腹腔镜下保留盆腔自主神经的广泛子宫切除术治疗早期宫颈癌临床价值探讨

目的探讨腹腔镜下保留盆腔自主神经的广泛子宫切除术(laparoscopic nerve-sparing radical hysterectomy,LNSRH)治疗早期宫颈癌的临床价值。方法选取2009年8月至2012年12月于青岛市市立医院,因子宫颈癌行腹腔镜下广泛子宫切除术的患者,采用随机数字表法将其分为两组,其中保留神经组(A组)21例,行腹腔镜下盆腔淋巴清扫(laparoscopic pelvic lymphadenectomy,LPL)+保留盆腔自主神经的广泛子宫切除术(LNSRH),对照组(B组)23例,行腹腔镜下盆腔淋巴清扫(LPL)+子宫广泛切除术(laparoscopic radical hysterectomy,LRH)。比较两组手术时间、术中出血量、手术范围及术后患者膀胱、直肠功能恢复情况。结果 A组20例成功手术,1例因术中处理子宫深静脉及膀胱静脉分支出血损伤神经组织改行LPL+LRH。4例Ⅱa期患者选择性保留病灶对侧盆腔神经,余成功保留双侧神经。A组手术时间较B组延长[(348.25±19.34)min、(273.04±28.87)min],差异有统计学意义(P<0.05),A组肛门排气时间较B组缩短[(38.80±8.33)h、(67.61±8.15)h],差异有统计学意义(P<0.05),A组术后10 d拨尿管率较B组高(60.00%、21.74%)。两组术中出血量、切除主韧带、骶韧带宽度及切除阴道壁长度差异无统计学意义(P>0.05)。结论 LPL+LNSRH作为早期宫颈癌手术治疗方法对改善术后患者尿潴留及肠道功能近期效果良好,远期疗效有待进一步观察。     

腹腔镜下保留盆腔自主神经的广泛性子宫切除术治疗早期宫颈癌的安全性及疗效的临床研究

目的:评估腹腔镜下保留盆腔自主神经的广泛性子宫切除术(LNSRH)治疗早期宫颈癌的安全性及疗效。方法:回顾性分析行广泛性子宫切除术的宫颈癌患者235例的临床资料,根据手术方式不同,分为LNSRH组116例,普通腹腔镜下广泛性子宫切除术组(LRH组)119例,比较两组的手术参数(包括手术时间、术中出血量、术中及术后并发症、宫旁切除长度、阴道切除长度、淋巴结切除数目),及术后的膀胱功能恢复指标(包括留置尿管天数、术后有无尿频、尿急、尿痛、腹压排尿、尿失禁、尿潴留以及排尿满意率),采用Kaplan-Meier法比较两组术后生存时间分布。结果:两组患者的各项手术参数比较,差异无统计学意义(P0.05);LNSRH组术后留置尿管天数、膀胱功能障碍发生率、腹压排尿、尿潴留以及排尿满意率明显优于LRH组,差异有统计学意义(P0.05);LNSRH组和LRH组术后5年生存率分别为86.4%和89.1%,术后生存时间分布差异无统计学意义(P0.05)。结论:LNSRH治疗早期宫颈癌是安全可靠的,与LRH比较,有较好的膀胱功能保护作用。     

腹腔镜下保留盆腔神经的广泛性子宫切除术16例临床研究

目的:评估腹腔镜保留盆腔神经的广泛性子宫切除术的临床可行性,及其对膀胱与直肠功能的保护作用。方法:比较行LNSRH与腹腔镜下广泛性子宫切除术(LRH)的宫颈癌患者的术中及术后情况。结果:LNSRH组术后拔除尿管及首次排气时间短于LRH组(P=0.039,P=0.041);两组的手术时间、术中失血量、清扫盆腔淋巴结数、宫旁组织切除长度及阴道切除长度均无显著差异(P0.05)。结论:LNSRH可在达到治疗效果的基础上促进患者术后膀胱和直肠功能的快速恢复。     

