腹腔镜联合GnRHa治疗卵巢型子宫内膜异位症临床疗效观察及复发相关因素分析

发布时间：2018-12-07 18:20

【摘要】：目的:子宫内膜异位症手术联合药物治疗方案多存在争议,影响术后复发因素也存在很大争议,本研究通过术后疼痛缓解、妊娠、复发情况分析腹腔镜保守手术联合Gn RHa(Gonadotropin-releasing hormone agonists,促性腺激素释放激素激动剂)不同治疗方法的疗效;研究子宫内膜异位囊肿腹腔镜保守手术后影响复发的相关因素。方法:收集2012年7月-2014年7月就诊北京妇产医院行腹腔镜保守手术,术中根据美国生育协会修正(r-AFS)的标准分期均为III期及以上,并经病理证实为子宫内膜异位症的育龄期女性360例。随访时间为术后2-3年,共收集随访病例317例,失访43例,失访率11.94%。收录临床基本资料及术后妊娠情况进行一般资料分析;根据术前术后是否联合使用Gn RHa以及使用时间分组,通过术后疼痛缓解情况、复发率、妊娠率方面分析不同治疗方法的疗效;将术后复发与未复发患者的基本资料进行统计分析,研究子宫内膜异位囊肿患者手术后复发的相关因素。结果:302例患者术前血CA125值的P25 18.35 U/ml,P75 52.5U/ml。术前无症状、疼痛、不孕患者的囊肿位置分布差异无统计学意义(P0.05)。单纯手术组、术后注射Gn RHa1-3针组、术后注射Gn RHa4-6针组在术后2-3年疼痛缓解情况、术后2-3年累计复发率、自然妊娠率方面无统计学差异(P0.05)。单纯手术组、术前使用Gn RHa组、术后使用Gn RHa组、术前术后均使用Gn RHa组、术后放置左炔诺孕酮宫内缓释系统(LNG-IUS)组在术后2-3年疼痛缓解情况、术后2-3年累计复发率、自然妊娠率方面无统计学差异(P0.05)。将可能影响子宫内膜异位囊肿术后复发的相关因素进行logistic回归分析,术前CA125指标(P0.05,OR值1,回归系数0)可能为复发的危险性因素;初潮年龄推迟(P0.05,OR值1,回归系数0)可能为复发的保护性因素。术后自然受孕人群平均年龄29.32±3.75岁,术后不孕人群平均年龄31.86±4.40岁,二者具有统计学差异(P0.05)。术后11名(3.47%)患者绝经,绝经平均年龄48.18岁。术后27人(8.52%)月经无规律,38人(11.99%)经量减少,18人经期缩短(5.68%),3人经期延长(0.95%)。结论:手术可能造成卵巢功能损伤,出现月经不规律的情况;术后联合使用Gn RHa对于术后2-3年疼痛的缓解、降低复发、提高妊娠率相比单纯手术组无明显优势;同样手术联合Gn RHa、LNG-IUS治疗相比单纯手术组于术后2-3年疗效也不理想;随访患者术后2-3年的复发率,发现术前CA125指标可能为卵巢型子宫内膜异位症复发的危险性因素、初潮年龄推迟可能为复发的保护性因素;术后自然妊娠率69.86%,术后自然受孕人群平均年龄与术后不孕人群平均年龄具有统计学差异,因此建议有生育要求的子宫内膜异位症患者术后尽早妊娠。
[Abstract]:Objective: there are many controversies in the combination of surgery and drug therapy for endometriosis, and the factors affecting the recurrence of endometriosis are also controversial. In this study, postoperative pain relief, pregnancy, To analyze the curative effect of laparoscopic conservative surgery combined with Gn RHa (Gonadotropin-releasing hormone agonists, gonadotropin releasing hormone agonist. To study the factors related to recurrence of endometrial cysts after laparoscopic conservative surgery. Methods: conservative laparoscopic surgery was performed at Beijing Obstetral Gynecology Hospital from July 2012 to July 2014. According to the standard staging of the American Fertility Association (r-AFS), stage III and above were all performed during the operation. And 360 women with endometriosis were confirmed by pathology. The follow-up period was 2-3 years. 317 cases were followed up and 43 cases were lost. The rate of missing visit was 11.94%. The basic clinical data and pregnancy after operation were collected and analyzed. According to whether combined use of Gn RHa before and after operation and time group, the curative effect of different treatment methods was analyzed through postoperative pain relief, recurrence rate and pregnancy rate. The basic data of postoperative recurrence and non-recurrence were statistically analyzed to study the related factors of postoperative recurrence of endometriosis cysts. Results: the preoperative CA125 of 302 patients was P 25 18.35 U / ml P 75 52.5 U / ml 路ml. There was no significant difference in the location of cysts in asymptomatic, pain and infertility patients before operation (P0.05). There was no significant difference in pain relief in postoperative 2-3 years, cumulative recurrence rate and natural pregnancy rate in postoperative 2-3 years in simple operation group, postoperative injection Gn RHa1-3 needle group and postoperative Gn RHa4-6 needle group (P0.05). In the simple operation group, Gn RHa group was used before operation, Gn RHa group was used after operation, Gn RHa group was used before and after operation, and the pain relief was observed in the group of intrauterine sustained release of levonorgestrel (LNG-IUS) for 2-3 years after operation. There was no significant difference in cumulative recurrence rate and natural pregnancy rate between 2-3 years after operation (P0.05). Logistic regression analysis showed that preoperative CA125 index (P0.05OR value 1, regression coefficient 0) might be the risk factor of recurrence. The delayed age of menarche (P 0.05 OR 1, regression coefficient 0) may be the protective factor of recurrence. The average age of spontaneous pregnancy group was 29.32 卤3.75 years old, and that of infertile group was 31.86 卤4.40 years old. There was statistical difference between the two groups (P0.05). There were 11 postmenopausal patients (3.47%) with an average age of 48.18 years. 27 cases (8.52%) had irregular menstruation, 38 cases (11.99%) decreased menstrual volume, 18 cases shortened menstrual period (5.68%), 3 cases prolonged menstrual period (0.95%). Conclusion: operation may result in ovarian function injury and irregular menstruation, postoperative combined use of Gn RHa can relieve pain, reduce recurrence and increase pregnancy rate in 2-3 years after operation. The effect of the same operation combined with Gn RHa,LNG-IUS was not satisfactory compared with that of the simple operation group in 2-3 years after operation. The recurrence rate of 2 to 3 years after follow-up showed that preoperative CA125 might be a risk factor for recurrence of ovarian endometriosis and delayed menarche might be a protective factor for recurrence. The natural pregnancy rate was 69.86, and the average age of the natural pregnant group was significantly different from that of the infertile group. Therefore, it was suggested that the endometriosis patients with fertility requirement should get pregnant as soon as possible after operation.
【学位授予单位】：首都医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R711.71

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