1995年法国Ravina在Lancet杂志上首次发表了子宫肌瘤的栓塞治疗,1997年Goodwin发表在美国应用经子宫动脉栓塞治疗子宫肌瘤的经验,此后子宫动脉栓塞治疗子宫肌瘤在全球范围内广泛应用。
根据美国介入放射学会的调查,从1997年到2000年已有超过1万子宫肌瘤患者接受了子宫肌瘤栓塞治疗,而且接受治疗的患者还在增加。
随着2007年Volkers在美国妇科与产科杂志和Edwards在新英格兰杂志发表两份子宫肌瘤栓塞与子宫肌瘤外科手术治疗的随机对照研究,其结果最终确立了子宫动脉栓塞治疗是子宫肌瘤的治疗方法之一。
子宫动脉栓塞治疗子宫肌瘤的技术成功率为96%;减少对子宫肌瘤所致的月经量过多的症状超过90%;子宫肌瘤体积缩小约50%-60%。
子宫肌瘤栓塞是指经双侧子宫动脉注入颗粒性栓塞剂堵塞细动脉水平的血流,造成子宫肌瘤不可逆性的缺血损伤同时避免对子宫的永久性损伤。
技术操作简单,一般大家最关心两个问题
1.栓塞剂的选择:
UAE可供选择的栓塞剂较多,一般选择颗粒型栓塞剂,总体可分为可吸收和不可吸收两种,可吸收栓塞剂以海藻酸钠微球颗粒(KMG)为代表,不可吸收栓塞剂以聚乙烯醇(PVA)为代表。而其他器官的常用栓塞剂如钢圈、无水乙醇、超液态碘油等不建议在UAE中使用。
栓塞剂颗粒大小的选择:栓塞剂的颗粒直径以500~700 μm为主,部分也可选择300~500 μm或700~900 μm。
栓塞后立即切除的肌壁间纤维瘤(F)周围标本的显微照片(苏木精-番红-伊红染色;放大倍数为200倍)显示,直径为500-700 μ m的校准微球(箭头)靶向闭塞了纤维瘤周围动脉丛。
例如,对于子宫肌瘤患者的UAE,一般选择直径500~700 μm的颗粒进行单一栓塞;也可以选择直径300~500 μm的颗粒进行内层血管网栓塞,再用500~700 μm的颗粒进行外层血管网的栓塞,最后用700~900 μm的颗粒进行主干栓塞的"三层栓塞法"[14]。
而子宫腺肌病由于内层血管网较为细小,外层血管网不明显,为达到较好的栓塞效果可适当选择较小颗粒的栓塞剂。动脉栓塞的效果与栓塞剂颗粒大小成反比。
2.栓塞程度:
栓塞分为完全性栓塞和不完全性栓塞两种。
判断不完全性栓塞,其根据是尽可能地只栓塞病灶的血管网而不栓塞子宫的正常血管网,在DSA中影像学表现为病灶血管网全部或部分消失,子宫的血管网存在,子宫动脉显影。
另1种为完全性栓塞,即将栓塞剂尽可能多地释放,将病灶血管网和子宫动脉对病灶主要供血的分支动脉主干完全栓塞,在DSA中影像学表现为病灶染色完全消失,子宫动脉的主干仅部分显影或完全不显影。
为获得更好的临床疗效,子宫腺肌病的栓塞程度要明显高于子宫肌瘤,而且必须是完全性栓塞。
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Abstract 摘要
Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.
子宫肌瘤和腺肌症是常见的良性肿瘤,可能导致严重的有害健康影响,包括危及生命的贫血、月经延长和盆腔疼痛;然而,高达 40%的女性未得到诊断。
传统的治疗方法,如肌瘤切除术或子宫切除术,可以有效地管理症状,但可能需要更长的住院时间并阻碍未来的生育。血管内治疗,如子宫动脉栓塞(UAE),是一种微创手术,已成为手术选择的良好替代方案,同时保留子宫并缩短住院时间。仔细的患者选择和适当的技术对于实现最佳结果至关重要。近年来,在术前和术后护理方面取得了进展,旨在提高结果并减轻 UAE 术前、术中及术后的不适。此外,成功率和再次干预率也可能取决于肌瘤的大小和位置。本文回顾了子宫肌瘤和腺肌症的血管内治疗现状。
Keywords:fibroid, adenomyosis, embolization, uterine artery embolization, interventional radiology
关键词:子宫肌瘤、腺肌病、栓塞、子宫动脉栓塞、介入放射学
先说结论:血管内治疗对腺肌病和子宫肌瘤都很有希望且有效。虽然传统的手术方法在过去已经取得了成功,但与之相关的并发症增加和住院时间延长。子宫动脉栓塞等血管内治疗具有微创和并发症极少的优点。需要注意的是,一些患者更喜欢侵入性较小的治疗方案。因此,医疗保健提供者应提供关于所有可用治疗方案的全面咨询,这可能包括保守治疗、药物治疗、微创治疗、手术治疗或其组合,以帮助患者就其护理做出明智的决定。总之,预计血管内治疗在未来作为纤维瘤和腺肌病的管理工具将发挥更重要的作用。
Uterine fibroids and adenomyosis are common gynecological conditions that can lead to increased morbidity and negatively impact women's quality of life. According to Krentel and De Wilde, 1 adenomyosis was found 40% of the time in patients who underwent a hysterectomy for general uterine complications. Despite their prevalence, approximately 35 to 50% of women would have evidence of undiagnosed fibroids through ultrasound. 2 Along with their asymptomatic nature, they can manifest as prolonged menstrual bleeding that often results in pelvic pain, iron-deficiency anemia, and infertility. 3 While myomectomy and hysterectomy are well-established surgical options, these options are invasive and result in women having prolonged hospitalization times. 4 Uterine artery embolization is a uterus-sparing nonsurgical option, and it is widely reported to involve shorter hospital lengths of stay and less postprocedural pain. 5 This review aims to discuss the current endovascular treatment trends for uterine fibroids and adenomyosis.
