| 摘要: | 研究背景 子宮肌瘤是婦女最常見的骨盆腔腫瘤，大於35歲的婦女，估計25%有子宮肌瘤(Buttram and Reiter 1981)，其中子宮內膜下肌瘤最易造成臨床症狀，包括經血過多、經痛、受孕困難、容易早期流產等(Narayan, Rajat et al. 1994; Pritts 2001)。在過去罹患子宮內膜下肌瘤的婦女只能選擇切除子宮或以剖腹的方式切開子宮取出肌瘤再將子宮縫合；手術性子宮鏡的發展，使子宮內膜下肌瘤的患者，得以使用內視鏡經陰道進入子宮腔，而後將子宮內膜下肌瘤切除，免去開腹手術的痛苦。以子宮鏡進行子宮內膜下肌瘤切除是對病人侵犯最小的手術方式，因此也被視為是對病人最好的手術方式。然而，並不是每一位子宮內膜下肌瘤的患者，皆能輕易的以子宮鏡進行肌瘤切除。當肌瘤越大、肌瘤侵犯到子宮肌肉層越多、手術的困難度將會提高，無法一次完全切除乾淨的機會將增加；同時，手術的合併症包括子宮穿孔、手術造成的出血難以控制、以及因手術中灌注液體吸收過多，造成的水中毒及電解質不平衡的機會皆會增多。
研究目的 本研究所要探討的主題有1. 哪些因素是影響手術是否能一次切除的因素，一次完成切除及多次才能完成切除在症狀的改善及是否容易復發是否有差別。2. 哪些因素是影響手術後復發的因素，復發的時間為何，是否受哪些因素的影響。3. 病患對接受此一手術後滿意度如何，對此一手術評價如何，滿意度及評價受哪些因素影響。
研究方法 本研究採回朔性研究設計，以筆者在最近過去六年擔任醫學中心主治醫師，於台中榮總接受子宮鏡子宮黏膜下肌瘤手術的病人為收案來源，時間為2000年11月至2006年10月，在此時間以前筆者已執行約100位子宮鏡手術病歷，因此病例皆由熟悉此手術的同一位醫師完成。由病歷紀錄、手術紀錄、護理紀錄、麻醉紀錄、門診紀錄等蒐集各項變數的資料，對資料不完整的部分以郵寄或電訪蒐集資料。
收案標準：接受手術性子宮鏡的病人，對單純為子宮內膜息肉、子宮腺肌瘤的患者排除。但子宮黏膜下肌瘤併子宮內膜息肉、子宮腺肌瘤的患者仍予以收案。在此期間共有220位病人符合收案標準， 204位病人完成收案，將此資料進行分析。
研究結果 在本研究中1到7年的追蹤僅有19位患者因復發而接受再一次手術，復發率為9.5%。在症狀的改善方面，本研究中有159位患者覺得症狀明顯改善，38位患者覺得症狀稍微改善，3位患者覺得症狀無改善。可見子宮鏡手術來治療子宮黏膜下肌瘤成效卓著
以無法全部切除、無法一次切除、復發、經血過多改善程度分別為依變項，與各自變項進行羅吉斯式回歸及逐步羅吉斯式回歸(stepwise logistic regression analysis)，分析各自變相與依變相的關係，由本研究所找出的影響全部切除的3個顯著因子--子宮大於正常，黏膜下肌瘤數目>3，肌瘤型態為type2。影響一次切除的3個顯著因子--經痛，黏膜下肌瘤>4cm，肌瘤位於上壁。影響復發而須再次手術的顯著因子為合併子宮腺肌瘤，肌瘤位於上壁及側壁；肌瘤能完全切除則是手術後不會復發的顯著因子。影響手術後經血過多改善程度不佳的顯著因子是合併子宮腺肌瘤，子宮大於正常，肌瘤能完全切除則是經血過多改善程度良好的顯著因子。
結論 子宮肌瘤惡性的機會低(約為五百分之一)，手術的目的在改善肌瘤所造成的臨床症狀；選擇並發展侵犯性小，療效佳的治療方式是醫療的必然趨勢。子宮鏡進行子宮內膜下肌瘤切除，無傷口、術後恢復快，可保留子宮，符合現代醫療的趨勢。
成功的手術能完全解除病人的臨床症狀，同時有者低的手術復發率，高的病患滿意度。肌瘤能完全切除則是經血過多改善程度良好及手術後不會復發的顯著因子。
在面對病人時，手術醫師應就病人年齡，生育狀況，臨床表現來做考量，並審視自己本身的手術能力，以提供適切的治療方式；執行子宮鏡手術前應詳細評估病人，手術中小心操作，適時輔以超音波監測手術，計算灌注液的進出，避免合併症的產生，安全的以子宮鏡處理子宮內膜下肌瘤是最重要的。
Background Uterine leiomyomas are benign solid tumors occurring in about 20% to 25% of women in their reproductive years. Submucous myomas may present a greater risk to the patient than either the intramural or subserous varieties because they cause excessive uterine bleeding, usually during menses, and they can cause dysmenorrhea as well as interfere with normal reproduction. Submucous myomas characteristically are associated with chronic endometritis, may have a greater risk for malignant change (leiomyosarcoma), and are prone to bleed.
A transcervical approach is minimally invasive surgery for myomectomy, and hysteroscopic myomectomy is the best treatment of women with submucous leiomyoma. However, not all submucous leiomyomas are easily treated by hysteroresectoscopy. Whereas hysteroscopic resection of a pedunculated submucous leiomyoma is not difficult, myomas that are partly or mostly intramural increase the risk for uterine perforation or incomplete excision.
