卵巢子宫内膜异位囊肿合并DIE患者的临床特征和腹腔镜手术后的远期预后

Clinical features and long-term outcomes after laparoscopic surgery in patients co-existing with ovarian endometrioma and deep infiltrating endometriosis

目的探讨卵巢子宫内膜异位囊肿(OMA)合并深部浸润型子宫内膜异位症(DIE)患者的临床特征及术后远期预后。方法回顾性分析2009年1月至2013年4月在北京协和医院由同一专业的子宫内膜异位症手术团队行腹腔镜卵巢囊肿剔除术的358例OMA患者的临床病理资料。术后至少随访8年。所有患者分为DIE组(合并DIE)和非DIE组(未合并DIE),并对其临床特征、手术结果和随访期间的远期预后进行比较分析。结果本研究共纳入OMA患者358例,其中DIE组190例(53.1%,190/358),非DIE组168例(46.9%,168/358)。DIE组与非DIE组的年龄分别为(33.7±5.4)和(32.5±5.3)岁(P=0.047),产次分别为(0.4±0.6)和(0.3±0.5)次(P=0.079)。DIE组与非DIE组术前的中重度痛经比例[分别为67.4%(128/190)、56.5%(95/168)]、慢性盆腔痛比例[分别为24.2%(46/190)、7.7%(13/168)]及血CA125水平升高比例[分别为79.9%(139/190)、65.2%(101/168)]均有明显差异(P均<0.05)。DIE组和非DIE组的手术时间分别为(75±21)和(39±36)min(P<0.01)。DIE组术中发现严重盆腔粘连的比例明显高于非DIE组,分别为91.6%(174/190)、53.6%(90/168),两组比较,差异有统计学意义(P<0.01)。DIE组较非DIE组合并子宫腺肌病的比例明显增加[分别为41.6%(79/190)、22.0%(37/168);P=0.001]。DIE组总复发率较高(21.6%,41/190),其中疼痛复发率为15.8%(30/190),囊肿复发率为8.4%(16/190);非DIE组术后总复发27例(16.1%,27/168),其中疼痛复发率为8.9%(15/168),囊肿复发率为10.7%(18/168);两组的总复发率、疼痛复发率及囊肿复发率分别比较,差异均无统计学意义(P=0.185、P=0.067、P=0.460)。分析远期生育结局,DIE组和非DIE组患者的活产率分别为100.0%(65/65)和94.4%(68/72),两组比较,差异无统计学意义(P=0.120)。结论与未合并DIE的OMA患者相比,合并DIE的OMA患者疼痛症状更严重,血CA125水平更高,术中发现的盆腔粘连情况也更严重。两组术后总复发率及各类型复发率虽未见明显差异,但合并DIE的OMA患者疼痛复发比例升高。合并DIE的OMA患者在长期随访期间妊娠的可能性较低,是否合并DIE对生育结局的影响不明显。

Objective To investigate the clinical features and long-term prognosis of patients co-existing with ovarian endometrioma(OMA)and deep infiltrating endometriosis(DIE).Methods Totally 358 OMA patients were retrospectively analyzed,who had a minimum of 8 years follow-up after laparoscopic cystectomy,which was performed by one professional endometriosis surgery team at Peking Union Medical College Hospital from January 2009 to April 2013.All women were divided into DIE group and non-DIE group,and analysis was performed in preoperative characteristics,surgical findings and postoperative outcomes during follow-up.Results A total of 358 OMA patients were included,of which 190 patients(53.1%,190/358)were in the DIE group,while other 168 patients(46.9%,168/358)in the non-DIE group.The average ages between the two groups were(33.7±5.4),(32.5±5.3)years(P=0.047),the average parity was(0.4±0.6)times vs(0.3±0.5)times(P=0.079).There were significant differences in the proportions of moderate to severe dysmenorrhea[67.4%(128/190)vs 56.5%(95/168)],chronic pelvic pain[24.2%(46/190)vs 7.7%(13/168)],and the increase in CA125[79.9%(139/190)vs 65.2%(101/168)]between the two groups(all P<0.05).The average operation time in the DIE and non-DIE groups was(75±21)vs(39±36)minutes(P<0.01).There was a significant difference in adenomyosis presence between the two groups[41.6%(79/190)vs 22.0%(37/168);P=0.001].All patients were followed up for at least 8 years.At the end of the follow-up,though the DIE group was with higher total rate of disease relapse,yet no significant difference was found between the two groups in statistical comparison[21.6%(41/190)vs 16.1%(27/168);P=0.185].A total of 41 cases in the DIE group recurred,the recurrence rate of pain was 15.8%(30/190),and the recurrence rate of cyst was 8.4%(16/190);27 cases had recurrence after operation in the non-DIE group,the recurrence rate of pain was 8.9%(15/168),and the recurrence rate of cyst was 10.7%(18/168).There were no significant differences in the pain recurrence rate(P=0.067)and cyst recurrence rate(P=0.460)between the two groups.As for the successfully pregnant patients,live birth rates were 100.0%(65/65)vs 94.4%(68/72)between DIE group and non-DIE groups(P=0.120).Conclusions Compared with the non-DIE group,OMA patients with concurrent DIE might have severe pain symptoms,higher probability of abnormal CA125 levels and more severe pelvic adhesions.Although there are no significant differences in the total recurrence rate and the recurrence rate of various types between the two groups,the proportion of pain recurrence in the DIE group is higher than that in the non-DIE group.In terms of fertility outcomes,patients in the DIE group are with lower likelihood of pregnancy after surgery during the long-time follow-up.DIE has no significant influence on the fertility outcome.