子宮肌瘤栓塞治療課件

子宮肌瘤栓塞治療的進(jìn)展子宮肌瘤栓塞治療栓塞在子宮肌瘤治療手段中地位的確立(2007)子宮肌瘤栓塞治療1995年Ravina首先在Lancet上報(bào)道了子宮肌瘤栓塞治療；RavinaJH,HerbreteauD,Ciraru-VigneronNetal.Arterialembolisationtotreatuterinemyomata.Lancet1995;346:671–672子宮肌瘤栓塞治療2004年美國(guó)婦產(chǎn)科學(xué)會(huì)認(rèn)可子宮肌瘤栓塞的作用；子宮肌瘤栓塞治療兩個(gè)隨機(jī)對(duì)照研究結(jié)果最終確立栓塞在子宮肌瘤治療手段的地位RESTtrialEdwardsRD,MossJG,LumsdenMAetal.Uterine-arteryembolizationversussurgeryforsymptomaticuterinefibroids.NEnglJMed2007;356:360–370.EMMYtrial

VolkersNA,HehenkampWJ,BirnieEetal.Uterinearteryembolizationversushysterectomyinthetreatmentofsymptomaticuterinefibroids:2years’outcomefromtherandomizedEMMYtrial.AmJObstetGynecol2007;196(6):519.e1–e11.子宮肌瘤栓塞治療最終確認(rèn)栓塞治療是子宮肌瘤中除子宮切除外的一種安全有效的治療方法！子宮肌瘤栓塞治療長(zhǎng)期療效子宮肌瘤栓塞治療SpiesJB,BrunoJ,Czeyda-PommersheimFetal.Long-termoutcomeofuterinearteryembolizationofleiomyomata.ObstetGynecol2005;106:933–939.子宮肌瘤栓塞治療KatsumoriT,KasaharaT&AkazawaK.Long-termoutcomesofuterinearteryembolizationusinggelatinspongeparticlesaloneforsymptomaticfibroids.AJRAmJRoentgenol2006;186:848–854.子宮肌瘤栓塞治療WalkerWJ&Barton-SmithP.Long-termfollowupofuterinearteryembolisation–aneffective

alternativeinthetreatmentoffibroids.BrJObstetGynaecol2006;113:464–468.

肌瘤栓塞后5-7年的結(jié)果月經(jīng)量改善壓迫癥狀是否愿意選擇和推薦UAE需要進(jìn)一步治療75%80%88%16%子宮肌瘤栓塞治療我院500例子宮肌瘤栓塞治療隨訪的有效率子宮肌瘤栓塞治療子宮肌瘤栓塞治療的有效率長(zhǎng)期而穩(wěn)定！子宮肌瘤栓塞治療影響療效的因素子宮肌瘤栓塞治療影響療效的因素栓塞不完全子宮動(dòng)脈主干栓塞不完全僅作單側(cè)子宮動(dòng)脈栓塞子宮栓塞不完全其他供血?jiǎng)用}（卵巢動(dòng)脈、變異子宮動(dòng)脈）肌瘤過(guò)大診斷問(wèn)題（月經(jīng)量過(guò)多或經(jīng)期延長(zhǎng)?。┎骞芗夹g(shù)子宮肌瘤栓塞治療子宮肌瘤栓塞治療并發(fā)癥子宮肌瘤栓塞治療

EdwardsRD,MossJG,LumsdenMAetal.Uterine-arteryembolizationversussurgeryforsymptomaticuterinefibroids.NEnglJMed2007;356:360–370.VolkersNA,HehenkampWJ,BirnieEetal.Uterinearteryembolizationversushysterectomyinthetreatmentofsymptomaticuterinefibroids:2years’outcomefromtherandomizedEMMYtrial.AmJObstetGynecol2007;196(6):519.e1–e11.SiskinGP,Shlansky-GoldbergRD,GoodwinSCetal.Aprospectivemulticentercomparativestudybetweenmyomectomyanduterinearteryembolizationwithpolyvinylalcoholmicrospheres:longtermclinicaloutcomesinpatientswithsymptomaticuterinefibroids.JVascIntervRadiol2006;17:1287–1295.DuttonS,HirstA,McPhersonKetal.AUKmulticentreretrospectivecohortstudycomparinghysterectomyanduterinearteryembolisationforthetreatmentofsymptomaticuterinefibroids(HOPEFULstudy):mainresultsonmedium-termsafetyandefficacy.BrJObstetGynaecol2007;114:1340–1351.WuO,BriggsA,DuttonSetal.Uterinearteryembolisationorhysterectomyforthetreatmentofsymptomaticuterinefibroids:acost-utilityanalysisoftheHOPEFULstudy.BrJObstetGynaecol2007;114:1352–1362.子宮肌瘤栓塞后并發(fā)癥發(fā)生情況