子宫肌瘤和腺肌症是常见的妇科疾病,可能导致发病率增加并负面影响女性的生活质量。根据 Krentel 和 De Wilde 的研究,40%的因一般子宫并发症而行子宫切除术的患者被诊断为腺肌症。尽管它们很普遍,大约有 35%至 50%的女性通过超声检查会有未诊断的子宫肌瘤的证据。除了它们的无症状性质外,它们可以表现为长期月经出血,这通常会导致盆腔疼痛、缺铁性贫血和不孕。虽然肌瘤切除术和子宫切除术是已确立的手术选择,但这些选择是侵入性的,导致女性住院时间延长。子宫动脉栓塞是一种保留子宫的非手术选择,广泛报道其涉及更短的住院时间和较少的术后疼痛。本综述旨在讨论目前子宫肌瘤和腺肌症的血管内治疗趋势。
Patient Selection 患者选择
UAE is a treatment option for adenomyosis and uterine fibroids, with both entities sharing common symptoms including prolonged menstrual bleeding, pelvic pressure, and dyspareunia. Patients commonly experience some form of combination of these symptoms; however, confirmation with history, physical exam, and imaging findings remains key to ensure that other conditions that often can present with similar symptoms are appropriately excluded. 6 The Uterine Fibroid Symptom Health-Related Quality of Life Questionnaire (UFS-QOL) is a tool specifically designed to assess the symptoms associated with uterine fibroids. The UFS-QOL was developed to measure symptoms and health-related quality of life in women with uterine fibroids. 7
UAE是治疗腺肌病和子宫肌瘤的一种选择,这两种疾病都共有一些常见症状,包括月经出血延长、盆腔压迫症状和性交疼痛。患者通常会有这些症状的一种或几种的组合;然而,通过病史、体格检查和影像学检查进行确认,仍然是确保适当排除其他可能具有类似症状的疾病的关键。 6 子宫肌瘤症状与健康相关生活质量问卷(UFS-QOL)是一种专门设计来评估与子宫肌瘤相关症状的工具。UFS-QOL 旨在测量患有子宫肌瘤女性的症状和与健康相关的生活质量。 7
Image modalities such as contrast-enhanced magnetic resonance imaging (MRI) and transvaginal ultrasound (TVUS) are the preferred methods to evaluate size, location, and number of fibroids. 8 Adenomyosis is often diagnosed on TVUS with the hallmark finding of a thickened endometrium and the presence of myometrial cysts. 9 Similarly, on MRI, adenomyosis is identified by myometrial cysts and a thickened junctional zone exceeding 12 mm. 9 On the other hand, uterine fibroids are usually defined by specific characteristics and enhancement patterns seen on MRI. 10 Highly cellular fibroids demonstrate a high signal intensity on T2-weighted images (WI) with characteristic avid postcontrast enhancement. However, degenerated fibroids tend to appear highly variable on MRI. 10 A study of 30 patients by Çakır et al 11 found that fibroids with higher T2-WI signal intensity in the preprocedural MRI were associated with a higher rate of post-UAE technical success.
影像学检查方法,如对比增强磁共振成像(MRI)和经阴道超声(TVUS),是评估子宫肌瘤大小、位置和数量的首选方法。 8 子宫腺肌病通常通过 TVUS 诊断,标志性发现为子宫内膜增厚和肌层囊肿的存在。 9 类似地,在 MRI 上,子宫腺肌病通过肌层囊肿和超过 12 毫米的增厚交界区来识别。 9 另一方面,子宫肌瘤通常通过 MRI 上的特定特征和增强模式来定义。 10 高细胞密度的子宫肌瘤在 T2 加权图像(WI)上表现出高信号强度,并具有特征性的对比增强。然而,退化的子宫肌瘤在 MRI 上往往表现出高度可变性。 10 Çakır 等人的一项针对 30 名患者的调查显示,术前 MRI 中 T2-WI 信号强度较高的子宫肌瘤与 UAE 术后技术成功率较高的相关性。
Fibroid Location 子宫肌瘤位置
During the initial patient encounter, clinicians should pay close attention to the location of the fibroids. Appropriately classifying fibroids is necessary for treatment planning and complication prevention. The Federation Internationale de Gynecolgie et Obstetriqueue (FIGO) classification system was developed to uniformly and consistently describe and classify uterine fibroid to facilitate communication, clinical care, and research ( Fig. 1 ). The FIGO system categorizes fibroids that are submucosal, other fibroids, and hybrid fibroids. The recent article by Munro et al 12 proposed an MRI reporting template for structured reporting of uterine fibroids using the FIGO classification system. While the FIGO classification system guides physicians with a more standardized algorithm for describing as well as characterizing uterine fibroids and treatment decision making, clinical findings and patient preference play an important role as well in deciding the best treatment strategy. Also, significant inter-reader variability has been found between gynecologists and radiologists when reporting FIGO types. In 2017, Lacayo et al 13 conducted a study that showed that the size of uterine fibroids did not affect the infarction rate, but rather the location of the fibroid was the only influencing factor. Pedunculated serosal tumors were less likely to have complete infarction compared to transmural fibroids. Additionally, multivariate analysis revealed that fibroids located at the cervix and lower uterine body, as well as the anterior wall of the uterus, were more likely to have an incomplete infarction. However, the reasons for this finding remain unclear and may be related to collateral arterial supply.
在初次接诊患者时,临床医生应密切关注子宫肌瘤的位置。对子宫肌瘤进行适当的分类对于治疗计划和并发症预防是必要的。国际妇产科学会(FIGO)的分类系统是为了统一和一致地描述和分类子宫肌瘤,以促进沟通、临床护理和研究而开发的( Fig. 1 )。
FIGO 系统将子宫肌瘤分为黏膜下肌瘤、其他肌瘤和混合肌瘤。
Munro 等人最近的文章 12 提出了使用 FIGO 分类系统对子宫肌瘤进行结构化报告的 MRI 报告模板。虽然 FIGO 分类系统为医生提供了更标准化的算法来描述和表征子宫肌瘤以及治疗决策,但在决定最佳治疗方案时,临床发现和患者偏好也起着重要作用。此外,在报告 FIGO 类型时,妇科医生和放射科医生之间发现了显著的阅读者间差异。 2017 年,Lacayo 等人进行了一项研究,该研究显示子宫肌瘤的大小不影响梗死率,而是肌瘤的位置是唯一的影响因素。
有蒂浆膜下肿瘤比穿透性肌瘤发生完全梗死的可能性更低。此外,多变量分析显示,位于宫颈和子宫下段以及子宫前壁的肌瘤更容易发生不完全梗死。然而,这一发现的原因尚不清楚,可能与侧支动脉供应有关。
Fig. 1. 图 1.
