Clinical efficacy of hysteroscopy combined with laparoscopy in treating moderate to severe intrauterine adhesions
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摘要:目的 探讨宫腔镜、腹腔镜联合手术在诊断和治疗中重度宫腔粘连的临床效果。方法 将120例有生育需求的经宫腔镜检查确诊为中重度宫腔粘连的患者随机分为2组, 对照组行宫腔镜下宫腔粘连分离术，观察组行宫腔镜、腹腔镜联合手术。观察2组患者术后宫腔恢复、月经改善情况，并随访2年观察2组患者妊娠情况。结果 120例患者均顺利完成手术，观察组术后1、3个月的月经改善率分别为85.0%(51/60)、76.7%(46/60), 宫腔再次粘连发生率分别为14.3%(9/60)、21.7%(13/60); 对照组术后1、3个月的月经改善率分别为14.3%(9/60)、21.7%(13/60), 宫腔再次粘连发生率分别为28.3%(16/60)、40.0%(24/60); 随访2年内对照组妊娠率为28.6%(16/56), 观察组妊娠率为47.3%(26/55)。结论 宫腔镜、腹腔镜联合手术治疗中重度宫腔粘连安全、有效，能够有效恢复宫腔状态，在术后月经恢复、预防粘连复发以及提高术后妊娠率方面均有显著效果。Abstract:Objective To evaluate the clinical efficacy of hysteroscopy combined with laparoscopy in moderate to severe intrauterine adhesions.Methods A total of 120 patients diagnosed as moderate to severe intrauterine adhesions by uteroscopy with birth demand in our hospital were randomly divided into two groups. The patients in the observation group performed laparoscopic-hysteroscopic hysteroscopic adhesiolysis, while those in the control group were operated transcervical resection of adhesion(TCRA). The clinical efficacy in improvement of menstruation and prevention of re-adhesion of two groups were observed. The pregnancy outcomes in 2 years of follow-up were observed.Results All the 120 patients successfully completed the surgeries. The improvement rates of menstruation at 1-, 3-month were 85.0%(51/60), 76.7%(46/60), respectively, in observation group, and 70.0%(42/60), 58.3%(34/60), respectively, in control group. The re-adhesion rates at 1-, 3-month were 14.3%(9/60), 21.7%(13/60) in observation group, and 28.3%(16/60), 40.0%(24/60), respectively, in the control group. The pregnancy rate was 47.3%(26/55) in the observation group, and 28.6%(16/56) in the control group at 2-year follow up.Conclusion Laparoscopic combined with hysteroscopy surgery for intrauterine adhesions is safe and practicable, and has preferable efficacy in the recovery of uterine normal function, postoperative menstruation recovery, prevention of re-adhesion and improvement of pregnancy.
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表 1 2组患者一般情况比较(x±s)[n(%)]
项目 对照组(n=60) 观察组(n=60) 年龄/岁 28.0±4.0 28.7±4.4 体质量指数/(kg/m2) 22.2±2.3 21.5±2.4 孕次/次 2.8±1.3 3.0±1.4 病程时间/月 12.1±6.1 11.5±5.0 AFS评分/分 8.1±1.9 8.4±1.9 不孕类型 原发不孕 3(5.0) 2(3.3) 继发不孕 52(86.7) 54(90.0) 术前月经 减少 45(75.0) 44(73.3) 闭经 9(15.0) 12(20.0) 正常 6(10.0) 4(6.7) 手术及病史 复发性流产史 9(15.0) 10(16.7) 宫腔操作史 57(95.0) 58(96.7) 结核病史 5(8.3) 3(5.0) 宫腔镜手术史 22(36.7) 25(41.7) 粘连程度 中度粘连 28(46.7) 23(38.3) 重度粘连 32(53.3) 37(61.7) AFS: 美国生育协会。 
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表 2 观察组患者输卵管通畅程度及合并盆腔病变情况[n(%)]
粘连程度 n 双侧通畅 PID 双侧梗阻 EMT PCO 中度 23 7(11.7) 9(15.0) 6(10.0) 6(10.0) 7(11.7) 重度 37 9(15.0) 18(30.0) 11(18.3) 8(13.3) 8(13.3) 合计 60 16(26.7) 27(45.0) 17(28.3) 14(23.3) 15(25.0) PID: 盆腔炎; EMT: 盆腔子宫内膜异位性疾病; PCO: 多囊卵巢。
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表 3 2组IUA患者随访2年内妊娠结局
组别 粘连程度 随访例数 妊娠结局 活产 流产或胎停 异位妊娠 妊娠中 合计 对照组 中度 26 2 2 1 3 8(30.8) 重度 30 3 2 1 2 8(26.7) 合计 56 5 4 2 5 16(28.6) 观察组 中度 21 5 2 0 5 12(57.1) 重度 34 4 5 1 4 14(41.2) 合计 55 9 7 1 9 26(47.3)* 与对照组比较, *P＜0.05。
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