使用二氧化碳光纤激光汽化卵巢子宫内膜异位瘤的生育保留程序
Summary
在该协议中，CO2 光纤激光技术被证明用于卵巢子宫内膜异位症的手术治疗，这在保留生育能力方面代表了一种可行的替代方案，其主要优点是不依赖于外科医生的技能和个人经验。
Abstract
子宫内膜异位症的手术治疗仍然是一个有争议的问题。膀胱切除术被认为是标准技术，似乎与由于无意中切除和健康卵巢组织的热损伤而导致的卵巢储备的潜在减少有关。新的消融技术具有降低的组织穿透深度和较少的热扩散到周围实质的热扩散，可能是膀胱切除术的可行替代方案。由于这些原因，本手稿的目的是证明使用CO2 光纤激光技术消融子宫内膜异位症胶囊并讨论临床结果。一旦囊肿被引流并清洗，就进行活检。囊肿外翻后，使用CO2 光纤激光器进行囊肿内表面的汽化。该技术简单且可重复，因为即使是没有任何手术经验的年轻外科医生也更有信心进行激光CO2 汽化而不是膀胱切除术。一项随机对照试验报告了 CO2 技术的积极影响，其中比较了切除子宫内膜异位症（膀胱切除术）的患者和接受 CO2 激光内膜异位瘤汽化的患者的术后滤泡计数 （AFC） 和抗苗勒管激素 （AMH） 水平的变化。与膀胱切除组相比，接受CO2 激光治疗的患者显示AFC显着增加，血清AMH水平降低，其中两个参数均显着降低。还评估了术后妊娠率，并在两种治疗后发现了可比的妊娠率。相反，与膀胱切除术相比，使用CO2 光纤激光技术治疗的患者具有更有利的体外受精（IVF）结果。
总之，CO2 光纤激光技术在卵巢保存，妊娠率和IVF结局方面可能是膀胱切除术在子宫内膜异位症手术治疗中的可行替代方案。此外，它具有独立于外科医生的技能和个人经验的优势。
Introduction
卵巢子宫内膜异位症的最佳手术治疗，特别是当保留生育能力是渴望后代的女性的首要任务时，仍然是一个有争议的问题。虽然膀胱切除术仍然是推荐的技术1，但以前的研究已经引起了一些担忧，即由于无意中切除健康的卵巢实质2，3，4，其可能对卵巢储备和生殖结局产生不利影响。
事实上，与非子宫内膜异位囊肿不同，子宫内膜异位症是一种假性囊肿，没有被真正的解剖胶囊5包围，其中由游离铁和活性氧（ROS）引起的炎症在用纤维组织6取代周围正常卵巢皮质组织中起作用。因此，缺乏明确的计划可能导致切除健康卵巢实质的风险增加，即使膀胱切除术由经验丰富的外科医生进行 7 ， 8 。
此外，膀胱切除术介导的损伤可导致血管形成受损，因为在凝血过程中，热损伤扩散到周围的健康卵巢实质，如先前的发现所示，其中膀胱切除术后报告了卵巢动脉血流的不良变化9，10，11。
在我们机构，对膀胱切除术后卵巢损伤的担忧导致自2015年以来引入CO 2光纤激光技术。这种外科手术可以以受控的组织穿透深度和很少的热扩散来传递能量，其灵感来自20多年前12年雅克·唐内兹（Jacques Donnez）的工作。
虽然涉及CO2 光纤激光技术的消融技术并不代表子宫内膜异位症手术治疗的新颖性，但许多外科医生可能对该手术没有信心。事实上，只有少数研究调查了这种技术对卵巢储备，妊娠结局和子宫内膜异位症复发率的影响。该协议的目的是概述自2015年推出CO 2光纤激光器技术以来使用CO2 光纤激光器技术获得的有希望的结果，并描述该技术的简单性和可重复性。
首先，为了评估CO2 光纤激光汽化和膀胱切除术对卵巢储备标志物的影响，于2017年至2018年间进行了多中心随机试验。通过使用使用简单随机化方法的计算机生成的随机化列表，共有60名患者以1：1的比例随机分配到第1组（膀胱切除术：30名患者）或第2组（CO2 激光蒸发：30名患者）。为了研究术后自发受孕，2015年至2019年间对142名女性进行了前瞻性观察性研究，比较了膀胱切除术和激光汽化14。当CO2 光纤激光汽化后未实现妊娠时，患者被转诊到体外受精（IVF）诊所，然后被纳入前瞻性观察性研究（n = 26），以研究卵巢对受控卵巢刺激的反应15。在此之后，对2015年至2018年期间接受治疗且随访至少12个月的较大样本量研究人群（n = 125，有或没有后代欲望的女性）进行回顾性分析，以评估两种手术技术后囊肿和/或疼痛症状的复发率16。
Protocol
Representative Results
Discussion
该方法的目的是全面概述自2015年以来，我们在圣拉斐尔科学研究所使用CO 2光纤激光技术的经验，当时该技术首次开始用于子宫内膜异位症的手术治疗。由于子宫内膜异位症是一种慢性良性妇科疾病，影响具有潜在后代欲望的育龄妇女，因此手术技术需要尽可能节省生育能力。
一项 Cochrane 评价18 比较了消融和剥离技术，报告了膀胱切除术组自发妊娠…
Declarações
The authors have nothing to disclose.
Acknowledgements
没有为这项研究寻求或获得外部资金。
Materials
| CO2 fiber laser | UltraPulse Duo system, Lumenis Ltd | AC-1059590 | |
| Insufflation Needle | Covidien | 10065003 | |
| Laparoscopic Forceps | Erbe Elektromedizin GmbH | 20195-133 | |
| Manipulator | Lumenis Ltd | ||
| UltraPulse Duo | Lumenis Ltd | GA-2000000 | CO2 laser system |
| VIO 3 | Erbe Elektromedizin GmbH | 10160-000 | electrosurgical unit |
| Voluson S8 | GE Healthcare | 186958SU5 | ultrasound scan voluson system 8 |
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