早期子宫颈癌患者腹腔镜下保留生育功能手术的临床效果观察

A retrospective study on the outcomes of the oncology, fertility and pregnancy in patients with early-stage cervical cancer after undergoing the fertility-sparing treatments

目的：探讨早期子宫颈癌患者腹腔镜下保留生育功能手术的疗效及妊娠结局。方法收集2010年2月至2015年9月上海交通大学医学院附属仁济医院收治的29例早期（Ⅰa2～Ⅰb1期）子宫颈癌患者作为研究组，行保留生育功能手术，手术方式包括经阴道子宫颈冷刀锥切＋腹腔镜下盆腔淋巴结切除术（PLD）或全腹腔镜下子宫颈广泛性切除术（RT；包含PLD）；以同期由同一组医师实施的腹腔镜下子宫广泛性切除术（RH；包含PLD）的早期子宫颈癌患者48例为对照组。对两组患者的围手术期相关指标、术后标本检查的相关指标、术后妊娠情况及术后肿瘤相关随访结果进行回顾性分析并比较。结果（1）研究组29例患者中，26例顺利完成保留生育功能手术，3例因术中快速冰冻病理检查阳性不符合保留生育功能条件而改行腹腔镜下RH。（2）围手术期相关指标：研究组与对照组的手术时间分别为（182±21）、（147±24）min，两组比较，差异有统计学意义（t=6.563，P〈0.01）；而两组间术中出血量[分别为（102±26）、（99±34）ml]、术后肛门排气时间[分别为（1.3±0.4）、（1.1±0.9）d]、住院时间[分别为（11.2±2.1）、（10.6±3.5）d]、尿潴留发生率[分别为10%（3/29）、10%（5/48）]、术后感染发生率[分别为3%（1/29）、2%（1/48）]分别比较，差异均无统计学意义（P〉0.05）。（3）术后标本检查的相关指标：研究组与对照组切除的盆腔淋巴结数[分别为（23.4±4.1）、（22.8±3.9）个]、主韧带长度[分别为（2.9±0.5）、（3.0±0.6）cm]、宫骶韧带长度[分别为（2.6±0.7）、（2.8±0.4）cm]、阴道长度[分别为（3.4±0.3）、（3.5±0.3）cm]分别比较，差异均无统计学意义（P〉0.05）。（4）术后妊娠及肿瘤复发：研究组26例成功保留生育功能患者中，术后仅14例患者有妊娠愿望，其中妊娠5例（5/14），包括足月分娩1例、早产1例、自然流产3例。研究组与对照组患者术后平均随访时间分别为29.4、30.2个月，随访期内两组患者的复发率分别为4%（1/26）、4%（2/48），两组患者复发率比较，差异无统计学意义（c2=0.004，P〉0.05）。结论早期子宫颈癌腹腔镜下保留生育功能手术的疗效肯定、安全可行，但其妊娠结局需待进一步改善。

Objective To explore the outcomes of the oncology, the fertility and pregnancy on patients with early-stage cervical cancer after undergoing fertility-sparing treatments, and to investigate its value on clinical treatment. Methods A total of 29 patients with cervical cancer （stage Ⅰa2-Ⅰb1） who had undergone the fertility-sparing treatments in Renji Hospital, School of Medicine, Shanghai Jiaotong University from February 2010 to September 2015 were analyzed retrospectively. Surgical procedures included transvaginal cervical cold knife conization （CKC）＋laparoscopic pelvic lymphadenectomy （PLD） or total laparoscopic uterine cervix extensive resection （RT; contains PLD）; 48 patients with early cervical cancer under going laparoscopic uterine extensive resection （RH; contains PLD） by the same group of physicians in the same period were chosen as the control group. The perioperative related indicators, postoperative specimen examination, pregnancies after surgery and postoperative tumor follow-up results were retrospectively analyzed and compared between the two groups. Results （1） Among these 29 patients in the study group, 26 cases were underwent the fertility-sparing surgery quick frozen pathological examinations were positive in 3 cases, which underwent total laparoscopic RT eventually. （2） The perioperative related indicators： compared with the study group and the control group, the operation time [（182 ± 21）, （147 ± 24） minutes, respectively] has significant difference （t=6.563, P〈0.01）. There were no significant difference （P〉0.05） in intra-operative blood loss [（102±26）, （99±34） ml], postoperative aerofluxus time [（1.3±0.4）, （1.1±0.9） days], the average length of hospital stay [（11.2 ± 2.1）, （10.6 ± 3.5） days], rate of urine retention [10%（3/29）, 10%（5/48）] and rate of postoperative infection [3%（1/29）, 2%（1/48）]. （3）Postoperative specimen examination：compared with the study group and the control group, there were no significant difference （P〉0.05） innumber of removed lymphatic nodes （23.4 ± 4.1, 22.8 ± 3.9）, length of cardinal ligament [（2.9 ± 0.5）, （3.0 ± 0.6） cm], lengthof uterosacral ligament [（2.6±0.7）, （2.8±0.4） cm], length of removed vaginal [（3.4±0.3）, （3.5±0.3） cm]. （4） Pregnancies after surgery and postoperative tumor follow-up results：in the study group, only 14 patients had fertility requirement after treatments. Pregnancies occurred in 5 women （5/14）, which included1 case of full-term labor, 1 case of preterm labor, and 3 cases of spontaneous abortion. The Average follow-up time in postoperative patients of the study group and control group was 29.4, and 30.2 months respectively. In follow-up period, compare with study group and the control group, there was no significant difference （χ2=0.004, P〉0.05） in the recurrence rate [4%（1/26）, 4%（2/48）]. Conclusion Fertility-sparing surgery of early-stage cervical cancer is safe but the outcome of the fertility and pregnancy is still need toimprove.