目的 比较和评价阴式全子宫切除术(total vaginal hysterectomy,TVH)、腹腔镜全子宫切除术(Lapros-copical hyterectomy,LH)、横切口开腹全子宫切除术(minilaporotomy hysterectomy,MiniLPT)等不同微创全子宫切除术式的效果及安全性,以指导临床选择最合理的术式.方法 检索CBM、中国期刊全文数据库、万方数据资源系统、MEDLINE、EMbase、CochraneDSR、ACP Journal Club、DARE、CCTR、CMR、HTA、和NHSEED等数据库中关于比较TVH、LH、MiniLPT术式中至少两种的随机对照试验、比较性研究、经济评价,罕见结局的报道可包括观察性研究.检索截止时间为2009年3月.采用GRADE标准及Cochrane Reviewer Handbook 4.2.3对RCT的质量评价标准进行评价.用Cochrane协作网提供的RevMan 4.2软件进行Meta分析.结果 最终纳入12个研究,包括10个随机对照试验,1个回顾性队列研究、1个前瞻性队列研究.Meta分析结果显示TVH组手术时间最短、出血量最少、术后疼痛最轻、恢复排便或者排气最快、出院最早.MiniLPT组术后住院时间比对照组(TVH/LAVH组)长,差异有统计学意义[WMD=37.0h,95%CI(13.5h,60.5h)];MiniLPT组术中出血量比对照组多,差异有统计学意义[WMD=208.5ml,95%CI(141.4ml,375.7ml)],MiniLPT组发热发生率比对照组高,差异有统计学意义[PetoOR=3.8,95%CI(1.1,12.6). TVH组手术时间比LH组短,差异有统计学意义[WMD=47.2min,95%CI(-62.3min,32.19min)];TVH组出血量比LAVH组少,差异有统计学意义[WMD=-158.7ml,95%CI(-190.9 ml,-126.4ml)];TVH组住院时间比LH组短,差异有统计学意义[WMD=-18.8 h,95%CI(-24.2 h,-13.5 h)];TVH组术后恢复排气或排便时间比LAVH组短,差异有统计学意义[WMD=8.1 h,95%CI(-10.8 h,-5.3 h)].另一方面,LH组创面缝合愈合不良事件发生率、继发感染发生率、发热发生率均比TVH组低,但差异无统计学意义.LH组比TVH组术后性功能质量更好.结论 在基本符合TVH适应证的情况下,TVH是最微创的手术方式,且性价比高.在TVH适应证以外,只要在可以操作的范围内,TVH仍然是创伤最小且效果最好的手术方式,但这一范围目前尚无统一标准,跟术者经验水平、手术习惯和患者具体情况相关.LH在改善术后生活质量、患者自我感觉方面较为优越.通过提高腹腔镜手术止血技巧减少术中出血量,减少一次性器具费用或其使用、增加其回收,可降低手术费用,并可以提高LH性价比.MiniLPT发展时间尚短,相关比较研究起步也晚,其优越性有待更多研究进一步评估.
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(Lapros-copical hyterectomy,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,以指導臨床選擇最閤理的術式.方法 檢索CBM、中國期刊全文數據庫、萬方數據資源繫統、MEDLINE、EMbase、CochraneDSR、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,罕見結跼的報道可包括觀察性研究.檢索截止時間為2009年3月.採用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箇研究,包括10箇隨機對照試驗,1箇迴顧性隊列研究、1箇前瞻性隊列研究.Meta分析結果顯示TVH組手術時間最短、齣血量最少、術後疼痛最輕、恢複排便或者排氣最快、齣院最早.MiniLPT組術後住院時間比對照組(TVH/LAVH組)長,差異有統計學意義[WMD=37.0h,95%CI(13.5h,60.5h)];MiniLPT組術中齣血量比對照組多,差異有統計學意義[WMD=208.5ml,95%CI(141.4ml,375.7ml)],MiniLPT組髮熱髮生率比對照組高,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=47.2min,95%CI(-62.3min,32.19min)];TVH組齣血量比LAVH組少,差異有統計學意義[WMD=-158.7ml,95%CI(-190.9 ml,-126.4ml)];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組術後恢複排氣或排便時間比LAVH組短,差異有統計學意義[WMD=8.1 h,95%CI(-10.8 h,-5.3 h)].另一方麵,LH組創麵縫閤愈閤不良事件髮生率、繼髮感染髮生率、髮熱髮生率均比TVH組低,但差異無統計學意義.LH組比TVH組術後性功能質量更好.結論 在基本符閤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,隻要在可以操作的範圍內,TVH仍然是創傷最小且效果最好的手術方式,但這一範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在改善術後生活質量、患者自我感覺方麵較為優越.通過提高腹腔鏡手術止血技巧減少術中齣血量,減少一次性器具費用或其使用、增加其迴收,可降低手術費用,併可以提高LH性價比.MiniLPT髮展時間尚短,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.
