Uticaj laparoskopske cistektomije endometrioma na rezervu jajnika

Abstract

Cilj: Laparaskopska cistektomija primenom tehnike „ljušćenja“ kapsule dovodi do klinički značajnog smanjenja rezerve jajnika. Proceniti rezervu jajnika kod žena sa endometriotičnom cistom jajnika prečnika ≥ 4 cm, pre i nakon laparoskopskog uklanjanja endometriotične ciste, primenom tkz. tehnike „ljuštenja“ kapsule uz korišćenje bipolarne struje za uspostavljanje hemostaze. Ispitati oštećenje rezerve jajnika kroz određivanje vrednosti Antimilerovog hormona (AMH) u serumu pre same operacije, kao i 6, 12 meseci nakon operacije. Ispitati uticaj cistektomije na endokrinološku funkciju jajnika procenjeno kroz određivanje koncentracije Folikulostimulirajućeg hormona (FSH) i Estradiola (E2) u serumu pre operacije, kao i 6, 12 meseci nakon laparoskopske operacije. Metodologija: Ispitivanje po tipu prospektivne, kohortne studije, koje je sprovedeno na Odeljenju za ginekologiju i akušerstvo Opšte bolnice u Subotici, od februara 2013. do novembra 2016. godine. Studija je uključila 54 pacijentkinje reproduktivne životne dobi između 18 i 42 godine, sa redovnim menstrualnim ciklusima između 25-35 dana. Kod svih pacijentkinja je preoperativno, ultrazvučno ustanovljeno postojanje cistične formacije koja izgledom odgovara endometriotičnoj cisti prečnika ≥ 4 cm, kod 37 pacijentkinja (n=37) na jednom a kod 17 pacijentkinja (n=17) na oba jajnika. Laparoskopskim i histopatološkim pregledom je kod svih pacijentkinja potvrđena dijagnoza endometriotične ciste. Rezerva jajnika procenjivana je preoperativno od 3-5 dana menstrualnog ciklusa, kroz određivanje vrednosti Folikulostimulirajućeg hormona (FSH), Estradiola (E2) i Antimullerovog hormona (AMH) iz uzorka krvi kao i 6 i 12 meseci postoperativno. Laparoskopska cistektomija je rađena u opštoj anesteziji u kasnoj folikularnoj fazi menstrualnog ciklusa. Laparoskopska cistektomija je rađena na sledeći način: nakon identifikacije ravni klivaža, zid ciste je odvojen tehnikom „ljušćenja“ od okolnog zdravog, okružujućeg tkiva jajnika uz upotrebu dva atraumatska zupčasta forcepsa primenom pokreta trakcije i kontra-trakcije uz očuvanje hilusa jajnika. Dobijen materijal je poslat na histopatološki pregled. Hemostaza je uspostavljana primenom struje snage oko 25 W, uz upotrebu bipolarnog forcepsa na ležište ciste...

significant decrease in ovarian reserve To investigate the ovarian reserve in women with endometrioma ≥4 cm before and after laparoscopic endometrioma „stripping“ surgery using bipolar current to achieve hemostasis. Damage to the ovarian reserve will be examined by measuring AMH concentration, before the operation and 6 and 12 months after the operation. To investigate the effect of cystectomy of endometrioma on endocrine function assessed by measuring concentration of Follicle-stimulating hormone (FSH) and estradiol (E2) in serum before and 6- and 12 months after the operation. Methods and matherials: This prospective cohort study was conducted in the General Hospital, Subotica, Serbia, from February 2013. to November 2016. Study included 54 patients of reproductive age from 18 - 42 years of age, with regular menstrual periods ranging from 25 to 35 days. In all of these patients endometrioma in total diameter ≥ 4 cm was diagnosed by transvaginal ultrasound examination, in 37 patients (n=37) unilateral and in 17 patients (n=17) bilateral endometriomas. The ovarian reserve of the patients was determined by measuring serum levels of AMH, FSH and estradiol in the early follicular phase of their spontaneous menstrual cycle from the 3rd to the 5th day before surgery, as well as 6 and 12 months after laparoscopic endometrioma stripping surgery using bipolar current to achieve haemostasis. All operations were performed during the late follicular phase of the menstrual cycle. Laparoscopic cystectomy was performed as follows: We performed a diagnostic inspection of the pelvis and abdomen to assess the extend of the disease. Then we lysed the adhaesions and liberated the ovary from its adhaesions and from adhaesions with surrounding organs, if present. Subsequently, if the endometrioma remained unruptured during adhaesion-lysis, we performed an incision of endometrioma at the animesenteric site of the affected ovary using bipolar cautery, and the endometrioma was drained by means of aspiration of the chocolate content and further extension of the incision into the antemesenteric edge. After idenification the cleavage plane, the pseudocapsule was stripped from the healthy surrounding normal ovarian tissue with the use of two atraumatic grasping forceps by means of traction and countertraction. In some cases, the identification of the cleavage plane was difficult because the reactive tissue of the endometrioma was strongly adhered during ovarian-lysis and adhaesion-lysis, the rupture site on the ovaries was the starting point for cyst enucleaion. When necessary, haemostasis was achieved by application of a 25-W current with the use of bipolar current on the cyst bed. No suures were placed after endometrioma cystectomy...