根据 FIGO 分类,子宫肌瘤的亚型根据是否存在黏膜下成分分为两组。
具有黏膜下成分的子宫肌瘤包括
0 型(有蒂宫腔内)、
1 型(黏膜下成分≥50%)、
2 型(黏膜下成分<50%)和
混合型子宫肌瘤(2-5 型)。
另一方面,无黏膜下成分的子宫肌瘤包括
3 型(子宫内膜接触的肌壁间子宫肌瘤)、
4 型(无子宫内膜接触的肌壁间子宫肌瘤)、
5 型(≥50%浆膜下成分的肌壁间子宫肌瘤)、
6 型(<50%浆膜下成分的肌壁间子宫肌瘤)、
7 型(有蒂浆膜下)、
8 型(非子宫肌层位置,如宫颈、阔韧带或寄生性子宫肌瘤)。
EIA,外髂动脉;IIA,内髂动脉。(数字插图由 Merve Ozen,MD 制作。)
Koziarz et al 14 conducted a meta-analysis of seven observational studies on UAE in patients with pedunculated subserosal fibroids to evaluate the effectiveness and safety of this treatment. The analysis showed that the risk of adverse events after UAE in patients with pedunculated subserosal fibroids was 1.7%. Furthermore, all adverse events were classified as mild using the SIR guidelines. 15
科齐亚茨等人对七项关于 UAE治疗有蒂浆膜下子宫肌瘤患者的观察性研究进行了荟萃分析,以评估该治疗的有效性和安全性。分析显示,有蒂浆膜下子宫肌瘤患者在接受 UAE 治疗后发生不良事件的概率为 1.7%。此外,所有不良事件均根据 SIR 指南被归类为轻微。
Fibroids that are mainly submucosal or transmural, with a volume of less than 66 mL, are more likely to be expelled following UFE. The average timeframe for fibroid expulsion after UFE is 15 weeks, with most occurrences taking place within 3 months. However, some expulsions have been recorded as early as a few days after the procedure, while others have been reported as late as 50 months after. Typically, the size of expelled fibroids is around 6 to 8 cm on average. 16 These conflicting findings suggest that further investigation is necessary to determine whether certain locations of fibroids may be more prone to incomplete treatment by UAE. There are only case reports documenting instances of expulsion following UAE for adenomyosis.
子宫肌瘤主要为黏膜下或穿透肌层,体积小于 66 毫升的,在 UFE 后更容易排出。UFE 后子宫肌瘤排出的平均时间为 15 周,大多数情况发生在 3 个月内。然而,有些排出发生在手术后的几天内,而有些则报告发生在术后 50 个月。通常,排出的子宫肌瘤大小平均为 6 到 8 厘米。这些相互矛盾的结果表明,有必要进一步调查以确定某些子宫肌瘤的位置是否可能更容易受到 UAE 的不完全治疗。目前只有关于 UAE 后腺肌症排出的病例报告。
Contraindications 禁忌症
The presence of an intrauterine device is not an absolute contraindication for UAE, and its removal prior to UAE is not mandatory but accepted as a relative contraindication. Absolute contraindications for UAE include a viable pregnancy, an active infection, and gynecologic malignancy. 17 Other relative contraindications that require extra caution are coagulopathy, severe contrast agent allergy, renal impairment, immunocompromised patients, chronic endometritis, and previous pelvic irradiation or surgery. 17 Intracavity fibroids are another relative contraindication for UAE as they have a higher rate of sepsis and fibroid expulsion, which will be discussed in an upcoming section. While a myomectomy has been limited by fibroid size and number, it has been found that a combined approach of both UAE and myomectomy for intracavity fibroids may be a safe and effective approach. 18
宫内节育器的存在不是 UAE 的绝对禁忌症,在 UAE 之前移除它不是强制性的,但被视为相对禁忌症。
UAE 的绝对禁忌症包括怀孕、活动性感染和妇科恶性肿瘤。
其他需要额外小心的相对禁忌症包括凝血病、严重对比剂过敏、肾功能损害、免疫抑制患者、慢性子宫内膜炎以及既往盆腔放疗或手术。 17
宫腔内肌瘤是 UAE 的另一个相对禁忌症,因为它们有更高的败血症和肌瘤排出率,这将在下一节中讨论。虽然子宫肌瘤切除术受肌瘤大小和数量的限制,但发现对于宫腔内肌瘤,UAE 和子宫肌瘤切除术的联合方法可能是一种安全有效的途径。 17
Procedural Workup 程序评估
UAEs are best performed as part of a collaborative effort between the interventional radiologist and gynecologist who has already discussed medical and surgical options with the patient. The interventional radiologist should set up a consultation before the procedure to review the patient's demographic information and symptoms and assess the risk for the procedure to see if the patient is a good candidate for UAE. 19
UAEs 最好作为介入放射科医生和已经与患者讨论过医疗和手术方案的妇科医生之间的协作努力的一部分进行。介入放射科医生应在手术前安排会诊,以审查患者的人口统计信息和症状,并评估手术风险,以确定患者是否是 UAE 的良好候选人。
As many as two-thirds of all women will have one or more fibroids in their lifetime, and only a fourth of them will have symptoms significant enough to warrant treatment. Symptoms may include abnormal uterine bleeding (AUB), bulk and pressure symptoms, and urinary symptoms. Pregnancy or fertility complications can also be associated with fibroids. 20
多达三分之二的女性在其一生中会患有至少一个子宫肌瘤,其中只有四分之一的人会出现足够严重的症状需要治疗。症状可能包括异常子宫出血(AUB)、体积和压迫症状,以及排尿症状。子宫肌瘤还可能与妊娠或生育并发症相关。
Patients with fibroids experiencing AUB should also be evaluated for other possible causes of abnormal bleeding. A thorough history and physical examination are essential. The International Federation of Gynecology and Obstetrics classifies AUB using PALM-COIEN. PALM represents anatomic etiologies, including polyps, adenomyosis, leiomyomas, and malignancy. COIEN represents medical causes, including coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise specified. Imaging, such as TVUS and MRI, can identify most anatomic etiologies, except for malignancies. All patients should undergo cervical cancer screening, and patients older than 45 or 40 years with risk factors for endometrial adenocarcinoma, including obesity or another history of unopposed estrogen, should undergo endometrial sampling, either with an office biopsy or a dilation and curettage in the office prior to undergoing further management. 21
子宫肌瘤患者出现异常子宫出血(AUB)时,还应评估其他可能的异常出血原因。详细的病史和体格检查是必不可少的。国际妇产科学会联合会使用 PALM-COIEN 对 AUB 进行分类。
PALM 代表解剖学病因,包括息肉、腺肌病、平滑肌瘤和恶性肿瘤。COIEN 代表医学原因,包括凝血病、排卵功能障碍、子宫内膜、医源性和未指定的其他原因。
影像学检查,如经阴道超声(TVUS)和磁共振成像(MRI),可以识别大多数解剖学病因,但不能识别恶性肿瘤。所有患者都应进行宫颈癌筛查,并且年龄超过 45 岁或 40 岁且具有子宫内膜腺癌风险因素的患者,包括肥胖或未经拮抗的雌激素病史,应在进行进一步管理之前进行子宫内膜取样,无论是通过门诊活检还是门诊扩张刮宫。
Patients with urinary symptoms or infertility should complete full workups by specialists in urinary dysfunction and infertility, respectively, before undergoing intervention of fibroids for these conditions. If fibroids are asymptomatic, patients and their doctors should discuss whether intervention is needed. For example, a patient who has infertility should make sure their partner undergoes a semen analysis prior to undergoing an invasive procedure with the expectation of solving their infertility.
