子宫腺肌病的手术治疗策略

doi:10.6040/j.issn.1671-7554.0.2021.1551

摘要/Abstract

摘要： 子宫腺肌病是育龄期女性常见激素依赖性炎症性疾病,以进行性加重的痛经、月经过多、不孕和子宫增大为主要临床表现,发病率逐年增加并呈年轻化趋势。子宫腺肌病的手术治疗往往是在药物治疗、非手术技术(包括子宫动脉栓塞术、高强度聚焦超声和射频消融等)无效或不愿意的基础上而执行的,具体术式需根据患者的年龄、临床症状、生育要求以及病灶的类型与范围等分层制定个体化手术策略。目前手术治疗主要包括子宫切除术、保守性病灶切除术、宫腔镜下囊性腺肌病灶切除术、宫腔镜下子宫内膜去除/射频消融术等术式。通过着重探讨各类术式的适用人群、手术操作要点及后续维持治疗方案等,以期个体化治疗并全程立体化管理,最大化优化疗效和提高生育力。

关键词: 子宫腺肌病, 子宫切除术, 腺肌病灶剔除术, 细胞减灭术, 宫腔镜

Abstract: Adenomyosis is a common hormone-dependent and inflammatory disease in women of childbearing age, manifested with progressive dysmenorrhea, menorrhagia, infertility and uterine enlargement. The morbidity increases year by year and shows a younger trend. Surgical treatment of adenomyosis is often performed due to ineffectiveness or unwillingness of drug therapy and non-surgical techniques(including uterine artery embolization, high-intensity focused ultrasound therapy and radiofrequency ablation). Specific surgical strategy needs to be formulated individually according to the patients’ age, clinical symptoms, fertility requirements and the type and scope of lesions. At present, surgical procedures include hysterectomy, conservative adenomyomectomy/cytoreductive surgery, hysteroscopic transcervical resection of endometrium/endometrial ablation, and so on. This article reviews the applicable population, key points of operation and maintenance treatment scheme of various surgical procedures, in order to ensure individualized treatment and life-long management of the disease, maximize the curative effects and improve fertility.

Key words: Adenomyosis, Hysterectomy, Adenomyomectomy, Cytoreductive surgery, Hysteroscopy

中图分类号:

R711.74

张信美,徐萍. 子宫腺肌病的手术治疗策略[J]. 山东大学学报 (医学版), 2022, 60(7): 26-31.

ZHANG Xinmei, XU Ping. Surgical treatment strategies of adenomyosis[J]. Journal of Shandong University (Health Sciences), 2022, 60(7): 26-31.

