资源描述
,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,子宫肌瘤的动脉栓塞治疗,(uterine artery embolization, UAE),1,子宫肌瘤的动脉栓塞治疗(uterine artery em,子宫肌瘤,子宫平滑肌瘤(,uterine leiomyoma,)简称子宫肌瘤(,uterine myoma,),由平滑肌细胞和不同数量的纤维结缔组织构成。,生育年龄女性最常见的良性肿瘤,多见于,30,50,岁,,41,50,岁为高峰,占,54.9,,,20,岁组和,60,岁以上组少见。资料统计,,30,岁以上女性发病率高达,20,30,,约占女性良性肿瘤的,51.78,。,10,30,有症状。常见症状是月经过频、过多、经期延长,贫血发生率增加,体质下降。,粘膜下肌瘤出血几率达,100,,肌壁间和浆膜下肌瘤出血率为,76,和,36,。,2,子宫肌瘤子宫平滑肌瘤(uterine leiomyoma ),UTERINE FIBROID,Benign tumor of uterine smooth muscle,Fibroids are not thought to be pre-cancerous,Also known as myomas,(肌瘤),or leiomyomas,(平滑肌瘤),Types: submucosal, intramural, and subserosal,3,UTERINE FIBROIDBenign tumor of,LOCATION OF UTERINE FIBROIDS,4,LOCATION OF UTERINE FIBROIDS4,5,5,SYMPTOMS OF UTERINE FIBROIDS,Menorrhagia,(,Heavier and longer menstrual bleeding,), sometimes with passage of blood clots. Anemia can occur if bleeding is severe,Pain, pressure, or feeling of fullness in the abdomen, pelvis or lower back,Frequent urination or constipation,(便秘),Pain and bleeding during or after intercourse,Infertility or miscarriage,6,SYMPTOMS OF UTERINE FIBROIDSMe,TREATMENT,surgery,micropuncture,UAE,HIFU,RF,medication,Chinese tradition medicine,7,TREATMENTsurgery7,HYSTERECTOMY,Surgical removal of uterus and fibroids, performed through abdominal incision or occasionally vaginally, sometimes with a laparoscope,Advantages: 100% Curative, No risk of future cancer, Well established procedure,Disadvantages: major surgery with potential surgical complications: ureteral injury, infection, adhesions (scarring), loss of child bearing,potential: emotional ? sexual ?,8,HYSTERECTOMYSurgical removal o,MYOMECTOMY,Individual fibroids are resected through an abdominal incision or sometimes with a laparoscope or hysteroscope,Advantages: Fertility