患者在进行子宫肌瘤干预之前,应分别由泌尿功能障碍和不孕症专家进行全面检查。如果子宫肌瘤无症状,患者和医生应讨论是否需要干预。例如,不孕症患者在进行旨在解决其不孕症的侵入性手术之前,应确保其伴侣进行精液分析。
Patients undergoing any procedure should not only understand the risks and benefits but also the alternatives for that procedure. As most women with fibroids are asymptomatic, many only need reassurance. For those suffering from AUB, hormonal intervention, including combined hormonal contraception, progesterone therapy, including systemic and intrauterine devices, as well as gonadotropin-releasing hormone agonists or antagonists, can be considered. Many patients looking into UAE have already been counseled on hysterectomy and myomectomy. However, a hysteroscopic myomectomy can treat the problem with minimal recovery if bleeding symptoms are related to an intracavitary fibroid, provided it is amenable to hysteroscopic resection.
患者在接受任何手术时,不仅应了解手术的风险和益处,还应了解该手术的替代方案。由于大多数子宫肌瘤女性没有症状,许多人只需要得到安慰。对于患有异常子宫出血(AUB)的女性,可以考虑激素干预,包括复方激素避孕药、孕激素治疗,包括全身和宫内装置,以及促性腺激素释放激素激动剂或拮抗剂。许多考虑进行 UAE(子宫动脉栓塞术)的患者已经接受了子宫切除术和肌瘤切除术的咨询。然而,如果出血症状与宫腔内肌瘤有关,并且适合进行宫腔镜下切除,那么宫腔镜下肌瘤切除术可以以最小的恢复期治疗该问题。
Procedure 程序
Anatomy 解剖学
Uterine arteries can have many variants occurring in up to 10 to 15% of the population. 22 During the procedure, it is important to examine the anterior division of the iliac artery since, in 51% of cases, the uterine artery arises from it 22 ( Fig. 2 ). While there are many variants, branches on both sides of the body are symmetrical in 91% of patients. 22
子宫动脉在人群中可存在多种变异,发生率高达 10%至 15%。 22 在手术过程中,检查髂动脉前支非常重要,因为在 51%的病例中,子宫动脉由此处起源 22 ( Fig. 2 )。尽管存在许多变异,但在 91%的患者中,身体两侧的分支是对称的。 22
Fig. 2. 图 2。
( a ) 1 型指的是最常见的情况,即子宫动脉起源于臀下动脉。
( b ) 2 型中,子宫动脉是臀下动脉的第二或第三分支,而阴部内动脉等其他分支可能是第一分支。
( c ) 3 型以臀下动脉、臀上动脉和子宫动脉都起源于同一水平(三叉)为特征。
( d ) 最后,4 型是指子宫动脉起源于臀下动脉和臀上动脉之前。(数字插图由 Merve Ozen,MD 提供。)(没必要记,见招拆招就行)
In 10% of patients, ovarian arteries can provide collateral arterial supply for adenomyosis and fibroids. Several studies have concluded that some failures after UAE have been associated with underlying ovarian collateral supply of the uterus. 23 24 25 26 Other collateral supply sources, such as the round ligament and inferior mesenteric arteries, have also been reported in case reports. One fear clinicians have in performing ovarian artery embolization is ovarian failure. There is also contradictory literature with Razavi et al 27 concluding that ovarian artery embolization should only be performed unilaterally. Most recent discussions about ovarian artery embolization are based on case reports and mostly retained ovarian function after the procedure. 28 In the FIRSTT study where UAE was compared with MRI-guided focused US (MRgFUS), UAE showed a significantly greater absolute decrease in anti-Müllerian hormone levels at 24 months compared with MRgFUS. 29 However, a higher incidence of a second fibroid procedure was observed in patients who underwent MRgFUS compared to those who underwent UAE, and the degree of symptom alleviation was comparatively lower with MRgFUS.
在 10%的患者中,卵巢动脉可以为腺肌症和子宫肌瘤提供侧支动脉供应。几项研究得出结论,UAE(子宫动脉栓塞术)后的某些失败与子宫的潜在卵巢侧支供应有关。
其他侧支供应来源,如圆韧带和肠系膜下动脉,也有病例报告。。临床医生在进行卵巢动脉栓塞时担心的是卵巢功能衰竭。 关于卵 巢动脉栓塞的文献也存在矛盾,Razavi 等人认为卵巢动脉栓塞应仅限单侧进行。最近关于卵巢动脉栓塞的讨论主要基于病例报告,并且大多数情况下术后卵巢功能得以保留。
在 FIRSTT 研究中,UAE 与 MRI 引导的聚焦超声(MRgFUS)进行了比较,UAE 在 24 个月时与 MRgFUS 相比,抗米勒管激素( anti-Müllerian hormone) 水平显著降低。然而,与 UAE 相比,接受 MRgFUS 的患者中观察到第二次子宫肌瘤手术的发生率更高,并且与 MRgFUS 相比,症状缓解程度较低。(译者:海扶刀消融逊于UAE,当然也有人持保留态度,目前仍有争议,需要更多RCT研究数据)
Vascular Access 血管通路
UAE is traditionally performed using femoral artery access, but in recent years, radial artery access has become more prevalent. Growing literature demonstrates increased success rate and decreased incidence of complications, leading us to consider transradial (TR) access as a preferred option for UAE. In some clinical situations, an alternative route to the more conventional transfemoral access (TFA) is a necessity, such as obesity and extensive peripheral lower extremity vascular disease. 30
UAE 传统上使用股动脉通路进行手术,但近年来,桡动脉通路的使用越来越普遍。越来越多的文献表明,经桡动脉(TR)通路的成功率提高,并发症发生率降低,这使我们考虑将 TR 通路作为 UAE 的首选方案。在某些临床情况下,与更传统的经股动脉通路(TFA)相比,选择替代通路是必要的,例如肥胖和广泛的周围下肢血管疾病。
The results of Sher et al's 31 retrospective study involving 374 patients are promising, as it suggests that TR UAE for symptomatic fibroids can be performed using a same-day discharge protocol with low rates of patient return. Additionally, Nakhaei et al 32 found that TRA UAE resulted in only five access site hematomas in 90 patients and one vasospasm in 92 cases, which is also reassuring for TR access.
