Divisions of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Faculty of Medicine, Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany.
Am J Obstet Gynecol. 2021 Oct;225(4):399.e1-399.e32. doi: 10.1016/j.ajog.2021.06.074. Epub 2021 Jun 26.
Opportunistic salpingectomy is now recommended at the time of routine gynecologic surgery to reduce the risk of future ovarian cancer, and performance of opportunistic salpingectomy has increased markedly at the time of benign hysterectomy. Salpingectomy has also been suggested to be feasible at the time of cesarean delivery in women desiring sterilization; however, uptake has not been previously studied on a national level.
This study aimed to examine recent population trends in the utilization and characteristics of salpingectomy at the time of cesarean delivery in the United States.
This is a population-based retrospective observational study querying the National Inpatient Sample between October 2015 and December 2018. The primary outcome measure was the temporal trend of bilateral salpingectomy at cesarean delivery, assessed with linear segmented regression with log transformation utilizing 3-month time increments. The secondary outcome measures included patient characteristics associated with bilateral salpingectomy, assessed with a multinomial regression model, and surgical outcome (hemorrhage, blood transfusion, hysterectomy, and oophorectomy) at the time of bilateral salpingectomy vs bilateral tubal ligation, assessed with generalized estimating equation in a propensity score-matched model.
There were 3,813,823 women at the age of 15 to 49 years who had cesarean deliveries included, of whom 397,260 (10.4%) had bilateral salpingectomy and 203,400 (5.3%) had bilateral tubal ligation overall. During the time period studied, performance of bilateral salpingectomy among women undergoing cesarean delivery significantly increased from 4.6% to 13.2% (odds ratio for the fourth quarter of 2018 vs the fourth quarter of 2015, 2.69; 95% confidence interval, 2.63-2.75; Figure panel). In contrast, performance of bilateral tubal ligation among women undergoing cesarean delivery significantly decreased from 11.3% to 2.4% (odds ratio, 0.20; 95% confidence interval, 0.19-0.21). By the third quarter of 2016, the number of women who had bilateral salpingectomy exceeded those who had bilateral tubal ligation at cesarean delivery (8.6% vs 7.3%). Increasing the utilization of bilateral salpingectomy did not vary across age groups; the salpingectomy rate increased from 7.5% to 21.1% among women at the age of ≥35 years and from 3.8% to 10.7% among women at the age of <35 years (both, P<.001). In a propensity score matched model, women in the bilateral salpingectomy group were more likely to have hemorrhage (3.8% vs 3.1%; odds ratio, 1.24; 95% confidence interval, 1.15-1.33), blood product transfusion (2.1% vs 1.8%; odds ratio, 1.16; 95% confidence interval, 1.04-1.30), hysterectomy (0.8% vs 0.4%; odds ratio, 2.28; 95% confidence interval, 1.84-2.82), and oophorectomy (0.3% vs 0.2%; odds ratio, 2.02; 95% confidence interval, 1.47-2.79) than those in the bilateral tubal ligation group. When restricted to the nonhysterectomy cases, the bilateral salpingectomy group had a higher rate of hemorrhage (3.4% vs 3.0%; odds ratio, 1.16; 95% confidence interval, 1.06-1.26) and oophorectomy (0.3% vs 0.1%; odds ratio, 1.75; 95% confidence interval, 1.22-2.50) than the bilateral tubal ligation group.
In the United States, the utilization of bilateral salpingectomy at the time of cesarean delivery increased rapidly between 2015 and 2018, replacing tubal ligation as the most common type of sterilization performed with cesarean delivery. The higher surgical morbidity in the bilateral salpingectomy group than the bilateral tubal ligation group observed in this study warrants further investigation.
目前推荐在常规妇科手术时行机会性输卵管切除术，以降低未来卵巢癌的风险，良性子宫切除术时行机会性输卵管切除术的比例显著增加。在有绝育需求的剖宫产时行输卵管切除术也被认为是可行的，但以前尚未在全国范围内进行过研究。
本研究旨在评估美国剖宫产时行输卵管切除术的近期人群趋势和特征。
这是一项基于人群的回顾性观察性研究，利用国家住院患者样本（National Inpatient Sample）数据库，检索了 2015 年 10 月至 2018 年 12 月的数据。主要结局指标是剖宫产时行双侧输卵管切除术的时间趋势，采用对数变换的线性分段回归，以 3 个月为时间增量进行评估。次要结局指标包括双侧输卵管切除术患者的特征，采用多分类回归模型进行评估，以及在双侧输卵管切除术与双侧输卵管结扎的倾向性评分匹配模型中，采用广义估计方程评估手术结局（出血、输血、子宫切除术和卵巢切除术）。
共纳入了 3813823 名年龄在 15 至 49 岁之间的行剖宫产的女性，其中 397260 名（10.4%）行双侧输卵管切除术，203400 名（5.3%）行双侧输卵管结扎术。在研究期间，剖宫产时行双侧输卵管切除术的比例从 4.6%显著增加至 13.2%（2018 年第四季度与 2015 年第四季度相比，比值比为 2.69；95%置信区间为 2.63-2.75；图面板）。相比之下，剖宫产时行双侧输卵管结扎术的比例从 11.3%显著下降至 2.4%（比值比为 0.20；95%置信区间为 0.19-0.21）。到 2016 年第三季度，行双侧输卵管切除术的女性数量超过了行双侧输卵管结扎术的女性（8.6% vs 7.3%）。双侧输卵管切除术的使用率在不同年龄组之间没有差异；35 岁及以上女性的输卵管切除术率从 7.5%增加至 21.1%，35 岁以下女性的输卵管切除术率从 3.8%增加至 10.7%（均 P<.001）。在倾向评分匹配模型中，双侧输卵管切除术组的女性更有可能出现出血（3.8% vs 3.1%；比值比为 1.24；95%置信区间为 1.15-1.33）、输血（2.1% vs 1.8%；比值比为 1.16；95%置信区间为 1.04-1.30）、子宫切除术（0.8% vs 0.4%；比值比为 2.28；95%置信区间为 1.84-2.82）和卵巢切除术（0.3% vs 0.2%；比值比为 2.02；95%置信区间为 1.47-2.79），而双侧输卵管结扎组的女性则相对较少。当仅限于非子宫切除术病例时，双侧输卵管切除术组的出血率（3.4% vs 3.0%；比值比为 1.16；95%置信区间为 1.06-1.26）和卵巢切除术率（0.3% vs 0.1%；比值比为 1.75；95%置信区间为 1.22-2.50）均高于双侧输卵管结扎组。
在美国，2015 年至 2018 年期间，剖宫产时行双侧输卵管切除术的使用率迅速增加，取代了双侧输卵管结扎术，成为剖宫产时最常见的绝育方式。本研究中观察到的双侧输卵管切除术组比双侧输卵管结扎术组更高的手术发病率需要进一步研究。
