- 學位論文
腹腔鏡卵巢囊腫切除術併雙極電燒灼術與併縫合術在子宮內膜異位瘤對於卵巢儲能功能的影響
The Effect of Laparoscopic Ovarian Cystectomy with Bipolar Coagulation versus Sutures in Endometrioma on Ovarian reserve
摘要
研究目的： 子宮內膜異位症是婦科常見疾病，伴隨有骨盆腔疼痛，不孕，子宮附屬器腫塊。本研究主要比較以腹腔鏡囊腫切除術合併燒灼術(Laparoscopic cystectomy and bipolar coagulation)與腹腔鏡囊腫切除術合併縫合術(Laparoscopic cystectomy and sutures)對於術後卵巢儲能功能的影響。 研究方法： 本研究經由中山醫學大學倫理委員會審查核准通過(案號: CS-11172)，且得到參與者的同意書。從西元2012年6月到2013年6月，患有單側或雙側子宮內膜異位瘤於中山醫學大學附設醫院婦產部，接受腹腔鏡卵巢囊腫切除手術的患者，由同一個團隊手術及照顧並且在術後追蹤卵巢功能。本研究採用一個前瞻性隨機對照臨床試驗(Prospective Randomized Controlled Trial)。受試者首先會隨機分成兩組，一組接受腹腔鏡囊腫切除術合併燒灼術;另一組接受腹腔鏡囊腫切除術合併縫合術。兩組受試者手術後皆接受一般常規術後照護，並且在術後回門診追蹤卵巢中竇卵泡總數(antral follicle count; AFC)和血清中抗穆勒氏管荷爾蒙(anti-Mullerian hormone; AMH)。 研究結果： 經篩選後共有12個病例納入分析，其中A組腹腔鏡囊腫切除術合併燒灼術組有6個病例而B組腹腔鏡囊腫切除術合併縫合術有6個病例。資料分析後，無論是年齡、身體質量指數(BMI)、腫瘤大小、rASRM評分(修訂的美國生殖醫學學會子宮內膜異位評分)、手術出血量等在兩組間均無統計學上的意義。在術前與術後卵巢中竇卵泡總數(AFC)的評估，AB組兩種手術方式對於術後卵巢中竇卵泡總數都有明顯上升(術前A組8.83 ± 1.72 : B組5.50 ± 2.59，術後一個月A組10.67 ± 2.80 : B組10.33 ± 3.33，術後六個月A組12.67 ± 3.01 : B組12.50 ± 4.18)。AB兩組的術後卵巢中竇卵泡總數上升均達統計上顯著意義(p<0.05)。在術後短期卵巢中竇卵泡總數上升的趨勢來看，B組在術後一個月和六個月的卵巢中竇卵泡總數上升幅度比A組較明顯，此差異並無統計學上的意義(p>0.05)。在手術後卵巢功能的評估，兩種手術方式對於術後血清中抗穆勒氏管荷爾蒙(AMH)都有減少(術前A組4.36 ± 1.79 : B組4.06 ± 3.49，術後一個月A組3.51 ± 1.91 : B組2.84 ± 1.94，術後六個月A組2.97 ± 1.92 : B組2.89 ± 2.42)。AB兩組對於術後血清中抗穆勒氏管荷爾蒙的減少並沒有達到統計學上的顯著意義(p>0.05)。在術後短期卵巢功能下降的趨勢來看，A組在術後六個月血清中抗穆勒氏管荷爾蒙下降的幅度比B組較明顯，此差異並無統計學上的意義(p>0.05)。B組雖然在術後一個月的血清中抗穆勒氏管荷爾蒙下降較明顯，但是下降的幅度在術後六個月已有所趨緩。相較之下A組在術後六個月的抗穆勒氏管荷爾蒙仍持續下降。如果將子宮內膜異位瘤的大小分成大於等於5公分(A組)與小於5公分(B組)去評估術後血清中抗穆勒氏管荷爾蒙(AMH)的影響，結果發現A組在術後AMH的下降比B組較明顯，此差異並無統計學上的意義(p>0.05)。 結論： 腹腔鏡囊腫切除術合併燒灼術與腹腔鏡囊腫切除術合併縫合術對於術後卵巢中竇卵泡總數都有明顯上升。可能原因是在術前檢測卵巢中竇卵泡總數時，子宮內膜異位瘤占據大部份的卵巢空間導致有些卵泡無法被超音波偵測到，造成總數低估的誤差。也有可能是卵巢實質在手術後所產生的反應。腹腔鏡囊腫切除術合併縫合術組在術後卵巢中竇卵泡總數上升幅度比合併燒灼術組較明顯。因此本研究認為腹腔鏡囊腫切除術合併縫合術可能對於卵巢組織傷害比合併燒灼術少。在術後血清中抗穆勒氏管荷爾蒙下降的趨勢來看，和合併縫合術組相比，合併燒灼術組在術後下降的較明顯。然而想達到更多臨床上的顯著意義，可能需要未來更多的樣本數和較長時間的追蹤來加以證實。
並列摘要
Research Purpose Endometriosis is a common gynecological medical condition which is associated with pelvic pain, infertility, and adnexal mass. The aim of this study was to compare the effects of laparoscopic ovarian cystectomy with bipolar coagulation versus sutures in endometrioma on ovarian reserve. Methods This study was approved by the Institutional Review Board of Chung Shan Medical University Hospital (CSMUH) and written informed consent was obtained from each participants. From June.2012 to June.2013, patients were diagnosed unilateral or bilateral endometrioma underwent laparoscopic ovarian cystectomy surgery at CSMUH and followed up ovarian reserve postoperatively. A study design of prospective randomized controlled trial was utilized in this research. Patients with endometriomas are divided randomly into two groups: bipolar coagulation