Sher 等人进行的涉及 374 名患者的回顾性研究结果显示令人鼓舞,因为它表明,对于有症状的子宫肌瘤,可以使用同一天出院方案进行经皮经腔子宫动脉栓塞术(TR UAE),且患者返院率低。此外,Nakhaei 等人发现,在 90 名患者中,经皮经腔子宫动脉栓塞术(TRA UAE)仅导致 5 个穿刺部位血肿,在 92 个病例中导致 1 例血管痉挛,这也对 TR 途径是令人放心的。
Embolic Agents 栓塞剂
One area of active research in UAE is the different embolic agents. During UAE, specific embolic agents must be used based on the physicians' experience as well as the size and location of the fibroids. 13 Several different embolic agents have been approved by the FDA for use in UAE, including polyvinyl alcohol particles (PVAs) and tris-acryl gelatin microspheres (TAGMs). A systemic review found that PVA was better at complete fibroid infarction after the first 24 hours when compared to TAGMs, but TAGM was better than PVA at <90% infarction rate outcome. 33 Regardless, nonspherical PVA particles and TAGMs produced similar rates of uterine fibroid infarction. 13
UAE研究活跃的一个领域是不同的栓塞剂。在 UAE 过程中,必须根据医生的经验以及子宫肌瘤的大小和位置来选择特定的栓塞剂。FDA 已批准多种栓塞剂用于 UAE,包括聚乙烯醇颗粒(PVAs)和三丙烯酸凝胶微球(TAGMs)。一项系统综述发现,与 TAGMs 相比,PVA 在首次 24 小时后对完全子宫肌瘤梗塞的效果更好,但 TAGM 在<90%梗塞率的结果上优于 PVA。无论如何,非球形 PVA 颗粒和 TAGMs 产生相似的子宫肌瘤梗塞率。
Calibrated microspheres are another type of embolic agent that is commonly used in the UAE. An advantage of calibrated microspheres is that, unlike PVA, they are more uniform in size, which results in more predictable embolization and minimizes the clogging of the catheters used during UAE. 34 In a prospective multicenter study, microspheres showed a low rate of adverse events, reduced uterine fibroid volumes, and improved quality of life. 35 In another prospective clinical trial, 8Spheres (Suzhou Hengrui Callisyn Biomedical Technology, China), a type of conformal microsphere, has been shown to relieve heavy menstrual bleeding effectively and has no significant impact on ovarian function. 36 Embozenes microspheres (Varian, United States) are another type of tightly calibrated microsphere that can be used as an embolic agent.
校准微球是另一种在 UAE 中常用的栓塞剂。校准微球的优势在于,与 PVA 不同,它们在尺寸上更加均匀,这导致栓塞更加可预测,并最小化了在 UAE 过程中使用的导管堵塞。在一项前瞻性多中心研究中,微球显示出低的不良事件发生率,减少了子宫肌瘤体积,并改善了生活质量。在另一项前瞻性临床试验中,8Spheres(苏州恒瑞凯瑞森生物医药技术,中国),一种符合性微球,已被证明可以有效缓解经量过多,并且对卵巢功能没有显著影响。Embozenes 微球(Varian,美国)是另一种可以用作栓塞剂的紧密校准微球。
Small-sized PVAs ranging between 100 and 300 μm were found to be safe and effective in treating adenomyosis in a study conducted by Yuan et al, 37 with an average follow-up of 42 months. They found no significant relationship between the clinical outcomes, the initial presence of adenomyosis, with or without fibroids, and the JZ thickness. 37
Yuan 等人在一项研究中发现,直径在 100 至 300 微米之间的PVAs在治疗腺肌症方面安全有效,平均随访时间为 42 个月。他们发现,临床结果与腺肌症初始存在与否、有无子宫肌瘤以及 JZ 厚度之间没有显著关联。
Regardless of type, embolic agents play an important role in the success of uterine artery embolization. Another important factor in the success of UAE is the determination of embolization end point strategy. Embolization with an endpoint of near stasis, as opposed to complete stasis, has been reported to result in less postprocedural pain. 38 It is now widely accepted that embolizing the uterine artery with a 5 to 10 heart-beat stasis is an adequate endpoint 39 ( Fig. 3 ).
无论类型如何,栓塞剂在子宫动脉栓塞术的成功中发挥着重要作用。UAE 成功的一个重要因素是确定栓塞终点策略。
与完全静止相比,以近乎静止为终点的栓塞已被报道可导致术后疼痛减轻。现在普遍认为,以 5 至 10 个心跳静止为终点的子宫动脉栓塞是一个足够的终点。
Fig. 3. 图 3。
一名34岁的女性出现大量和长期的月经出血,盆腔疼痛和压力症状。提供了只有子宫切除术作为一种治疗选择的时候,她进行了自己的研究后,来到我们的诊所寻求照顾。
(a)UAE(子宫动脉栓塞术)前矢状位T1加权脂肪饱和对比增强(CE)图像显示多发性增强肌瘤。(b)栓塞前左UA横段(箭头)的数字减影血管造影(DSA)显示UA肥大和多发性肌瘤染色。(c)栓塞后左UA DSA显示UA闭塞和宫颈-阴道分支通畅(箭头)。(d)6个月随访CE MRI显示子宫尺寸减小,肌瘤无增强,与囊性变性一致。在临床随访期间,她表示重度、持续出血和大块症状已消退。
其他一些病例
Periprocedural Pain Management
围手术期疼痛管理
UAE can be associated with moderate to severe postprocedural pain, and effective pain management is important for patient comfort and satisfaction. Several studies have recently investigated the use of different pain management strategies after UAE. These strategies include preprocedural oral analgesics, local anesthesia, epidural patient-controlled analgesia, conscious sedation, and general anesthesia. 40
UAE 可能与术后中到重度疼痛相关,有效的疼痛管理对患者的舒适度和满意度至关重要。(无痛治疗对患者非常重要)
最近有几项研究调查了 UAE 后使用不同的疼痛管理策略。这些策略包括术前口服镇痛药、局部麻醉、硬膜外患者自控镇痛、镇静麻醉和全身麻醉。
Some interventional radiologists prefer administering pain medications before or during the UAE to minimize postprocedural pain. The combination of medications that can be administered is a loading dose of hydromorphone hydrochloride or nonsteroidal anti-inflammatory drugs (NSAIDs) and a patient-controlled analgesia. Ondansetron is the preferred antiemetic due to its effectiveness and tolerability. 39 This approach is also believed to avoid postembolization syndrome (PES), which will be discussed as one of the most common postprocedural complications after UAE for fibroids and adenomyosis.
