子宫内膜异位症患者腹腔镜术后复发风险及不同促性腺激素释放激素激动剂方案应用效果分析

Risk of recurrence in patients with endometriosis after laparoscopic surgery and effect analysis of different gonadotropin-releasing hormone agonist regimen

目的 分析子宫内膜异位症患者腹腔镜术后复发风险及不同促性腺激素释放激素激动剂(GnRHa)方案的应用效果。方法 选取2019年1月—2022年6月于宁波市第七医院及复旦大学附属妇产科医院接受腹腔镜手术治疗的150例子宫内膜异位症患者,根据术后GnRHa方案不同将其分为两组,甲组(75例)采用醋酸亮丙瑞林微球3.75 mg进行治疗,乙组(75例)采用醋酸戈舍瑞林缓释植入剂3.6 mg进行治疗。分别于治疗前、治疗后1年检测两组患者的血清雌二醇(E_(2))、抗苗勒管激素(AMH)及窦卵泡计数(AFC)。随访1年,记录两组患者的妊娠情况及复发情况,并评估两组患者的临床疗效。根据复发情况将患者分为复发组与未复发组,对比两组患者的临床资料,并采用logistic回归分析法分析子宫内膜异位症患者腹腔镜术后复发的相关因素。结果 随访1年,150例患者中共35例(23.33%)出现复发。复发组与未复发组患者的术前痛经史[有:20例(57.14%)vs.36例(31.30%),无:15例(42.86%)vs.79例(68.70%)]、术前孕次[0次:12例(34.29%)vs.75例(65.22%),1次:15例(42.86%)vs.28例(24.35%),≥2次:8例(22.86%)vs.12例(10.43%)]、囊肿最大直径[<6 cm:14例(40.00%)vs.83例(72.17%),≥6 cm:21例(60.00%)vs.32例(27.83%)]、深部子宫内膜异位灶[18例(51.43%)vs.33例(28.70%)]、后穹窿触痛[16例(45.71%)vs.28例(24.35%)]、美国生殖医学学会(ASRM)分期[Ⅰ~Ⅱ期:12例(34.29%)vs.65例(56.52%),Ⅲ~Ⅳ期:23例(65.71%)vs.50例(43.48%)]、盆腔病变位置[单侧:16例(45.71%)vs.78例(67.83%),双侧:19例(54.29%)vs.37例(32.17%)]等相比,差异均有统计学意义(χ^(2)=7.657、10.739、12.157、6.180、5.910、5.311、5.068,均P<0.05)。多因素logistic回归分析结果显示:术前痛经史、术前孕次多、囊肿最大直径≥6 cm、深部子宫内膜异位灶、后穹窿触痛、ASRM分期Ⅲ~Ⅳ期、盆腔病变位置为双侧均为子宫内膜异位症患者腹腔镜术后复发的危险因素(均P<0.05)。治疗后1年,甲组患者的E_(2)水平[(41.56±5.15)pg/ml]低于乙组[(49.57±6.34)pg/ml],AMH水平[(4.18±0.74)ng/ml]、AFC[(10.42±1.18)个]高于乙组[(3.47±0.75)ng/ml、(9.54±1.12)个],差异均有统计学意义(t=8.493、5.836、4.684,均P<0.05)。甲组患者的妊娠率(72.00%)高于乙组(56.00%),复发率(14.46%)低于乙组(32.00%),总有效率(76.00%)高于乙组(60.00%),差异均有统计学意义(χ^(2)=4.167、6.298、4.412,均P<0.05)。结论 术前痛经史、术前孕次多、囊肿最大直径≥6 cm、深部子宫内膜异位灶、后穹窿触痛、ASRM分期Ⅲ~Ⅳ期、盆腔病变位置为双侧均为子宫内膜异位症患者腹腔镜术后复发的危险因素。相较于醋酸戈舍瑞林缓释植入剂,在子宫内膜异位症患者腹腔镜术后采用醋酸亮丙瑞林微球可有效改善卵巢功能,提高妊娠率,降低复发率,疗效显著。

