难治性卵巢内膜异位囊肿超声下介入治疗28例分析

目的:探讨超声引导下介入治疗复发性卵巢子宫内膜异位囊肿的临床价值。方法:在超声引导下经腹部及经阴道对28例卵巢子宫内膜异位囊肿术后复发者进行穿刺抽液、注入无水乙醇硬化治疗,术前、术后超声检查的跟踪随访作回顾性分析。结果:28例均一次穿刺成功,术后随访8～48个月有2例再次复发。结论:经超声引导穿刺、注入无水乙醇介入治疗子宫内膜异位囊肿解决了手术治疗后复发的棘手问题,是一种简单有效的治疗方法。     

阴道超声对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值

目的探讨阴道超声及血清CA125测定对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值。方法对卵巢子宫内膜异位囊肿及子宫腺肌病患者631例进行回顾性分析，术前均经阴道超声检查，部分患者进行了血清CA125测定。结果阴道超声检查卵巢子宫内膜异位囊肿符合率98．7％；子宫腺肌病符合率91．7％；卵巢子宫内膜异位囊肿合并子宫腺肌病符合率95．1％。血清CA125检查卵巢子宫内膜异位囊肿，阳性率39．4％；子宫腺肌病阳性率52．2％；卵巢子宫内膜异位囊肿合并子宫腺肌病阳性率59．2％。结论阴道超声可做为较准确诊断卵巢子宫内膜异位囊肿及子宫腺肌病的首选方法。阴道超声下囊肿穿刺是治疗卵巢子宫内膜异位囊肿的简便、有效的方法之一。血清CA125测定可做为卵巢子宫内膜异位囊肿及子宫腺肌病的协助诊断方法，应进一步完善对照组的研究。     

超声下穿刺治疗复发性卵巢子宫内膜异位囊肿46例临床分析

目的:探讨超声下穿刺治疗复发性卵巢子宫内膜异位囊肿的临床价值。方法:对46例复发性卵巢子宫内膜异位囊肿患者,经超声引导穿刺,注入无水乙醇治疗。观察随访1年。结果:46例患者共52个囊肿,超声诊断为卵巢子宫内膜异位囊肿复发,穿刺均1次性成功。39例治愈,7例复发,治愈率为84.8%。结论:超声下介入治疗对复发性卵巢子宫内膜异位囊肿,是一种安全、简单、微创、有效的方法。     

卵巢子宫内膜异位囊肿腹腔镜手术的治疗价值

应用电视腹腔镜手术治疗卵巢子宫内膜异位囊肿７８例，镜下施行卵巢子宫内膜异位囊肿剔除术６３例附件切除术１５例，无１例中转开腹，全部手术均未发生严重并发症。７８例患者Ⅲ期６０例，Ⅳ期１８例，不孕症患者４６例，占５９％，术后随访７１例，随访率为９１．０２％；术后复发５例，复发率为６．４１％，不孕组中妊娠２４例，妊娠率为５２．１７％。     

应用聚维酮碘液介入治疗卵巢子宫内膜异位囊肿84例结果分析

目的：观察应用聚维酮碘液（povidone iodine,PI）介入治疗卵巢子宫内膜异位囊肿的疗效。方法：84例有卵巢巧克力囊肿的患者经阴道超声引导下行囊肿穿刺抽吸，并注入PI进行治疗，随访12个月，判定疗效。结果：治愈51例，有效30例，无效3例，总有效率为96．4％（81／84）；4例复发，复发率为4．9％（4／81）。34不孕患者中有20例于术后21个月行体外受精（IVF）助孕，13例获得妊娠；未行IVF助孕的14例患者6例于穿刺后自然妊娠。结论：阴道超声引导穿刺并注入PI治疗卵巢巧克力囊肿是一种高效、可靠、安全和经济的方法，尤其对不孕妇女更为适用。     

