Objective:To study the value of molecular classification in postoperative adjuvant therapy for endometrial carcinoma (EC).Methods:Patients with stage Ⅰ EC who underwent surgical-pathological staging surgery and molecular classification in Peking University Third Hospital from January 2020 to April 2022 were retrospectively analyzed. The influence of different molecular types of EC on postoperative adjuvant therapy were studied.Results:The age of the 196 patients was (55.1±10.2) years old, and the body mess index (BMI) was (26.0±3.9) kg/m 2. Molecular classification was performed in 196 stage ⅠEC patients, identifying the 4 subgroups: POLE mutation (POLEmut, n=19, 9.7%), mismatch repair-deficient (dMMR, n=28, 14.3%), no-specific molecular profile (NSMP, n=142, 72.4%) and p53 mutation (p53abn, n=7, 3.6%). Molecular classification was one of the influencing factors on the selection of postoperative adjuvant therapy for EC patients ( P=0.003). POLEmut, dMMR and NSMP subtypes were not the variables in selecting radiotherapy or combined chemo-radiotherapy postoperatively. p53abn subtype was not the influencer for radiotherapy, however, it may contribute to the selection of combined chemo-radiotherapy postoperatively ( P<0.001). Conclusion:The p53abn subtype in the molecular classification is an influencing factor in the selection of combined chemo-radiotherapy for EC patients postoperatively.

目的:分析全子宫切除术后阴道断端裂开的病例特点,识别高危因素、探索治疗方法.方法:回顾分析北京大学第三医院妇产科2009年至2021年行全子宫切除或广泛/次广泛子宫切除术后发生阴道断端裂开的18例患者的临床资料,对其术前临床特征、手术参数、术后发病时间、诱发因素、症状、脱出脏器特征及修复方式进行描述.结果:阴道断端裂开发病率为0.2％(18/8929),患者平均年龄(47.1±7.5)岁,平均体质量指数(BMI)(21.4±2.0)kg/m2.前次手术为腹腔镜手术15例、开腹手术3例.手术指征为恶性肿瘤15例、癌前病变1例、良性疾病2例.中位发病时间128.5 d.发病诱因包括性生活8例、经阴道超声检查3例、排便困难3例、无明显诱因4例.经阴式修复11例、腹腔镜修复5例、开腹1例、腹腔镜+阴式1例.4例患者同时行部分大网膜切除术.结论:全子宫切除术后阴道断端裂开多发生在恶性肿瘤患者术后,主要诱发因素为性生活及经阴道超声检查,多数可经阴式修复.

目的 探讨包块型剖宫产瘢痕妊娠(cesarean scar pregnancy,CSP)的临床特点及治疗方法.方法 回顾性分析2010年1月～2020年12月我院28例包块型CSP的临床特征及诊治情况.均有人流、药流或清宫史,术后异常阴道出血21例(其中失血性休克3例),血hCG下降不理想7例.入院距上次手术时间1～120 d,中位数21 d,其中<2周6例.包块直径14～66(35.3±14.7)mm;包块与膀胱间子宫肌层厚度1～5(1.7±1.0)mm.血β-hCG>1000 mIU/ml 18例(64.3％).行宫腔镜手术10例,宫、腹腔镜联合手术9例,腹腔镜手术5例,开腹手术4例.结果 行CSP残留组织清除27例,其中13例同时行剖宫产瘢痕修补,联合双侧子宫动脉栓塞或双侧子宫动脉上行支阻断6例,联合甲氨蝶呤治疗4例;腹腔镜全子宫双侧输卵管切除1例.手术均顺利完成,无并发症发生.其中5例术中或术后输悬浮红细胞400 ml.术后18～52 d(中位数26 d)血β-hCG降至正常范围.除全子宫切除术患者,余27例术后21～54 d月经复潮.结论 剖宫产瘢痕处剩余肌层薄和包块大是包块型CSP的两个重要特点,可采用联合治疗以减少并发症,提高疗效.

