经阴道自然腔道内镜子宫肌瘤剔除术。
完整摘要 · 中文译文
背景：经阴道自然腔道内镜手术（vNOTES）避免了腹部切口，越来越多地用于良性妇科手术，但关于保留生育功能的子宫肌瘤剔除术的证据仍然有限。 方法：我们检索了PubMed、MEDLINE、EMBASE和Scopus（2000年1月1日至2025年7月31日），查找比较研究（vNOTES vs. 多孔或腹腔镜内镜单部位[LESS]子宫肌瘤剔除术）和单臂vNOTES队列。两名审稿人筛选/提取数据。使用纽卡斯尔-渥太华量表（比较研究）和乔安娜·布里格斯研究所（JBI；病例系列）评估偏倚风险。当可获得平均值±标准差（SD）时，进行随机效应荟萃分析（逆方差）；异质性通过I2评估。 结果：共纳入七项研究（三项比较性研究；四项单臂研究），总计348例vNOTES和272例腹腔镜手术病例。三项队列被纳入vNOTES与LESS比较的荟萃分析，涉及手术时间、出血量、住院时间、首次排气时间和中转率；两项队列被纳入感染汇总分析。手术时间无明显差异（均数差[MD] -2.2分钟，95%置信区间[CI] -10.8至6.4），出血量亦无明显差异（MD -1.9毫升，95% CI -20.2至16.5）。vNOTES与更早的首次排气相关（MD -7.4小时，95% CI -9.7至-5.1）。住院时间较短，但异质性高且估计不精确（MD -0.95天，95% CI -2.28至0.38；I²=96%）。术后感染估计在两个队列中倾向于LESS（RR 6.00，95% CI 1.10至32.63）。中转率不常见，但仅发生在vNOTES组（RR 5.01，95% CI 0.89至28.15）。在所有vNOTES队列中，直肠损伤发生率为4/348（1.15%）。 结论：在由专家中心治疗的高度选择患者中，vNOTES子宫肌瘤剔除术似乎是可行的，低确定性证据提示其肠道恢复早于LESS。然而，现有比较性证据为事件稀疏且观察性；所报告的直肠损伤和阴道/袖口感染应被视为产生假说的安全性信号，而非确定的比较风险。推广性和长期生殖结局仍不确定，因为需要来自比较性研究的更强有力证据。
完整摘要 · 英文原文
BACKGROUND: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) avoids abdominal incisions and is increasingly used for benign gynecologic surgery, but evidence for fertility-sparing myomectomy remains limited. METHODS: We searched PubMed, MEDLINE, EMBASE and Scopus (January 1, 2000 - July 31, 2025) for comparative studies (vNOTES vs. multi-port or laparoendoscopic single-site [LESS] myomectomy) and single-arm vNOTES cohorts. Two reviewers screened/extracted data. Risk of bias was assessed using Newcastle-Ottawa (comparative) and Joanna Briggs Institute (JBI; case series). Random-effects meta-analysis (inverse-variance) was performed when mean ± standard deviation (SD) were available; heterogeneity was assessed with I2. RESULTS: Seven studies were included (three comparative; four single-arm), totaling 348 vNOTES and 272 laparoscopic cases. Three cohorts contributed to the meta-analysis of vNOTES versus LESS for operative time, blood loss, length of stay, time to first flatus, and conversion; two cohorts contributed to infection pooling. There was no clear difference in operative time (mean differences [MD] -2.2 min, 95% confidence interval [CI] -10.8 to 6.4) or blood loss (MD -1.9 mL, 95% CI -20.2 to 16.5). vNOTES was associated with earlier first flatus (MD -7.4 h, 95% CI -9.7 to -5.1). Length of stay was shorter but highly heterogeneous and imprecise (MD -0.95 days, 95% CI -2.28 to 0.38; I2=96%). Postoperative infection estimates favored LESS in two cohorts (RR 6.00, 95% CI 1.10 to 32.63). Conversion was uncommon but occurred only in vNOTES arms (RR 5.01, 95% CI 0.89 to 28.15). Across all vNOTES cohorts, rectal injury occurred in 4/348 (1.15%). CONCLUSIONS: In highly selected patients treated in expert centres, vNOTES myomectomy appears feasible, with low-certainty evidence suggesting earlier bowel recovery versus LESS. However, the available comparative evidence is event-sparse and observational; reported rectal injuries and vaginal/cuff infections should be interpreted as hypothesis-generating safety signals rather than definitive comparative risks. Generalizability and long-term reproductive outcomes remain uncertain, as there is need for more robust evidence from comparative studies.