility from January 2010 to January 2014 were analyzed retrospectively. These patients were treated with uterine artery occlusion （group A,n=32） ,lesion resection （group B, n = 33）, or their combination （group C, n= 28）. Follow-up indicators were compared among the three groups. Seven potential factors influencing postoperative reproductive prognosis were evaluated by univariate analysis and multivariate logistic regression analysis. Results The menstruation amount,dysmenorrhea score and uterine size significantly reduced after treatment in all the three groups （P〈0.05）. These indictors reached their lowest levels at postoperative month 12 ,and then showed an upward trend. Furthermore, these indictors in group C were significantly different from those in group A and group B since postoperative month 12 （P〈0. 05）. Univariate analysis showed that the 1-year pregnancy rate was correlated with age,JZ thickness, EM, standard postoperative medication and assisted reproductive technology （P〈0.05）. Multivariate logistic regression analysis showed that the independent risk factors included age35 years and JZ thickness〉12 mm （OR=2. 327 and OR=3. 025 ,respectively; P〈 0.05）. However,JZ thickness〈10 mm and standard postoperative medication were the protective factors for 1-year pregnancy rate （OR= 0. 328 and OR = 0. 357, respectively; P〈0.05）. Conclusion Both uterine artery occlusion and lesion resection,especially their combination, have longterm curative effects on AM. Multiple factors are correlated with postoperative reproductive prognosis.