经阴道与宫腹腔镜两种手术方式治疗子宫切口憩室效果的Meta分析

Transvaginal Surgery versus Hysteroscopic and Laparoscopic Surgery for Previous Cesarean Scar Defect:a Meta Analysis

目的对比经阴道与宫腹腔镜两种不同术式治疗剖宫产术后子宫切口憩室(previous cesarean scar defect,PCSD)的效果。方法计算机检索PubMed、Web of Science、EMbase、the Cochrane Central Register of Controlled Trials(CENTRAL)、知网、维普和万方数据库,搜集各数据库关于宫腹腔镜手术和阴式手术治疗PCSD的随机对照试验(RCTs),检索时限全部从建库截至2020年5月30日。由2名研究人员独立筛选文献、提取数据并评价纳入文献研究的偏倚风险,对存在争议部分由另1名研究者重新评估,对符合纳入标准的文献进行Meta分析。结果最终纳入21篇RCTs研究,包括1211例患者,其中接受宫腹腔镜联合手术606例(宫腹腔镜组),经阴道手术605例(阴式组)。宫腹腔镜组术后经期短于阴式组[RR=1.1,95%CI=(1.04,1.16),P<0.001]、手术耗时长于阴式组[MD=19.59,95%CI=(11.24,27.94),P<0.00001];术中出血量少于阴式组[MD=-6.02,95%CI=(-11.47,-0.56),P<0.00001];术后阴道出血时间短于阴式组[MD=-2.62,95%CI=(-3.18,-2.06),P<0.00001];住院时间少于阴式组[MD=-2.58,95%CI=(-3.6,-1.55),P<0.00001];术后并发症低于阴式组[RR=0.24,95%CI=(0.11,0.56),P<0.001];住院费用高于阴式组[MD=4956.08,95%CI=(3132.88,6779.28),P<0.0001]。术后肛门排气时间[MD=0.11,95%CI=(-0.03,0.24),P=0.13]、术后妊娠率[RR=1.16,95%CI=(0.8,1.68),P=0.43]比较,2组差异无统计学意义(P>0.05)。结论较阴式手术,宫腹腔镜联合手术治疗PCSD其手术耗时更长,住院费用更高,但月经改善情况更优,术中出血量和术后并发症更少,术后阴道出血时间和住院时间更短。因受纳入文献质量的限制,建议临床谨慎选择。

Objective To compare the effects of transvaginal surgery and combined hysteroscopic and laparoscopic surgery on previous cesarean scar defect(PCSD).Methods The PubMed,Web of Science,EMbase,the Cochrane Library,CNKI,Viper and Wanfang were searched from inception to May 30,2020 to collect the randomized controlled trials(RCTs)on the treatment of PCSD with transvaginal surgery and combined hysteroscopic and laparoscopic surgery.Two researchers independently screened the literature,extracted the data and evaluated the risk of bias.The disputed data were reevaluated by another researcher.Meta-analysis was performed on the studies that met the inclusion criteria.Results Totally 21RCTs were included in this study.Among the 1211 patients,606 underwent hysteroscopic and laparoscopic surgery,and 605 underwent transvaginal surgery.Compared with transvaginal surgery,the combined hysteroscopic and laparoscopic surgery shortened postoperative menstrual period[RR=1.1,95%CI=(1.04,1.16),P<0.001],prolonged operation time[MD=19.59,95%CI=(11.24,27.94),P<0.00001),reduced intraoperative bleeding[MD=-6.02,95%CI=(-11.47,-0.56),P<0.00001]and complications[RR=0.24,95%CI=(0.11,0.56),P<0.001],shortened postoperative bleeding time[MD=-2.62,95%CI=(-3.18,-2.06),P<0.00001]and hospital stay[MD=-2.58,95%CI=(-3.6,-1.55),P<0.00001],and increased hospital expenses[MD=4956.08,95%CI=(3132.88,6779.28),P<0.0001].There were no significant differences between the two groups in time to first flatus[MD=0.11,95%CI=(-0.03,0.24),P=0.13]and postoperative pregnancy rate[RR=1.16,95%CI=(0.8,1.68),P=0.43].Conclusion Compared with transvaginal surgery,the combined hysteroscopic and laparoscopic surgery for the treatment of PCSD can prolong operation time,increase hospital costs,improve therapeutic efficiency,reduce intraoperative blood loss and postoperative complications,and shorten postoperative vaginal bleeding time and hospital stay.However,the procedure should be chosen carefully due to the quality of included literature.