盆腔器官脱垂严重影响患者生活质量,对于高龄、合并症多的中重度盆腔器官脱垂的患者,如无性生活要求,可考虑行阴道封闭术.标准的阴道部分封闭术( Le Fort colpocleisis,LFC)是Le Fort 1877年首次提出的[ 1 ].LFC 术后子宫发生恶性肿瘤较少见,2019年12月我科收治1例LFC术后发生子宫癌肉瘤,报道如下.

目的 探讨妊娠中期卵巢良性肿瘤患者应用腹腔镜手术治疗的有效性和安全性.方法 回顾性分析2015年1月至2018年6月期间,北京大学第三医院收治的18例因中期妊娠合并卵巢良性肿瘤入院行腹腔镜手术治疗的患者临床资料,包括患者年龄、手术孕周、手术时间、术中出血量、术后住院日、术后病理结果、分娩结局.结果 18例患者手术均为腹腔镜,无中转开腹,无手术及麻醉并发症,患者平均年龄(30.5±3.0)岁,孕周(16.0±5.0)周,手术时间(61.0±19.0)min,术中出血(8.4±5.0)mL,术后住院时间(1.8±1.0)d,最终18例足月分娩,其中剖宫产7例,阴道分娩11例,新生儿均无窒息、畸形发生.结论 腹腔镜手术治疗中期妊娠合并卵巢良性肿瘤,安全有效,效果显著,对妊娠结局及新生儿无不良影响,可作为常规技术进行开展.

目的 探讨孕前宫颈环扎术治疗宫颈机能不全的疗效.方法 回顾分析我科2017年1月～2020年6月20例宫颈机能不全孕前行腹腔镜或经阴道宫颈环扎的临床资料.16例行腹腔镜宫颈环扎术,利用简易举宫器,于子宫峡部外1/3浆肌层由后向前或由前向后进针环扎宫颈内口;4例行经阴道宫颈环扎术,上推膀胱后打开后穹隆阴道黏膜至宫颈筋膜,向上分离至宫颈内口上1 cm,于宫颈内口水平缝合宫颈1/2肌层1周.结果 20例手术顺利,手术时间(40.9±12.1)min,术中出血量(7.8±4.3)ml.腹腔镜宫颈环扎术16例术中出血(7.9±4.7)ml;12例术后妊娠,其中9例已分娩(7例足月分娩).经阴道宫颈环扎术4例术中出血(7.5±2.9)ml;2例术后妊娠,其中1例足月顺产,1例目前孕30周.7例有中孕期宫颈环扎失败史中,5例术后妊娠,其中3例已分娩,分娩孕周分别为35、36+5、38+1孕周,1例尚在孕期,1例早孕期胚胎停育.结论 对于宫颈机能不全的患者,尤其是经历孕期宫颈环扎术后失败的患者,孕前行宫颈环扎术是一种简单、安全、有效的方法.

阴道上皮内瘤变(VAIN)是一类比较罕见的癌前病变,高危型人乳头瘤病毒持续感染是其主要的发病原因.多数VAIN患者无明显临床症状,常易漏诊,因宫颈病变或宫颈癌行子宫切除术的患者易发生VAIN,病变常位于阴道残端,难以发现,治疗更加困难.目前,临床上尚无治疗残端VAIN的指南,常见的治疗手段包括手术治疗、物理治疗、局部药物治疗等,手术切除治愈率高且可发现隐匿性的阴道癌.治疗后应严密随访,警惕阴道癌的发生.对于拟行子宫切除术患者,术前需仔细评估宫颈及阴道壁情况,及早发现和治疗VAIN,本文对残端阴道上皮内瘤变的临床特征进行综述.