保留盆腔自主神经对宫颈癌患者术后性生活质量影响的探讨

目的 探讨腹腔镜下保留盆腔自主神经的广泛子宫切除术(laparoscopic nerve sparing radical hysterectomy,LNSRH)对早期宫颈癌患者术后性生活质量的影响。 方法 选取2011年8月至2013年3月因早期子宫颈癌(Ⅰa2～Ⅰb1期)于青岛市市立医院行腹腔镜下广泛子宫切除术的患者,采用随机数字表法将其分为2组,其中LNSRH组29例,行LNSRH+腹腔镜下盆腔淋巴结清扫术（laparoscopic pelvic lymphadenectomy,LPL）,对照组30例,行腹腔镜下广泛子宫切除（laparoscopic radical hysterectomy,LRH）+LPL（LRH组）。术前及术后1年采用女性性功能指标量表(female sexual function index,FSFI)对所有患者进行问卷调查,评价其性生活质量。 结果 术前两组FSFI总评分及各部分得分差异无统计学意义,术后LNSRH组FSFI总评分高于LRH组,差异有统计学意义（P<0.05）。术后各部分评分中性欲望、性唤起、阴道润滑、性高潮、性满意度得分LNSRH组均高于LRH组,差异有统计学意义（P<0.05）;性交痛评分两组之间差异无统计学意义。结论 LNSRH患者较LRH患者术后有较为理想的性生活状态,LNSRH可能对提高早期宫颈癌患者术后性生活质量有效。     

腹腔镜下盆腔淋巴结切除+阴式广泛宫颈切除术治疗早期宫颈癌16例临床效果及妊娠结局的观察分析

目的:探讨年轻宫颈癌保留生育功能患者行腹腔镜下盆腔淋巴结切除+阴式广泛宫颈切除术(VRT)后的临床效果及妊娠结局。方法:选择2011年1月至2015年12月就诊于宁夏医科大学总医院行腹腔镜下盆腔淋巴结切除+VRT的早期宫颈癌患者16例(VRT组),同期30例早期宫颈癌行腹腔镜下广泛子宫切除术+盆腔淋巴结切除术(LRH)患者作为对照(LRH组),对比观察两种手术的的临床效果;随访16例患者的累积妊娠率及妊娠结局。结果:两组在年龄、临床分期、病理分化程度、淋巴血管间隙受侵、鳞癌抗原表达、手术时间、术后发热率、术后并发症以及术后复发等指标上差异无统计学意义(P0.05)。VRT组术中出血量、术后住院天数明显优于LRH组(P0.05)。16例腹腔镜下盆腔淋巴结切除+VRT术后1年妊娠12例,累积妊娠次数15次;1年足月产4例次(33.3%),流产11例次(73.3%)。结论:对年轻宫颈癌患者,腹腔镜下盆腔淋巴结切除+VRT手术可达到与广泛子宫切除术+盆腔淋巴结切除术同样临床效果,同时可保留生育功能,但需提高妊娠率及生殖预后。     

