良性疾病全子宮切除術不同微創術式間比較的系統評價_《中國循證醫學雜志》

作者：

黃志華 ¹ , 屠蕊沁 ¹ , 吳利俊 ²

1. 上海市復旦大學附屬中山醫院婦產科 (上海 200032）；2. 上海市復旦大學附屬婦產科醫院病理科（上海 200011）;

關鍵詞：

全子宮切除術陰式全子宮切除術腹腔鏡全子宮切除術小橫切口開腹全子宮切除術 Meta 分析系統評價

DOI：

10.7507/1672-2531.20100405

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目的　比較和評價陰式全子宮切除術（total vaginal hysterectomy，TVH）、腹腔鏡全子宮切除術（Laproscopicalhyterectomy，LH）、橫切口開腹全子宮切除術（minilaporotomy hysterectomy，MiniLPT）等不同微創全子宮切除術式的效果及安全性，以指導臨床選擇最合理的術式。
方法　檢索CBM、中國期刊全文數據庫、萬方數據資源系統、MEDLINE、EMbase、Cochrane DSR、ACP Journal Club、DARE、CCTR、CMR、HTA、和NHSEED 等數據庫中關于比較TVH、LH、MiniLPT 術式中至少兩種的隨機對照試驗、比較性研究、經濟評價，罕見結局的報道可包括觀察性研究。檢索截止時間為2009 年3 月。采用GRADE 標準及Cochrane Reviewer Handbook 4.2.3 對RCT 的質量評價標準進行評價。用Cochrane 協作網提供的RevMan 4.2 軟件進行Meta 分析。
結果　最終納入12 個研究，包括10個隨機對照試驗，1 個回顧性隊列研究、1 個前瞻性隊列研究。Meta 分析結果顯示TVH 組手術時間最短、出血量最少、術后疼痛最輕、恢復排便或者排氣最快、出院最早。MiniLPT 組術后住院時間比對照組（TVH/LAVH 組）長，差異有統計學意義［WMD= 37.0 h，95%CI（13.5 h，60.5 h）］；MiniLPT 組術中出血量比對照組多，差異有統計學意義［WMD= 208.5 ml，95%CI （141.4 ml，375.7 ml）］，MiniLPT 組發熱發生率比對照組高，差異有統計學意義［PetoOR= 3.8，95%CI （1.1，12.6）］。TVH 組手術時間比LH 組短，差異有統計學意義［WMD= 47.2 min，95%CI （– 62.3 min，32.19 min）］；TVH 組出血量比LAVH 組少，差異有統計學意義［WMD= – 158.7 ml，95%CI（– 190.9 ml，– 126.4 ml）］；TVH 組住院時間比LH 組短，差異有統計學意義［WMD= – 18.8 h，95%CI（– 24.2 h，– 13.5 h）］；TVH 組術后恢復排氣或排便時間比LAVH 組短，差異有統計學意義［WMD= 8.1 h，95%CI（– 10.8 h，– 5.3 h）］。另一方面，LH 組創面縫合愈合不良事件發生率、繼發感染發生率、發熱發生率均比TVH 組低，但差異無統計學意義。LH 組比TVH組術后性功能質量更好。
結論　在基本符合TVH 適應證的情況下，TVH 是最微創的手術方式，且性價比高。在TVH 適應證以外，只要在可以操作的范圍內，TVH 仍然是創傷最小且效果最好的手術方式，但這一范圍目前尚無統一標準，跟術者經驗水平、手術習慣和患者具體情況相關。LH 在改善術后生活質量、患者自我感覺方面較為優越。通過提高腹腔鏡手術止血技巧減少術中出血量，減少一次性器具費用或其使用、增加其回收，可降低手術費用，并可以提高LH 性價比。MiniLPT 發展時間尚短，相關比較研究起步也晚，其優越性有待更多研究進一步評估。

引用本文： 黃志華,屠蕊沁,吳利俊. 良性疾病全子宮切除術不同微創術式間比較的系統評價. 中國循證醫學雜志, 2010, 10(3): 323-338. doi: 10.7507/1672-2531.20100405 復制