Objective: To assess surgical outcomes of implanted porcine small intestinal submucosa (SIS) mesh in the rabbit vesicovaginal space (VVS) and explore its application value in pelvic floor reconstruction surgery. Methods: Sixteen male rabbits were randomly divided into four groups, and each group had four rabbits. All groups of rabbits were implanted with SIS mesh in the vesicovaginal space. They were humanely killed after a postoperative period of 7, 30, 90 and 180 days by group. The grafted area was removed with the surrounding bladder and vaginal tissues. The specimens were embedded in paraffin and then stained with HE and Masson's trichrome stains for visual observations, cells counts, and assessment of tissues and collagen fibers. Results: (1) After HE staining, a large number of inflammatory response cells mainly eosinophils and lymphocytes infiltrated around the SIS mesh in 7 days group, and neovascularization was observed, the infiltration area of inflammatory response cells further increased in 30 days group, the infiltration area of inflammatory response cells significantly reduced in 90 days group, while the inflammatory response basically subsided in 180 days group. (2) After Masson's trichromestaining, the collagen structure of SIS mesh in 7 days group was clear and intact. While, the collagen structure of SIS mesh was partially degraded in 30 days group, the SIS meshes of 4 rabbits were completely degraded, but the collagen fragments of SIS remained in 90 days group. In 180 days group, the SIS mesh of all rabbits was degraded, and one of them had the formation of new collagen fibers. Conclusions: SIS mesh implanted into the VVS of rabbits can lead to a transient non infective inflammatory reaction, which could be completely degraded and a small amount of new collagen fibers could be produced after 180 days of implantation. Which shown that SIS mesh should be used cautiously in pelvic floor reconstruction surgery.

目的 探讨单孔腹腔镜在妇科常见手术中的应用价值.方法 选取2016年4月—2018年8月在本院实施的单孔腹腔镜手术66例作为单孔腹腔镜组,其中输卵管切除27例,附件囊肿剔除术25例,全子宫附件切除14例;选取相同疾病的传统腹腔镜手术66例作为传统腹腔镜组,比较手术时间、切口开关时间、手术操作时间、术中出血量、术后疼痛评分(采用视觉模拟评分法,简称VAS评分)、术后住院时间、患者满意度情况.结果 两组均成功实施手术,无手术并发症发生.单孔腹腔镜组附件手术总时间(37.5±11.2)min、切口开关时间(8.4±2.6)min、手术操作时间(27.4±10.4)min,均明显长于传统腹腔镜组(20.1±6.4)min、(3.5±0.4)min、(18.1±7.9)min,差异有统计学意义(P<0.001);单孔腹腔镜组术中出血量(10.2±3.9)ml、术后疼痛VAS评分(4.4±1.3)分均高于传统腹腔镜组(3.5±1.6)ml、(2.7±0.8)分,差异有统计学意义(P<0.001).单孔腹腔镜组子宫切除手术总时间(62.1±22.1)min、切口开关时间(7.9±2.9)min、手术操作时间(45.5±19.3)min,均明显长于传统腹腔镜组(41.2±12.4)min、(3.4±0.7)min、(32.1±9.9)min,差异有统计学意义(P<0.05);单孔腹腔镜组术中出血量(25.7±12.6)ml、术后疼痛VAS评分(5.1±1.6)分高于传统腹腔镜组(12.4±3.8)ml、(3.4±1.4)分,差异有统计学意义(P<0.05).单孔腹腔镜组对手术的主观评价明显优于传统腹腔镜组,非常满意率分别为72.7％(48/66)和59.1％(39/66).结论 单孔腹腔镜行妇科常见手术,手术时间、操作难度增加,但切口美观隐匿,患者治疗满意度增加,在妇科疾病的治疗中有一定的应用价值.

