宫腔镜与宫腹腔镜联合手术治疗剖宫产术后瘢痕憩室导致异常子宫出血的临床效果比较

Comparison of clinical effect of hysteroscopy combined with laparoscopy in the treatment of abnormal uterine bleeding caused by postoperative scar diverticulum after cesarean section

目的探讨宫腔镜与宫腹腔镜联合手术治疗剖宫产术后瘢痕憩室(PCSD)所致异常子宫出血的临床效果,为临床治疗选择合适方案提供参考。方法回顾性分析2018—2020年在华中科技大学同济医学院附属同济医院妇科行宫腔镜手术或宫腹腔镜联合手术治疗的52例PCSD患者的临床资料和相关指标,根据治疗方法将研究对象分为宫腔镜组(36例)和宫腹腔镜组(16例)。比较两组患者三维彩超子宫和憩室数据、术中和术后指标及月经改善情况的差异。结果宫腔镜组患者子宫前位占比(66.67%)高于宫腹腔镜组(50.00%),差异无统计学意义(χ^(2)=1.300,P>0.05)。两组患者子宫长度、宽度及高度比较,差异均无统计学意义(均P>0.05)。宫腔镜组患者子宫憩室残余肌层厚度[(0.31±0.09)cm]大于宫腹腔镜组[(0.19±0.09)cm],憩室宽度[(0.78±0.40)cm]小于宫腹腔镜组[(1.53±1.31)cm],差异均有统计学意义(t=3.170、-2.230,均P>0.05)。宫腔镜组术中见子宫憩室腔内子宫内膜占比(94.44%)高于宫腹腔镜组(68.75%),差异有统计学意义(χ^(2)=4.270,P<0.05)。宫腔镜组患者手术时间[(79.00±16.50)min]、术中出血量[(16.00±18.00)ml]及住院天数[(5.80±1.80)d]均显著小于宫腹腔镜组[(161.20±37.90)min、(80.60±48.40)ml及(8.40±1.40)d],差异均有统计学意义(t=-5.090、-5.190及-8.320,均P<0.05)。宫腔镜组患者治疗有效率(88.89%)和宫腹腔镜组(87.50%)比较,差异无统计学意义(χ^(2)=0.000,P>0.05)。结论根据不同憩室大小和残余肌层厚度选择宫腔镜和宫腹腔镜手术均能有效改善PCSD所致异常子宫出血症状。对于憩室小、残余肌层厚度高及憩室腔有明显内膜并无再生育要求患者,宫腔镜手术具有手术时间短、出血少、住院时间短及疗效好的优点。

Objective To explore the curative effect of hysteroscopic surgery and hysteroscopic combined with laparoscopy surgery in improving abnormal uterine bleeding caused by Post-cesarean section scar diverticulum,and to provide the evidence for clinical treat-ment.Methods The clinical data and related indexes of 52 patients with PCSD who underwent hysteroscopic surgery or laparoscopic com-bined with hysteroscopic surgery in Tongji Hospital Affiliated to Tongji Medical College,Huazhong University of science and technology from 2018 to 2020 were analyzed retrospectively.The data of uterus and diverticulum,intraoperative and postoperative indicators and the improve-ment of menstruation were compared between the two groups.Results The ratio of uterine anterior position in hysteroscopy group(66.67%)was higher than that in hysteroscopy combined with laparoscopy group(50.00%),yetwithout statistically significant differences(χ^(2)=1.300,P>0.05).There were no significant differences in uterine length,width and height between the two groups(all P>0.05).The re-sidual muscle of uterine diverticulum in hysteroscopy group[(0.31±0.09)cm]was thicker than that in hysteroscopy combined with laparos-copy group[(0.19±0.09)cm],and the diverticulum width[(0.78±0.40)cm]was smaller than that in hysteroscopy-laparoscopic group[(1.53±1.31)cm].The statistically differences were significant(t=3.170 and-2.230,all P<0.05).The endometrium in the divertic-ulum was seen more frequently in hysteroscopic group(94.44%)than that in hysteroscopy combined with laparoscopy group(68.75%)during operation,the difference was statistically significant(χ^(2)=4.270,P<0.05).The operative time[(79.00±16.50)min],intraoper-ative blood loss[(16.00±18.00)ml]and hospital stay[(5.80±1.80)d]of patients in hysteroscopy group were significantly lower than those in hysteroscopycombined with laparoscopic group[(161.20±37.90)min,(80.60±48.40)ml]and(8.40±1.40)d],with signifi-cant statistically difference(t=5.090,5.190 and 8.320,all P<0.05).The effective rate of hysteroscopy group(88.89%)and hysteros-copycombined with laparoscopic group(87.50%)showed no significant statistically difference(χ^(2)=0.000,P>0.05).Conclusion Bothhysteroscopy surgery and hysteroscopy combined with laparoscopic surgery can improve the symptoms of abnormal uterine bleeding caused by PCSD effectively.For patients with smaller diverticulum,thicker residual mus-cle layer,obviously intima in diverticulum,and without reproductive requirement,hysteroscopic surgery has the advantages of short operation time,less bleeding,short hospital stay and good curative effect.