1.	Falcone T, Walters M. Hysterectomy for benign disease. Obstet Gynecol, 2008, 111: 753-767.
2.	夏恩蘭. 子宮切除術的術式選擇. 國外醫學婦產科分冊, 2005, 32(5): 269-277.
3.	Reich H, Roberts L. Laparoscopic hysterectomy incurrent gynaecological practice. Reviews in Gynaecological Practice, 2003, 3: 32-40.
4.	Sculpher M, Manca A, Abbott J, et al. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy. BMJ, 2004, 328(7432): 134-137.
5.	Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, 2006, 2: 1-125.
6.	Kluivers K, Ohnson N, Chien P, et al. Comparison of laparoscopic and abdominal hysterectomy in terms of quality of life A systematic review. EurJ Obstet Gynecol Reprod Biol, 2008, 136: 3-8.
7.	Panici P, Zullo M, Angioli R, et al. Minilaparotomy hysterectomy a valid option for the treatment of benign uterine pathologies. EurJ Obstet Gynecol Reprod Biol, 2005, 119(2): 232-236.
8.	Fanfani F, Fagotti A, Longo R, et al. Minilaparotomy in the management of benign gynecologic disease. Eur J Obstet Gynecol Reprod Biol, 2005, 119: 232-236.
9.	申向梅, 林學霞. 小切口開腹改良全子宮切除術的臨床應用. 河南外科學雜志, 2004, 10(5): 28-29.
10.	Muzii L, Basile S, Zupi E, et al. Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy:A prospective ,randomized, multicenter study. J Mini Inva Gynecol, 2007, 14: 610-615.
11.	Drahonovsky J, Pan M, Baresova S, et al. Clinical comparison of laparoscopy-assisted vaginal hysterectomy (LAVH) and total laparoscopy hysterectomy (TLH) in women with benign disease of uterus -- a prospective randomized study. Ceska Gynekologie, 2006, 71(6): 431-437.
12.	Morelli M, Caruso M, Noia R, et al. Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomized trial. Minerva Ginecologica, 2007, 59(2): 99-105.
13.	Hwang J, Seow K, Tsai Y, et al. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g a prospective randomized study. Acta Obstet Gynecol Scand, 2002, 81(12): 1132-1138.
14.	Ottosen C, Lingman G, Ottosen L, et al. Three methods for hysterectomy a randomised, prospective study of short term outcome. Br J Obstet Gynaecol, 2000, 107(11): 1380-1385.
15.	Ayoubi M, Fanchin T, Monrozies X, et al. Respective consequences of abdominal, vaginal, and laparoscopic hysterectomies on women’s sexuality. Eur J Obstet Gynecol Reprod Biol, 2003, 111: 179-182.
16.	Soriano D, Goldstein A, Lecuru F, et al. Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy. Acta Obstetricia Et Gynecologica Scandinavica, 2001, 80(4): 337-341.
17.	Darai E, Soriano D, Kimata P, et al. Vaginal Hysterectomy for Enlarged Uteri,With or Without Laparoscopic Assistance:Randomized Study. Obstet Gynecol, 2001, 97(5): 712-716.
18.	Sesti F, Ruggeri V, Pietropolli A, et al. Laparoscopically assisted vaginal hysterectomy versus vaginal hysterectomy for enlarged uterus. JSLS, 2008, 12(3): 246-251.
19.	Sesti F, Calonzi F, Ruggeri V, et al. A comparison of vaginal, laparoscopic- assisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. Int J Gynecol Obstet, 2008, 103(3): 227-231.
20.	Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ, 2004, 328(7432): 129-133.
21.	Ribeiro S, Ribeiro R, Santos N, et al. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynecol Obstet, 2003, 83(1): 37-43.
22.	Meltomaa S, Makinen J, Taalikka M, et al. One-year cohort of abdominal, vaginal, and laparoscopic hysterectomies complications and subjective outcomes. J Am Coll Surg, 1999, 189(4): 389-396.
23.	劉新民. 經陰道子宮切除術. 見: 湯春生, 劉新民, 主編. 婦產科手術學. 第3版. 北京: 人民衛生出版社, 2007: 191-202.
24.	豐有吉, 李荷蓮. 女性生殖系統解剖. 見: 王晨虹, 主編. 婦產科學. 第1版. 北京:人民衛生出版社, 2004: 9-11.
25.	豐有吉, 李荷蓮. 正常妊娠. 見: 李荷蓮, 主編. 婦產科學. 第1版. 北京: 人民衛生出版社, 2004: 44-46.
26.	劉彥. 婦科微創手術學研究進展. 中國實用婦科與產科雜志, 2007, 23(1): 15-16.
27.	Sesti F, Capobianco F, Capozzolo T, et al. Isobaric gasless laparoscopy versus minilaparotomy in uterine myomectomy a randomized trial. Surg Endosc, 2008, 22: 917-923.
28.	Panici P, Zullo M, Angioli R, et al. Surgery by minilaparotomy in benign gynecologic disease 1996. Obstet Gynecol,1996, 87(3): 456-459.
29.	劉新民. 經腹子宮切除術. 見: 劉新民, 主編. 婦產科手術學. 北京: 人民衛生出版社, 2007: 140-190.
30.	Makinen J, Johansson J, Tomas C, et al. Morbidity of 10110 hysterectomies by type of approach. Human Reproduction, 2001, 16(7): 1473-1478.
31.	Miskry T, Magos A. Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse. Acta Obstet Gynecol Scand, 2003, 82: 351-358.
32.	Vaisbuch E, Goldchmit C, Ofer D, et al. Laparoscopic hysterectomy versus total abdominal hysterectomy: A comparative study. Eur J Obstet Gynecol Reprod Biol, 2006, 126: 234-238.
33.	Persson P, Wijma K, Hammar M, et al. Psychological wellbeing after laparoscopic and abdominal hysterectomy—a randomised controlled multicentre study. BJOG, 2006, 113: 1023-1030.
34.	Kluivers K, Hendriks J, Mol B, et al. Quality of life and surgical outcome after total laparoscopic hysterectomy versus total abdominal hysterectomy for benign disease: A randomized, controlled trial. J Minim Invasive Gynecol, 2007, 14: 145-152.
35.	Doesey J, Holtz P, Griffiths R, et al. cost and charges associated with three alternative technigues of hysterectomy. N Engl J Med, 1996, 335(7): 476-482.