腹腔镜下保留盆腔植物神经的解剖性广泛性子宫切除术37例临床分析

目的 探讨腹腔镜下保留盆腔植物神经的解剖性广泛性子宫切除术(LANSRH)治疗早期宫颈癌的可行性,并评价其改善术后膀胱功能的效果.方法 选择2006年10月至2007年9月接受LANSRH的临床分期为Ⅰb1～Ⅱa期的宫颈癌患者37例(LANSRH组),选择同期接受非保留盆腔植物神经的腹腔镜广泛性子宫切除术(LRH)的Ⅰb1～Ⅱa期宫颈癌患者25例作为对照(LRH组).比较两组患者的手术时间、术中出血量、切除的淋巴结数、宫颈旁组织和阴道切除的长度,并对术后的膀胱功能进行评估和分级.结果 两组患者均在腹腔镜下顺利完成手术.(1)LANSRH组患者手术时间、术中出血量、切除淋巴结数、宫颈旁组织切除长度及阴道切除长度分别为(175±41)min、(233±104)ml、(13±4)个、(3.6±0.5)cm和(3.5±1.0)cm,分别与LRH组[分别为(178±30)min、(218±77)ml、(15±6)个、(3.7±0.6)cm和(3.5±0.8)cm]比较,差异均无统计学意义(P>0.05).(2)拔除尿管后,LANSRH组患者中35例(95%)有膀胱充盈感,32例(86%)有自主排尿及排尿完全感;LRH组患者中,22例(88%)有膀胱充盈感,19例(76%)有自主排尿及排尿完全感;两组分别比较,差异均无统计学意义(P>0.05).LANSRH组患者留置尿管时间为(10.6±2.7)d,与LRH组[(17.2±4.2)d]比较,差异有统计学意义(P<0.05).LANSRH组患者中,膀胱功能为0、Ⅱ级者分别为68%(25/37)和3%(1/37),分别与LRH组[分别为40%(10/25)和12%(3/25)]比较,差异均有统计学意义(P<0.05);膀胱功能为Ⅰ级者,LANSRH组和LRH组分别为24%(9/37)和48%(12/25),两组之间比较,差异无统计学意义(P>0.05).(3)两组患者均未发生术中并发症,无需输血治疗.术后病理检查提示,所有患者宫颈旁均无肿瘤侵犯,也无淋巴结转移发生.两组患者随访11～19个月,所有患者均健在,均无复发和转移. 结论采用LANSRH治疗早期宫颈癌安全、可行,能保留支配膀胱的下腹下神经丛,在术后短期内明显改善患者的膀胱功能.     

腹腔镜下和经腹广泛子宫切除及盆腔淋巴结清扫术治疗早期子宫恶性肿瘤的近期疗效分析

目的:探讨腹腔镜下广泛子宫切除加盆腔淋巴结清扫术治疗子宫恶性肿瘤的近期疗效及应用价值.方法:对协和医院妇产科2008年3月至2009年4月间的70例早期子宫恶性肿瘤患者行腹腔镜下广泛子宫切除加盆腔淋巴结清扫术(TLRH+LPL组),并与同期48例经腹广泛子宫切除术和淋巴结清扫术(ARH+APL组)的病例作为对照,比较两种术式的术中、术后情况及并发症等.结果:行腹腔镜手术的70例患者,有2例中转开腹,中转率为2.9%.TLRH+LPL组在手术时间、术中出血量、淋巴结切除数目和术后体温恢复正常平均时间上与ARH+APL组相比,具有明显优势,差异均有高度统计学意义(P<0.01);但膀胱功能恢复时间及术后并发症的发生率,两组比较差异无统计学意义(P>0.05).结论:腹腔镜下广泛子宫切除加盆腔淋巴结清扫术具有同常规的经腹手术同样的安全性和有效性,同时缩短了手术时间,减少了手术创伤,为微创手术治疗妇科恶性肿瘤提供了良好的应用前景.     

120例早期宫颈癌患者行LNSRH术与LRH术治疗的回顾性对比研究

目的探究腹腔镜下保留自主神经的广泛子宫切除术(LNSRH)、腹腔镜下广泛性全子宫切除术(LRH)对早期宫颈癌患者的治疗效果及安全性。方法回顾性分析2014年2月至2016年3月安徽安庆市立医院收治的早期宫颈癌手术患者的临床资料,根据手术方式的不同将其分为LRH组(62例)、LNSRH组(58例),比较围手术期指标、膀胱功能指标情况,随访统计术后复发情况。结果两组患者手术时间、术中出血量、宫旁切除长度、阴道切除长度、淋巴结清扫数目比较差异均无统计学意义(P0.05);与LRH组比较,LNSRH组患者术后10 d尿管拔除率较高,导尿管留置时间较短(P 0.05),尿潴留及总体膀胱功能障碍发生率较低(P 0.05);两组患者术后化疗、放疗率、5年内复发率比较差异均无统计学意义(P0.05);Kaplan-Meier生存分析显示两组患者DFS比较差异无统计学意义(P0.05)。结论 LNSRH手术与LRH手术效果相当,与LRH手术相比,LNSRH手术可降低膀胱功能障碍发生率。     