一些介入放射科医生更喜欢在 UAE 前后或期间给予止痛药,以最大限度地减少术后疼痛。可以给予的药物组合是盐酸氢吗啡酮或非甾体抗炎药(NSAIDs)的负荷剂量以及患者控制的镇痛。由于奥丹司琼的有效性和耐受性,它是首选的抗恶心药。 39 这种方法也被认为可以避免栓塞后综合征(PES),这将在讨论 UAE 治疗子宫肌瘤和腺肌病后最常见的术后并发症之一时进行讨论。
A study from Katsumori et al 41 investigating intra-arterial lidocaine administration immediately after UAE with TAGM for leiomyoma was found to be safe. Still, it did not contribute to a significant reduction in pain or amount of narcotic agents administered. 41
一项由 Katsumori 等人进行的研究发现,在 UAE 后立即通过动脉内给予利多卡因治疗子宫肌瘤是安全的。然而,它并没有导致疼痛或使用的麻醉剂剂量的显著减少。
Another approach gaining more popularity for periprocedural pain is superior hypogastric nerve block. Yoon et al 42 showed that superior hypogastric nerve block significantly decreased pain and nausea after uterine artery embolization as compared with a sham procedure.
另一种越来越受欢迎的围手术期疼痛治疗方法是高位腹下神经阻滞。Yoon 等人 42 的研究表明,与安慰剂手术相比,高位腹下神经阻滞显著降低了子宫动脉栓塞术后的疼痛和恶心。
In a recent systematic review of post-UAE pain control regimens, the authors compared the average maximum pain scores of 26 studies that tested various medications, such as opioids, NSAIDs, acetaminophen, intra-arterial lidocaine, steroids, ketamine, or α2 adrenergic receptor agonists. After analyzing these groups' mean maximal pain scores, the authors concluded that there was no significant difference between them. Thus, they suggested that using opioids along with NSAIDs and acetaminophen may be sufficient in controlling post-UAE pain. 43
在最近的一项关于 UAE 术后疼痛控制方案的系统性综述中,作者比较了 26 项研究测试的平均最大疼痛评分,这些研究测试了各种药物,如阿片类药物、非甾体抗炎药、对乙酰氨基酚、动脉内利多卡因、类固醇、氯胺酮或α2 肾上腺素能受体激动剂。在分析这些组的平均最大疼痛评分后,作者得出结论,它们之间没有显著差异。因此,他们建议使用阿片类药物与 NSAIDs 和对乙酰氨基酚联合使用可能足以控制 UAE 术后疼痛。
Overall, the choice of pain management strategy after UAE should be individualized based on patient factors and preferences. Further research is needed to evaluate the benefits and risks of the different alternatives. Furthermore, providing detailed preprocedural counseling to patients regarding post-UAE pain timeline and severity can manage patient's expectations and reduce procedure-related anxiety.
总体而言,UAE 后疼痛管理策略的选择应根据患者因素和偏好个性化。需要进一步研究以评估不同替代方案的利益和风险。此外,向患者提供有关 UAE 后疼痛时间表和严重程度的详细术前咨询,可以管理患者的期望并减少与手术相关的焦虑。
Postprocedural Care 术后护理
After undergoing UAE to treat fibroids and adenomyosis, most patients undergo a similar cascade of events referred to as PES. PES consists of pelvic pain, nausea, vomiting, and fever that start around 10 to 20 minutes after the procedure and usually peaks at around the eighth hour. 44 Diagnosis of PES can be difficult for non-interventionalists and may warrant further investigation to exclude other differentials like sepsis. 45 While it is not completely understood, the etiology of PES is believed to be due to the release of inflammatory mediators from tissue infarction after embolization. 46 One prospective study assessed that women who underwent UAE had a mean postprocedural score of 7/10 (±2.47) and an average hospital stay of 31.2 hours. 39 Many therapies have been tried to decrease postprocedural pain, such as intra-arterial lidocaine and steroids. A randomized prospective study showed that using intra-arterial lidocaine caused a significant reduction in the early hours of postprocedural pain. 47 Another study showed that administration of a single-dose intravenous infusion of dexamethasone decreased pain scores 12 hours after UAE as well as the incidence of nausea and vomiting. 48 After controlling the nausea and vomiting, the patient is discharged with narcotic agents to be taken on an as-needed basis. 39
经 UAE 治疗子宫肌瘤和腺肌症后,大多数患者会经历被称为 PES 的类似事件链。PES 包括盆腔疼痛、恶心、呕吐和发热,通常在手术后 10 至 20 分钟开始,通常在第 8 小时左右达到高峰。
PES 的诊断对于非介入医生来说可能很困难,可能需要进一步调查以排除其他不同病因,如败血症。虽然原因尚不完全清楚,但 PES 的病因被认为是由于栓塞后组织梗死释放炎症介质。一项前瞻性研究评估了接受 UAE 的妇女的平均术后评分为 7/10(±2.47),平均住院时间为 31.2 小时。许多治疗方法已被尝试以减少术后疼痛,如动脉内利多卡因和类固醇。一项随机前瞻性研究显示,使用动脉内利多卡因可显著减少术后早期疼痛。 一项研究显示,单剂量静脉滴注地塞米松可降低 UAE 后 12 小时的疼痛评分,以及恶心和呕吐的发生率。控制恶心和呕吐后,患者带用麻醉剂出院,按需服用。
Aside from PES, other complications, although rare, can also arise after UAE. Fibroid expulsions (FEs) are a late complication that may occur where the necrotic fragments of the fibroid are expulsed through the cervical canal. 45 Symptoms can include vaginal bleeding, cramping, and pelvic pain. Larger sloughed off fibroids can also cause a blockage at the cervical os, which could lead to infection. Certain factors predispose patients to FE, such as size and location of the tumor, with submucosal and transmural fibroids having the highest risk. 49 Pedunculated fibroids, while historically thought of as high risk, have a low risk of adverse events and FE; they can safely be treated with UAE. 14 The treatment of FE depends on a case-by-case basis, as most women tolerate FE well, with 50% needing no operative intervention. 50 While the rate of fibroid expulsion ranges from 1.7 to 50%, 50 it is still a serious complication that must be addressed. Another rare complication that may arise from UAE involves chronic vaginal discharge. While often asymptomatic, one study found vaginal discharge mixed with spherical particles from intramural and submucosal fibroids. 51