can be preserved , well established procedure, less invasive if laparoscopic or hysteroscopic,9,MYOMECTOMY Individual fibroids,MYOMECTOMY DISADVANTAGES,Potential surgical complications as with hysterectomy,Only part of uterus is treated and recurrence can occur,15 to 25 % need repeat procedure usually hysterectomy,Not all fibroids amenable to myomectomy,Adhesions can lead to infertility,10,MYOMECTOMY DISADVANTAGES Poten,术式选择,目的:除去肌瘤、消除症状,要求:最佳术式、最佳效果,术式宜简单、创伤小,术后恢复快,不易产生并发症或后遗症,不影响远期生活质量。,11,术式选择目的:除去肌瘤、消除症状11,术 式,优 点,缺 点,子宫全切术(包括经腹、经阴、腹腔镜),可以完整地切除病变子宫、无复发,A:,断扎附件容易影响卵巢血供,致卵巢功能早衰,B:,破坏了盆底的完整性,C:,缩短了阴道、影响性生活,D:,手术难度、易出血、损伤泌尿道,子宫次全切除术,手术操作相对简单,并发症少,可以避免全切术的大部分缺点,A:,存在子宫颈残端癌的可能性,B:,仍有影响卵巢功能的问题存在,子宫筋膜内子宫切除术,避免了子宫全切术和子宫次全切除术的缺点,术后对卵巢功能仍有影响,子宫体中心切除术,不断扎子宫附件,操作简单,创伤相对减少,无泌尿道损伤的危险性,出血相对较多,仍,存在子宫颈残端癌的可能性,子宫肌瘤切除术(经腹、经阴、腹腔镜、宫腔镜),保留子宫,不影响卵巢功能,保留妊娠机会,复发率,20,25,;,妊娠、分娩时子宫破裂危险,术 式 优 缺 点 比 较,12,术 式优 点缺 点子宫全切术(包括经腹、经阴、腹,“,individual project,”,symptom,Age,demand of bearing,size,position,condition,13,“individual project”symptom 1,UAE,1991,年,法国妇科专家,Jacques Ravina,用子宫动脉术前栓塞来减少术中出血,偶然发现子宫肌瘤的病人已不需手术了。,1994,年,Ravina,首次报道将,UAE,应用于子宫肌瘤的治疗,14,UAE1991年,法国妇科专家Jacques Ravina,UAE,机 理,1.,栓塞子宫动脉可阻断肌瘤的供血血管,达到肌瘤去血管化。,正常子宫肌层有完善的交通血管网(双侧子宫动脉、卵巢动脉、阴部内动脉等),不会坏死;,子宫肌瘤的血供主要依靠双侧子宫动脉,新生的肿瘤血管为肌瘤提供终端营养,其为一独立的新生血管网,无储备的交通血管;,15,UAE 机 理1. 栓塞子宫动脉可阻断肌瘤的供血血管,达到肌,2.,肌瘤细胞分裂程度相对活跃,对缺血缺氧耐受力较差,致肌瘤平滑肌细胞变性坏死,肌瘤细胞总数明显减少,致瘤体萎缩;,3.,肌瘤细胞坏死致其自分泌(雌激素)现象消失,对子宫平滑肌的刺激消失,避免复发。,UAE,机理,16,2.肌瘤细胞分裂程度相对活跃,对缺血缺氧耐受力较差,致肌瘤平,子宫的血供,17,子宫的血供17,18,18,子宫动脉分支,升支,降支:,子宫颈、阴道上部,弓状动脉,宫底支,输卵管支,卵巢支,19,子宫动脉分支弓状动脉19,20,20,DSA,21,DSA21,22,22,旋转,DSA,23,旋转 DSA23,子宫肌瘤的血供,大部分由双侧子宫动脉同时供血,少数由单侧子宫动脉供血,肌瘤完全由右侧子宫动脉供血,24,子宫肌瘤的血供大部分由双侧子宫动脉同时供血肌瘤完全由右侧子宫,双侧供血,25,双侧供血25,动脉末期,实质期,26,动脉末期实质期26,子宫肌瘤为良性肿瘤,不会恶变,(肉瘤变,0.1,0.6,),,且在更年期后子宫肌瘤将自行萎缩,因此,只要症状改善,治疗目的就达到了,与恶性肿瘤非要彻底切除的治疗原则有本质的不同。