子宮切除術後進行壓力型尿失禁手術的風險可能增加一倍


  October 25, 2007 —根據發表於10月27日Lancet期刊的一篇全球人口基礎的世代研究,不論手術技術,接受過子宮切除術的婦女需要接受壓力型尿失禁手術的風險可能更高;一篇相關評論指出,這些資料的研究不同於之前的那些研究,因為以前的研究樣本小且資料蒐集困難。
  
  Danderyd大學醫院的Daniel Altman醫師和同事指出,子宮切除術治療良性適應症會增加下泌尿道後遺症風險,但是結果尚不確定;我們目標在確定子宮切除術治療良性適應症後進行壓力型尿失禁手術的風險。
  
  該研究使用1973年到2003年的瑞典住院註冊資料,比較165,260位接受婦女子宮切除術的婦女(曝露世代)進行壓力型尿失禁手術的發生率,對照組是479,506位年紀和居住地區相符但未進行子宮切除術者(未曝露世代);使用Cox 相對危險迴歸(Cox proportional hazards regression)確認風險比(hazard ratios (HRs))。
  
  從1973到2003年,壓力型尿失禁手術的比率,在曝露世代是每100,000人-年有179 (95% 信心區間 [CI], 173 – 186),而未曝露世代則是76(95% CI, 73 – 79);不論手術技術,接受子宮切除術者的壓力型尿失禁手術比率是未曝露世代的兩倍以上 (HR, 2.4; 95% CI, 2.3 – 2.5)。
  
  風險因追蹤期間而略有不同,最高的整體風險是在手術後5年內(HR, 2.7; 95% CI, 2.5 – 2.9),最低的風險則是在手術10年以後(HR, 2.1; 95% CI, 1.9 – 2.2)。
  
  作者指出,子宮切除術治療良性適應症,不論手術技術,都會增加後續的壓力型尿失禁手術風險;婦女必須接受子宮切除術風險的相關諮詢,以及在手術前考慮其他治療選擇;我們的研究發現,對婦女接受子宮切除術治療良性適應症的公共衛生和臨床運用相當重要。
  
  研究作者提出,造成需要進行壓力型尿失禁手術的風險原因,包括子宮和子宮頸於骨盆腔底部手術時發生創傷,此外,子宮切除術會損傷尿道擴約肌,以及尿道和膀胱頸 。
  
  研究限制包括無法計算潛在行為和生活型態,如抽菸、費力工作、以及身體質量指數對壓力型尿失禁的影響。
  
  瑞典醫學會和Eli Lilly藥廠贊助此項研究,作者宣稱沒有相關財經關係。
  
  在伴隨而來的建議中,英國Royal Free醫院的Adam Magos醫師指出,這些研究發現和以前的研究-包括Altman醫師之前的研究有所衝突。
  
  Magos醫師表示,事實是有許多研究以泌尿症狀和膀胱功能評估子宮切除術後的影響,但是沒有一致性,無法否認地,之前的研究比較小型且追蹤期短,但是大多數報告均提到沒有子宮切除術的不利影響或者好處。
  
  Magos醫師指出,看起來似乎單純子宮切除術對膀胱功能不會有不良影響,至少在最初,而需要改善的是原本存在的症狀;如果子宮切除術導致泌尿道壓力失禁是事實,只是在手術後數年發生,或者可能和子宮切除術沒有任何關係,只是以我們尚不清楚的不同方式同意婦女的子宮切除術。

Risk for Stress-Urinary-Incont

By Laurie Barclay, MD
Medscape Medical News

October 25, 2007 — Regardless of surgical technique, women who have had a hysterectomy are at a much greater risk for needing stress-urinary-incontinence surgery, according to the results of a nationwide, population-based, cohort study reported in the October 27 issue of The Lancet. An accompanying Comment notes that results from this registry data study differ significantly from those of previous studies, which were smaller and gathered the data differently.

"Hysterectomy for benign indications has been associated with an increased risk for lower-urinary-tract sequela, but results have been inconclusive," write Daniel Altman, MD, from Danderyd University Hospital in Stockholm, Sweden, and colleagues. "We aimed to establish the risk for stress-urinary-incontinence surgery after hysterectomy for benign indications."

Using the Swedish Inpatient Registry from 1973 to 2003, the investigators compared the occurrence of stress-urinary-incontinence surgery in 165,260 women who had undergone hysterectomy (exposed cohort) with that in a control group of 479,506 individuals, matched by year of birth and county of residence, who had not had a hysterectomy (unexposed cohort). Cox's proportional hazards regression was used to determine hazard ratios (HRs).

From 1973 to 2003, the rate of stress-urinary-incontinence surgery per 100,000 person-years was 179 (95% confidence interval [CI], 173 – 186) in the exposed cohort, compared with 76 (95% CI, 73 – 79) in the unexposed cohort. Regardless of surgical technique, risk for stress-urinary-incontinence surgery in the group that underwent hysterectomy was more than double that in the unexposed cohort (HR, 2.4; 95% CI, 2.3 – 2.5).

This risk was slightly different depending on duration of follow-up. The highest overall risk was within 5 years of surgery (HR, 2.7; 95% CI, 2.5 – 2.9), and the lowest risk was observed after an observation period of 10 years or more (HR, 2.1; 95% CI, 1.9 – 2.2).

"Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for subsequent stress-urinary-incontinence surgery," the authors write. "Women should be counselled on associated risks related to hysterectomy, and other treatment options should be considered before surgery.... Our findings have important public-health and clinical applications, in view of the many women undergoing hysterectomy for benign indications."

Reasons proposed by the study authors to explain the increased risk of needing stress-urinary-incontinence surgery include surgical trauma caused when the uterus and cervix are severed from pelvic floor supportive tissues. In addition, hysterectomy could compromise the urethral sphincter mechanism, as well as urethral and bladder neck support.

Study limitations include the inability to account for some potential behavioral and lifestyle factors possibly associated with stress urinary incontinence, such as smoking, strenuous work, and body mass index.

The Swedish Society of Medicine and Eli Lilly, Sweden, supported this study. The authors have disclosed no relevant financial relationships.

In the accompanying Comment, Adam Magos, MD, from Royal Free Hospital, London, United Kingdom, notes that these findings conflict with those of earlier studies, including those from Dr. Altman's group.

"The truth is that there have been many studies that looked at the after-effects of hysterectomy in terms of urinary symptoms and bladder function, but there is no consensus," Dr. Magos writes. "Admittedly, previous studies have tended to be smaller with short follow-ups, but more than one have reported either no detrimental effect of hysterectomy or even benefits.

"It seems likely that a simple hysterectomy does not adversely affect bladder function, at least initially, and indeed pre-existing symptoms may improve," Dr. Magos writes. "If hysterectomy-induced urinary stress incontinence is a reality, it only becomes so several years after the surgery, as already suggested. Or perhaps it has nothing to do with hysterectomy, and women who agree to hysterectomy are just different in ways that we do not yet understand."

Lancet. 2007;370:1494–1499.

    
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