子宫纤维瘤的微创治疗课件

P M Yuen阮邦武DirectorofMinimallyInvasiveGynaecology HongKongSanatorium HospitalHonoraryClinicalAssociateProfessor CUHKHonoraryProfessor CapitalUniversityofMedicalSciences BeijingPastPresident AsiaPacificAssociationforGynecologicEndoscopy MinimallyInvasiveTherapy APAGE 子宫纤维瘤的微创治疗 纤维瘤的外科治疗 SurgicalTreatmentforFibroids SurgeryistheprincipaltreatmentforfibroidsThemainindicationsare SymptomaticfibroidsEnlargingfibroids especiallyaftermenopauseSubfertilityandrecurrentmiscarriageFailedalternativetreatmentLargeasymptomaticfibroids 外科是纤维瘤的原则治疗主要的适应症是症状性纤维瘤增大性纤维瘤 特别是闭经后低生育力和复发性流产失败的交替治疗大的无症状性的纤维瘤 MIS是 标准 纤维瘤的外科管理已经从剖腹术转变到了微创外科大多数的纤维瘤能借助于内窥镜管理 腹腔镜或宫腔镜外科的专业特长 特别是腹腔镜的缝合是很关键的 MISisthestandard SurgicalmanagementoffibroidshaschangedfromlaparotomytominimallyinvasivesurgeryMostfibroidscanbemanagedendoscopicallyeitherbylaparoscopyorhysteroscopySurgeon sexpertise especiallylaparoscopicsuturing iscrucial 执行子宫切除术和肌瘤切除术的决定依赖于妇女的年龄对保留生育潜力的渴望对保留子宫的渴望纤维瘤的位置 数量和大小妇女的优先权应该被尊重 子宫切除术或肌瘤切除术 HysterectomyorMyomectomy Thedecisiontoperformhysterectomyormyomectomydependson TheageofthewomanThedesiretoretainreproductivepotentialThedesiretoretaintheuterusTheposition numberandsizeofthefibroidsThewoman spreferenceshouldberespected 子宫切除术 排除纤维瘤的症状和复发问题风险性的确定治疗消除月经和将来的生育能力提高生活质量高满意度 95 短期和长期 甚至在经历并发症的人群中并发率10 15 主要并发症4 5 5 6 在性功能 肠功能或泌尿功能中没有副作用 AdefinitetreatmentwhicheliminatesbothsymptomsandriskofrecurrentproblemsfromfibroidRemovemenstruationandfuturefertilityImprovequalityoflifeHighsatisfactionrate 95 bothshorttermandlongterm eveninthosewithexperiencingcomplicationsComplicationrate10 15 majorcomplication4 5 5 6 Noadverseeffectsonsexual bowelorurinaryfunctions Hysterectomy Pinionetal1994O Connoretal1997 全子宫切除术与次子宫切除术比较 3RCTS包含733个病人跟踪大于1 2年所有的子宫切除术是通过剖腹产无证据支持存留的子宫颈与改善性功能有关 或降低失禁率或便秘阴道上子宫切除术 失血减少了 但是输血率是相同的在阴道上子宫切除术群里 住院时间减少了 TotalvsSubtotalhysterectomy 3RCTSinvolving733patientsfollowedby1 2yearsAllhysterectomywerebylaparotomyNoevidencetosupportthatleavingthecervixwasassociatedwithimprovedsexualfunctionorlowerratesofincontinenceorconstipationBloodlosswasreducedwithsupracervicalhysterectomybutthetransfusionrateswerethesameLengthofstaywasdecreasedinthesupracervicalgroupLethabyetalCochraneDatabaseSystRev2006 腹腔镜方法是可选择的 腹腔镜与剖腹术比较更长的手术时间更快的术后恢复更短的住院时间减少手术期间的失血血红蛋白水平更少降低更少的术后纤维瘤发病率更少的伤口或腹腔感染更快恢复正常活动 LongeroperatingtimeFasterpostoperativerecoveryShorterdurationofhospitalstayLowerintra operativebloodlossSmallerdropinhaemoglobinlevelFewerpost operativefebrilemorbidityFewerwoundorabdominalwallinfectionsFasterreturntonormalactivity CochraneDatabaseSystRev2006 Laparoscopicapproachisthechoice