病例數(shù)輕微并發(fā)癥嚴(yán)重并發(fā)癥Razavi

(2003)6711%Siskin（2006）7726%EMMY（2006）8864%4.9%REST(2006)10634%12%HOPEFUL(2007)64919%

子宮肌瘤栓塞治療我院子宮肌瘤栓塞術(shù)后并發(fā)癥輕微并發(fā)癥腹痛27/500（5.4%）發(fā)熱410/500（82%）陰道出血432/500（86.4%）血尿11/500（2.2%）嚴(yán)重并發(fā)癥（6/500，2.6%）膀胱誤栓1/500（0.2%）短暫性閉經(jīng)3/500（0.6%）卵巢衰竭3/500（0.6%）栓塞失敗1/500（0.2%）栓塞后肌瘤脫落4/500（0.8%）栓塞后盆腔感染1/500（0.2%）術(shù)后復(fù)發(fā)10/500（2%）子宮肌瘤栓塞治療栓塞對(duì)卵巢功能的影響子宮肌瘤栓塞治療2001年Spies認(rèn)為栓塞僅對(duì)年齡大于45歲的患者有影響，術(shù)后閉經(jīng)發(fā)生率為14%；2003年P(guān)ron卻發(fā)現(xiàn)小于40歲的3%患者出現(xiàn)術(shù)后閉經(jīng)；雖然較多的研究通過(guò)FSH在栓塞前后的變化來(lái)說(shuō)明栓塞治療對(duì)卵巢較少的影響，但是病例數(shù)均較少。這類研究沒(méi)有考慮到栓塞中常見(jiàn)的卵巢子宮動(dòng)脈吻合問(wèn)題，KIM的研究發(fā)現(xiàn)若出現(xiàn)該吻合則患者術(shù)后會(huì)出現(xiàn)FSH的上移。SpiesJB,RothAR,GonsalvesSMetal.Ovarianfunctionafteruterinearteryembolizationforleiomyomata:assessmentwithuseofserumfolliclestimulatinghormoneassay.JVascIntervRadiol2001;12:437–442.PronG,BennettJ,CommonAetal.TheOntarioUterineFibroidEmbolizationTrial.Part2.Uterinefibroidreductionandsymptomreliefafteruterinearteryembolizationforfibroids.FertilSteril2003;79:120–127.SpiesJB,RothAR,GonsalvesSMetal.Ovarianfunctionafteruterinearteryembolizationforleiomyomata:assessmentwithuseofserumfolliclestimulatinghormoneassay.JVascIntervRadiol2001;12:437–442.AhmadA,QadanL,HassanNetal.Uterinearteryembolizationtreatmentofuterinefibroids:effectonovarianfunctioninyoungerwomen.JVascIntervRadiol2002;13:1017–1020.HealeyS,BuzagloK,SetiLetal.Ovarianfunctionafteruterinearteryembolizationandhysterectomy.JAmAssocGynecolLaparosc2004;11:348–352.TropeanoG,DiStasiC,LitwickaKetal.Uterinearteryembolizationforfibroidsdoesnothaveadverseeffectsonovarianreserveinregularlycyclingwomenyoungerthan40years.FertilSteril2004;81:1055–1061.HovsepianDM,RattsVS,RodriguezMetal.Aprospectivecomparisonoftheimpactofuterinearteryembolization,myomectomy,andhysterectomyonovarianfunction.JVascIntervRadiol2006;17:1111–1115.KimHS,TsaiJ,LeeJMetal.Effectsofutero-ovariananastomosesonbasalfollicle-stimulatinghormonelevelchangeafteruterinearteryembolizationwithtris-acrylgelatinmicrospheres.JVascIntervRadiol2006;17:965–971.KimHS,ThonseVR,JudsonKetal.Utero-ovariananastomosis:histopathologiccorrelationafteruterinearteryembolizationwithorwithoutovarianarteryembolization.JVascIntervRadiol2007;18:31–39.子宮肌瘤栓塞治療如何處理子宮動(dòng)脈造影中卵巢支顯影的病例？子宮肌瘤栓塞治療我院在子宮肌瘤栓塞子宮動(dòng)脈造影中其雙側(cè)卵巢支顯影處理的臨床研究子宮肌瘤栓塞治療子宮動(dòng)脈造影中卵巢支顯影情況雙側(cè)卵巢支顯影單側(cè)卵巢支顯影無(wú)卵巢支顯影

