CAJ | 학술논문

目的探讨阴式筋膜外子宫颈切除术保守性治疗Ⅰ a1期宫颈鳞癌及不适于行宫颈锥切术的宫颈上皮内瘤变(CIN)Ⅲ级患者的可行性及安全性.方法选择大面积CINⅢ(阴道镜下病变面积≥3/4)、CINⅡ～Ⅲ锥切术后或环形电切术(LEEP)术后复发、病变残存或切缘阳性、经LEEP并活检后病理诊断的宫颈鳞癌Ⅰ a1期(除外脉管受累)、CINⅢ合并阴道上段上皮内瘤变(VAIN),且要求保留子宫和(或)生育功能的患者,行阴式筋膜外子宫颈切除术治疗,对其临床资料进行分析.结果 79例接受阴式筋膜外子宫颈切除术的患者中,Ⅰ a1期宫颈鳞癌6例,大面积CINⅢ61例(23例累及腺体),CINⅢ合并VAIN 3例,CINⅢLEEP术后病变残存6例、切缘阳性2例,CINⅡ锥切术后复发1例.79例患者的平均手术时间为39 min,平均出血量为40ml,平均住院时间为10 d.3例CINⅢ合并VAIN者切除阴道壁2 cm以上,占3.8％ (3/79).无手术副损伤,无输尿管损伤,无术中、术后大出血.随访未发现术后复发病例,月经异常14例,无性生活影响.5例有生育要求的患者中,1例患者自然流产1次,人工流产1次,现术后第3次妊娠20+2周.足月妊娠分娩4例,其中3例为剖宫产,1例为顺产.结论对于Ⅰ a1期宫颈鳞癌、大面积CINⅢ、CINⅢ合并VAIN以及CINⅡ～Ⅲ锥切术后复发、病变残存、切缘阳性等不适于行宫颈锥切术患者,阴式筋膜外子宫颈切除术是一种安全有效的保守性治疗术式.
목적 탐토음식근막외자궁경절제술보수성치료Ⅰ a1기궁경린암급불괄우행궁경추절술적궁경상피내류변(CIN)Ⅲ급환자적가행성급안전성.방법 선택대면적CINⅢ(음도경하병변면적≥3/4)、CINⅡ～Ⅲ추절술후혹배형전절술(LEEP)술후복발、병변잔존혹절연양성、경LEEP병활검후병리진단적궁경린암Ⅰ a1기(제외맥관수루)、CINⅢ합병음도상단상피내류변(VAIN),차요구보류자궁화(혹)생육공능적환자,행음식근막외자궁경절제술치료,대기림상자료진행분석.결과 79례접수음식근막외자궁경절제술적환자중,Ⅰ a1기궁경린암6례,대면적CINⅢ61례(23례루급선체),CINⅢ합병VAIN 3례,CINⅢLEEP술후병변잔존6례、절연양성2례,CINⅡ추절술후복발1례.79례환자적평균수술시간위39 min,평균출혈량위40ml,평균주원시간위10 d.3례CINⅢ합병VAIN자절제음도벽2 cm이상,점3.8％ (3/79).무수술부손상,무수뇨관손상,무술중、술후대출혈.수방미발현술후복발병례,월경이상14례,무성생활영향.5례유생육요구적환자중,1례환자자연유산1차,인공유산1차,현술후제3차임신20+2주.족월임신분면4례,기중3례위부궁산,1례위순산.결론 대우Ⅰ a1기궁경린암、대면적CINⅢ、CINⅢ합병VAIN이급CINⅡ～Ⅲ추절술후복발、병변잔존、절연양성등불괄우행궁경추절술환자,음식근막외자궁경절제술시일충안전유효적보수성치료술식.
Objective To explore the feasibility and safety of transvaginal external fascia trachelectomy to conservatively treat patients with stage Ⅰ a1 squamous carcinoma of the uterine cervix (SCC) and cervical intraepithelial neoplasia (CIN) Ⅲ,who are not suitable to take cold knife conization (CKC).Methods From July 2002 to September 2010,those patients who had a strong desire to preserve the uterus or fertility but also are confronted with following situations received transvaginal external fascia trachelectomy:CIN Ⅲ with large area lesion (colposcopically observed lesion area was larger than 3/4 of the cervix),or patients with CIN Ⅱ-Ⅲ suffered recurrence or had persistent lesion or positive margin after CKC or LEEP,or patients with CIN Ⅱ-Ⅲ upgraded into stage Ⅰa1 SCC through LEEP and pathological confirmation (except for those with lymphovascular space invasion),or CIN Ⅲ patients complicated with upper vaginal intraepithelial neoplasia (VAIN).Their clinical information and data were reviewed and analyzed.Results Among the 79 cases,who underwent transvaginal external fascia trachelectomy,six were stage Ⅰa1 SCC,61 were CIN Ⅲ with a large area lesion (23 cases had glandular involvement),three were CIN Ⅲ complicated with VAIN,six were CIN Ⅲ with persistent lesion after LEEP,two were CIN Ⅲ with positive margins after LEEP,and one case had recurrence after conization.The median age of these patients was 33 years old,ranging from 23 to 40 years old.The mean operation time was 39 min (rang 20-60 min),the average amount of bleeding was 40 ml (rang 1-300 ml) and the mean hospital stay was 10 d (rang 6-17 d).The CIN Ⅲ patients complicated with VAIN received this surgery with resection of the adjacent vaginal mucosa more than 2 cm in 3.8％ (3/79).The median follow-up time was 49 months (8-85 months) and none of these patients had ureteral injury or large amount of intraoperative or postoperative bleeding or post-operative recurrence.No patient complained any effect on their sexual life.Among the five patients with reproductive desire,one was at her 22 w gestation after one induced abortion and one spontaneous abortion,four patients experienced term birth in which three were cesarean section and one was natural labour.Conclusions Transvaginal external fascia trachelectomy is a safe and effective conservative treatment for stage Ⅰ al SCC,CIN Ⅲ with large area lesion,CIN Ⅲ complicated with VAIN and CIN Ⅱ-Ⅲ suffering recurrence,persistent lesion or positive margins after CKC and others that are not suitable to take CKC.