Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Yale School of Public Health, New Haven CT.
Department of Radiology, Georgetown University School of Medicine, Washington, DC.
Am J Obstet Gynecol. 2023 Sep;229(3):275.e1-275.e17. doi: 10.1016/j.ajog.2023.05.020. Epub 2023 May 26.
Few studies have directly compared different surgical procedures for uterine fibroids with respect to long-term health-related quality of life outcomes and symptom improvement.
We examined differences in change from baseline to 1-, 2-, and 3-year follow-up in health-related quality of life and symptom severity among patients who underwent abdominal myomectomy, laparoscopic or robotic myomectomy, abdominal hysterectomy, laparoscopic or robotic hysterectomy, or uterine artery embolization.
The COMPARE-UF registry is a multiinstitutional prospective observational cohort study of women undergoing treatment for uterine fibroids. A subset of 1384 women aged 31 to 45 years who underwent either abdominal myomectomy (n=237), laparoscopic myomectomy (n=272), abdominal hysterectomy (n=177), laparoscopic hysterectomy (n=522), or uterine artery embolization (n=176) were included in this analysis. We obtained demographics, fibroid history, and symptoms by questionnaires at enrollment and at 1, 2, and 3 years posttreatment. We used the UFS-QoL (Uterine Fibroid Symptom and Quality of Life) questionnaire to ascertain symptom severity and health-related quality of life scores among participants. To account for potential baseline differences across treatment groups, a propensity score model was used to derive overlap weights and compare total health-related quality of life and symptom severity scores after enrollment with a repeated measures model. For this health-related quality of life tool, a specific minimal clinically important difference has not been determined, but on the basis of previous research, a difference of 10 points was considered as a reasonable estimate. Use of this difference was agreed upon by the Steering Committee at the time when the analysis was planned.
At baseline, women undergoing hysterectomy and uterine artery embolization reported the lowest health-related quality of life scores and highest symptom severity scores compared with those undergoing abdominal myomectomy or laparoscopic myomectomy (P<.001). Those undergoing hysterectomy and uterine artery embolization reported the longest duration of fibroid symptoms with a mean of 6.3 years (standard deviation, 6.7; P<.001). The most common fibroid symptoms were menorrhagia (75.3%), bulk symptoms (74.2%), and bloating (73.2%). More than half (54.9%) of participants reported anemia, and 9.4% women reported a history of blood transfusion. Across all modalities, total health-related quality of life and symptom severity score markedly improved from baseline to 1-year with the largest improvement in the laparoscopic hysterectomy group (Uterine Fibroids Symptom and Quality of Life: delta= [+] 49.2; symptom severity: delta= [-] 51.3). Those undergoing abdominal myomectomy, laparoscopic myomectomy, and uterine artery embolization also demonstrated significant improvement in health-related quality of life (delta= [+]43.9, [+]32.9, [+]40.7, respectively) and symptom severity (delta= [-]41.4, [-] 31.5, [-] 38.5, respectively) at 1 year, and the improvement persisted from baseline for uterine-sparing procedures during second (Uterine Fibroids Symptom and Quality of Life: delta= [+]40.7, [+]37.4, [+]39.3 SS: delta= [-] 38.5, [-] 32.0, [-] 37.7 and third year (Uterine Fibroids Symptom and Quality of Life: delta= [+] 40.9, [+]39.9, [+]41.1 and SS: delta= [-] 33.9, [-]36.5, [-] 33.0, respectively), posttreatment intervals, however with a trend toward decline in degree of improvement from years 1 and 2. Differences from baseline were greatest for hysterectomy; however, this may reflect the relative importance of bleeding in the Uterine Fibroids Symptom and Quality of Life, rather than clinically meaningful symptom recurrence among women undergoing uterus-sparing treatments.
