子宫腺肌症治疗

湖北省妇幼保健院Maternityandchildcarecentersinhubeiprovince王燕WangYanprojectdate20/09/2007高强度聚焦超声治疗子宫腺肌症的临床研究TheClinicalStudyOfUltrasound-guidedHigh-intensityFocusedUltrasoundAblationForAdenomyosis概念onception02子宫腺肌病(adenomyosis,AM)一种常见妇科疾病，多发生在30-50岁经产妇。本病的发病机制尚不清楚AdenomyosisisacommonGynecologicaldiseasethatusuallyaffectmultiparasof30-to-50year-olds.Thepathogenesisofthisdiseaseisnotclear现状：发病率升高，发病年龄呈下降趋势,对患者生活质量的影响也越来越大Thecurrentsituation:Theincidenceratesrisedwhiletheageofonsetdeclined,theinfluenceonthequalityoflifeofpatientsaregettingmoreandmoreserious文献资料：literature&information:•可能与人工流产、宫内放置节育器、输卵管结扎、诊断性刮宫、分娩等因素相关——常损伤子宫内膜及浅肌层，导致基底层子宫内膜侵入子宫肌层内生长Adenomyosismayberelatedtothefactorsofinducedabortion、IUD、tuballigation、curettage、childbirth,etc--whichusuallydamagetheendometriumandshallowmyometrium,causedthebasallayerofendometriuminvadeintomyometrium•观察observation•手术治疗surgery•药物治疗drugs治疗therapy症状Symptoms年龄Age生育要求Desireoffertility,根治性手术Radicalsurgery子宫+双附件切除术Hysterectomyandbilateralsalpingo-oophorectomy(BSO)手术治疗surgicaltreatment保守性手术：Conservativeoperation子宫内膜去除术（Transcervicalesectionofendometrium,TCRE）介入（UterineArterialEmbolization,UAE）腹腔镜子宫动脉结扎术（LaparoscopicUterineArteryLigation,LBUAB）超声聚焦治疗（HighIntensityFocusedUltrasound,HIFU）电消融治疗electricalablation子宫腺肌瘤挖除术myomectomyforuterinemyoma+腹腔镜子宫动脉阻断术（Laparoscopicuterinearteryblockage,LBUAB）+腹腔镜子宫神经去除术（Laparoscopyuterinenerveablation,LUNA）•根治性手术：1%Radicalsurgery•保守性手术：80-95%Conservativeoperation治疗方式的选择Thechoiceoftreatments手术治疗的不足之处thedefectsofsurgicaltreatment不能处理微小病灶——复发Can'tdealwiththesmalllesions-Relapse不能去除病因——复发Havebeenunabletoremovethecauses-Relapse增加患者的压力和负担Increasingthepressureandburdenofpatients•保留子宫Preservationoftheuterus•非侵入性Non-invasive•不需麻醉Noanesthesia•并发症、副作用少Therewerefewsideeffectsandcomplications•保留生育功能Conservefertility•可重复性好Wellrepeatability理想治疗方式Theidealtreatmants研究方法ResearchmethodsHighIntensityFocusedUltrasoundAblationbyHaifu'sModelJC200skin•非月经期、非妊娠期、非哺乳期•Non-menstrual，un-pregnant，nonpuerperalwomen.•经妇检和B超确定为子宫腺肌病患者•GynecologicalexaminationandType-Bultrasonicscanevidenceoftypicalfeaturesofadenomyosis.•所有病例均有渐进性痛经、经量增多、经期延长以及下腹部坠胀、腰酸、腹痛等症状•Allthecaseswiththeclinicalsymptomsofprogressivedysmenorrhea,menorrhagia,menostaxis,nextabdominalpainandswelling,lumbaracid,abdominalpain.•无实施镇静镇痛的禁忌证，治疗前均签署知情同意书同意超声消融治疗•Withoutthecontraindicationstosedativeandanalgesic,signaconsentformbeforetreatment.病例选择caseselection•下腹部瘢痕致明显声衰减或有放射治疗病史Theabdomenscarledtoobviousacousticattenuationorreceivedradiationtreatment.