除 PES 外,其他并发症虽然罕见,但在 UAE 后也可能发生。子宫肌瘤排出(FEs)是一种晚期并发症,可能发生在肌瘤的坏死碎片通过宫颈管排出时。
症状可能包括阴道出血、痉挛和盆腔疼痛。较大的脱落的子宫肌瘤也可能导致宫颈口阻塞,这可能导致感染。某些因素使患者易患 FE,如肿瘤的大小和位置,黏膜下和穿透肌层的子宫肌瘤风险最高。
有蒂子宫肌瘤,虽然历史上被认为是高风险,但不良事件和 FE 的风险较低;它们可以安全地通过 UAE 治疗。FE 的治疗取决于个案,因为大多数女性对 FE 的耐受性良好,其中 50%的女性不需要手术干预。尽管子宫肌瘤排出的发生率在 1.7%到 50%之间,但这仍然是一种严重的并发症,必须加以解决。UAE 可能引起的另一种罕见并发症是慢性阴道分泌物。虽然通常无症状,但一项研究发现,阴道分泌物中混合有来自肌层和黏膜下子宫肌瘤的球形颗粒。
Outcomes 结果
The outcomes of UAE on uterine fibroids are 50 to 60% fibroid size reduction, 88 to 92% reduction of bulk symptoms, greater than 90% elimination of uterine bleeding, and 75% elimination of symptoms. 52 The complications of UAE on uterine fibroids include 2 to 17% with prolonged vaginal discharge, 3 to 15% with fibroid expulsion, and 1 to 3% with septicemia according to SIR Standards of Practice Guidelines. 52 UAE has lower success with adenomyosis, where 76% of women had a resolution of symptoms. 53 Complications of UAE in adenomyosis are postprocedural pain in 87% of patients, persistent amenorrhea in 6 to 21% of patients, and need for hysterectomy in 14% of patients. 54
子宫肌瘤 UAE 治疗的结果是 50 至 60%的肌瘤体积减小,88 至 92%的体积症状减轻,超过 90%的子宫出血消除,以及 75%的症状消除。 52
子宫肌瘤 UAE 治疗的并发症包括 2 至 17%的阴道分泌物延长,3 至 15%的肌瘤排出,以及 1 至 3%的败血症,根据 SIR 实践指南标准。 52 UAE 在腺肌病治疗中的成功率较低,其中 76%的女性症状得到缓解。 53 腺肌病中 UAE 的并发症包括 87%的患者术后疼痛,6 至 21%的患者持续闭经,以及 14%的患者需要子宫切除术。 54
While the outcomes of UAE for both fibroids and adenomyosis are high, success also depends on the size of the embolic agent being used. According to one study, the use of only 500 to 700 μm particles resulted in a high rate of failed tumor infarction in uterine fibroids. 55 That same study showed that using 700- to 900-μm particles resulted in better imaging results and fewer repeat interventions. 55 TAGM particles can also be a great embolic agent for adenomyosis. One study showed that using microspheres ranging from 500 to 700 μm in size achieved a necrosis rate of 44.1%. 56
尽管 UAE 治疗子宫肌瘤和腺肌症的效果良好,但成功也取决于所使用的栓塞剂的大小。
根据一项研究,仅使用 500 至 700 微米的颗粒会导致子宫肌瘤肿瘤梗死失败率较高。该研究还显示,使用 700 至 900 微米的颗粒可以获得更好的成像结果和更少的重复干预。TAGM 颗粒也可以是腺肌症的一个很好的栓塞剂。一项研究表明,使用 500 至 700 微米范围的微球可以达到 44.1%的坏死率。
A recent deep learning-based study on predicting UAE outcomes found that there was no significant difference in UAE treatment response between fibroids' locations. 57 Similar to this finding, Firouznia et al 58 found that lesion location is not a factor in determining the clinical outcome of UAE. However, a study by Katsumori et al 59 showed that fibroid location within the uterus affects the likelihood of infarction after embolization. More specifically, they found that the anteriorly located fibroids and cervical fibroids have a lower infarction rate after UAE. The reasons for incomplete infarction of fibroids at these locations are unclear, but could be related to collateral arterial supply. One possible explanation for this phenomenon is that it may be linked to either the distribution of microspheres influenced by gravity during procedures performed while the patient is supine or hormonal changes resulting in shifts between watershed regions of the uterus, ovaries, or vagina based on the menstrual cycle phase. 60 The location of the fibroids is also important, as discussed earlier, due to the potential risk of expulsion. Sher et al 31 also found that submucosal location and pain are predictors of symptom recurrence.
近期一项基于深度学习预测 UAE 结果的研究发现,在纤维瘤的位置方面,UAE 治疗反应没有显著差异。与这一发现相似,Firouznia 等人发现,病变位置不是决定 UAE 临床结果的因素。
然而,Katsumori 等人的研究表明,子宫内纤维瘤的位置会影响栓塞后的梗死可能性。更具体地说,他们发现,位于前方的纤维瘤和宫颈纤维瘤在 UAE 后的梗死率较低。这些位置纤维瘤不完全梗死的原因尚不清楚,但可能与侧支动脉供应有关。这种现象的一个可能解释是,它可能与患者仰卧时手术过程中受重力影响的微球分布有关,或者与月经周期阶段导致的子宫、卵巢或阴道分水岭区域的变化有关。如前所述,纤维瘤的位置也很重要,因为存在排出的潜在风险。 Sher 等人 31 还发现,黏膜下位置和疼痛是症状复发的预测因素。
During the initial workup, the total volume and bulk of the fibroids are considered as part of the treatment decision making. Current evidence supports UAE as a safe and effective option to treat giant fibroids (volume ≥700 cc) causing bulk symptoms. However, the limited available data indicate a relatively higher risk of complications and reinterventions when compared with nongiant fibroids. Patients should be selected, counseled, and managed in a multidisciplinary fashion, as bulk symptoms take longer to improve after UAE. 61
在初步检查过程中,子宫肌瘤的总体积和体积被视为治疗决策的一部分。现有证据支持 UAE(子宫动脉栓塞术)作为一种安全有效的治疗巨大子宫肌瘤(体积≥700 cc)引起体积症状的选项。然而,有限的可获得数据表明,与非巨大子宫肌瘤相比,UAE 的并发症和再次干预的风险相对较高。患者应通过多学科方式选择、咨询和管理,因为 UAE 后体积症状的改善需要更长的时间。 61
While patients receive an extensive workup to rule out malignancy as described in the workup section, it may be difficult to differentiate leiomyoma from leiomyosarcoma on MRI. In a study that reviewed more than 300 patients who had follow-up after UAE, 4 were found to have leiomyosarcoma after UAE for presumed fibroids. 62 This study highlights that patients should be carefully assessed for underlying leiomyosarcoma and counseled accordingly.