子宫颈癌患者广泛性子宫切除术后下泌尿道的尿动力学特点

目的 探讨宫颈癌患者在广泛性子宫切除手术前后下泌尿道的尿动力学特点.方法 选择Ⅰ b～Ⅱa期宫颈癌患者46例,分别于广泛性子宫切除术前及术后进行尿动力学检查.结果 26例(57%)患者术前排尿模式正常但术后需借助于腹压排尿;排尿后残余尿量明显增加,术后为(205±201)ml,而术前为(5±3)ml,两者比较,差异有统计学意义(P＜0.01).术后正常尿意膀胱容量较术前显著增加,分别为(365±108)、(286±84)ml,两者比较,差异有统计学意义(P=0.01);最大膀胱容量较术前显著增加,分别为(670±174)、(402±124)ml,两者比较,差异有统计学意义(P=0.05);膀胱顺应性显著下降[分别为(15±5)、(102±64)ml/cm H2O(1 cm H2O=0.098 kPa),P＜0.01];最大逼尿肌收缩压显著下降[分别为(11±5)、(39±14)cm H2O,P＜0.01];功能性尿道长度缩短[分别为(31±7)、(39±7)mm,P＜0.01].结论 广泛性子宫切除术后下泌尿道功能障碍,其尿动力学特点表现为膀胱感觉功能减退,逼尿肌功能受损,而尿动力学检查有助于早期诊断.     

阴式广泛全子宫切除加腹腔镜下淋巴结切除术与开腹手术治疗早期宫颈癌疗效比较

目的探讨阴式广泛全子宫切除加腹腔镜下淋巴结切除术治疗早期宫颈癌的临床价值。方法 2004年11月至2011年4月于佛山市妇幼保健院,回顾性分析行阴式广泛全子宫切除加腹腔镜下淋巴结切除术的90例早期宫颈癌患者(阴式组)的病例资料,抽取同期行开腹广泛全子宫切除加盆腔淋巴结切除术42例(开腹组)作为对照。结果两组手术时间差异无统计学意义(P>0.05)。阴式组术中出血量[(348±114)mL]、肠道功能恢复时间[(36.76±4.9)h]、住院天数[(10.56±2.10)d]均少于开腹组的[(398±127)mL]、[(40.09±6.5)h]、[(11.79±2.45)d],差异有统计学意义(P<0.05)。阴式组切除阴道长度[(3.12±0.17)cm]大于开腹组的[(3.05±0.21)cm](P<0.05)。阴式组尿潴留发生率(30.0%)较开腹组(11.9%)高(P<0.05)。阴式组术后5年内复发率(14.6%)低于开腹组(31.5%)(P<0.05)。结论阴式广泛全子宫切除加腹腔镜下淋巴结切除术式创伤小,术后恢复快,手术彻底,有临床应用价值。     

Laparoscopic Radical Hysterectomy versus Abdominal Radical Hysterectomy: A Non-randomized Study

This study compared results obtained with laparoscopic radical hysterectomy (LRH) versus abdominal radical hysterectomy (ARH) to determine the applicability of LRH as an alternative for treatment of early stage cervical cancer. A class III LRH technique is described. Between January 1994 and November 1996, 49 radical hysterectomies were performed at Notre-Dame Hospital for Stage IA₂ and IB₁ cervical cancer. Three patients were excluded from the study because LRH was offered as an alternative only when the Quetelet Index (QI) was equal to or less than 33. Twenty-three patients were scheduled for LRH and 23 for ARH. Both groups were comparable for age, QI, stage, tumour diameter and histology. The mean operating time was 390 minutes for LRH and 240 minutes for ARH (p = 0.0001 ). Blood loss was less in the LRH group (475 cc versus 1,060 cc, p = 0.0001). One LRH patient required an immediate laparotomy to secure haemostasis. In the LRH group, one eventration occurred as well as two unusual neurological complications. The post-operative stay was shorter for LRH (p = 0.0265). The numbers of para-aortic and pelvic nodes obtained were comparable. There were three recurrences, one in the LRH group and two in the ARH group. The average follow-up was 49 months in both groups. With experience, the mean operating time, complication rate, need for analgesia and length of hospital stay decreased considerably with the LRH procedure. Cosmetic results were superior. This procedure remains time consuming and difficult to perform, limiting its applicability as an alternative to ARH for the treatment of early stage cervical cancer. Ongoing research is suggested.     

