《巴西肿瘤外科协会盆腔廓清术治疗宫颈癌指南》解读

doi:10.3877/cma.j.issn.1673-5250.2021.02.004

2019年12月，巴西肿瘤外科协会(Brazilian Society of Surgical Oncology)针对放、化疗后局部持续或复发宫颈癌(PRCC)患者的补救性盆腔廓清术(PE)治疗，颁布《巴西肿瘤外科协会盆腔廓清术治疗宫颈癌指南》(Guidelines of the Brazilian Society of Oncologic Surgery for Pelvic Exenteration in the Treatment of Cervical Cancer)(以下简称为《PE指南》)。该指南基于目前文献中可获得最佳证据，对局部PRCC患者进行补救性PE的最佳处理方式提出建议。这是全球首次颁布的关于PE作为局部PRCC患者治疗选择的指南。笔者拟就该指南涉及的局部PRCC患者接受根治性或姑息性PE治疗的适应证、术前评估、术中评估，PE治疗手术入路及技巧、PE手术范围分类，PE患者尿路重建、阴道重建、肠道重建、盆底功能重建，以及PE术后患者随访等内容进行详细解读。

关键词: 宫颈肿瘤, 持续或复发宫颈癌, 盆腔廓清术, 肿瘤复发, 局部, 手术后并发症, 盆底功能重建, 修复外科手术, 女(雌)性

The Guidelines of the Brazilian Society of Oncologic Surgery for Pelvic Exenteration in the Treatment of Cervical Cancer (hereinafter referred to PE Guidelines) had been published in December 2019 for patients with locally persistent or recurrent cervical cancer (PRCC) after radiotherapy or chemotherapy. Recommendations for the best management of patients with locally PRCC undergoing salvage pelvic exenteration (PE) were developed and based on the best evidence available in literature. This is the first guideline or consensus on PE in the treatment of locally PRCC which has been proposed in the world. The research contents of PE Guidelines include indications for curative and palliative PE, preoperative and intraoperative evaluation, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-ups, which will be interpreted in this article.

Key words: Uterine cervical neoplasms, Persistent or recurrent cervical cancer, Pelvic exenteration, Neoplasm recurrence, local, Postoperative complications, Pelvic floor reconstruction, Reconstructive surgical procedures, Female

表1 《PE指南》证据水平(质量)分级体系

证据水平(质量)	证据来源
Ⅰ	来源于≥1项方法学质量高(偏倚风险低)的针对局部PRCC患者PE的大型随机对照试验，或对进行良好、无异质性的针对局部PRCC患者PE的随机对照试验进行的Meta分析
Ⅱ	来源于针对局部PRCC患者PE的小规模随机对照试验，或方法学质量较低的针对局部PRCC患者PE的大型随机对照试验，或偏倚风险高的Meta分析
Ⅲ	来源于针对局部PRCC患者PE的前瞻性队列研究
Ⅳ	来源于针对局部PRCC患者PE的回顾性队列研究或病例对照研究
Ⅴ	来源于针对局部PRCC患者PE的病例报告和专家观点

表1 《PE指南》证据水平(质量)分级体系

证据水平(质量)	证据来源
Ⅰ	来源于≥1项方法学质量高(偏倚风险低)的针对局部PRCC患者PE的大型随机对照试验，或对进行良好、无异质性的针对局部PRCC患者PE的随机对照试验进行的Meta分析
Ⅱ	来源于针对局部PRCC患者PE的小规模随机对照试验，或方法学质量较低的针对局部PRCC患者PE的大型随机对照试验，或偏倚风险高的Meta分析
Ⅲ	来源于针对局部PRCC患者PE的前瞻性队列研究
Ⅳ	来源于针对局部PRCC患者PE的回顾性队列研究或病例对照研究
Ⅴ	来源于针对局部PRCC患者PE的病例报告和专家观点

表2 《PE指南》推荐级别(强度)分级体系

推荐级别(强度)	证据与强度
A	强烈建议：有力证据证明具有疗效和重大临床益处
B	一般建议：强或中度证据证明具有疗效，但是临床益处有限
C	可选：疗效证据不足，或临床益处不会超过风险或缺点
D	一般不推荐：中度证据证明无效或导致不良结果
E	不推荐：有力证据证明否定疗效或导致不良结果

表2 《PE指南》推荐级别(强度)分级体系

推荐级别(强度)	证据与强度
A	强烈建议：有力证据证明具有疗效和重大临床益处
B	一般建议：强或中度证据证明具有疗效，但是临床益处有限
C	可选：疗效证据不足，或临床益处不会超过风险或缺点
D	一般不推荐：中度证据证明无效或导致不良结果
E	不推荐：有力证据证明否定疗效或导致不良结果

表3 PE手术范围分类

手术范围	肛提肌以上切除			肛提肌以下切除
手术范围	前PE	后PE	全PE	前PE	后PE	全PE
子宫/输卵管/卵巢	切除	切除	切除	切除	切除	切除
阴道	部分切除	部分切除	部分切除	切除	切除	切除
外阴	保留	保留	保留	术中评估后决定	保留	术中评估后决定
膀胱、尿道	切除	保留	切除	切除	保留	切除
直肠	保留	切除	切除	保留	切除	切除
肛门括约肌	保留	保留	保留	保留	切除	切除

表3 PE手术范围分类

手术范围	肛提肌以上切除			肛提肌以下切除
手术范围	前PE	后PE	全PE	前PE	后PE	全PE
子宫/输卵管/卵巢	切除	切除	切除	切除	切除	切除
阴道	部分切除	部分切除	部分切除	切除	切除	切除
外阴	保留	保留	保留	术中评估后决定	保留	术中评估后决定
膀胱、尿道	切除	保留	切除	切除	保留	切除
直肠	保留	切除	切除	保留	切除	切除
肛门括约肌	保留	保留	保留	保留	切除	切除

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Interpretation of the Guidelines of the Brazilian Society of Oncologic Surgery for Pelvic Exenteration in the Treatment of Cervical Cancer

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Interpretation of the Guidelines of the Brazilian Society of Oncologic Surgery for Pelvic Exenteration in the Treatment of Cervical Cancer