groups (laparoscopic cystectomy + bipolar coagulation) and sutures group (laparoscopic cystectomy + sutures). All participants received routine postoperative care and regular outpatient department follow up. The primary outcome of this study was the impact on ovarian reserve, as determined by serum anti-Mullerian hormone and antral follicle count. Results After screening a total of 12 patients were enrolled in this study. Six of them were underwent laparoscopic cystectomy and bipolar coagulation (Group A) and other six were underwent laparoscopic cystectomy and sutures (Group B). The statistical analysis showed no difference between demographic data and perioperative data, ex: age, body mass index (BMI), tumor size, estimated blood loss, and revised American Society for Reproductive Medicine (rASRM) score in these two groups. There were statistically significant differences between preoperative and postoperative AFC in these two groups (p<0.05). Both groups showed an increase in post-operative AFC (preoperatively group A 8.83 ± 1.72 : group B 5.50 ± 2.59, one month postoperatively group A 10.67 ± 2.80 : group B 10.33 ± 3.33, six months postoperatively group A 12.67 ± 3.01 : group B 12.50 ± 4.18). Compared to group A, the increases of AFC postoperatively were more prominent in group B. The result showed the decreases in AMH for both group A and group B, but the decreases were not statistically significantly in both groups. Compared to group B, the decreases of AMH were more prominent in group A (preoperatively group A 4.36 ± 1.79 : group B 4.06 ± 3.49, one month postoperatively group A 3.51 ± 1.91 : group B 2.84 ± 1.94, six months postoperatively group A 2.97 ± 1.92 : group B 2.89 ± 2.42). The changes in AMH in patients with mean endometrioma ≥5cm (n=6) or <5cm (n=6) were compared separately. The postoperative AMH levels were lower in patients with mean endometrioma size ≥5cm compared with size <5cm. The results were not statistically significant (p>0.05). Discussion The effect of laparoscopic cystectomy with bipolar coagulation (Group A) versus sutures (Group B) on AFC reached statistical significance. Both surgical methods showed increases in post-operative AFC. The results may be either due to the response of ovarian parenchyma after surgery or due to the presence of endometrioma that affect the correct measurement of AFC preoperatively. Compared to group A, the increases of AFC were more prominent in group B. Both surgical methods showed decreases in post-operative AMH. Compared to group B, the ovarian reserve damage as determined by AMH was more prominent in group A. Future studies with larger sample sizes and long term follow up may need in order to reach statistical significance.