Surgicopathologic outcome of laparoscopic versus open radical hysterectomy

OBJECTIVE: To compare the surgicopathologic outcome of total laparoscopic radical hysterectomy (LRH) with that of abdominal radical hysterectomy (ARH) for the treatment of early-stage cervical cancer. METHODS: Radical hysterectomy specimens of sequential patients undergoing LRH (N=50) were compared with those of historical controls selected from consecutive women who have had conventional ARH (N=48), and who met the same criteria for eligibility as the cases. To evaluate the extent of parametrial resection, parametrial tissues were systematically measured at their widest dimensions before tissue processing. RESULTS: No difference was found in demographics, histologic type, tumor stage and grade between the two groups. The parametrial width was similar between LRH and ARH in both type II (right parametrium: 2.4 cm (1-3) vs. 2.3 (1.8-4.0), p=0.28; left parametrium: 2.3 cm (1.8-4) vs. 2.2 (1.2-3.0), p=0.54) and type III radical hysterectomy (right parametrium: 3.8 cm (2.3-6.5) vs. 3.4 (1.7-7.0), p=0.59; left parametrium: 3.6 cm (2-6) vs. 3.5 (1.5-6.5), p=0.82). There were no significant differences between the two groups with regard to lymph nodes yield and likelihood of identifying positive margins or metastatic disease. CONCLUSION: Our results suggest that laparoscopically managed patients with cervical cancer undergo a similar extent of surgery as those treated with the traditional ARH, as judged by objective pathologic criteria.     

Vaginal Radical Hysterectomy versus Abdominal Radical Hysterectomy in the Treatment of Early-Stage Cervical Cancer

The purpose of this study is to compare the safety, efficacy, and potential benefits of vaginal radical hysterectomy (VRH) versus abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer who underwent a laparoscopic pelvic lymphadenectomy (LPL), followed either by a VRH (Schauta) in 25 cases or ARH in 27 cases. For the 52 patients, the mean lymph nodes count obtained by LPL was 27 (range 8–59), and the only complication was an external iliac vein trauma requiring laparotomy. Both VRH and ARH groups were comparable in terms of age, weight, parity, stage, histology, and tumor volume. The mean blood loss was 400 cc for VRH vs 450 cc for ARH, operating time was 270 min vs 280 min, blood transfusion in 5 vs 4 women, and postoperative stay was 7 days for both groups. The only intraoperative complication in addition to the vein trauma was a cystotomy which occurred in 2 VRH patients. Febrile morbidity was noted in 4 VRH patients vs 9 ARH patients. There were one preperitoneal abscess and one hematoma in the VRH group vs 4 wound infections and 1 hematoma after ARH. Ileus occurred in 1 VRH vs 4 ARH patients. The current mean follow-up time is 27 months (8–52) and there has been one recurrence so far in the ARH group. Even though this is a retrospective study, our data indicate that VRH and ARH are comparable, except for the absence of an abdominal scar and less febrile morbidity with the vaginal approach. However, in our opinion, the main advantage in learning the Schauta operation is that the experience gained allows one to offer radical trachelectomy to selected young patients who wish to preserve their fertility.     