目的 探讨阴道镜下宫颈量化指标在绝经后宫颈高级别鳞状上皮内病变(high-grade squamous intraepithelial lesion,HSIL)患者术式选择中的价值.方法 对2012年1月～2019年4月我院收治的年龄≥50岁宫颈HSIL,因无法宫颈锥切而直接行筋膜外全子宫切除术的绝经后宫颈萎缩患者(全切组)以及行锥切后再行筋膜外全子宫切除患者(锥切组)进行1:1配对,每组各41例.阴道镜下分别测量宫颈前后径D1和宫颈横径D2.根据D1和D2构建判别模型,研究判别模型的灵敏度、特异度及与手术分组符合率.另外选取35例锥切术进行验证.结果 全切组D1、D2分别为(1.58±0.41)cm和(1.69±0.39)cm,锥切组分别为(2.10±0.31)cm和(1.90±0.39)cm,2组间D1和D2差异有统计学意义(P=0.000,P=0.015).根据D1和D2构建的判别模型与手术分组相比,灵敏度和特异度分别为82.93％(95％CI:70.90％ ～94.95％)和75.61％(95％CI:61.89％ ～89.33％).2组患者通过分类判别函数分类后术式符合率为79.27％(65/82),35例验证分类判别函数分类后术式符合率为82.86％(29/35).结论 阴道镜下宫颈径线测量可以更客观地反映患者宫颈情况,与主观判断选择手术方式有一定的一致性,可考虑作为术式选择的临床量化指标.

目的:探讨早期高分化子宫内膜癌及子宫内膜不典型增生患者保留生育功能治疗的结局.方法:回顾性分析2010年1月至2017年12月就诊于北京大学第三医院要求保留生育功能的早期高分化子宫内膜癌患者43例及不典型增生患者77例的临床病理资料及治疗结局.结果:保守治疗的完全缓解(CR)率为96.67％ (116/120),不典型增生组患者保守治疗3个月CR的比例显著高于子宫内膜癌组(74.03％ vs 41.86％,P＜0.05).109例患者有妊娠要求,妊娠率为43.12％ (47/109)、活产率为33.03％(36/109).分析显示,体质量指数(BMI)、是否癌变及合并有糖尿病或胰岛素抵抗与治疗缓解后能否成功妊娠有关(P＜0.05),而治疗获得CR的时间及缓解后维持治疗与妊娠无关(P＞0.05).复发率为32.76％(38/116),中位复发间隔为17月,是否癌变(RR 5.624)是影响复发的独立危险因素(P＜0.05),达CR后的维持治疗(RR0.385)及妊娠(RR0.382)是影响复发的保护性因素(P＜0.05).子宫内膜癌组的中位复发间隔为13月,子宫内膜不典型增生组为24月,两组差异有统计学意义(P＜0.05).复发后重复孕激素治疗的有效率为100.00％ (31/31).结论:早期高分化子宫内膜癌和不典型增生的有生育要求的患者,保守治疗安全有效.保守治疗3个月子宫内膜不典型增生疗效好于子宫内膜癌.BMI、是否合并糖尿病和胰岛素抵抗及癌变与其妊娠有关,治疗达CR后的维持治疗并不影响妊娠,但治疗后复发率较高,妊娠和维持治疗是预防复发的保护因素.复发后重复保守治疗仍然有效.

目的 探讨单一部位切口腹腔镜手术(laparoendoscopic single-site surgery,LESS)在巨大卵巢肿瘤(直径>10 cm)中的应用价值.方法 对2017年4月～2018年12月在我院因巨大卵巢囊肿行卵巢囊肿剔除或患侧附件切除的46例资料进行回顾性分析,其中LESS 23例,肿瘤直径(16.32±5.06)cm,传统三孔腹腔镜手术23例,肿瘤直径(14.08±2.78)cm,2组差异无显著性(t=1.861,P=0.069).比较2组手术时间、术中出血量、手术并发症、术后24 h疼痛视觉模拟评分(Visual Analogue Scale,VAS)、住院时间、术后满意度.结果 LESS组行卵巢囊肿剔除18例,患侧附件切除2例,卵巢肿瘤分期手术(大网膜部分切除+盆腔及腹主动脉旁淋巴结活检)3例;三孔组分别为16例、6例、1例.2组手术过程顺利,均无术中及术后并发症.LESS组无囊肿破裂,三孔组囊肿破裂5例(21.7％),差异有显著性(P=0.049),2组术式、手术时间、术中出血量、术后住院时间差异无显著性(P>0.05),但术后切口疼痛VAS评分LESS组[(4.17±1.24)分]高于三孔组[(3.47±0.94分)](t=2.157,P=0.036).术后6个月2组满意度差异无显著性(P>0.05).结论 对于巨大卵巢肿瘤,LESS手术难度低,探查全面,安全可行,患者满意度高,具有一定的应用价值.