LH的额外的优点 子宫切除术前盆腔和腹腔的评估漏斗形骨盆韧带的结扎有利于疑难卵巢的切除使阴道子宫切除术的操作复杂化的子宫纤维瘤的管理粘连的松解术子宫内膜异位的治疗止血的更好控制 EvaluationofthepelvicandabdominalcavitybeforehysterectomyLigationofinfundibulo pelvicligamenttofacilitatedifficultovaryremovalManagementofuterinefibroidsthatcomplicatetheperformanceofvaginalhysterectomyLysisofadhesionsTreatmentofendometriosisBettercontrolofhaemostasis AdditionalAdvantagesofLH TLH是 的选择 所有的都在直接和清楚的视线下避免困难的阴道手术切割时避免损伤被阴道穹窿膨胀的膀胱和输尿管阴道更少的缩短更少损伤阴道韧带的支持阴道断端的更好止血 AllunderdirectandclearvisionAvoiddifficultvaginalsurgeryAvoidinjurytobladderandureterbydistendingthevaginalfornixforincisionLessshorteningofthevaginaLessdamagetotheligamentoussupportofthevaginaBetterhaemostasisonthevaginalcuff TLHisthechoice 子宫切除术的途径选择根据病人的解剖和外科医生的经验 对TLH的限制是什么 Thechoiceofrouteforhysterectomy WhatisthelimitforTLH dependsonthepatient sanatomyandthesurgeon sexperience ACOG 肌瘤切除术 去除纤维瘤 保留子宫为目的减轻症状保留生育功能提高生育力症状的消除发生在80 100 子宫切除术的危险性在2 病发率在8 11 甚至在绝经前妇女中选择 Aimstoremovefibroidsandconservetheuterus Torelievesymptoms Topreservereproductivefunction ToimprovefertilitySymptomsresolutionoccursin80 100 Hysterectomyriskis2 Complicationrate8 11 Anoptioneveninperi menopausalwomen Myomectomy 纤维瘤畸变腔更少可能怀孕 RR0 36 95 CI0 18 0 74 更多可能自然流产 RR1 7 95 CI1 4 2 1 对畸形腔纤维瘤的肌瘤切除术增加怀孕率 RR2 03 95 CI1 08 3 83 降低流产率 38 5VS50 RR0 77 95 CI0 36 1 66 纤维瘤和生育能力 Fibroidsdistortingcavity lesslikelytobecomepregnant RR0 36 95 CI0 18 0 74 morelikelytohaveaspontaneousabortion RR1 7 95 CI1 4 2 1 Prittsetal2009 Myomectomyforcavity distortingfibroidsIncreaseconceptionrate RR2 03 95 CI1 08 3 83 Decreasemiscarriagerate 38 5versus50percent RR0 77 95 CI0 36 1 66 Casiniretal2006 FibroidsandFertility 剖腹术的粘连率高于腹腔镜无粘连障碍 28 1 vs22 6 有粘连障碍 22 vs15 9 术后伤口粘连突出的伤口高于平伤口 比值比 2 53 P 0 02 摘出的浆膜下肌瘤数 比值比 3 29 P 0 001 和最大的子宫肌瘤直径 比值比 1 05 P 0 00 与伤口突出有相当大的关系 术后粘连 Adhesionsratehigherinlaparotomythanlaparoscopy withoutadhesionbarrier 28 1 vs22 6 withadhesionsbarrier 22 vs15 9 Tinellietal2010Postoperativewoundadhesionhigherinprotrudingwoundthanflatwound oddsratio 2 53 p 0 02 Thenumberofenucleatedsubserosalmyomas oddsratio 3 29 p 0 001 andthediameterofthelargestfibroid oddsratio 1 05 p 0 001 weresignificantlyassociatedwithwoundprotrusionKumakirietal2012 Post operativeadhesions 更少的粘连形成子宫粘连 45 vs90 附件粘连 25 70 相似的术后生育能力怀孕率 48 vs54 活产率 75 vs78 怀孕期间疤痕破裂率没有不同AM后 0 002 0 5 LM后 1 纤维瘤的复发率没有不同AM 单个11 多个26 LM 单个16 3 多个36 6 和AM的比较结果 Lessadhesionsformation Uterineadhesion 45 Vs90 Adnexaladhesion 25 Vs70 Similarpost operativefertility Pregnancyrate 48 vs54 Livebirthrate 75 vs78 Nodifferenceinthescarrupturerateduringpregnancy AfterAM 0 002 0 5 