围产期子宫切除术后再次行腹腔探查术患者的临床特点分析

目的 探讨产后出血围产期子宫切除术后再次腹腔探查手术的原因及临床特点.方法 回顾性分析1999年1月至2009年7月广州市重症孕产妇救治中心收治的88例产后出血致围产期子宫切除病例,其中14例为再次探查手术组,74例为非再次探查手术组.比较两组的如下各项指标:分娩方式、子宫切除指征及方式、再次探查手术的间隔时间及手术方式、并发症、失血量、输血量、格拉斯哥评分、呼吸机辅助呼吸率、重症监护病房入住率、重症监护病房入住时间、住院时间及结局等.结果 88例围产期子宫切除患者中再次探查手术者14例,发生率为15.91%,均因子宫切除后腹腔内出血行再次探查手术.再次探查手术组患者并发弥漫性血管内凝血的比例显著高于非再次探查手术组(92.9%与43.2%,x2=11.598,P=0.001),同时羊水栓塞比例也显著增高(28.6%与2.7%,x2=8.663,P=0.003).再次探查手术止血方式:宫颈残端切除(5例),残端缝扎止血(8例)和右附件切除及腹膜后血肿清除(1例).再次探查手术组比非再次探查手术组患者具有更高的出血量、输血量、重症监护病房入住率及呼吸机辅助呼吸率[(8752.9±4593.0)ml与(3742.4±2689.9)ml,P=0.000;(8163.6±3903.1)ml与(2958.8±2323.0)ml,P=0.000;100.0%与41.9%,P=0.000;100.0%与24.3%,P=0.000];同时格拉斯哥评分≤8分比例及多器官功能障碍综合征比例显著增高(71.4%与25.7%,x2=9.179,P=0.002;71.4%与14.9%,x2=17.735,P=0.000);且ICU入住时间及住院时间明显延长[ICU入住时间:(11.4±10.0)d与(1.3±2.3)d;住院时间:(24.0±13.1)d与(12.7±7.0)d,P均=0.000].14例患者均临床痊愈出院.结论 围产期子宫切除术后再次探查手术的发生率不低,腹腔内出血是再次探查手术的主要原因.再次探查手术可能与凝血功能障碍及子宫切除方式选择不当等有关.再次探查手术患者并发症严重.

Abstract：

Objective To analyse the causes and clinical characteristics of re-exploration after peripartum hysterectomy due to postpartum hemorrhage. Methods Clinical data was analysed retrospectively including 88 critically ill obstetric patients who underwent peripartum hysterectomy due to postpartum hemorrhage in the Obstetric Critical Care Center of Guangzhou from January 1999 to July 2009, which were divided into re-explored group (n= 14) and non-re-explored group (n=74)depending on whether the patient underwent re-exploration after peripartum hysterectomy. The main demographic data and clinical details were compared between the two groups, including mode of delivery, indication and type of hysterectomy, interval from hysterectomy to re-exploration, surgical intervention, complications, blood loss, blood transfusion,Glasgow Coma Score(GCS), the need for mechanical ventilation, intensive care unit stay and hospital stay. Results Fourteen out of the 88 (15.91%) patients underwent re-exploration due to internal bleeding after peripartum hysterectomy.Removal of cervical stump was performed in five patients and stump hemostasis in eight cases.Significant difference was found between the re-exploration and non-re-explored group on thepercentage of patients complicated with disseminated intravascular coagulation(92.9% vs 43.2%,x2=11.598,P=0.001) and amniotic fluid embolism (28.6% vs 2.7%, x2 =8.663, P=0.003).0.000], blood transfusion [(8163.6± 3903.1 ) ml vs (2958.8± 2323.0) ml, P = 0.000], intensive care unit admission rate (100.0% vs 41.9%, x2 = 15.909, P= 0.000), the need for mechanical ventilation (100.0% vs 24.3%,P=0.000), the number of patients with GCS≤8 score (71.4% vs 25.7% ,x2 = 9.179, P = 0.002 ), the number of multiple organ dysfunction syndrome ( 71.4% vs 14.9%, x2 = 17.735, P = 0.000), intensive care unit stay [ ( 11.4 ± 10.0 ) d vs ( 1.3 ± 2.3 ) d, P =0.000] and hospital stay[(24.0±13.1) d vs (12.7±7.0) d, P=0.000]. Allof the 14 cases were clinical recovered before discharge. Conclusions The rate of re-exploration after peripartum hysterectomy is not low, and internal bleeding is the most common causes. The re-exploration after peripartum hysterectomy might be associated with coagulopathy and the mode of hysterectomy, and patients may experience more severe complications.     