목적 비교화평개음식전자궁절제술(total vaginal hysterectomy,TVH)、복강경전자궁절제술(Lapros-copical hyterectomy,LH)、횡절구개복전자궁절제술(minilaporotomy hysterectomy,MiniLPT)등불동미창전자궁절제술식적효과급안전성,이지도림상선택최합리적술식.방법 검색CBM、중국기간전문수거고、만방수거자원계통、MEDLINE、EMbase、CochraneDSR、ACP Journal Club、DARE、CCTR、CMR、HTA、화NHSEED등수거고중관우비교TVH、LH、MiniLPT술식중지소량충적수궤대조시험、비교성연구、경제평개,한견결국적보도가포괄관찰성연구.검색절지시간위2009년3월.채용GRADE표준급Cochrane Reviewer Handbook 4.2.3대RCT적질량평개표준진행평개.용Cochrane협작망제공적RevMan 4.2연건진행Meta분석.결과 최종납입12개연구,포괄10개수궤대조시험,1개회고성대렬연구、1개전첨성대렬연구.Meta분석결과현시TVH조수술시간최단、출혈량최소、술후동통최경、회복배편혹자배기최쾌、출원최조.MiniLPT조술후주원시간비대조조(TVH/LAVH조)장,차이유통계학의의[WMD=37.0h,95%CI(13.5h,60.5h)];MiniLPT조술중출혈량비대조조다,차이유통계학의의[WMD=208.5ml,95%CI(141.4ml,375.7ml)],MiniLPT조발열발생솔비대조조고,차이유통계학의의[PetoOR=3.8,95%CI(1.1,12.6). TVH조수술시간비LH조단,차이유통계학의의[WMD=47.2min,95%CI(-62.3min,32.19min)];TVH조출혈량비LAVH조소,차이유통계학의의[WMD=-158.7ml,95%CI(-190.9 ml,-126.4ml)];TVH조주원시간비LH조단,차이유통계학의의[WMD=-18.8 h,95%CI(-24.2 h,-13.5 h)];TVH조술후회복배기혹배편시간비LAVH조단,차이유통계학의의[WMD=8.1 h,95%CI(-10.8 h,-5.3 h)].령일방면,LH조창면봉합유합불량사건발생솔、계발감염발생솔、발열발생솔균비TVH조저,단차이무통계학의의.LH조비TVH조술후성공능질량경호.결론 재기본부합TVH괄응증적정황하,TVH시최미창적수술방식,차성개비고.재TVH괄응증이외,지요재가이조작적범위내,TVH잉연시창상최소차효과최호적수술방식,단저일범위목전상무통일표준,근술자경험수평、수술습관화환자구체정황상관.LH재개선술후생활질량、환자자아감각방면교위우월.통과제고복강경수술지혈기교감소술중출혈량,감소일차성기구비용혹기사용、증가기회수,가강저수술비용,병가이제고LH성개비.MiniLPT발전시간상단,상관비교연구기보야만,기우월성유대경다연구진일보평고.
Objective To compare and assess the effectiveness between total vaginal hysterectomy (TVH), Laproscopical hysterectomy (LH) and minilaporotomy hysterectomy (MiniLPT). Methods We searched CBM, CKNJ, MEDLINE, EMbase, Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED to screen randomized controlled trials (RCTs) comparing one surgical approach to another of extrafascial hysterectomy (between TVH, LH and miniLPT) which were done to those women with benign gynecological diseases. As to economy assessment, studies of cost-effective analysis were also included. Those observational studies reporting rare or important long-term outcome were also included. The quality of the included studies was evaluated by GRADE (Grades of Recommendation, Assess-ment, Development and Evaluation) system and principle of Cochrane Reviewer Handbook 4.2.3 RCT. Results Finally, we identified 12 trials including 10 RCTs, 1 retrospective cohort study and 1 respective cohort study. Cost-effective analy-sis showed when in indication of VH, TVH was more cost-effective than LH. When TVH was less but still accessible, meta-analysis showed TVH had significant advantages than the other two approaches in many sides. Compared with LH arm, operation time was shorter at a WMD 47.2 min and 95%CI 32.2 to 62.3 min, blood loss was less at a WMD 158.7 ml and 95%CI-190.9 to-126.4 ml, hospital stay was shorter at a WMD 23.9 h and 95%CI-25.4 to-13.9 h, and the first stool or to break wind was quicker at a WMD-8.1 h and 95%CI-10.8 to-5.3 h in TVH arm. But on the other side, the incidence rates of bad wound healing (such as vaginal cuff infection, abdominal wall infection, wound dehiscence, etc.), of secondary infection (such as UTI, URI, unknown infection, etc.), and of febrility were less common in LH arm than those in TVH ann with no significant difference. Meanwhile, ratio of sexual hypofunction, declined marital life quality and worse body image were more in TVH arm than those in LH arm, implying LH arm provided a better post-operation sexual life recov-ery. Operation time was longest in miniLPT arm at a WMD 37.0 h and 95%CI 13.5 to 60.5 h and blood loss was most at a WMD 208.5 ml and 95%CI 141.4 to 375.7 ml, too. The febrility rate was also the most common in miniLPT arm at a Peto OR 3.8 and 95% CI 1.1 to 12.6. The differences were significant. Condusiun TVH is the least invasive approach and better in cost-effectiveness when accessible. However, when inaccessible, the limitations remain unclear, depending on surgeons' own techniques and experience as well as patients' individual conditions. LH does better in improving quality of life and body image. Cost-effectiveness of LH may become much better by reducing blood loss during operation through improving techniques or instruments of hemostasis. Limited application of non-reproducible instrument or cost and promotion of their recycle may help a lot in bringing down LH operation cost, too. Owing to limited studies, the advan-tage of miniLPT should be evaluated more precisely by its technical development and more penetrating researches. There are huge gaps in standardized high-quality RCTs, performance and research of long-term outcomes and health economy comparing different approaches to total hysterectomy in China.