Abstract Objective To compare the chemoresistance and survival in patients with stage IIIC or IV epithelial ovarian cancer who were treated with neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) or primary debulking surgery (PDS). The clinical characteristics of patients who benefited from NACT were further evaluated. Methods We retrospectively analyzed 220 patients who underwent NACT followed by IDS or PDS from January 2002 to December 2016. Differences in clinicopathological features, chemoresistance and prognosis were analyzed. Results The incidence rate for optimal cytoreduction and chemoresistance in the NACT group was relatively higher than PDS group. No differences were observed in progression free survival or overall survival. Patients without macroscopic RD in NACT group (NACT-R0) had a similar prognosis compared to those in PDS group who had RD<1 cm, and a relatively better prognosis compared to the PDS group that had RD ≥ 1 cm. The survival curve showed that patients in NACT-R0 group that were chemosensitive seemed to have a better prognosis compared to patients in PDS group that had RD. Conclusion Patients without RD after PDS had the best prognosis, whereas patients with RD after NACT followed by IDS had the worst. However, even if patients achieved no RD, their prognosis varied depending on chemosensitivity. Survival was better in patients who were chemosensitive compared to thosewho underwent PDS but had RD. Hence evaluating the chemosensitivity and feasibility of complete cytoreduction in advance is crucial.

Objective To explore the value of primary and Advanced levels of laparoscopic simulating training in different seniority of gynecologic residents.Methods 77 residents in their first to forth training-year were divided into two groups:1-2 year resident and 3-4 year resident,trained with different levels of simulating training plans respectively and then assessed in the Department of Obstetrics and Gynecology in Peking University Third Hospital.Results The qualified rate of primary and advanced simulation training was 85.7％ and 57.1％ respectively.The qualified rate of primary training (80.4％ vs.100.0％,P=0.028) and advanced training (12.5％ vs.57.14％,P=0.000) were significantly different between 1-2 year residents and 3-4 year residents.The operative skills improved significantly in all the residents.In the 1-2 year residents,the scores of the primary training increased more obviously,while in the 3-4 year residents,the scores of the advanced training increased significantly.Conclusion It might be more effective for residents with different seniority to receive different levels of simulating training accordingly,so as to improve their laparoscopic operative skills more effectively.

通过对NB23和NB25两个显亏病种组的费用结构分析,发现平均住院日、诊查环节总费用、治疗环节总费用、材料费和总药费是亏损发生的危险因素,术前平均住院日为保护因素,依此提出从医院层面加强成本控制、从科室层面提高医疗效率、从管理层面强化质量监管、从发展层面鼓励技术创新、从政策层面支持支付标准动态调整等策略建议,以探索在DRG付费制度下的精益化管理模式.

子宫腺肌病是妇科临床常见病症,较大的囊性病变罕见,正确认识该病临床特点和鉴别诊断对临床治疗有重要意义,手术病灶去除是子宫囊性腺肌瘤的一种可行且有效的治疗手段.本文就北京大学第三医院妇科诊断并治疗的1例子宫囊性腺肌瘤的临床病例资料进行分析.

Objective To investigate the value of laparoscopic bilateral uterine artery occlusion combined with hysteroscopic resection in the treatment of cesarean scar pregnancy ( CSP ) . Methods A total of 62 patients with CSP were admitted to this hospital from January 2013 to May 2015.Transvaginal ultrasound was performed for primary screening , and pelvic MRI for diagnosis. Uterine arteries were separated and coagulated during laparoscopic surgery , followed by hysteroscopic surgery .The postoperative serum hCG level tests and ultrasonography examinations were conducted for evaluating the surgical outcomes . Results The procedure was successfully completed under laparoscopy and hysteroscopy without surgical complications or conversions to open surgery in all the cases.The median blood loss was 30 ml (P25:20 ml, P75:100 ml).In 4 patients the intraoperative bleeding reached 600, 600, 800, and 800 ml, respectively, due to large lesions, with blood transfusions requirement in 3 patients.One patient received secondary hysteroscopy due to unsatisfied hCG decrease .The serum hCG levels dropped to normal in 4-75 d (30.9 ±16.9 d) after operation. The menstuation cycles recovered to normal in 20-75 d (34.8 ±11.4 d).During follow-ups for 4-32 months (15.8 ±8.0 months) in 62 cases, 5 patients had subsequent pregnancy , 4 of which had full-term pregnancy and 1 of which experienced CSP again and received hysteroscopic removal of pregnancy . Conclusion Laparoscopic bilateral uterine artery coagulation and hysteroscopic removal of pregnancy is an ideal choice for the treatment of CSP with good outcomes .

