Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, New South Wales, Australia (Drs. Leonardi, Ong, and Condous); Sydney Medical School Nepean, The University of Sydney, Sydney, Australia (Drs. Leonardi, Condous, and Tong); Imperial College London Medical School, London, United Kingdom (Dr. Gibbons); NICM Health Research Institute, Western Sydney University, Penrith, Australia (Drs. Armour and Cave); Translational Health Research Institute, Western Sydney University, Sydney, Australia, (Drs. Armour and Mol); Robinson Research Institute, The University of Adelaide, Adelaide, Australia (Drs. Wang and Johnson); Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia (Dr. Wang); Fertility Plus, National Women's Hospital, Auckland, New Zealand (Drs. Glanville and Johnson); Department of Obstetrics & Gynaecology, Cairns Hospital, Cairns, Australia (Dr. Hodgson); Department of Obstetrics and Gynaecology, Mater Hospital Brisbane, Brisbane, Australia (Dr. Jacobson); Auckland Gynaecology Group and Repromed Auckland, Auckland, New Zealand (Dr. Johnson).
Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, New South Wales, Australia (Drs. Leonardi, Ong, and Condous); Sydney Medical School Nepean, The University of Sydney, Sydney, Australia (Drs. Leonardi, Condous, and Tong); Imperial College London Medical School, London, United Kingdom (Dr. Gibbons); NICM Health Research Institute, Western Sydney University, Penrith, Australia (Drs. Armour and Cave); Translational Health Research Institute, Western Sydney University, Sydney, Australia, (Drs. Armour and Mol); Robinson Research Institute, The University of Adelaide, Adelaide, Australia (Drs. Wang and Johnson); Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia (Dr. Wang); Fertility Plus, National Women's Hospital, Auckland, New Zealand (Drs. Glanville and Johnson); Department of Obstetrics & Gynaecology, Cairns Hospital, Cairns, Australia (Dr. Hodgson); Department of Obstetrics and Gynaecology, Mater Hospital Brisbane, Brisbane, Australia (Dr. Jacobson); Auckland Gynaecology Group and Repromed Auckland, Auckland, New Zealand (Dr. Johnson).
J Minim Invasive Gynecol. 2020 Feb;27(2):390-407.e3. doi: 10.1016/j.jmig.2019.10.014. Epub 2019 Oct 31.
We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis compared with alternative treatments. Moreover, we aimed to assess the risks of operative laparoscopy compared with those of alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision making around surgery.
We searched MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. In addition, a manual search of reference lists of relevant studies was conducted.
Published and unpublished randomized controlled trials (RCTs) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible.
TABULATION, INTEGRATION, AND RESULTS: In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies of interest were identified to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at 6 months compared with diagnostic laparoscopy (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61-4.34; p <.001; 2 RCTs, 102 participants; low-quality evidence). Because the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference regarding clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99-1.92; p = .06; 4 RCTs, 624 participants; moderate-quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared with diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84-4.65; p = .12; 5 RCTs, 554 participants; very-low-quality evidence). No studies reported on the progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and locations in asymptomatic women with endometriosis. We found no studies that reported on the timing of surgery. No quantitative or qualitative studies specifically aimed at elucidating the factors informing a woman's choice for surgery were identified.
Operative laparoscopy may improve overall pain levels but may have little or no difference with respect to fertility-related or adverse outcomes when compared with diagnostic laparoscopy. Additional high-quality RCTs, including comparing surgery to medical management, are needed, and these should report adverse events as an outcome. Studies on patient preference in surgical decision making are needed (International Prospective Register of Systematic Review registration number: CRD42019135167).
我们进行了一项系统评价和荟萃分析，旨在回答在有明确子宫内膜异位症的女性中，与其他治疗方法相比，手术腹腔镜是否是一种有效的治疗方法。此外，我们旨在评估手术腹腔镜与替代治疗方法相比的风险。此外，我们旨在系统地回顾关于患者偏好对手术决策影响的文献。
我们检索了 MEDLINE、Embase、PsycINFO、ClinicalTrials.gov、CINAHL、Scopus、OpenGrey 和 Web of Science，检索时间从成立到 2019 年 5 月。此外，还对相关研究的参考文献进行了手动搜索。
纳入了以任何语言描述手术与任何其他干预措施比较的已发表和未发表的随机对照试验（RCT），特别关注时间及其对疼痛和生育能力的影响。包括但不限于子宫内膜异位症、腹腔镜、盆腔疼痛和不孕等关键词的研究均包括在内。在预期缺乏关于患者偏好的 RCT 的情况下，所有关于该主题的原始研究均被认为符合条件。
列表、整合和结果：共审查了 1990 项研究。确定了 12 项研究符合纳入标准，以评估疼痛（n=6）、生育力（n=7）、生活质量（n=1）和疾病进展（n=3）的结果。确定了 7 项有价值的研究来评估患者的偏好。有证据表明，与诊断性腹腔镜检查相比，手术腹腔镜可能在 6 个月时改善总体疼痛水平（风险比[RR]，2.65；95%置信区间[CI]，1.61-4.34；p<0.001；2 项 RCT，102 名参与者；低质量证据）。由于证据质量非常低，尚不确定手术腹腔镜是否能提高活产率。与诊断性腹腔镜检查相比，手术腹腔镜可能对临床妊娠率几乎没有或没有差异（RR，1.29；95%CI，0.99-1.92；p=0.06；4 项 RCT，624 名参与者；中等质量证据）。与诊断性腹腔镜检查相比，手术腹腔镜是否会导致不良结局尚不确定（RR，1.98；95%CI，0.84-4.65；p=0.12；5 项 RCT，554 名参与者；极低质量证据）。没有研究报告子宫内膜异位症进展为有症状状态或在无症状子宫内膜异位症女性中根据病变体积和位置评估疾病严重程度的进展。我们没有发现报告手术时机的研究。没有专门旨在阐明女性选择手术的因素的定量或定性研究被确定。
与诊断性腹腔镜检查相比，手术腹腔镜可能会改善整体疼痛水平，但在生育相关或不良结局方面可能没有差异或差异很小。需要更多高质量的 RCT，包括比较手术与药物治疗，并且这些研究应该将不良事件作为一个结果进行报告。需要研究手术决策中患者偏好的研究（国际前瞻性系统评价注册号：CRD42019135167）。