Garnet1964 FalconeDubuissonetal2000 Nodifferenceinfibroidrecurrence AM Singleton11 multiple26 LM Singleton16 3 multiple36 6 Malone1969 Rossettietal2001 OutcomecomparedwithAM 多层的闭合和精确的止血是必行的腹腔镜的缝合是困难的 消耗时间的 腹腔镜缝合 Laparoscopicsuturing MultilayeredclosureandmeticuloushaemostasisaremandatoryLaparoscopicsuturingisdifficultandtimeconsuming 单向的倒钩在许多点上准确地抓起组织 跨越伤口提供张力的分配有效的倒钩和焊接环设计通过消除打结的需要加速了关闭速度V Loc缝合的用途 显著减少了 缝合时间 10 4vs16 5min 手术时间 51 18vs58 18min 手术期间出血和血红蛋白的下降 V Loc伤口闭合器 Theunidirectionalbarbspreciselygraspthetissueatnumerouspoints providingdistributionoftensionacrossthewound Theefficientbarbandweldedlooppdesignspeedsclosurebyeliminatingtheneedtotieanyknots TheuseofV Locsuture significantlyreduces Suturingtime 10 4vs16 5min Operativetime 51 18vs58 18min Intraopertivebleedingandhaemoglobindrop Angiolietal2012 V LocWoundClosureDevice 禁忌症4个或超过3CM的多个纤维瘤使用 GnRH 促性腺激素释放激素类似物后纤维瘤 8CM接近子宫动脉或子宫角的纤维瘤 7纤维瘤个体选择基于病理结果和外科技能 有限制吗 Contraindications 4ormorefibroidsover3cm Fibroid 8cmafterGnRHanalogues Fibroidnearuterinearteryorcornu Dubuisson Chapron1996 7fibroids Rossettietal2001 Individualchoicebasedon pathologicalfindingsandsurgicalskill Hassonetal1992 Cittadini1998 Istherealimit 子宫动脉和子宫动脉与卵巢动脉的吻合点的腹腔镜双极凝血子宫动脉在内髂骨动脉的水平是闭合的在卵巢与子宫之间的副动脉 在子宫卵巢韧带内 用双极镊子是可凝固的LUAO的结果显性纤维瘤平均降低58 8 症状改善93 2 低并发率7 3 纤维瘤复发率2年9 0 腹腔镜子宫动脉闭合 LaparoscopicbipolarcoagulationofuterinearteriesandanastomoticsitesofuterinearterieswithovarianarteriesUterinearteryisoccludedattheleveloftheinternaliliacartery Thecollateralarteriesbetweenovariesanduterus intheutero ovarian ligament arecoagulatedusingbipolar forceps Lichtingeretal2002 Leeetal2005 ResultofLUAO Meanreductionofdominantfibroid57 8 Symptomsimprovement93 2 Lowcomplicationrate7 3 Fibroidrecurrencerate9 0 at2yrs Holubetal2004 Holubetal2006 LapUterineArteryOcclusion 在LM中LUAO的角色 LUAO和LM 非RCT 减少了手术失血改善了症状的消散 98 1 VS83 1 降低了纤维瘤复发 6 2 VS20 7 怀孕率没有不同LUAO与LM 非RCT 相似的手术失血更长的手术时间 100 34VS90 37min 降低了纤维瘤复发 2 VS13 RoleofconcurrentLUAOinLM UAELUAOP价值年龄33 134 9NS显性纤维瘤6848NS纤维瘤容积萎缩在6个月53 39 0 063完全肌瘤梗死在6个月82 23 0 001并发率31 11 0 006子宫内坏死31 3 0 001怀孕率69 67 NS分娩率50 46 NS流产率34 33 NS出生体重 gms 327027680 013IUGR率13 38 0 046 UAEvsLUAO ComplicationrateIntrauterinenecrosisPregnancyrateDeliveryrateAbortionrateBirthweight gms IUGRrate 31 31 69 50 34 327013 11 3 67 46 33 276838 0 0060 001NSNSNS0 0130 046 Maraetal2012 NonRCTwith100womenineachgroup 适当选择妇女的方法 希望保留子宫的和对最优化未来生育能力没有兴趣的妇女主要对症状的控制有效减少子宫大小和多发性纤维瘤技术成功98 100 月经过多改善81 94 压力性症状改善64 96 子宫容积减少35 52 纤维瘤容量减少37 69 子宫动脉栓塞 Technicalsuccess98 100 Menorrhagiaimprovedin81 94 Pressuresymptomsimprovedin64 96 