在患者接受广泛的检查以排除恶性病变,如检查部分所述的同时,在 MRI 上区分平滑肌瘤和平滑肌肉瘤可能很困难。在一项回顾了超过 300 名接受 UAE 术后随访的患者的研究中,发现有 4 名患者在 UAE 治疗后被诊断为平滑肌肉瘤。 62 这项研究强调,应仔细评估患者是否存在潜在平滑肌肉瘤,并据此进行咨询。
Fertility and UAE 生育与 UAE
Unlike hysterectomy, minimally invasive interventions such as UAE may help preserve fertility, especially in cases of symptomatic adenomyosis and large fibroids, according to recent studies. 63In fact, research indicates that even patients with larger uteri and fibroids greater than 10 cm do not experience significantly higher complication rates, suggesting that fibroid size should not be a contraindication for UAE.63However, one study found that miscarriage rates were highest in the UAE group compared to other minimally invasive techniques like HIFU and transcervical radiofrequency ablation.64Nonetheless, this study identified maternal age as a confounding variable that could have contributed to the odds of fetal and maternal complications.64Another systematic review was conducted on a cohort of 2,000 women, out of which 1,575 underwent myomectomies, while 424 underwent UAE, as reported by Zanolli et al.65The study revealed that the birth rate outcome was 60.6% for both UAE and myomectomies, compared to 75.6% for the latter. There was a higher rate of spontaneous abortion of 27.4% for the UAE, as opposed to 19.0% for myomectomies.65Again, the study indicated that the patients who underwent UAE were older and had smaller fibroids when compared to those who underwent laparoscopic myomectomy.65On the other hand, a meta-analysis of 189 patients, of which 44 became pregnant (23.3%) after UAE, found that the live birth rate was estimated to be 88.6% among patients aged 24.5 to 33 years, indicating that UAE does not significantly affect birth rates compared to the general population.66A meta-analysis by Jiang et al67investigated the overall pregnancy outcomes after uterus-sparing nonexcisional treatments such as UAE and ablation in patients with adenomyosis. Between January 2000 and 2022, 13 studies with 1,319 patients with adenomyosis were included. The pregnancy and miscarriage rates after nonexcisional treatments were 51 and 22%, respectively, without a statistically significant difference compared to adenomyosis excision outcomes. Overall, recent literature suggests that UAE on a young cohort does not have a negative impact on fertility or pregnancy outcomes when compared to the general population.
与子宫切除术不同,根据最近的研究,微创干预措施如 UAE 可能有助于保留生育能力,尤其是在有症状的腺肌症和大型子宫肌瘤的情况下。
事实上,研究表明,即使子宫较大且子宫肌瘤大于 10 厘米的患者,并发症发生率也并未显著升高,这表明子宫肌瘤的大小不应成为 UAE 的禁忌症。然而,一项研究发现,与 HIFU 和经宫颈射频消融等微创技术相比,UAE 组的流产率最高。尽管如此,这项研究将母体年龄确定为可能影响胎儿和母体并发症发生几率的混杂变量。
Zanolli 等人对 2000 名女性进行了另一项系统综述,其中 1575 名女性接受了子宫肌瘤切除术,而 424 名女性接受了 UAE。该研究显示,UAE 和子宫肌瘤切除术的出生率结果均为 60.6%,而后者为 75.6%。
UAE 组的自然流产率较高,为 27.4%,而子宫肌瘤切除术组为 19.0%。 65
再次,该研究指出,与接受腹腔镜子宫肌瘤切除术的患者相比,接受 UAE 的患者年龄较大,子宫肌瘤较小。 65
另一方面,一项对 189 名患者的荟萃分析,其中 44 名(23.3%)在 UAE 后怀孕,发现 24.5 至 33 岁年龄段的患者的活产率估计为 88.6%,表明与普通人群相比,UAE 对生育率没有显著影响。 66
Jiang 等人进行的一项荟萃分析研究了腺肌病患者接受子宫保留非切除性治疗(如 UAE 和消融术)后的整体妊娠结果。从 2000 年 1 月到 2022 年,纳入了 13 项研究,共涉及 1,319 名腺肌病患者。非切除性治疗后的妊娠率和流产率分别为 51%和 22%,与腺肌病切除性治疗结果相比,没有统计学上的显著差异。总的来说,近期文献表明,与普通人群相比,UAE 对年轻人群的生育能力或妊娠结果没有负面影响。
Conclusion 结论
Endovascular treatments are promising and effective for both adenomyosis and uterine fibroids. While traditional surgical approaches have been successful in the past, there was an increase in complications and longer hospital times associated with them. Endovascular treatments like uterine artery embolization are minimally invasive with very few complications. It is important to note that some patients prefer less invasive treatment options. Therefore, healthcare providers should provide comprehensive counseling on all available treatment options, which may include conservative, medical, minimally invasive, surgical, or a combination thereof, to help patients make informed decisions about their care. In conclusion, endovascular treatment is expected to play a more significant role as a management tool for both fibroids and adenomyosis in the future.
血管内治疗对腺肌病和子宫肌瘤都很有希望且有效。虽然传统的手术方法在过去已经取得了成功,但与之相关的并发症增加和住院时间延长。
子宫动脉栓塞等血管内治疗具有微创和并发症极少的优点。需要注意的是,一些患者更喜欢侵入性较小的治疗方案。因此,医疗保健提供者应提供关于所有可用治疗方案的全面咨询,这可能包括保守治疗、药物治疗、微创治疗、手术治疗或其组合,以帮助患者就其护理做出明智的决定。
总之,预计血管内治疗在未来作为纤维瘤和腺肌病的管理工具将发挥更重要的作用。
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