口服米非司酮配合局部注射无水乙醇治疗子宫内膜异位囊肿38例观察

目的：探讨米非司酮结合超声介入无水乙醇局部注射治疗子宫内膜异位囊肿的临床价值。方法：对58例盆腔子宫内膜异位囊肿行经阴道超声引导下囊肿穿刺、抽液并注射无水乙醇（硬化治疗）。治疗组38例于治疗当月起口服米非司酮（25mg,qd）3－6个月；对照组20例单行囊肿硬化治疗。随访2年，比较两组治疗后的复发率，观察米非司酮的辅助疗效及其副反应。结果：治疗组和对照组的复发率1年各为5．3％和30．0％，2年各为7．9％及35．0％，两组间比较有显著差异（P＜0．01）；治疗组1年及2年复发率比较无显著性差异（P＞0．05）。结论：加用米非司酮治疗3－6个月经周期可有效地降低子宫内膜异位囊肿穿刺硬化治疗的复发率，副反应轻。     

卵巢子宫内膜异位囊肿的微创性诊断与治疗

目的探讨B超介导下囊肿穿刺术对卵巢子宫内膜异位囊肿(EMA)的诊断价值和术中囊内注入狄波普维拉(DMPA)维持治疗意义。方法对52例临床诊断为卵巢子宫内膜异位囊肿患者在B超下行囊肿穿刺术,观察囊液性状和并作涂片病理检查,对符合卵巢子宫内膜异位囊肿的患者,腔内注入DMPA,并进行随访。结果经穿刺术校正诊断7例,占13.46％。穿刺术使所有患者近期症状缓解,术中加用DMPA可使症状与体征复发率显著减低。对复发病例可行第二次穿刺术,或再加DMPA治疗仍能有效缓解痛经。DMPA的主要副作用可致阴道点滴状出血及停药后排卵恢复慢,用药组中近期无1例受孕。结论B超引导下的囊肿穿刺术,是对卵巢内膜异位囊肿的一种可行的微创性诊断与治疗方法,DMPA囊腔内给药和术后维持治疗能有效地控制症状和促使异位病灶萎缩。     

复发性卵巢子宫内膜异位症的管理

子宫内膜异位症（内异症）是慢性复发性疾病,年复发率约10%。复发性卵巢子宫内膜异位症一般指卵巢子宫内膜异位囊肿复发,是内异症最常见的复发类型,也是导致再次手术的主要原因。治疗原则基本遵循初始治疗,但应个体化。治疗包括药物治疗和手术治疗。常用药物有孕激素类、促性腺激素释放激素激动剂（GnRH-a）、复方口服避孕药物及中医中药等。有些药物比如地诺孕素可以使复发的卵巢子宫内膜异位囊肿明显变小甚至消失,从而免去了患者承受再次手术的风险,近年来广泛推荐使用。再次手术对卵巢储备功能影响更大,术后仍易复发,部分患者也可选择超声引导穿刺治疗。对合并不孕者首先推荐辅助生殖技术。药物维持治疗及长期管理是减少卵巢子宫内膜异位囊肿复发的关键。业已证明,长期使用孕激素类、GnRH-a和复方口服避孕药等均可预防卵巢子宫内膜异位囊肿复发。     

卵巢巧克力囊肿保守性手术后检测异位内膜组织中雌孕激素受体指导用药的探讨

目的探讨ER、PR在子宫内膜异位症治疗方面的意义.方法ER、PR的测定用免疫组化SP法.治疗组术后根据受体情况分别给予丹那唑、TMX、或安宫黄体酮治疗,对照组术后未用药.结果卵巢巧克力囊肿患者增生期和分泌期ER、PR的阳性率均低于正常子宫内膜(P＜0.05).治疗组无一例复发,而对照组复发率为24%.结论根据卵巢异位内膜囊肿患者术后受体情况,进行药物巩固治疗,对于防止术后复发,提高治愈率有一定的意义.     