Anoptionforappropriatelyselectedwomenwhowishtoretaintheiruteriandarenotinterestedinoptimizingfuturefertility MainlyforsymptomcontrolEfficacydecreaseswithuterinesizeandmultiplefibroids Uterinevolumereduction35 52 Fibroidvolumereduction37 69 UterineArteryEmbolization 明显的骨盆疼痛栓塞后综合症20 35 子宫肌瘤的排出多达4 10 卵巢功能的散失5 8 子宫感染 1 肺栓塞 0 25 操作后并发症 Post proceduralcomplications SignificantpelvicpainPost embolizationsyndrome 20 35 Goodwinetal1999 Hemingwayetal1988 Expulsionoffibroids upto4 10 Bradleyetal1998 Berkowitzetal1999 Lossofovarianfunction 5 8 Uterineinfection 1 Pulmomaryembolism 0 25 Walkeretal2004 Oligiarietal2005 Ravinaetal1998 Chrismanetal2000 Tropeanoetal2008 Czeyda Pommersheim etal2006 5 7年后症状控制降低到72 73 的病人数纤维瘤复发率2 5年内10 4年后53 3 大多数是新生长和再生长一起发生在12 5 37 5 子宫切除术的风险12 18个月为2 9 6 9 5年13 7 32 长期结果 Longtermresult Symptomscontroldecreasedto72 73 ofpatientsafter5 7years Popovicetal2009 Fibroidrecurrence 10 within2 5yearsand53 3 after 4years Mostlyarenewgrowthswithre growthoccurredin12 5 37 5 Marretetal2003 Kimetal2010 Hysterectomyrisk 2 9 6 9 at12 18months 13 7 32 at5years Spiesetal2005 Huangetal2006 Gabriel Coxetal 2007 vanderKooijetal2010 Mossetal2011 与子宫切除术和肌瘤切除术比较 UAE使住院时间更短 更快恢复活动 出院后更高的次要并发症 还有无计划的就诊和再住院率主要并发率没有不同UAE与子宫肌瘤切除术相比 UAE与更高的再手术率有关 29 33 vs3 6 UAE与手术比较 UAEvsSurgery Comparedwithhysterectomyandmyomectomy UAEresultedinshorterhospitalstay quickerreturntoactivities andahigherminorcomplicationrateafterdischargeaswellastheunscheduledvisitsandreadmissionrates Therewasnodifferenceinthemajorcomplicationrates CochraneSystRev2006 UAEisassociatedwithahigherre operationratethanmyomectomy 29 33 vs3 6 Broderetal2002 Spiesetal2005 主要并发症 Majorcomplications RESTtrial N 157 Edwardsetal2007HOPEFULtrial N Duttonetal2007EMMYtrial N 177 Hehenkampetal2005 UAE Surgery 12 20 14 5 4 5 14 8 1 3 UAE手术REST试验 N 157 12 20 HOPEFUL试验 N 4 5 14 8 EMMY试验 N 177 1 3 14 5 一个RCT显示肌瘤切除术后怀孕的可能性要比UAE高 77 5 vs50 UAE增加了自发性流产的风险 在纤维瘤中 包括怀孕 35 vs16 UAE增加了剖腹产和产后出血的风险 UAE增加怀孕并发症 UAEincreasespregnancycomplications AnRCTshowedthatthelikelihoodofconceivingishigheraftermyomectomythanUAE 77 5 vs50 Maraetal2008 UAEincreasesriskofspontaneousmiscarriage 35 vs16 infibroidcontainingpregnancies Homer Saridogan2010 UAEincreasesriskofCaesareansectionandpost partumhaemorrhageHomer Saridogan2010 多普勒指引宫颈旁的钳子关闭子宫动脉钳子沿着侧阴道穹窿放置在9和3点的位置 通过多普勒听觉信号来区分子宫动脉钳子在两侧被关闭以便挤压子宫动脉对抗子宫的侧边缘钳子保留在此位置6个小时 临时的子宫动脉闭合 Temporaryuterinearteryocclusion Dopplerguidedparacervicalclamptooccludetheuterinearteries TheFlowstatsystemTheclampisplacedalongthelateralvaginalfornicesatthe9and3o clockpositionstoidentifytheuterinearterybytheDopplerauditorysignalThec