子宫肌瘤栓塞治疗的进展.ppt

1、子宫肌瘤栓塞治疗的进展,栓塞在子宫肌瘤治疗手段中地位的确立(2007),1995年Ravina首先在Lancet上报道了子宫肌瘤栓塞治疗；,Ravina JH, Herbreteau D, Ciraru-Vigneron N et al. Arterial embolisation to treat uterine myomata. Lancet 1995; 346: 671672,2004年美国妇产科学会认可子宫肌瘤栓塞的作用；,两个随机对照研究结果最终确立栓塞在子宫肌瘤治疗手段的地位,REST trial Edwards RD, Moss JG, Lumsden MA et al. Ute

2、rine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med 2007; 356: 360370. EMMY trial Volkers NA, Hehenkamp WJ, Birnie E et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years outcome from the randomized EMMY tr

3、ial. Am J Obstet Gynecol 2007; 196(6): 519. e1e11.,最终确认栓塞治疗是子宫肌瘤中除子宫切除外的一种安全有效的治疗方法！,长期疗效,Spies JB, Bruno J, Czeyda-Pommersheim F et al. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol 2005; 106: 933939.,Katsumori T, Kasahara T 186: 848854.,Walker WJ 113: 464468.,我院50

4、0例子宫肌瘤栓塞治疗随访的有效率,子宫肌瘤栓塞治疗的有效率长期而稳定！,影响疗效的因素,影响疗效的因素,栓塞不完全 子宫动脉主干栓塞不完全 仅作单侧子宫动脉栓塞 子宫栓塞不完全 其他供血动脉（卵巢动脉、变异子宫动脉） 肌瘤过大 诊断问题（月经量过多或经期延长！） 插管技术,子宫肌瘤栓塞治疗并发症,Edwards RD, Moss JG, Lumsden MA et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med 2007; 356: 360370. Vol

5、kers NA, Hehenkamp WJ, Birnie E et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years outcome from the randomized EMMY trial. Am J Obstet Gynecol 2007; 196(6): 519. e1e11. Siskin GP, Shlansky-Goldberg RD, Goodwin SC et al. A prospective mult

6、icenter comparative study between myomectomy and uterine artery embolization with polyvinyl alcohol microspheres: longterm clinical outcomes in patients with symptomatic uterine fibroids. J Vasc Interv Radiol 2006; 17:12871295. Dutton S, Hirst A, McPherson K et al. A UK multicentre retrospective coh

7、ort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy. Br J Obstet Gynaecol 2007;114: 13401351. Wu O, Briggs A, Dutton S et al. Uterine artery embolisation or hysterectomy fo

8、r the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study. Br J Obstet Gynaecol 2007; 114: 13521362.,我院子宫肌瘤栓塞术后并发症,轻微并发症 腹痛 27/500 （5.4%） 发热 410/500 （82%） 阴道出血 432/500 （86.4%） 血尿 11/500 （2.2%） 严重并发症 （6/500，2.6%） 膀胱误栓 1/500 （0.2%） 短暂性闭经 3/500 （0.6%） 卵巢衰竭 3/500 （0.6

9、%） 栓塞失败 1/500 （0.2%） 栓塞后肌瘤脱落 4/500 （0.8%） 栓塞后盆腔感染 1/500 （0.2%） 术后复发 10/500 （2%）,栓塞对卵巢功能的影响,2001年Spies认为栓塞仅对年龄大于45岁的患者有影响，术后闭经发生率为14%； 2003年Pron却发现小于40岁的3%患者出现术后闭经； 虽然较多的研究通过FSH在栓塞前后的变化来说明栓塞治疗对卵巢较少的影响，但是病例数均较少。 这类研究没有考虑到栓塞中常见的卵巢子宫动脉吻合问题，KIM的研究发现若出现该吻合则患者术后会出现FSH的上移。,Spies JB, Roth AR, Gonsalves SM et

10、 al. Ovarian function after uterine artery embolization for leiomyomata: assessment with use of serum follicle stimulating hormone assay. J Vasc Interv Radiol 2001; 12: 437442. Pron G, Bennett J, Common A et al. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and sy

11、mptom relief after uterine artery embolization for fibroids. Fertil Steril 2003;79: 120127. Spies JB, Roth AR, Gonsalves SM et al. Ovarian function after uterine artery embolization for leiomyomata: assessment with use of serum follicle stimulating hormone assay. J Vasc Interv Radiol 2001; 12: 43744

12、2. Ahmad A, Qadan L, Hassan N et al. Uterine artery embolization treatment of uterine fibroids: effect on ovarian function in younger women. J Vasc Interv Radiol 2002; 13: 10171020. Healey S, Buzaglo K, Seti L et al. Ovarian function after uterine artery embolization and hysterectomy. J Am Assoc Gyn

13、ecol Laparosc 2004; 11: 348352. Tropeano G, Di Stasi C, Litwicka K et al. Uterine artery embolization for fibroids does not have adverse effects on ovarian reserve in regularly cycling women younger than 40 years. Fertil Steril 2004;81: 10551061. Hovsepian DM, Ratts VS, Rodriguez M et al. A prospect

14、ive comparison of the impact of uterine artery embolization, myomectomy, and hysterectomy on ovarian function. J Vasc Interv Radiol 2006;17: 11111115. Kim HS, Tsai J, Lee JM et al. Effects of utero-ovarian anastomoses on basal follicle-stimulating hormone level change after uterine artery embolizati

15、on with tris-acryl gelatin microspheres. J Vasc Interv Radiol 2006; 17: 965971. Kim HS, Thonse VR, Judson K et al. Utero-ovarian anastomosis: histopathologic correlation after uterine artery embolization with or without ovarian artery embolization. J Vasc Interv Radiol 2007;18: 3139.,如何处理子宫动脉造影中卵巢支显

16、影的病例？,我院在子宫肌瘤栓塞子宫动脉造影中其双侧卵巢支显影处理的临床研究,子宫肌瘤栓塞患者,子宫动脉造影其双侧卵巢支显影,非显影组,显影 明胶海绵组,显影组,非显影 聚乙烯醇组,非显影 明胶海绵组,三组病例临床症状改善情况,*三组进行组组间2检验，统计学未见组组间疗效有差异性。,三组病例栓塞前后FSH的变化,#三组独立t检验分析，和*三组组间方差分析，FSH变化无统计学差异性,对于肌瘤栓塞中子宫动脉造影其双侧卵巢支显影病例可以采用自制明胶海绵颗粒为栓塞材料进行处理，其疗效可以保证且对卵巢功能影响不大。,目前子宫肌瘤栓塞对卵巢功能的影响尚无结论！,子宫肌瘤栓塞治疗对怀孕与生育的影响,目前，对有

17、生育要求的患者不建议使用栓塞治疗。,缺乏对栓塞治疗对怀孕影响的研究结果 目前栓塞对怀孕影响的研究仅限于个案报道和小病例报道。 缺乏足够的证据支持栓塞治疗对怀孕和生殖的益处。,腹腔镜子宫动脉结扎和栓塞治疗肌瘤对怀孕的随机多中心对照研究2008,Holub,Z, Mara, M, Kuzel D et al. Pregnancy outcomes after uterine artery occlusion: prospective multicentric study Fertility and Sterility 2007,腹腔镜子宫动脉结扎和栓塞治疗肌瘤对怀孕的随机多中心对照研究2008,Holub,Z, Mara, M, Kuzel D et al