经阴道穿刺并口服药物治疗卵巢子宫内膜异位囊肿

卵巢子宫内膜异位囊肿（巧囊）是育龄妇女的中常见的妇科病之一，中等以上大小的囊种，单纯的药物治疗无效，腹腔镜及开腹手术又有重新形成盆腔粘粘连及复发再手术的可能性^[1,2]，经阴道穿刺囊肿注入无水乙醇进行治疗已多有报道，但有较高的复发率^[3]，在此基础上，我院基础开展在B超引导下行巧囊穿刺治疗后配合口服药物治疗，现报告如下。     

Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation

Several surgical treatment modalities have been described in cases of isolated or multiple ovarian endometriotic cysts. The aim of this preliminary study was to investigate and test the efficacy of ethanol sclerotherapy (EST) for recurrent endometriotic cysts, before ovarian stimulation in infertile patients with an adequate ovarian status. In the setting of a prospective comparative study, EST was proposed to 31 infertile patients with recurrence of ovarian endometriomas before inclusion in assisted reproduction cycles. Reproductive outcome was compared with that of patients who had previous laparoscopic cystectomy for recurrent endometriomas. The mean size of endometriomas treated with sclerotherapy was 38.6 ± 11.2 mm in diameter. Ovarian cysts recurred in 12.9% of cases; at a mean time of 10 months after EST. Ovarian reserve and ovarian response to stimulation were better in the EST group than in the control group. Consequently, clinical and cumulative pregnancy rates of the study group were higher than those of the control group (48.3% versus 19.2%, P = 0.04; and 55.2% versus 26.9%, P = 0.03, respectively). Ethanol sclerotherapy may be a good alternative to surgical management of recurrent endometriotic cysts before assisted reproductive treatment. It could be advised for selected infertile patients.     

Rapid recurrence of endometrioma after transvaginal ultrasound-guided aspiration

OBJECTIVE: Ultrasound-guided aspiration is a less invasive management option for recurrent endometrioma. We postulated that the endometriotic tissue in the epithelial lining of endometrioma had undergone pressure atrophy after a period of observation, and resolution of the endometrioma can be achieved by aspiration of its content. STUDY DESIGN: A prospective study was carried out in which patients with recurrent endometrioma that remain stationary in size for a period of at least 6 months were included. Ultrasound-guided aspiration of endometrioma was performed transvaginally under conscious sedation. Ultrasound scan examination was performed at 1, 3, 6, and 12 months after aspiration to detect recurrence. RESULTS: Eight endometriomas were aspirated in six patients. The mean diameter and volume of endometrioma at aspiration were 31.0 mm (range, 18.0-46.3 mm) and 21.9 ml (range, 3.16-52.0 ml), respectively. There were no major complications. Cytological examination revealed hemosiderin-laden macrophages; neither malignant cells nor endometrial cells were detected in all cases. Six ovarian cysts recurred in five women (83.3%), all recurrence were detected within 3 months after aspiration. CONCLUSION: We concluded that although transvaginal ultrasound-guided aspiration is a safe procedure, but the recurrence rate after aspiration is unacceptably high, and hence cannot be recommended as a treatment option for recurrent endometrioma.     

Toward understanding the natural history of ovarian carcinoma development: a clinicopathological approach

OBJECTIVE: The natural history of the development of ovarian carcinoma is not known. It also remains undetermined whether ovarian carcinomas develop from benign and/or borderline malignant tumors or arise de novo from the ovarian surface epithelium. METHODS: To address these issues clinicopathologically, we reviewed the clinical charts of 543 patients with epithelial ovarian carcinoma and 252 patients with borderline tumors who underwent laparotomy at seven hospitals and collected patients whose clinical and transvaginal ultrasonography (USG) findings for adnexal regions 12 months or fewer prior to the surgery were available. Histological slides of the resected specimens were reexamined concerning the diagnosis and histological grade, as well as the presence or absence of benign- or borderline-like lesions adjacent to the carcinoma. RESULTS: Forty-nine patients had had gynecological examination with transvaginal USG 12 months or fewer prior to laparotomy. Among them, 35 had carcinomas (11 serous, 6 mucinous, 8 clear cell, 10 endometrioid) and 14 had borderline tumors (8 serous, 6 mucinous). Of the 35 patients with carcinoma, 19 (54%) had been followed up for benign-appearing cysts or endometriotic cysts. In these cases, serial USG examinations revealed an increase in size and/or appearance of the solid part of the cyst. In the remaining 16 (46%), however, there had been no apparent abnormalities in USG, and such cases occurred most frequently for serous carcinomas. CONCLUSIONS: Our findings suggest that approximately half of ovarian carcinomas develop secondarily from preexisting, benign-appearing cysts or endometriotic cysts, whereas the remaining half seem to develop suddenly from a normal-appearing ovary. This appears to be consistent with two possible pathways of ovarian carcinoma development; adenoma-carcinoma sequence and de novo carcinogenesis.     