•急性感染性疾病未控制、慢性盆腔感染至盆腔器官Uncontrolledacuteinfectivedisease,thechronicpelvicinfectiontopelvicorgans.•下腹部多次大手术、严重粘连者Reccivedrepeatedlyabdominamajorsurgerywithseriouslyadhesions.盆腔内有金属植入物Therearemetalimplantsinpelvic.•严重心肺疾病史及患者不能俯卧2h者Withhistoryofseriouslypriorheartandlungdisease,inabilitytolieinapronepositionfor2hours.•合并子宫外脏器内膜异位者未纳入本研究Withtheinternalorgansoftheuterusendometriosis.病例排除标准ExcludingcriterionPatientdata：Characteristics病例基本资料Cases病例数40Age（median）：yearsold年龄：（岁）27-49（37.9）Number（Uterinemyoma+adenomyosis）病灶数（子宫腺肌瘤+子宫腺肌病）37Number（adenomyosis）病灶数（子宫腺肌病）3Anterior/Posterior/Both前壁/后壁/前后壁11/15/14Maximaldia.（mean）最大径（厘米）2.5-8.4cmPatientdata：accompanyingsymptoms患者资料：伴随症状Case病例数40Withsymptoms（%）出现症状率100%Lowerabdominalswellingpain下腹部胀痛88%Increasedmenses月经量增多91%Disorderofmenstualcycle月经周期紊乱95%Painatlumbosacralportionduringtheperiod经期腰骶部疼痛89%•预处理：皮肤脱脂、脱气，膀胱及肠道准备pretreatment：degreasing，degassing，intestinalandbladderpreparation•镇静镇痛方案：芬太尼、咪唑安定Sedationandanalgesia:midazolam,fentanyl.•治疗前、后超声造影Receivecontrast-enhancedultrasoundbeforeandaftertreatment.治疗方法therapeuticmethod治疗参数Treatmentparameter•Frequency频率：1MHz•Focallength焦距：134mm•Diameteroftrasnducer治疗头直径：220mm•Scanningmode扫描模式：singleexposure点扫描Thickness层面距离：4-5mm•Startingpower开始功率：250w-300w•Maximalpower最大功率：400w•评估方法Methodsofevaluation：超声造影contrast-enhancedultrasound彩色超声定期随访检查（治疗后1、3、6个月）Regularfollow-upbyColorDopplerSonography(aftertreatment1month,3month,6month)临床症状评分theclinicalsymptomgrades•评估内容evaluatingcontent:消融定量评估quantitativeablationevaluation腺肌瘤及子宫消融前后声像图变化comparedthechangingoftheacousticimageofuterusandendometriomabeforeandaftertreatment.临床症状改善theimprovementofsymptoms腺肌病消融后的疗效评估内容Theevaluationsofefficacyafter应用超声造影计算腺肌病的消融疗效computietheeffectiveinablatingbycontrast-enhancedultrasound病例插图1The1thillustrationofcases腺肌瘤体积（FV）=消融体积（NPV）=体积消融比率=NPV/FV×100%=应用超声造影计算腺肌病的消融疗效computietheeffectiveinablatingbycontrast-enhancedultrasound病例插图2The2thillustrationofcases腺肌瘤体积（FV）=消融体积（NPV）=体积消融比率=NPV/FV×100%=应用超声造影计算腺肌病的消融疗效computietheeffectiveinablatingbycontrast-enhancedultrasound病例插图3The3thillustrationofcases腺肌瘤体积（FV）=消融体积（NPV）=体积消融比率=NPV/FV×100%=治疗前后各指标变化情况Thechangeofindexsbeforeandaftertreatment结果results时间time腺肌症病灶/腺肌瘤平均体积Uterinemyoma/adenomyosismeancorpuscularvolume（cm3）Hb（g/L）治疗前beforetreatment14687.5治疗后aftertreatmet101.2120•在40例腺肌病患者中，32例(80%)治疗后即刻出现团块状灰度变化，5例(12.5%)出现整体灰度变化，3例(7.5%)治疗中未观察到灰度变化•Inthe40caseofadenomysis,thereare32cases(80%)appearedlumpishgrayscalechangeimmediatelyaftertreatment,32cases(80%)a