Objective To analyze the risk of recurrence in patients with endometriosis after laparoscopic surgery and application effects of different gonadotropin-releasing hormone agonist(GnRHa) regimen.Methods A total of 150 patients with endometriosis who received laparoscopic surgery in Ningbo Seventh Hospital and Obstetrics & Gynecology Hospital of Fudan University from January 2019 to June 2022 were selected and divided into two groups according to different postoperative GnRHa regimens.The cases in group A(75 cases) were treated with leuprelin acetate microspheres 3.75 mg.The cases in group B(75 cases) were treated with 3.6 mg goserrelin acetate sustained release implant.Serum estradiol(E_2),anti-Müllerian hormone(AMH),and antral follicle count(AFC) of the two groups were measured before and 1 year after treatment.During one-year follow-up,the pregnancy status and recurrence of the two groups were recorded,and the clinical efficacies of the two groups were evaluated.According to the recurrence after treatment,the patients were divided into recurrence group and non-recurrence group.The clinical data of the two groups were compared,and the related factors of recurrence of patients with endometriosis after laparoscopic surgery were analyzed by logistic regression analysis.Results After one year,35 cases(23.33%) recurred.There were statistically significant differences in preoperative dysmenorrhea history [yes:20 cases(57.14%) vs.36 cases(31.30%),no:15 cases(42.86%) vs.79 cases(68.70%)],preoperative pregnancy times [0:12 cases(34.29%) vs.75 cases(65.22%),1:15 cases(42.86%) vs.28 cases(24.35%),≥2:8 cases(22.86%) vs.12 cases(10.43%)],maximum cyst diameter [<6 cm:14 cases(40.00%) vs.83 cases(72.17%),≥6 cm:21 cases(60.00%) vs.32 cases(27.83%)],deep endometriosis focus [18 cases(51.43%) vs.33 cases(28.70%)],posterior fornix tenderness [16 cases(45.71%) vs.28 cases(24.35%)],American Society for Reproductive Medicine(ASRM) stage [stage Ⅰ-Ⅱ:12 cases(34.29%) vs.65 cases(56.52%),stage Ⅲ-Ⅳ:23 cases(65.71%) vs.50 cases(43.48%)],and pelvic lesion location [unilateral:16 cases(45.71%) vs.78 cases(67.83%),bilateral:19 cases(54.29%) vs.37 cases(32.17%)] between recurrence group and non-recurrence group(χ~2=7.657,10.739,12.157,6.180,5.910,5.311,5.068,all P<0.05).Multivariate logistic regression analysis showed that preoperative history of dysmenorrhea,multiple pregnancies before surgery,maximum cyst diameter≥6 cm,deep endometriosis focus,posterior fornix tenderness,ASRM stage Ⅲ-Ⅳ,and bilateral location of pelvic lesions were all risk factors for recurrence of patients with endometriosis after laparoscopic surgery(all P<0.05).At one year after treatment,E_(2) level in group A [(41.56±5.15) pg/ml] was lower than that in group B [(49.57±6.34) pg/ml],AMH level [(4.18±0.74) ng/ml]and AFC(10.42±1.18) were higher than those in group B [(3.47±0.75) ng/ml,(9.54±1.12)],there were statistically significant differences(t=8.493,5.836,4.684,all P<0.05).The pregnancy rate in group A(72.00%) was higher than that in group B(56.00%),the recurrence rate(14.46%) was lower than that in group B(32.00%),and the total effective rate(76.00%) was higher than that in group B(60.00%),there were statistically significant differences(χ~2=4.167,6.298,4.412,all P<0.05).Conclusion History of dysmenorrhea before surgery,multiple pregnancies before surgery,maximum diameter of cyst≥6 cm,deep endometriosis focus,posterior fornix tenderness,ASRM stage Ⅲ-Ⅳ,and bilateral location of pelvic lesions are all risk factors for recurrence in patients with endometriosis after laparoscopic surgery.Compared with goserrelin acetate sustained-release implant,leuprelin acetate microspheres after laparoscopy in patients with endometriosis can effectively improve ovarian function,increase pregnancy rate,and reduce recurrence rate,with significant efficacy.