53（41.4%，53/128）31（24.2%，31/128）44（34.3%，44/128）子宮肌瘤栓塞治療子宮肌瘤栓塞患者子宮動(dòng)脈造影其雙側(cè)卵巢支顯影非顯影組顯影明膠海綿組顯影組非顯影聚乙烯醇組非顯影明膠海綿組子宮肌瘤栓塞治療三組病例臨床癥狀改善情況

顯影組非顯影聚乙烯醇組非顯影明膠海綿組栓塞后月經(jīng)量恢復(fù)正常20/2020/2117/19栓塞前壓迫癥狀消失1/21/13/3總體癥狀改善21/22，95.4%21/22，95.4%20/22，90.9%χ2值0.5323*P>0.05*三組進(jìn)行組組間χ2檢驗(yàn)，統(tǒng)計(jì)學(xué)未見(jiàn)組組間療效有差異性。子宮肌瘤栓塞治療三組病例栓塞前后FSH的變化

顯影組非顯影聚乙烯醇組非顯影明膠海綿組栓塞前FSH(IU/L)11.10±1.5013.07±1.1811.45±1.74栓塞后FSH(IU/L)11.26±0.8913.21±1.2211.83±1.35P（t值）#>0.05(0.6919)>0.05(0.7121)>0.05(2.8533)P（F值）*>0.05(0.4096)#三組獨(dú)立t檢驗(yàn)分析，和*三組組間方差分析，F(xiàn)SH變化無(wú)統(tǒng)計(jì)學(xué)差異性子宮肌瘤栓塞治療對(duì)于肌瘤栓塞中子宮動(dòng)脈造影其雙側(cè)卵巢支顯影病例可以采用自制明膠海綿顆粒為栓塞材料進(jìn)行處理，其療效可以保證且對(duì)卵巢功能影響不大。

子宮肌瘤栓塞治療目前子宮肌瘤栓塞對(duì)卵巢功能的影響尚無(wú)結(jié)論！子宮肌瘤栓塞治療子宮肌瘤栓塞治療對(duì)懷孕與生育的影響子宮肌瘤栓塞治療目前，對(duì)有生育要求的患者不建議使用栓塞治療。缺乏對(duì)栓塞治療對(duì)懷孕影響的研究結(jié)果目前栓塞對(duì)懷孕影響的研究?jī)H限于個(gè)案報(bào)道和小病例報(bào)道。缺乏足夠的證據(jù)支持栓塞治療對(duì)懷孕和生殖的益處。子宮肌瘤栓塞治療腹腔鏡子宮動(dòng)脈結(jié)扎和栓塞治療肌瘤對(duì)懷孕的隨機(jī)多中心對(duì)照研究2008腹腔鏡子宮動(dòng)脈結(jié)扎術(shù)與栓塞治療后生育情況

腹腔鏡子宮動(dòng)脈結(jié)扎術(shù)栓塞治療P值懷孕病例3820—

妊娠病例4028—

術(shù)后到懷孕時(shí)間（月）8.6±2.79.1±2.5NS懷孕率（%）38/81(46.9)

20/39(51.2)NS自然受孕39/40(97.5)27/28(96.4)NS誘導(dǎo)排卵1/40(2.5)0/28(0)NS試管受精0/40(0)1/28(3.5)NS流產(chǎn)率4/36(11.1)14/25(56)<.001正在妊娠6/40(15)1/28(4.1)NS異位妊娠1/40(2.5)1/28(3.5)NS中止妊娠1/40(2.5)2/28(7.1)NSHolub,Z,Mara,M,KuzelDetal.Pregnancyoutcomesafteruterinearteryocclusion:prospectivemulticentricstudyFertilityandSterility2007,子宮肌瘤栓塞治療腹腔鏡子宮動(dòng)脈結(jié)扎和栓塞治療肌瘤對(duì)懷孕的隨機(jī)多中心對(duì)照研究2008腹腔鏡子宮動(dòng)脈結(jié)扎術(shù)與栓塞治療后生產(chǎn)和新生兒情況

腹腔鏡子宮動(dòng)脈結(jié)扎術(shù)26例栓塞10例早產(chǎn)4(15.3)2(20.0)自然生產(chǎn)7(26.9)2(20.0)剖腹產(chǎn)19(73.1)8(80.0)并發(fā)癥顯露異常22產(chǎn)后出血02前置胎盤10子宮破裂00先兆子癇01新生兒胎齡（周）38