Clinical and surgical aspects of ovarian endometriotic cysts

The case histories of 263 patients with histologically proven endometriotic cysts of the ovaries (1962-1979) were studied. The diagnosis frequency increased continuously during the observation period. Most patients were aged 35-39 years. The admission diagnosis was rarely endometriosis. The clinical picture and the extent of the disease rarely showed correlation. At laparotomy 12% of the chocolate cysts had ruptured spontaneously (31 of 263) and half of the cysts ruptured during surgery without adverse effects on the postoperative course. The recurrence rate in patients treated by conservative surgery was 7%. The most frequent accompanying diseases were uterine fibroids (42%) and adenomyosis (42%). One third of the patients presented with bilateral endometriotic cysts. Further foci of endometriosis tissue were frequently found in the affected ovary (55%) and in the other pelvic organs (43%). Only 4% of the ipsilateral oviducts were closed at their fimbrial end, and only 10% showed signs of endosalpingitis. The incidence of infection in endometriotic cysts--formation of an isolated ovarian abscess--was between 8% and 18%, while the risk of carcinoma was less than 1%.     

腹腔镜卵巢子宫内膜异位囊肿剥除术对卵巢储备功能的影响

目的:探讨腹腔镜卵巢子宫内膜异位囊肿(巧囊)剥除术对卵巢储备功能可能造成的影响。方法:前瞻性对照研究,对照组:单侧卵巢成熟性囊性畸胎瘤行腹腔镜囊肿剥除术20例;实验组:卵巢子宫内膜异位囊肿行腹腔镜囊肿剥除术80例。实验组分为4组:A组:单侧巧囊35岁(27例),B组:单侧巧囊≥35岁(13例),C组:双侧巧囊35岁(28例)和D组:双侧巧囊≥35岁(12例)。比较各组手术前、手术后24h内血清FSH,LH,E2的变化并根据单侧巧囊的大小和类型分层分析。随访患者术后6月基础FSH的恢复情况,术后6月超声测量患者双侧卵巢的体积。结果:双侧各组(C,D两组)卵巢子宫内膜异位囊肿剥除术后24h内FSH较术前明显增高(P0.05),E2明显减低(P0.05),LH变化不明显。畸胎瘤组及单侧各组(A,B组)手术前后各激素水平均无统计学差异,分层分析单侧巧囊大小和类型,各组内组间激素水平变化亦无明显差异。C组患者术后6月基础FSH恢复至正常范围内占72.22%,而D组患者基础FSH恢复至正常范围内仅占55.56%,差异有统计学意义(P0.05)。单侧卵巢囊肿剥除术后6月患侧与对侧卵巢缩小率均有显著差异(P0.05),单侧卵巢囊肿剥除术后与双侧卵巢囊肿剥除术后患侧卵巢缩小率无统计学差异。结论:腹腔镜双侧卵巢子宫内膜异位囊肿剥除术对卵巢储备功能有一定的影响,但大部分患者可在术后6个月内恢复。     

长效达菲林联合阴道超声引导下穿刺治疗卵巢子宫内膜异位囊肿及对辅助生殖技术结局的影响

目的:探讨长效达菲林联合阴道超声引导下穿刺治疗卵巢子宫内膜异位囊肿及对辅助生殖技术(ART)结局的影响。方法:回顾分析因不孕要求实施IVF-ET的子宫内膜异位症患者126例,比较卵巢子宫内膜异位囊肿行长效达菲林联合囊肿穿刺组(实验组)与单用长效达菲林组(对照组)囊肿大小变化、早卵泡期(基础)FSH、LH、E2水平、Gn启动日FSH、LH、E2水平、取卵日E2水平、获卵数、受精率、卵裂率、优质胚胎数及IVF-ET结局的差异。结果:实验组与对照组相比,卵巢大小、基础内分泌及启动日LH、E2、受精率、卵裂率、临床妊娠率均无统计学差异。穿刺组囊肿全部消失,未穿刺组96个囊肿31个消失。实验组启动日FSH低于对照组,取卵日E2明显高于对照组(P<0.05),优质胚胎数、成熟卵泡数明显多于对照组(P<0.05)。结论:因子宫内膜异位症导致不孕而要求行辅助生殖技术的患者,尤其不愿手术的患者,可以先行囊肿穿刺术,同时使用超长方案ART治疗可获得更多优质胚胎数,因而可能有助于提高累积妊娠率。     