1. Falcone T, Walters M. Hysterectomy for benign disease. Obstet Gynecol, 2008, 111: 753-767.
2. 夏恩蘭. 子宮切除術的術式選擇. 國外醫學婦產科分冊, 2005, 32(5): 269-277.
3. Reich H, Roberts L. Laparoscopic hysterectomy incurrent gynaecological practice. Reviews in Gynaecological Practice, 2003, 3: 32-40.
4. Sculpher M, Manca A, Abbott J, et al. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy. BMJ, 2004, 328(7432): 134-137.
5. Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, 2006, 2: 1-125.
6. Kluivers K, Ohnson N, Chien P, et al. Comparison of laparoscopic and abdominal hysterectomy in terms of quality of life A systematic review. EurJ Obstet Gynecol Reprod Biol, 2008, 136: 3-8.
7. Panici P, Zullo M, Angioli R, et al. Minilaparotomy hysterectomy a valid option for the treatment of benign uterine pathologies. EurJ Obstet Gynecol Reprod Biol, 2005, 119(2): 232-236.
8. Fanfani F, Fagotti A, Longo R, et al. Minilaparotomy in the management of benign gynecologic disease. Eur J Obstet Gynecol Reprod Biol, 2005, 119: 232-236.
9. 申向梅, 林學霞. 小切口開腹改良全子宮切除術的臨床應用. 河南外科學雜志, 2004, 10(5): 28-29.
10. Muzii L, Basile S, Zupi E, et al. Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy:A prospective ,randomized, multicenter study. J Mini Inva Gynecol, 2007, 14: 610-615.
11. Drahonovsky J, Pan M, Baresova S, et al. Clinical comparison of laparoscopy-assisted vaginal hysterectomy (LAVH) and total laparoscopy hysterectomy (TLH) in women with benign disease of uterus -- a prospective randomized study. Ceska Gynekologie, 2006, 71(6): 431-437.
12. Morelli M, Caruso M, Noia R, et al. Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomized trial. Minerva Ginecologica, 2007, 59(2): 99-105.
13. Hwang J, Seow K, Tsai Y, et al. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g a prospective randomized study. Acta Obstet Gynecol Scand, 2002, 81(12): 1132-1138.
14. Ottosen C, Lingman G, Ottosen L, et al. Three methods for hysterectomy a randomised, prospective study of short term outcome. Br J Obstet Gynaecol, 2000, 107(11): 1380-1385.
15. Ayoubi M, Fanchin T, Monrozies X, et al. Respective consequences of abdominal, vaginal, and laparoscopic hysterectomies on women’s sexuality. Eur J Obstet Gynecol Reprod Biol, 2003, 111: 179-182.
16. Soriano D, Goldstein A, Lecuru F, et al. Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy. Acta Obstetricia Et Gynecologica Scandinavica, 2001, 80(4): 337-341.
17. Darai E, Soriano D, Kimata P, et al. Vaginal Hysterectomy for Enlarged Uteri,With or Without Laparoscopic Assistance:Randomized Study. Obstet Gynecol, 2001, 97(5): 712-716.