,27,子宫肌瘤为良性肿瘤,不会恶变(肉瘤变0.10.6),且,UAE,适应证,与手术治疗的适应证基本相同:,1.,育龄期女性,绝经期前;,2.,肌瘤诊断明确且因之引起的经血过多及压迫症状明显;,3.,保守治疗(药物治疗及肌瘤切除术)无效或复发者;,4.,拒绝手术要求保留子宫及生育功能者;,5.,有特殊宗教信仰不能输血及手术者;,6.,经本人同意选择行栓塞治疗者;,7.,无症状性子宫肌瘤,肌瘤直径,4cm,;,8.,无症状性肌瘤,直径,4cm,,病人心理负担重,要求治疗者;,9.,体弱或合并严重内科疾病不能耐受手术者;,10.,巨大子宫肌瘤子宫切除前的栓塞治疗,利于减少术中出血。,28,UAE 适应证与手术治疗的适应证基本相同:28,UAE,相对禁忌证,1.,穿刺部位感染;,2.,妊娠或可疑妊娠者;,3.,盆腔炎或阴道炎未治愈者;,4.,心、肝、肾等重要器官功能障碍;,5.,急性炎症期或体温在,37.5,C,以上;,6.,严重动脉硬化及高龄患者。,29,UAE 相对禁忌证1. 穿刺部位感染;29,UAE,禁忌证,1.,妊娠;,2.,怀疑子宫平滑肌肉瘤;,3.,与附件肿块无法鉴别;,4.,子宫肌瘤生长迅速怀疑肉瘤变;,5.,带细蒂的浆膜下子宫肌瘤、阔韧带肌瘤及游离的子宫肌瘤;,6.,子宫动静脉瘘;,7.,多种对比剂过敏史;,8.,严重凝血机制异常。,30,UAE 禁忌证1.妊娠;30,术前准备,常规术前检查和准备,妇科检查、血常规凝血分析、肝肾功能、心电图、胸透、碘过敏试验、抗感染、备皮等,特殊术前检查和准备,超声检查,黑白超声:,彩色超声,2.,诊断性刮宫,排除子宫内膜癌及子宫肉瘤;了解肌瘤与宫腔的关系,3. MRI,4.,穿刺活检,5.,宫腔镜,31,术前准备常规术前检查和准备特殊术前检查和准备31,栓 塞 材 料,聚乙烯醇(,polyvinyl alcohol, PVA,)颗粒,直径,500700um,(,Ivalon,),真丝线段,明胶海绵,碘化油平阳霉素,32,栓 塞 材 料聚乙烯醇(polyvinyl alcohol,33,33,操 作 步 骤,股动脉穿刺,超选择性插管至子宫动脉,注入栓塞剂,34,操 作 步 骤34,UAE,技术难点,超选择性动脉插管技术,微导管和微导丝的应用,35,UAE 技术难点超选择性动脉插管技术35,36,36,37,37,PRE and POST UAE,38,PRE and POST UAE38,39,39,40,40,41,41,42,42,43,43,44,44,治疗前,治疗后三月,45,治疗前治疗后三月45,46,46,47,47,3 M,48,3 M48,49,49,F,24,50,F,2450,6M,16M,51,6M 16M51,Outcome of UAE,症状改善,肌瘤缩小,无需手术,52,Outcome of UAE 症状改善52,病人耐受性,利多卡因局麻,病人一直清醒,插管过程病人无疼痛或其它不适。,不补液、不输血、不开刀、不疼痛、不拆线。,53,病人耐受性利多卡因局麻,病人一直清醒,插管过程病人无疼痛或其,疗 效,栓塞成功率,99%,以上,有效率,8098%,6,月后肿瘤缩小,50%,以上,54,疗 效栓塞成功率99%以上54,正常子宫会不会坏死,正常子宫组织的供血来自于子宫动脉及其它盆腔小动脉,侧枝循环丰富,极少发生坏死。,55,正常子宫会不会坏死正常子宫组织的供血来自于子宫动脉及其它盆腔,能不能再怀孕,能!但不是,100%,保证能再怀孕,与栓塞材料和栓塞剂用量有关。,56,能不能再怀孕能!但不是100%保证能再怀孕,与栓塞材料和栓塞,并 发 症,无死亡病例报道,小于,0.6%,病例仍需手术,误栓、股动脉损伤等发生率,0.1%,以下,57,并 发 症无死亡病例报道57,并 发 症,严重并发症罕见,发生率,2,栓塞后综合征:疼痛、发热、恶心、呕吐,粘膜下或带蒂肌瘤坏死脱落导致剧烈腹痛及子宫出血,卵巢功能衰竭致闭经,58,并 发 症严重并发症罕见,发生率258,Rosiness of TAE,子宫肌瘤,产后大出血,宫外孕,恶性肿瘤动脉化疗,术前栓塞减少出血,59,Rosiness of TAE子宫肌瘤59,
展开阅读全文