腹腔镜与开腹手术治疗早期宫颈癌的疗效比较

Comparison of the short-term and long-term outcomes of laparoscopic surgery and open surgery for early-stage cervical cancer

目的比较腹腔镜与开腹手术治疗早期宫颈癌（ⅠA2～ⅡA2期）患者的近远期疗效。方法回顾性分析2007年1月至2014年5月广西壮族自治区6家三级甲等医院收治的1 863例临床分期为ⅠA2～ⅡA2期宫颈癌患者的临床资料，分为腹腔镜组1 071例，开腹组792例，比较两组患者的近、远期疗效，并分析影响患者预后的因素。近期疗效包括手术相关指标和手术并发症，远期疗效包括生命质量（包括盆底功能和性功能）以及复发和生存情况，其中盆底功能评估采用女性下尿路症状国际尿失禁标准问卷（ICIQ－FLUTS），性功能评估采用女性性功能量表（FSFI）。结果腹腔镜组与开腹组患者的手术时间分别为（257±69）min和（238±56）min，术中失血量分别为（358±314）ml和（704±431）ml，术后肛门排气时间分别为（2.5±0.9）d和（2.9±0.8）d，留置尿管时间分别为（15±7）d和（18±9）d，住院时间分别为（19±16）d和（30±21）d，差异均有统计学意义（均P〈0.05）。腹腔镜组和开腹组患者的术中腹膜后淋巴结切除数分别为（21±9）个和（21±11）个，左宫旁组织切除宽度分别为（2.5±0.8）cm和（2.7±0.7）cm，右宫旁组织切除宽度分别为（2.6±0.3）cm和（2.7±0.2）cm，阴道组织切除长度分别为（2.4±0.7）cm和（2.2±0.7）cm，差异均无统计学意义（均P〉0.05）。腹腔镜组和开腹组患者术中并发症的发生率分别为8.1%（87/1 071）和10.7%（85/792），差异无统计学意义（P〉0.05）。但腹腔镜组患者术中血管损伤的发生率为2.6%（28/1 071），明显低于开腹组[7.7%（61/792），P〈0.001]。腹腔镜组患者术后并发症的发生率为33.8%（362/1 071），明显低于开腹组[40.2%（318/792），P〈0.05]；术后伤口愈合不良的发生率为0.7%（7/1 071），明显低于开腹组[4.0%（32/792），P〈0.05]。ICIQ－FLUTS问卷调查分层分析后显示，腹腔镜组保留盆腔自主神经术式患者术后尿失禁的发生率为28.4%（67/236），明显低于开腹组[35.9%（71/198），P＝0.004]，但两组患者不同程度尿失禁的发生率比较，差异无统计学意义（P〉0.05） 。FSFI问卷调查分层分析显示，腹腔镜组保留盆腔自主神经术式患者术后12个月性功能障碍的发生率为47.0%（111/236），明显低于开腹组[58.6%（116/198），P＝0.001]，且问卷中6个不同维度评分，腹腔镜组均明显高于开腹组（P〈0.05）。腹腔镜组与开腹组患者的5年总生存率分别为94.0%和90.2%，5年无瘤生存率分别为93.9%和89.1%，差异均无统计学意义（均P〉0.05）。单因素生存分析显示，肿瘤直径、临床分期、宫颈间质浸润深度、淋巴脉管浸润及腹膜后淋巴结转移状态均与患者的5年总生存率有关（均P〈0.05）；而肿瘤直径、临床分期、宫颈间质浸润深度及腹膜后淋巴结转移状态均与患者的5年无瘤生存率有关（均P〈0.05）。多因素生存分析显示，淋巴结转移和淋巴脉管浸润是影响宫颈癌患者5年总生存率的独立因素（均P〈0.05），而间质浸润深度和淋巴结转移是影响宫颈癌患者5年无瘤生存率的独立因素（均P〈0.05）。结论腹腔镜手术治疗早期宫颈癌与开腹手术比较，能减少术中出血、促进术后恢复、改善患者的术后远期生命质量，而二者的术后复发和生存情况无明显差异。腹腔镜手术治疗早期宫颈癌是一种较为安全、有效的方法。