参考文献

[1] 中国医师协会妇产科医师分会子宫内膜异位症专业委员会. 子宫腺肌病诊治中国专家共识[J]. 中华妇产科杂志, 2020, 55(6): 376-382.
[2] 黄秀峰, 张信美. 子宫腺肌病的手术治疗现状与思考[J]. 中国计划生育和妇产科, 2019, 11(4): 15-17. HUANG Xiufeng, ZHANG Xinmei. Current status and thinking of surgical treatment of adenomyosis [J]. Chinese Journal of Family Planning & Gynecotokology, 2019, 11(4): 15-17.
[3] 张信美, 徐萍. 子宫腺肌病分层治疗及管理[J]. 浙江大学学报(医学版), 2019, 48(2): 123-129. ZHANG Xinmei, XU Ping. Stratified treatment and management of adenomyosis [J]. Journal of Zhejiang University(Medical Sciences), 2019, 48(2): 123-129.
[4] van den Bosch T, de Bruijn AM, de Leeuw RA, et al. Sonographic classification and reporting system for diagnosing adenomyosis [J]. Ultrasound Obstet Gynecol, 2019, 53(5): 576-582.
[5] Kishi Y, Suginami H, Kuramori R, et al. Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification [J]. Am J Obstet Gynecol, 2012, 207(2): 114.
[6] Bourdon M, Oliveira J, Marcellin L, et al. Adenomyosis of the inner and outer myometrium are associated with different clinical profiles [J]. Hum Reprod, 2020, 36(2): 349-357.
[7] Kishi Y, Yabuta M, Taniguchi F. Who will benefit from uterus-sparing surgery in adenomyosis-associated subfertility? [J]. Fertil Steril, 2014, 102(3): 802-807.
[8] Tan J, Moriarty S, Taskin O, et al. Reproductive outcomes after fertility sparing surgery for focal and diffuse adenomyosis: a systematic review [J]. J Minim Invasive Gynecol, 2018, 25(4): 608-621.
[9] Osada H, Silber S, Kakinuma T, et al. Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis [J]. Reprod Biomed Online, 2011, 22(1): 94-99.
[10] 黄琼施, 黄秀峰, 张晶, 等. 改良双瓣法病灶切除术在弥漫性子宫腺肌病中的应用分析[J].实用妇产科杂志, 2014, 30(8): 605-608. HUANG Qiongshi,HUANG Xiufeng,ZHANG Jing, et al. Evaluation on the efficacy of a double-flap method of adenomyomectomy for diffuse uterine adenomyosis [J]. Journal of Practical Obstetrics and Gynecology, 2014, 30(8): 605-608.
[11] Yasuo O, Masato N, Yuko A, et al. Association of uterine wall thickness with pregnancy outcome following uterine-sparing surgery for diffuse uterine adenomyosis [J]. Aust N Z J Obstet Gynaecol, 2016, 56(1): 88-91.
[12] Osada H. Uterine adenomyosis and adenomyoma: the surgical approach [J]. Fertil Steril, 2018, 109(3): 406-417.
[13] Younes G, Tulandi T. Conservative surgery for adenomyosis and results: a systematic review [J]. J Minim Invasive Gynecol, 2018, 25(2): 265-276.
[14] Rocha TP, Andres MP, Borrelli GM, et al. Fertility-sparing treatment of adenomyosis in patients with infertility: a systematic review of current options [J]. Reprod Sci, 2018, 25(4): 480-486.
[15] Gordts S, Campo R, Brosens I. Hysteroscopic diagnosis and excision of myometrial cystic adenomyosis [J]. Gynecol Surg, 2014, 11(4): 273-278.
[16] Philip CA, Le Mitouard M, Maillet L, et al. Evaluation of NovaSure global endometrial ablation in symptomatic adenomyosis: a longitudinal study with a 36- month follow-up [J]. Euro J Obstet Gynecol Reprod Biol, 2018, 227: 46-51. doi: 10.1016/j.ejogrb.2018.04.001.
[17] El-Nashar SA, Hopkins MR, Creedon DJ, et al. Prediction of treatment outcomes after global endometrial ablation [J]. Obstet Gynecol, 2009, 113(1): 97-106.
[18] Ofer G, Jenya K, Michael H, et al. Perioperative predictors of successful hysteroscopic endometrial ablation [J]. Gynecol Obstet Invest, 2007, 63(4): 205-208.
[19] Saremi A, Bahrami H, Salehian P, et al. Treatment of adenomyomectomy in women with severe uterine adenomyosis using a novel technique [J]. Reprod Biomed Online, 2014, 28(6): 753-760.
[20] Nishida M, Takano K, Arai Y, et al. Conservative surgical management for diffuse uterine adenomyosis [J]. Fertil Steril, 2010, 94(2): 715-719.
[21] Shu SR, Luo X, Wang ZX, et al. Fifteen cases clinical analysis of wedge-shaped resection of uterus treating adenomyosis- CONSORT [J]. Medicine(Baltimore), 2016, 95(24): 3805.
[22] Fujishita A, Masuzaki H, Khan KN, et al. Modified reduction surgery for adenomyosis. A preliminary report of the transverse H incision technique [J]. Gynecol Obstet Invest, 2004, 57(3): 132-138.
[23] Sun C, Ren XY, Gao Y, et al. Clinical efficacy and safety of major uterine wall resection and reconstruction of the uterus combined with LNG-IUS for the treatment of severe adenomyosis [J]. Geburtshilfe Frauenheilkd, 2020, 80(3): 300-306.
[24] Gao YF, Shan SZ, Zhao X, et al. Clinical efficacy of adenomyomectomy using “H” type incision combined with Mirena in the treatment of adenomyosis [J]. Medicine(Baltimore), 2019, 98(11): 14579.
[25] 张信美, 石一复. 子宫腺肌症患者子宫次全切除术后的危险性探讨[J]. 现代妇产科进展, 2001, 10(2): 120-122. ZHANG Xinmei, SHI Yifu. The risk in the patients with adenomyosis after supracervical hysterectomy [J]. Progress in Obstetrics and Gynecology, 2001, 10(2): 120-122.
[26] Liu JX, Li JY, Zhao XY, et al. Transvaginal ultrasound- and laparoscopy-guided percutaneous microwave ablation for adenomyosis: preliminary results [J]. Int J Hyperthermia, 2019, 36(1): 1232-1237.

多维度评价

Viewed

Full text

Abstract

Cited

Shared

Discussed