多胎妊娠孕中期减至双胎与初始双胎妊娠的妊娠结局比较

目的 探讨多胎妊娠孕妇孕中期行减胎术减至双胎后与初始双胎孕妇的妊娠结局比较.方法 选择2007年8月至2010年9月在山东大学附属省立医院妇产科门诊或住院、多胎妊娠孕妇567例,其中双胎妊娠孕妇478例为非减胎组;妊娠12周以后在本院实施孕中期减胎术(在超声引导下经腹的胎心内氯化钾注射法),由初始多胎减至双胎的孕妇89例为减胎组.减胎组孕妇中,初始三胎70例,初始四胎13例,初始五胎及以上6例.观察两组孕妇年龄、分娩孕周、妊娠并发症、新生儿出生体质量及新生儿结局.结果 (1)两组孕妇年龄及分娩孕周:非减胎组与减胎组孕妇平均年龄分别为(29.7±4.5)和(29.9±5.0)岁,两组比较,差异无统计学意义(P=0.755).非减胎组与减胎组孕妇平均分娩孕周分别为(35.3±3.9)和(34.4±6.3)周,两组比较,差异有统计学意义(P＜0.01).分娩孕周＜28周者(即流产)在非减胎组发生率为6.3％( 30/478),在减胎组为15.7％( 14/89),两组比较,差异有统计学意义(P=0.002).(2)两组妊娠并发症:子痫前期发生率在非减胎组及减胎组分别为8.2％ (39/478)和12.4％(11/89),两组比较,差异无统计学意义(P=0.199);妊娠期糖尿病发生率在非减胎组及减胎组分别为1.7％(8/478)和3.4％( 3/89),两组比较,差异无统计学意义(P =0.287).(3)两组新生儿情况:①非减胎组两个胎儿出生体质量差值＞400g的发生率为28.9％(138/478),减胎组为27.0％ (24/89),两组比较,差异无统计学意义(P=0.715).非减胎组两个胎儿出生体质量差值＞100g的发生率为75.1％(359/478),减胎组为75.3％(67/89),两组比较,差异无统计学意义(P =0.972).②非减胎组新生儿平均出生体质量为(2700 ±468)g,明显高于减胎组的(2352 ±602)g,两组比较,差异有统计学意义(P＜0.01).非减胎组＞孕36周+1 分娩的新生儿平均出生体质量为(2809 ±424)g,减胎组为(2707±506)g,两组比较,差异有统计学意义(P＜0.01).③减胎组及非减胎组＞28孕周分娩新生儿的死亡率分别为1.3％( 1/78)和2.2％( 10/448);减胎组及非减胎组新生儿患病率分别为3.8％ (3/78)和4.0％ (18/448),两组＞28孕周分娩的新生儿死亡率及患病率分别比较,差异均无统计学意义(P =0.588、0.943).结论 多胎妊娠减胎至双胎的妊娠结局较初始双胎者差,其流产率较高;多胎妊娠减胎后分娩孕周受初始胎儿数的影响,新生儿出生体重质量低于初始双胎.     

宫颈锥切术对妊娠结局的影响

目的 探讨宫颈冷刀锥切(cold knife conization,CKC)与环形电切术(loop electrical excision procedure,LEEP)对妊娠结局及分娩方式的影响。方法 采用回顾性病例对照研究,分析2004年1月至2010年1月在中山大学附属第一医院及广州市番禺区何贤纪念医院诊断为宫颈上皮内瘤变(cervical intraepithelial neoplasia,CIN)Ⅱ～Ⅲ并接受宫颈锥切术治疗后的妊娠患者228例,其中行LEEP 168例、CKC 60例。按年龄、孕次、产次、经济收入相匹配的原则,1:1随机收集同期分娩的健康孕妇为对照组,观察各组的妊娠天数、胎膜早破(premature rupture of membranes,PROM)发生率、终止妊娠方式和新生儿出生体重。结果 病例组和对照组的妊娠天数分别为（268.3±26.2）d和(279.4±25.3)d,差异有统计学意义（t=4.60,P＜0.01）;早产率分别为18.0％ (41/228)和4.4％(10/228)(x2=21.22,P＜0.05);PROM发生率分别为10.1％(23/228)和1.3％(3/228)(x2=16.32,P＜0.05),病例组发生PROM的风险是对照组的8.42倍（OR=8.42,95％ CI：2.49～28.44）。2组剖宫产率分别为69.3％(158/228)和39.0％ (89/228),差异有统计学意义(x2=42.06,P＜0.05)。病例组中LEEP组与CKC组妊娠天数分别为(269.8±24.6)d和（260.2±26.5）d,差异有统计学意义(t=4.01,P＜0.01）;早产率分别为13.1％ (22/168)和31.6％ (19/60)(x2=10.34,P＜0.05)。新生儿出生体重分别为(3358.5±812.2)g和（3295.9±832.6）g,差异有统计学意义(t=3.08,P＜0.01);PROM发生率分别为7.1％ (12/168)和18.3％ (11/60),差异有统计学意义(x2=6.10,P＜0.05)。结论 宫颈锥切术增加了孕妇早产、PROM发生率;LEEP对妊娠结局的影响小于CKC。因此对有生育要求的患者,应优先考虑LEEP并告知相关风险。     

