腹腔镜与宫腔镜手术治疗不同体积Ⅱ型子宫肌瘤的疗效分析

Curative effect of transcervical resection of the myoma and laparoscopic myomectomy for type Ⅱ uterus myoma of different volume

目的 比较腹腔镜与宫腔镜手术治疗不同体积Ⅱ型子宫肌瘤的临床效果。方法回顾性分析2010年1月至2018年11月我院进行腹腔镜与宫腔镜手术的Ⅱ型子宫肌瘤299例患者的临床资料,其中采取腹腔镜手术100例(腹腔镜组),采取宫腔镜手术199例(宫腔镜组)。将所有患者根据Ⅱ型子宫肌瘤的体积分为3个亚组,小体积亚组(肌瘤直径<4cm)149例;中等体积亚组(4cm≤肌瘤直径≤5cm)103例;大体积亚组(肌瘤直径>5cm)47例。比较3个亚组患者按两种不同手术方法的临床治疗效果,分别对比手术时间、术中出血量、术中中转手术方式发生率、一次手术完整切除率、较严重并发症发生例数、肠蠕动恢复时间。结果小体积亚组:宫腔镜手术方式较腹腔镜手术在手术时间[(48.5±6.76)minvs.(57.8±8.02)min]、术中出血量[(67.9±12.48)mLvs.(74.6±10.46)mL]、肠蠕动恢复时间[(7.5±1.43)hvs.(20.1±4.5)h]等方面有优势,差异有统计学意义(P<0.05);2组患者术中中转手术方式发生率(1.6%vs.0)、一次手术切除率(95%vs.100%)和较严重并发症发生率(0.85%vs.0)比较,差异无统计学意义(P>0.05)。中等体积亚组:两种手术方式除肠蠕动恢复时间[(8.19±1.56)hvs.(18.56±3.86)h,P<0.05]宫腔镜略有优势外,其他指标比较差异均无统计学意义(P>0.05)。大体积亚组:除术中中转手术方式发生率(21%vs.7.1%)外,两种术式其他差异无统计学意义(P>0.05)。宫腔镜较腹腔镜在其他手术指标方面体现出一定的劣势,差异具有统计学意义(P<0.05)。结论宫腔镜手术在肌瘤直径<4cm时能够更快更彻底地切除肌瘤,术中出血少,术后恢复快,在小体积Ⅱ型子宫肌瘤的治疗中具有较明显的优势。但随子宫肌瘤体积增大,宫腔镜手术优势逐渐减小,在肌瘤直径4~5cm时二者疗效相当。在大体积亚组,肌瘤直径>5cm的子宫肌瘤中,宫腔镜手术并不优于腹腔镜手术且并发症风险明显增大。

Objective To compare the clinical effect of transcervical resection of the myoma(TCRM)and laparoscopic myomaectomy(LM)for typeⅡsubmucosal uterus myoma according to different diameter of myoma.Methods The clinical data of 299 patients with typeⅡsubmucosal uterus myoma who were admitted into our hospital from January 2010 to November 2018 were retrospectively analyzed.Among these patients,100 cases received laparoscopic surgery(laparoscopic group)and 199 cases received hysteroscopic surgery(hysteroscopic group).And the patients were divided into three subgroups according to the volume of uterus myoma.There were 149 cases in the small volume group(myoma diameter<4 cm),103 cases in the medium volume group(4 cm≤myoma diameter≤5 cm),and 47 cases in the large volume group(myoma diameter>5 cm).The clinical therapeutic effects of the three subgroups were compared according to two different surgical methods.The operative time,intraoperative blood loss,incidence of intraoperative change of operation method,rate of complete resection,incidence of serious complications,and recovery time of intestinal peristalsis were respectively compared.Results The small volume group:the operation time[(48.5±6.76)min vs.(57.8±8.02)min],intraoperative blood loss[(67.9±12.48)mL vs.(74.6±10.46)mL],and recovery time of intestinal peristalsis[(7.5±1.43)hours vs.(20.1±4.5)hours]of hysteroscopic group is significantly less than the laparoscopic group(P<0.05);while the incidence of intraoperative transfer operation(1.6%vs.0),the rate of complete resection(95%vs.100%),and the incidence of serious complications(0.85%vs.0)in the two groups were of no significant difference(P>0.05).The medium volume group:the recovery time of intestinal peristalsis of the hysteroscopic group had a slight advantage compared with that of the laparoscopic group[(8.19±1.56)hours vs.(18.56±3.86)hours](P<0.05);and there was no statistically significant difference between the two groups in terms of the other indicators(P>0.05).The large volume group:there was no statistically significant difference between the two groups,except for the incidence rate of intraoperative change of operation method(21%vs.7.1%).Conclusion Hysteroscopic surgery can remove myoma more quickly and thoroughly when the diameter of the myoma is less than 4 cm,with less intraoperative bleeding and faster postoperative recovery.And it has more obvious advantages in the treatment of small volumeⅡtype uterus myoma.However,with the increase of the myoma volume,the advantages of hysteroscopic surgery gradually decrease.When the diameter of myoma is 4 to 5 cm,the efficacy of hysteroscopic surgery and laparoscopic surgery is the same.In the large volume group,hysteroscopic surgery have no advantages in medical results compared with the laparoscopic surgery,and the risk of complications was significantly increased when the diameter of myoma is more than 5 cm.