ObjectiveTo evaluate the short-term and long-term outcomes after laparoscopic surgery compared with traditional laparotomy in cases of stage ⅠA2-ⅡA2 cervical cancer.MethodsWe conducted a retrospective study on the clinical data of 1 863 patients diagnosed as FIGO stages ⅠA2-ⅡA2 cervical cancer in 6 third-grade class-A hospitals in Guangxi province between January 2007 and May 2014. One thousand and seventy-one received laparoscopy, and 792 received laparotomy. T-test, U-test and χ2 test were used to compare the short-term and long-term outcomes. The short-term outcomes included surgical related outcomes and operative complications, and the long-term outcomes included quality of life （pelvic floor functions and sexual functions）, survival and recurrence. Pelvic floor function and sexual function were assessed with the International Consultation on Incontinence Quesonnaire Female Lower Urinary tract（ICIQ-FLUTS） and the Female Sexual Function Inventory （FSFI）, respectively. Survival rates were estimated by Kaplan-Meier analysis. The survival curves were compared with Log-rank test. Cox regression analysis was used to evaluaterisk factors for prognosis.Results（1）The short-term outcomes ： There were significant difference in operative time（[（257±69） vs（238±56）min], estimated blood loss[（358±314） vs（707±431）ml], anus exhausting time[（2.5±0.9） vs （2.9±0.8）d], preserved days of catheter[（15±7） vs（18±9）d], and post-operative length of stay[（19±16） vs （30±21）d] between the laparoscopic surgery group and the opensurgery group（P〈0.05）. There was no significant difference in lymph nodes yielded[（21±9） vs （21±11）], left parametrial width[（2.5±0.8） vs （2.7±0.7）cm], right parametrial width [（2.6±0.3） vs （2.7±0.2）cm], vaginal cuff length[（2.4±0.7） vs （2.2±0.7）cm] between the laparoscopic surgery group and the opensurgery group（P〉0.05）. The intra-operative complications occurred in 8.1%（87/1 071）in the laparoscopic surgery group and in 10.7%（85/792）in the open surgery group（P〉0.05）. However, the complications of vascular injury in the laparoscopic surgery group[2.6%（28/1 071）]was lower than that in the open surgery group[7.7%（61/792）, P〈0.001]. The laparoscopic surgery exhibited lower post- operative complication rate [33.8%（362/1 071）vs 40.2%（318/792）, P〈0.05] and poorer wound healing rate [0.7%（7/1 071）vs 4.0%（32/792）, P〈0.05]. （2）The long-term outcomes（Hierarchical analysis）： The overall incontinence in ICIQ-FLUTS questionnaire in nerve-sparing laparoscopic group [28.4%（67/236）] was lower than that in the open surgery group [35.9%（71/198）, P=0.004] . However, There was no significant difference in degree of incontinence between the two groups（P〉0.05）. The overall sexual dysfunction in FSFI questionnaire after 12 months of postoperative in the nerve-sparing laparoscopic group [47.0%（111/236）]was lower than that in the open surgery group [58.6%（116/198）, P=0.001], and the six different dimension scores in the laparoscopic surgery group were higher than that in the open surgery group （P〈0.05）. The recurrence rate was 3.5%（35/1 007）in the laparoscopicsurgery group and 4.7%（35/740）in the open surgery group（P〉0.05）. The 5-year OS was 94.0% for the laparoscopic surgery group and 90.2% for the open surgery group（P〉0.05）, and the 5-year DFS was 93.9% for the laparoscopic surgery group and 89.1% for the open surgery group（P〉0.05）. （3） Prognostic fators： In univariate analysis, tumor dimension, clinical stage, deep stromal invasion, LVSI, and retroperitoneal lymph node metastasis signficantly affected 5-year OS and 5-year DFS（P〈0.05）; In multivariate analyses, LVSI, deep stromal invasion and LN metastasis were independent prognostic factors（P〈0.05）.ConclusionsLaparoscopy can reduceestimated blood loss, accelerate postoperative recovery and improve the quality of life after surgery compared to laparotomy, and it ensures the same oncological results as open surgery. Laparoscopic approach is a safe and effective treatment for early-stage cervical cancer.