改良盆底重建术与传统手术治疗盆腔器官脱垂的随访评价

目的:评价经阴道全子宫切除术加改良盆底重建术和经阴道全子宫切除术加阴道前后壁修补术治疗盆腔脏器脱垂的治疗效果。方法:对2007年4月至2011年4月盆腔脏器脱垂Ⅱ～Ⅳ度102例患者进行术后3个月、6个月、12个月、36个月随访,其中经阴道子宫切除术加改良盆底重建术(重建组)65例,经阴道子宫切除术加阴道前后壁修补术(传统组)37例。采用POP-Q分度法,Ⅱ度及Ⅱ度以上判定为复发。结果:重建组2例(3.08%)复发,传统组6例(16.21%)复发,两组复发率差异有统计学意义(P<0.05);重建组复发患者均合并网片侵蚀、外露,剪除外露网片并局部雌激素治疗后放置子宫托,目前疗效满意;传统组复发患者分别行子宫托治疗、改良盆底重建术、Prolift盆底重建术、阴道封闭术,目前疗效满意;重建组35例术后恢复性生活,传统组25例术后恢复性生活,性功能问卷评分均较术前下降(P<0.05),但两组术后性功能评分无显著差异(P>0.05)。结论:改良盆底重建术作为一种新术式,能更好地修补缺陷、实现结构重建和组织替代,其复发率低,尤其是对于Ⅲ～Ⅳ度脱垂患者较传统手术更具优势。术后复发患者首选子宫托治疗,传统组可行网片再次手术治疗,阴道封闭术为最后的选择方法。     

Basal ovarian cysts and clomiphene citrate ovulation induction cycles

OBJECTIVE: To evaluate the effect of simple basal ovarian cysts in patients undergoing infertility treatment with clomiphene citrate. To evaluate the effect of clomiphene citrate on pretreatment simple ovarian cysts. METHODS: Prospective cohort trial of 84 infertility patients undergoing ovulation induction with clomiphene citrate. Patients with basal ovarian cysts of 10 mm or greater (n = 42) were compared with patients without ovarian cysts (n = 42). The main outcome measure was ovulation determined by menstrual cycle day 21 progesterone level. Each patients with an ovarian cyst was also evaluated for persistence or resolution of the cyst in association with ovulation and cyst size. Pretreatment and posttreatment transvaginal ultrasound examinations were performed on all patients. RESULTS: Demographic data were similar among the groups. The mean ovarian cyst size was 17.4 +/- 5.8 mm. Patients in the ovarian cyst group were significantly less likely to ovulate (80.9% versus 97.6%, P < .05), but did not differ in pregnancy rate compared with patients without baseline ovarian cysts (4.8% versus 11.9%, P = .43). Persistent ovarian cysts occurred in 36.7% of the patients. The initial size of the cyst did not predict cyst persistence. CONCLUSION: According to these data, basal ovarian cysts significantly reduce ovulatory events in patients treated with clomiphene citrate. LEVEL OF EVIDENCE: II-2.     

Ultrasonically guided puncture of endometrial cysts--aspiration of contents and infusion of ethanol

Ultrasonically guided transvaginal or transabdominal puncture of an endometrial cyst with a transvaginal or transabdominal sector probe was done safely and correctly. In 7 endometrial cysts in 5 patients, we aspirated the contents, flushed with saline solution and cleaned the interior cysts. At last 99.9% ethanol was infused into 6 cysts for 30 minutes. In all cases puncture of the endometrial cyst was successful and the contents of the endometrial cyst were collected. There were no major side effect and no recurrence of endometrial cyst. It was proven that the aspiration of contents and infusion of ethanol were superior methods for treating endometrial cysts.