尿道中段吊帶對於壓力型尿失禁有幫助


  【24drs.com】根據線上發表於7月1日考科藍實證醫學資料庫的一篇系統性回顧,尿道中段吊帶(Midurethral sling)手術對於壓力型尿失禁婦女相當安全,短期與中期的效果也不錯。
  
  不過,這個吊帶植入物是由手工製造的不可吸收塑膠網帶,因此可以解釋術後疼痛與受傷的報告。雖然證據也顯示有長期效果,當考量吊帶手術時,必須衡量併發症以及重複手術的長期需求等差異。
  
  另一個考量是利用恥骨後的路徑,帶子通過恥骨後面並經由腹部離開,或者是經閉孔路徑,帶子是以邊對邊通過,經由腹股溝離開。
  
  第一作者、英國Bradford皇家醫院的Abigail A. Ford醫師在新聞稿中表示,這是相當重要的回顧研究,讓婦女們知道,有微創性手術可以治療這個令人感到虛弱的狀況;它提供婦女更多資訊,而有助於做出明智選擇。
  
  不過,Ford醫師提醒婦女,考慮任何類型的手術之前,可以嘗試比較無侵犯性的替代方法,如骨盆底(凱格爾)運動。因為每種手術都有一些風險,婦女們須仔細衡量目前的漏尿情況有多嚴重,以及考慮手術結果有沒有任何可能出錯的機會。
  
  經閉孔插入組的膀胱損傷風險比較低(0.6%,恥骨後組為4.5%),而大血管或內臟損傷率、平均手術時間、手術失血量、住院天數等,也都是經閉孔插入組較低;經閉孔組術後排尿功能障礙方面的表現也比較好(4%,恥骨後組為7%)。
  
  經閉孔手術的缺點是,短期內的腹股溝疼痛率比較高(6.4% vs 1.3%),另有四篇試驗的一些低品質證據顯示,重複手術的需求高於恥骨後插入組。
  
  對於經閉孔技術,並無證據顯示偏好使用內側到外側或是外側到內側插入,但是,對於恥骨後的帶子,從底部往頂部的方法比從頂部往底部的路徑更有效。
  
  在1-5年的追蹤期間,任一種手術之後,帶子侵蝕到陰道的整體比率為大約2%,兩組的性交時疼痛比率也都很低。
  
  本篇系統性回顧的81篇試驗中,共有12,113名婦女、55篇試驗(8652名參與者)直接比較恥骨後吊帶與經閉孔吊帶,有中等品質的證據顯示,在12個月時,任一種路徑都可有效緩解約80%婦女的症狀。
  
  不過,報告5年資料的少數研究中,任一組的個案治癒率平均約為70%,經閉孔組介於43%-92%,恥骨後組為51%-88%。
  
  資深作者、英國Cumbria Morecambe Bay國家健康服務信託基金大學醫院的Joseph Ogah在新聞稿中表示,我們必須更加瞭解這些婦女的長期結果,而不是在這領域開始任何新試驗,我們必須從現有的試驗獲得長期追蹤。
  
  雖然這篇回顧比較了這個領域的兩個最常見手術方式,對於它們和已經被它們取代的舊式手術比較,我們還需要更有力的證據。
  
  研究者搜尋考科藍尿失禁分組登記資料庫(Cochrane Incontinence Group Specialised Register),檢視了隨機分組或半隨機控制試驗,這兩類型試驗組都包含了一種尿道中段吊帶手術。回顧分析的作者們獨立檢視可能符合條件之研究的研究方法品質,以及從納入的試驗摘錄資料。
  
  資料來源:http://www.24drs.com/
  
  Native link:Midurethral Sling Helpful for Stress Urinary Incontinence

Midurethral Sling Helpful for Stress Urinary Incontinence

By Laurie Barclay, MD
Medscape Medical News

Midurethral sling operations for stress urinary incontinence in women have a good safety pro?le and are highly effective in the short and medium term, based on a systematic review published online July 1 in the Cochrane Database of Systematic Reviews.

However, the sling implant is made of an artificial, nonabsorbable plastic mesh tape, which may explain reports of postoperative pain and injury. Although evidence is also building for long-term efficacy, differences in complications and the long-term need for repeat surgery should be weighed when considering sling surgery.

An additional consideration is use of the retropubic route, in which the tape passes behind the pubic bone and exits via the abdomen, or the transobturator route, in which the tape passes side-to-side and exits via the groin.

"This is a very significant review informing women about the minimally invasive surgical options available for the treatment of this very debilitating condition," lead author Abigail A. Ford, MD, from the Bradford Royal Infirmary, United Kingdom, said in a news release. "It helps to give women more information to make an informed choice."

However, Dr Ford cautions women to try less invasive alternatives such as pelvic floor (Kegel) exercises before contemplating any type of surgery. "As all surgery carries some risk, women must weigh up carefully how much they are troubled by their urine leakage against taking a small chance that things may go wrong as a result of surgery," she said.

Risk for bladder damage during surgery was lower with transobturator insertion (0.6% vs 4.5% in the retropubic group), as were rates of major vascular or visceral injury, mean operating time, operative blood loss, and length of hospital stay. The transobturator group also fared better in terms of postoperative voiding dysfunction (4% vs 7% in the retropubic group).

The downside of the transobturator procedure was greater likelihood of groin pain in the short term (6.4% vs 1.3%), as well as some low-quality evidence from four trials suggesting an increased need for repeat surgery compared with retropubic insertion.

For transobturator techniques, there was no evidence favoring the use of a medial-to-lateral vs a lateral-to-medial insertion, but for retropubic tapes, a bottom-to-top route was more effective than a top-to-bottom route.

At 1- to 5-year follow-up, the overall rate of erosion of the tape into the vagina was about 2% after either type of surgery, and both groups also had low rates of pain during sexual intercourse.

Of 81 trials included in the systematic review, enrolling a total of 12,113 women, 55 trials (8652 participants) directly compared retropubic and transobturator slings. There was moderate-quality evidence that either route effectively resolved symptoms in approximately 80% of women at around 12 months.

However, few studies reported 5-year data, and among these, subjective cure rates in either group were approximately 70%, ranging from 43% to 92% in the transobturator group, and from 51% to 88% in the retropubic group.

"We need to know more about what happens to women in the long term," senior author Joseph Ogah, MBBS, MRCOG, from University Hospitals of Morecambe Bay National Health Service Foundation Trust, Cumbria, United Kingdom, said in the news release. "Rather than starting any new trials in this area we need to obtain long-term follow up from the existing trials.

"Although this review compares the two most common operations in current practice in the developed world, we need more robust evidence about how well they compare with the older types of surgery that they have superseded."

The investigators identified randomized or quasirandomized controlled trials in which both trial groups involved a midurethral sling operation by searching the Cochrane Incontinence Group Specialised Register. Two review authors independently examined the methodological quality of potentially eligible studies and extracted data from the included trials.

The National Institute for Health Research funded this review. Dr Ford received funding from Johnson & Johnson for part sponsorship to attend the 2014 International Urogynaecology Association conference. One coauthor received funding from Astellas for attendance at the European Urogynaecological Association meeting in Berlin. Dr Ogah received funding for conference registration fees and speaker honoraria by Astellas UK and was sponsored to attend workshops by Johnson & Johnson and Speciality European Pharma. The remaining coauthor has disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online July 1, 2015.

    
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