促性腺激素释放激素激动剂联合腹腔镜手术治疗大子宫腺肌病疗效的研究

Study of effect of gonadotropin-releasing hormone combined with laparoscopic surgery in the treatment of adenomyosis

目的 评价术前使用促性腺激素释放激素激动剂（gonadotropin releasing hormone agonists,GnRHa）对子宫体积≥孕12周的子宫腺肌病患者腹腔镜微创手术的影响及GnRHa联合腹腔镜对子宫腺肌病的治疗疗效。方法 收集2011年1月至2015年1月青岛市立医院收治的子宫体积≥孕12周的子宫腺肌病患者34例的临床资料。术前予GnRHa（戈舍瑞林）皮下注射2~3针（1针/28 d）,停药15~30 d综合评估后进行腹腔镜子宫腺肌病病灶切除术。记录药物治疗前后的子宫腺肌瘤体积、血红蛋白水平、血清（cancer antigen 125,CA 125）水平及手术完成情况。术后自愿接受GnRHa继续治疗的18例患者为研究组,未接受GnRHa继续治疗的16例患者为对照组。术后3、6、9、12月监测痛经程度、月经量、子宫体积、血清CA 125水平、血红蛋白水平及围绝经期症状发生情况。结果 34例患者术前在GnRHa治疗后腺肌瘤体积明显缩小（P〈0.05）,血红蛋白水平明显升高（P〈0.05）,CA 125水平显著下降（P〈0.05）。所有患者均采用腹腔镜完成手术,无中转开腹者。术后研究组和对照组的经量过多及痛经改善情况在随访12月时、子宫体积在随访9、12月时、CA 125水平在随访6月时出现明显变化,差异有统计学意义（P〈0.05）;两组血红蛋白水平比较差异无统计学意义（P〉0.05）。治疗过程中,需反向添加治疗患者11例,添加治疗后,潮热出汗、骨关节痛等围绝经期症状均得到不同程度的改善。结论 在子宫体积≥孕12周的子宫腺肌病患者中,术前使用2~3月戈舍瑞林可以显著提高血红蛋白水平,缩小腺肌瘤体积,有利于腹腔镜手术的顺利进行;手术前后连续使用GnRHa较单纯术前用药可获得更好的疗效,推迟疾病的复发,值得临床推广。

Objective To evaluate the effect of preoperative use of gonadotropin releasing hormone agonists （GnRHa） on laparoscopic surgery of adenomyosis patients with uterine volume ≥ 12 weeks of pregnant. And to study the efficacy of GnRHa combined with laparoscopy in the treatment of adenomysis. Methods The date of 34 patients with adenomyosis whose uterine volume ≥ 12 weeks of pregnant hospitalized in Qingdao Municipal Hospital from January 2011 to January 2015 were collected. Subcutaneous injected 2 to 3 needles GnRHa （goserelin） （1 pin /28 days） before surgery, after 15 ~ 30 days of withdrawal, the patients were performed laparoscopic hysterectomy. Uterine myoma volume, hemoglobin levels, serum CA125 level before and after drug treatment and operation situation were recorded. After surgery, 18 patients who received GnRHa therapy were treated as the research group, 16 patients without GnRHa treatment were set as control group. The degree of dysmenorrhea, menstruation, uterine volume, serum CA125 level, hemoglobin level and the occurrence of menopausal symptoms were monitored 3, 6, 9, 12 months after the operation. Results The volume of the tumor of 34 patients was significantly reduced after GnRHa treatment before surgery（P 〈 0. 05）, the level of hemoglobin was significantly elevated （ P 〈 0.05 ）, and the level of CA125 significantly decreased （ P 〈 0. 05 ）. All patients underwent laparoseopic surgery, no one conversed to laparotomy. Hypermenorrhea and improvement of dysmenorrheal of two groups had significant difference when 12 months after follow -up, and there was significant difference in the volume of uterus between 9 and 12 months after follow -up; serum CA 125 levels were significantly different at 6 months of follow- up （P 〈 0.05 ） ;there was no significant difference in hemoglobin level between the two groups （ P 〉 0.05 ）. During the treatment, the number of the patients in the research group needing to add back therapy was 11, and after the treatment, sweating, bone and joint pain and other perimenopausal symptoms were improved in different degree. Conclusion Before the operation, use goserelin 2 ~ 3 months can significantly increased hemoglobin levels and reduced adenomyoma volume in patients with adenomyosis whose uterine volume≥ 12 weeks of pregnant, besides, it is conducive to the smooth progress of laparoscopic surgery. Continuous use of GnRHa before and after surgery can acquire better curative effect than single preoperative medication, delay disease relapse, which is worthy of clinical promotion.