Purpose To identified the predictive factor for the outcome of hysteroscopic myomectomy. To know which factors influence success, failure and recurrence for appropriate treatment and counseling of patients.
Method From Nov 2000 to Oct 2006, 220 patient with abnormal uterine bleeding (menorrhagia or metrorrhagia) and with one or more submucous myoma were treated hysteroscopy and confirmed histologically, were included in this study. hysteroscopic treatment of submucous myoma were all performed using an intrauterine bipolar diathermy system (versapoint). All hysteroscopies were done by one operator who is skillful in hysteroscopic operation. Adequate follow-up was obtained in 204 patients. The remaining patients were lost to follow-up and withdrawn from the study.
Logistic regression analysis, and stepwise logistic regression analysis were used to defined the prognostic factors for surgery outcomes. Four dependent variable: one-step surgery, complete resection, recurrence, the degree of menorrhagia improvement were used in analysis. Independent variable included: patient age, gravity, parity, combined with dysmenorrhea, combined with intramural myoma, uterine enlargement, the number of submucous myoma, the size of submucous myoma, the type of submucous myoma。
Result 200 patients were collected in our study. During the 1 to 7 years follow-up at surgery. 19 patient recurrence and need further surgery. The recurrence rate were 9.5%. The factors affect the reoccurrence is submucous myoma combined with adenomyosis, submucous myoma over ant wall and lateral wall. The factors affect the improvement of menorrhagia is myoma combined with adenomyosis and uterus enlarged than normal size.
Complete resection with positive result to myoma recurrence and menorrhagia control. The factor affect the complete resection is uterus enlarged than normal size, submucous myoma more than three and type 2 submucous myoma( myoma protruding to endometrial cavity less than 50%)
Conclusion In our study, hysteroscopic myomectomy combined myoma is a safe and effective method for patient with submucous myoma. To reduce the need of reintervention, appropriate patient selection and improved technique are necessary. The technique also offers significant economic savings compared with the conventional surgical methods.
An accurate preoperative assessment of the uterine condition by sonohysterography or diagnostic hysteroscopy is required for proper counseling and so that a surgeon with adequate experience can be chosen. |
