全子宫切除术在宫颈上皮内瘤变治疗中的应用

Application of total hysterectomy in treatment of cervical intraepithelial neoplasia

目的探讨全子宫切除术在宫颈上皮内瘤变治疗中的临床应用价值。方法回顾性分析2009年1月至2016年12月第二军医大学长海医院收治的因宫颈上皮内瘤变行全子宫切除术的283例患者的临床资料,其中全子宫切除术前行宫颈环形电切除术(LEEP)206例(术前LEEP组),阴道镜活组织检查后直接行全子宫切除术28例(活检组),全子宫切除术中同时行LEEP 49例(术中LEEP组)。比较各组手术前后病理升级率、病理降级率、病灶残留率等指标的差异,并对患者年龄、孕产次、绝经年限、病理结果、人乳头瘤病毒(HPV)感染及肿瘤家族史等临床特征对术后病灶残留的影响行单因素及多因素分析。结果术前LEEP组治愈率35.92%(74/206),病灶残留率64.08%(132/206),病理降级率63.11%(130/206),病理升级率3.88%(8/206),发现癌变2例;活检组手术前后病理诊断一致率57.14%(16/28),病理降级率35.71%(10/28),病理升级率7.14%(2/28),术后发现浸润癌1例;术中LEEP组病灶残留率为40.82%(20/49),病理降级率65.31%(32/49),病理升级率8.16%(4/49),术后发现浸润癌2例。单因素分析示年龄和绝经年限为LEEP术后病灶残留的影响因素(P<0.05),多因素分析示绝经年限越长的患者病灶残留风险越低(P=0.02)。孕产次、病变累及腺体、切缘阳性、HPV感染、肿瘤家族史对病灶残留的影响无统计学意义。结论全子宫切除术对于防止宫颈癌前病变的复发及降低浸润癌的发病率有重要作用,适用于筛查机会少、随访条件差、无生育要求的人群。对于未绝经及绝经年限短的宫颈高级别上皮内病变患者需更加严密的随访,必要时可行全子宫切除术。

ObjectiveTo investigate the clinical value of total hysterectomy in the treatment of cervical intraepithelial neoplasia.MethodsWe retrospectively analyzed the clinical data of283patients undergoing total hysterectomy for cervical intraepithelial neoplasia in Changhai Hospital of Second Military Medical University from Jan.2009to Dec.2016.Among the patients,206cases received loop electrosurgical excision procedure(LEEP)before total hysterectomy(pre operative LEEP group),28only received total hysterectomy directly after colposcopy biopsy(hysterectomy group)and49received LEEP during total hysterectomy(intra operative LEEP group).The changes of pathological grade and the lesion residual rates of the patients before and after operation were compared.The effect of clinicopathological features(age,pregnancy times,partus times,abortion times,menopausal years,pathology,human papilloma virus(HPV)infection,tumor family history and so on)on postoperative residual lesion were analyzed by univariate and multivariate analysis.ResultsThe cure rate,lesion residual rate,pathological downgrade rate and pathological upgrade rate in the pre operative LEEP group was35.92%(74/206),64.08%(132/206),63.11%(130/206)and3.88%(8/206),respectively,and two cases with canceration were found.In the hysterectomy group,the consistent rate of pathological diagnosis before and after operation,pathological downgrade rate and pathological upgrade rate were57.14%(16/28),35.71%(10/28)and7.14%(2/28),respectively,and one case with invasive carcinoma was found after operation.The lesion residual rate,pathological downgrading rate and pathological upgrading rate in the intra operative LEEP group were40.82%(20/49),65.31%(32/49)and8.16%(4/49),respectively,and two cases with invasive carcinoma were found after operation.Univariate analysis showed that age and menopausal years were the factors influencing lesion remaining after LEEP(P<0.05).Multivariate analysis showed that patients with longer menopausal years had lower risk of lesion remaining(P=0.02).The pregnancy times,partus times,abortion times,lesion involving glands,positive margins,HPV infection and family history of cancer had no significant effects on postoperative lesion remaining.ConclusionTotal hysterectomy plays an important role in preventing the recurrence of cervical precancerous lesion and reducing the incidence of invasive carcinoma.It is suitable for people with few screening opportunities,poor follow up conditions and no fertility requirements.Patients with high grade intraepithelial lesion who are not menopausal or have short menopausal years need to be followed up more closely and can receive total hysterectomy if necessary.