All treatment modalities were associated with significant improvements in health-related quality of life and symptom severity reduction 1-year posttreatment. However, abdominal myomectomy, laparoscopic myomectomy and uterine artery embolization indicated a gradual decline in symptom improvement and health-related quality of life by third year after the procedure.
很少有研究直接比较不同的子宫肌瘤手术方法在长期健康相关生活质量结果和症状改善方面的差异。
我们研究了接受腹式子宫肌瘤切除术、腹腔镜或机器人子宫肌瘤切除术、腹式子宫切除术、腹腔镜或机器人子宫切除术或子宫动脉栓塞术的患者在基线至 1、2 和 3 年随访期间健康相关生活质量和症状严重程度的变化差异。
COMPARE-UF 登记是一项多机构前瞻性观察队列研究，研究对象为接受子宫肌瘤治疗的女性。纳入了 1384 名年龄在 31 至 45 岁之间的女性，其中 237 名接受了腹式子宫肌瘤切除术、272 名接受了腹腔镜子宫肌瘤切除术、177 名接受了腹式子宫切除术、522 名接受了腹腔镜子宫切除术和 176 名接受了子宫动脉栓塞术。我们通过问卷在入组时和治疗后 1、2 和 3 年获得了人口统计学、肌瘤病史和症状信息。我们使用 UFS-QoL（子宫肌瘤症状和生活质量）问卷来确定参与者的症状严重程度和健康相关生活质量评分。为了考虑治疗组之间潜在的基线差异，使用倾向评分模型来获得重叠权重，并使用重复测量模型比较入组后的总健康相关生活质量和症状严重程度评分。对于这个健康相关生活质量工具，尚未确定特定的最小临床重要差异，但根据以往的研究，认为 10 分的差异是合理的估计。在规划分析时，指导委员会同意使用这个差异。
在基线时，与接受腹式子宫肌瘤切除术或腹腔镜子宫肌瘤切除术的患者相比，接受子宫切除术和子宫动脉栓塞术的患者报告的健康相关生活质量评分最低，症状严重程度评分最高（P<.001）。接受子宫切除术和子宫动脉栓塞术的患者报告的子宫肌瘤症状持续时间最长，平均为 6.3 年（标准差为 6.7；P<.001）。最常见的子宫肌瘤症状是月经过多（75.3%）、肿块症状（74.2%）和腹胀（73.2%）。超过一半（54.9%）的参与者报告贫血，9.4%的女性报告有输血史。在所有治疗方式中，健康相关生活质量和症状严重程度评分从基线到 1 年显著改善，腹腔镜子宫切除术组的改善最大（Uterine Fibroids Symptom and Quality of Life：差值=+49.2；症状严重程度：差值=-51.3）。接受腹式子宫肌瘤切除术、腹腔镜子宫肌瘤切除术和子宫动脉栓塞术的患者在 1 年时也表现出健康相关生活质量（差值=+43.9、+32.9、+40.7）和症状严重程度（差值=-41.4、-31.5、-38.5）的显著改善，并且这些改善在第二（Uterine Fibroids Symptom and Quality of Life：差值=+40.7、+37.4、+39.3；症状严重程度：差值=-38.5、-32.0、-37.7）和第三年（Uterine Fibroids Symptom and Quality of Life：差值=+40.9、+39.9、+41.1；症状严重程度：差值=-33.9、-36.5、-33.0）的随访间隔内持续存在，但随着时间的推移，改善程度呈下降趋势。与其他治疗方式相比，子宫切除术的改善程度最大；然而，这可能反映了 Uterine Fibroids Symptom and Quality of Life 中出血的相对重要性，而不是接受子宫保留治疗的女性临床有意义的症状复发。
所有治疗方式在治疗后 1 年都与健康相关生活质量的显著改善和症状严重程度的降低相关。然而，腹式子宫肌瘤切除术、腹腔镜子宫肌瘤切除术和子宫动脉栓塞术表明，术后 3 年内症状改善和健康相关生活质量的改善程度逐渐下降。
