Schindler A E, Bühler K, Lübben G, Kienle E
Zentrum für Frauenheilkunde, Universitätskliniken Essen, Aachen.
Zentralbl Gynakol. 1998;120(4):183-90.
Medical oestrogen suppressive therapy has to be considered as an important principle in the management of endometriosis. In the last years GnRHa became the "gold standard" as pre or postoperative measures before/after surgical intervention. We analyzed the data of 198 patients, most of them with recurrent endometriosis histologically confirmed during first-look laparoscopy. Patients were treated in a prospective, multicentre phase III study with the six months GnRHa leuprorelinacetate depot (LAD) followed by a second-look laparoscopy for precise assessment of therapeutic effects. In all stages of endometriosis a 35% reduction of the r-AFS-score compared to the baseline could be achieved due to surgical intervention during first-look laparoscopy with a further improvement of 64% after GnRHa-therapy and surgery during second-look laparoscopy. Two subgroups of patients (24 vs. 45) could be analyzed according to the time of second-look laparoscopy (< or = 30 days vs. > or = 60 days after last injection) showing a comparable r-AFS-score reduction. Both, superficial lesions and deep infiltrating nodules, endometriomas, peritoneal implants and obliterated cul de sac could successfully be treated through the combined medical-surgical approach. Pre- or postoperative therapy with a GnRHa facilitates surgical excision of the implants, a subtle adhesiolysis and often complete removal of all visible lesions. In a high percentage of patients, including advanced stages of the disease, a preservation of ovarian tissue to ensure the childbearing potential could be achieved by minimal-invasive techniques. These results can be claimed as the prerequisites for long-term relief of endometriosis complaints and encouraging pregnancy rates in endometriosis related infertility. This confirms great clinical benefit of the combined medical-surgical approach for the treatment of this enigmatic disease.
医学雌激素抑制疗法必须被视为子宫内膜异位症管理中的一项重要原则。在过去几年中，GnRHa成为手术干预前后术前或术后措施的“金标准”。我们分析了198例患者的数据，其中大多数患者在首次腹腔镜检查时经组织学证实患有复发性子宫内膜异位症。患者在一项前瞻性、多中心III期研究中接受治疗，使用六个月的GnRHa亮丙瑞林醋酸盐长效注射剂（LAD），随后进行二次腹腔镜检查以精确评估治疗效果。在子宫内膜异位症的所有阶段，由于首次腹腔镜检查时的手术干预，r-AFS评分与基线相比可降低35%，在二次腹腔镜检查时进行GnRHa治疗和手术后进一步改善64%。根据二次腹腔镜检查的时间（末次注射后≤30天与≥60天）可分析两个患者亚组（24例与45例），显示r-AFS评分降低相当。浅表病变和深部浸润结节、子宫内膜瘤、腹膜植入物和闭塞的直肠子宫陷凹均可通过联合药物-手术方法成功治疗。术前或术后使用GnRHa进行治疗有助于手术切除植入物、精细的粘连松解，且通常能完全切除所有可见病变。在高比例的患者中，包括疾病晚期，通过微创技术可以保留卵巢组织以确保生育潜力。这些结果可被视为子宫内膜异位症症状长期缓解以及子宫内膜异位症相关不孕症令人鼓舞的妊娠率的先决条件。这证实了联合药物-手术方法治疗这种疑难疾病具有巨大的临床益处。
