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Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials
American Journal of Obstetrics and Gynecology ( IF 9.8 ) Pub Date : 2021-09-30 , DOI: 10.1016/j.ajog.2021.09.015
Salvatore Giovanni Vitale 1 , Gaetano Riemma 2 , Jose Carugno 3 , Tirso Perez-Medina 4 , Luis Alonso Pacheco 5 , Sergio Haimovich 6 , John Preston Parry 7 , Attilio Di Spiezio Sardo 8 , Pasquale De Franciscis 2
Affiliation  

Objective

To assess the efficacy of mechanical strategies to avoid the recurrence of intrauterine adhesions, to evaluate the impact on subsequent fertility after hysteroscopic adhesiolysis and to rank the available antiadhesive options.

Data Sources

MEDLINE, Scopus, ClinicalTrials.gov, CINAHL, Scielo, EMBASE, PROSPERO, Cochrane Library, conference proceedings, and international controlled trials registries were searched without temporal, geographic, and language restrictions.

Study Eligibility Criteria

Randomized trials that analyzed the recurrence, reproductive outcomes, or both in women undergoing hysteroscopic adhesiolysis followed by mechanical prevention of intrauterine adhesions were included. The exclusion criteria included the following: quasi-randomized trials and trials without randomization and studies including patients undergoing hysteroscopic surgery that was different from adhesiolysis.

Study Appraisal and Synthesis Methods

The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension statement for network meta-analyses guidelines were followed. We performed a network meta-analysis based on the random effects model for mixed multiple treatment comparisons to rank the antiadhesive strategies by surface under the cumulative ranking curve area. Quality assessment was performed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was the recurrent presence of intrauterine adhesions.

Results

Eleven studies with data for 1596 women were identified as applicable. A copper intrauterine device together with an intrauterine balloon (surface under the cumulative ranking curve area=46.4%) or with cross-linked hyaluronic acid gel (surface under the cumulative ranking curve area=21.3%) seemed effective in preventing adhesions recurrence. Regarding the fecundity, hyaluronic acid gel demonstrated the highest pregnancy rates (surface under the cumulative ranking curve area=79.8%). The greatest degrees of change in the mean adhesions scores were found with the use of hyaluronic acid gel plus an intrauterine device (surface under the cumulative ranking curve area=38.9%). For postsurgical adhesion severity, hyaluronic acid gel plus intrauterine device (surface under the cumulative ranking curve area=49.9%) followed by intrauterine device alone (surface under the cumulative ranking curve area=30.8%) was ranked the highest. Dried amnion graft (surface under the cumulative ranking curve area=53.8%) and uterine balloon (surface under the cumulative ranking curve area=45%) showed the greatest menstrual pattern improvement.

Conclusion

Cross-linked hyaluronic acid gel, with or without insertion of a copper intrauterine device, seems to be the most effective approach. However, the lack of a clear best therapy suggests the need for further studies to draw firm conclusions.



中文翻译:

宫腔镜粘连松解术后宫腔粘连复发的术后屏障策略:随机对照试验的网络荟萃分析

客观的

评估机械策略避免宫腔粘连复发的效果,评估宫腔镜粘连松解术后对后续生育能力的影响,并对可用的抗粘连选择进行排名。

数据源

检索了 MEDLINE、Scopus、ClinicalTrials.gov、CINAHL、Scielo、EMBASE、PROSPERO、Cochrane 图书馆、会议论文集和国际对照试验注册库,没有时间、地理和语言限制。

学习资格标准

随机试验分析了接受宫腔镜粘连松解术然后机械预防宫腔粘连的妇女的复发、生殖结果或两者。排除标准包括:半随机试验和非随机试验以及包括接受不同于粘连松解术的宫腔镜手术患者的研究。

研究评估和综合方法

遵循系统评价的首选报告项目和网络荟萃分析指南的荟萃分析扩展声明。我们基于混合多重治疗比较的随机效应模型进行了网络荟萃分析,以在累积排序曲线区域下按表面对抗粘连策略进行排序。使用 Cochrane Handbook for Systematic Reviews of Interventions 中概述的标准进行质量评估。主要结果是反复出现宫腔粘连。

结果

11 项包含 1596 名女性数据的研究被确定为适用。铜宫内节育器与宫内球囊(累积曲线下面积=46.4%)或交联透明质酸凝胶(累积曲线下面积=21.3%)似乎可有效预防粘连复发。关于生殖力,透明质酸凝胶的受孕率最高(累积排序曲线下面积=79.8%)。使用透明质酸凝胶加宫内节育器发现平均粘连评分的最大程度变化(累积排序曲线下面积=38.9%)。对于术后粘连严重程度,透明质酸凝胶加宫内节育器(累积排序曲线下面积=49. 9%)其次是单独的宫内节育器(累积排序曲线下面积=30.8%)排名最高。干燥的羊膜移植物(累积排名曲线下面积=53.8%)和子宫球囊(累积排名曲线下面积=45%)显示出最大的月经模式改善。

结论

交联透明质酸凝胶,无论是否插入铜宫内节育器,似乎是最有效的方法。然而,缺乏明确的最佳疗法表明需要进一步研究以得出明确的结论。

更新日期:2021-09-30
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