目的 首次报道疆内首家妇科单孔腹腔镜手术(LESS)的开展情况,并探讨其在妇科微创领域中的应用.方法 乌鲁木齐市妇幼保健院单孔腹腔镜下完成的输卵管手术、卵巢手术和子宫手术共29例与2014年-2016年乌鲁木齐市妇幼保健院在传统腹腔镜下行输卵管手术699例、卵巢手术136例、宫腹腔镜联合探查术24例、全子宫切除术手术64例、子宫肌瘤剔除术85例进行对比.结果 手术成功完成,术中出血量与传统的腹腔镜手术无明显差异,但手术时间略有延长.结论 传统腹腔镜下能完成的输卵管、卵巢、子宫的各类妇科良性手术,单孔腹腔镜下均能够完成.

子宫内膜癌是威胁女性健康的常见恶性肿瘤,预后与肿瘤类型、疾病期别、治疗方法等密切相关.提高子宫内膜癌患者的早期诊断、早期治疗率,可显著改善患者的预后,明确子宫内膜癌的病理类型、确定肿瘤临床病理分期,决定辅助治疗方案的选择.本文根据子宫内膜癌的诊断和治疗方法情况,整理文献资料并进行了综述.

Objective To summarize the clinical characteristics of recurrent endometrial carcinoma.Methods A total of 22 cases of recurrent endometrial carcinoma from January 2006 to December 2015 were enrolled.Primary diagnosis of endometrial carcinoma were made in our hospital,with complete clinical data and standard NCCN staging operation.The recurrence of endometrial cancer was confirmed by pathological diagnosis after second surgery or biopsy.Clinical data were retrospectively analyzed.Results The median age of primary diagnosis was 52 years old (rang,44-63 years old).And the most common clinical symptom was postmenopausal vaginal bleeding (54.5％,12/22).There were 18 cases (81.8％) of endometrial adenocarcinoma,3 cases (13.6％) of serous adenocarcinoma,and 1 case (4.5％) of clear cell carcinoma.As to the muscular layer infiltration,there were 14 cases (63.6％) ＜ 1/2,7 cases (31.8％) ＞ 1/2 and 1 case (4.5％) involving the whole layer.There were 4 cases (18.2％) of positive pelvic lymph node and no para-aortic lymph nodes metastasis.As to the postoperative clinical pathologic stage,there were 12 cases (54.5％) of FIGO Ⅰ A,5 cases (22.7％) of FIGO Ⅰ B,1 case (4.5％) of FIGO Ⅱ,and4 cases (18.2％) of FIGO ⅢC1.The median recurrent time was 4 years (rang,1.5-7 years),without obvious self-conscious symptoms,including serum CA125 elevated in 12 cases (54.5％) and positive ultrasound,CT or X-ray examination findings in 10 cases (45.5％).As to the recurrence location,14 cases (63.6％) were in the pelvic cavity,6 cases (27.3％) of retroperitoneal lymph nodes,1 case (4.5％) of anterior abdominal wall accompaning lung metastasis,and 1 case (4.5％) of lung metastasis.Three patients accept Lynch syndrome screening,of which 2 cases were positive.Conclusions Muscular layer infiltration is common in recurrence of endometrial cancer,with no obvious clinical symptoms.Pelvic cavity is the most common location of recurrence.