Laparoscopic versus open radical hysterectomy in women with early stage cervical cancer: A systematic review and meta-analysis

This review aimed to evaluate the short term and long-term outcomes of laparoscopic radical hysterectomy (LRH) versus abdominal radical hysterectomy (ARH) for early-stage cervical cancer. A search of PubMed, Medline and Scopus databased from 2000 to 2018 was conducted. Thirty studies were retrieved including 22 retrospective cohort studies and 8 prospective cohort studies. LRH was comparable with ARH in 5-year overall survival (RR = 1.0. 95%CI 0.98–1.03; p = 0.33) and 5-year disease-free survival (RR = 1.02 95%CI 0.97–1.06; p = 0.98). The majority of included studies reported the negative cancer factors which drive adjuvant therapy were similar between two approaches. LRH was associated with lower blood loss and blood transfusion, less postoperative complication, shorter hospital stays and similar intraoperative complication rate compared to ARH. Our data suggested LRH for early-stage cervical cancer was as safe and effective in terms of long-term outcomes, but with lower surgical morbidities.     

Comparison of Survival Outcomes after Laparoscopic Radical Hysterectomy versus Abdominal Radical Hysterectomy in Patients with Cervical Cancer

ObjectiveA meta-analysis was performed to compare survival outcomes including disease-free survival (DFS) between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in patients with cervical cancer.Data SourcesWe searched PubMed, EMBASE, Google scholar, and the Cochrane library for studies published between December 2004 and May 2020. Manual searches of related articles and relevant bibliographies of published studies were also performed.Methods of Study SelectionTwo researchers independently extracted the data. Studies with survival outcome information were included.Tabulation, Integration, and ResultsA total of 36 eligible clinical trials were included in this meta-analysis. When all studies were pooled, the hazard ratio (HR) of LRH for the risk of DFS and overall survival (OS) compared with ARH was 1.24 (95% confidence interval [CI], 1.09–1.41; p = .001; I² = 37.5%) and 1.27 (95% CI, 1.04–1.56; p = .020; I² = 45.5%), respectively. In a subgroup analysis, significant harmful effects of DFS in patients with LRH increased in studies using the HR presented by the article (HR, 1.41; 95% CI, 1.21–1.64; p <.001), matched retrospective design (HR, 1.49; 95% CI, 1.19–1.88; p = .001), large-scale studies (HR, 1.34; 95% CI, 1.16–1.55; p <.001), and studies published after the Laparoscopic Approach to Cervical Cancer trial (HR, 1.46; 95% CI, 1.25–1.71; p <.001). However, LRH did not affect DFS (HR, 1.04; 95% CI, 0.59–1.81; p = .898) or OS (HR, 0.57; 95% CI, 0.31–1.05; p = .073) of patients with cervical cancer with cervical masses <2 cm.ConclusionThis meta-analysis demonstrated that LRH was associated with higher recurrence rates than ARH. However, LRH showed similar recurrence and OS among patients with cervical masses <2 cm (Centre for Reviews and Dissemination 42020191713).