18. Sesti F, Ruggeri V, Pietropolli A, et al. Laparoscopically assisted vaginal hysterectomy versus vaginal hysterectomy for enlarged uterus. JSLS, 2008, 12(3): 246-251.
19. Sesti F, Calonzi F, Ruggeri V, et al. A comparison of vaginal, laparoscopic- assisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. Int J Gynecol Obstet, 2008, 103(3): 227-231.
20. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ, 2004, 328(7432): 129-133.
21. Ribeiro S, Ribeiro R, Santos N, et al. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynecol Obstet, 2003, 83(1): 37-43.
22. Meltomaa S, Makinen J, Taalikka M, et al. One-year cohort of abdominal, vaginal, and laparoscopic hysterectomies complications and subjective outcomes. J Am Coll Surg, 1999, 189(4): 389-396.
23. 劉新民. 經陰道子宮切除術. 見: 湯春生, 劉新民, 主編. 婦產科手術學. 第3版. 北京: 人民衛生出版社, 2007: 191-202.
24. 豐有吉, 李荷蓮. 女性生殖系統解剖. 見: 王晨虹, 主編. 婦產科學. 第1版. 北京:人民衛生出版社, 2004: 9-11.
25. 豐有吉, 李荷蓮. 正常妊娠. 見: 李荷蓮, 主編. 婦產科學. 第1版. 北京: 人民衛生出版社, 2004: 44-46.
26. 劉彥. 婦科微創手術學研究進展. 中國實用婦科與產科雜志, 2007, 23(1): 15-16.
27. Sesti F, Capobianco F, Capozzolo T, et al. Isobaric gasless laparoscopy versus minilaparotomy in uterine myomectomy a randomized trial. Surg Endosc, 2008, 22: 917-923.
28. Panici P, Zullo M, Angioli R, et al. Surgery by minilaparotomy in benign gynecologic disease 1996. Obstet Gynecol,1996, 87(3): 456-459.
29. 劉新民. 經腹子宮切除術. 見: 劉新民, 主編. 婦產科手術學. 北京: 人民衛生出版社, 2007: 140-190.
30. Makinen J, Johansson J, Tomas C, et al. Morbidity of 10110 hysterectomies by type of approach. Human Reproduction, 2001, 16(7): 1473-1478.
31. Miskry T, Magos A. Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse. Acta Obstet Gynecol Scand, 2003, 82: 351-358.
32. Vaisbuch E, Goldchmit C, Ofer D, et al. Laparoscopic hysterectomy versus total abdominal hysterectomy: A comparative study. Eur J Obstet Gynecol Reprod Biol, 2006, 126: 234-238.
33. Persson P, Wijma K, Hammar M, et al. Psychological wellbeing after laparoscopic and abdominal hysterectomy—a randomised controlled multicentre study. BJOG, 2006, 113: 1023-1030.
34. Kluivers K, Hendriks J, Mol B, et al. Quality of life and surgical outcome after total laparoscopic hysterectomy versus total abdominal hysterectomy for benign disease: A randomized, controlled trial. J Minim Invasive Gynecol, 2007, 14: 145-152.
35. Doesey J, Holtz P, Griffiths R, et al. cost and charges associated with three alternative technigues of hysterectomy. N Engl J Med, 1996, 335(7): 476-482.

《中國循證醫學雜志》

良性疾病全子宮切除術不同微創術式間比較的系統評價

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《中國循證醫學雜志》

良性疾病全子宮切除術不同微創術式間比較的系統評價

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