Hysterectomize or not during Pelvic Reconstructive Surgeries

Transcription

1 Hysterectomize or not during Pelvic Reconstructive Surgeries 吳銘斌醫師 Ming-Ping Wu, M.D., Ph.D. 奇美醫院婦產部婦女泌尿科主任台北醫學大學醫學院副教授成功大學醫學院臨床醫學所博士

2 Problems to be resolved during pelvic reconstructive surgery (PRS)? To mesh or not? (Wu MP 2008 Taiwanese J Obstet Gynecol) Two-step or one-step for SUI and POP? To hysterectomize or not? Is hysterectomy mandatory during pelvic reconstructive surgery?

3 The myth of uterus --Hysterectomize or not? woman= man with womb?

4 To hysterectomize or not during PRS Q1: Is hysterectomy mandatory during PRS? Q2: Does hysterectomy (or uterine preservation) compromise the success rate? Q3: Does hysterectomy increase the surgical complication rate? Q4: Does hysterectomy affect vesico-urinary function? Q5: The further pathologic condition after surgery? Cervical malignancy, uterine malignancy, Abnormal uterine bleeding, Childbearing,

5 男女平均壽命 台灣平均壽命 2007 首度突破 78 歲總平均 歲 男性為 75.1 歲, 比前年增加 0.23 歲 女性為 81.9 歲, 比前年增加 0.49 歲 美國 男性為 75 歲, 女性為 80 歲 ; 日本 ( 最長壽的國家 ) 男性為 79 歲 女性為 86 歲

6 POP-Q Post-OP Pre-OP Bump RC 1996 AJOG

7 The Evolution of Pelvic Reconstructive Surgeries??? **SIS (Cook); Pelvicol (Bard) VTH? Biologic materials** VTH? Tension-free vaginal mesh + procedural kits* VTH? Vaginal repair of anterior, posterior compartment + mesh VTH? Abdominal (LSC) sacrocolpopexy + mesh VTH? Sacro-spinous lig. suspension *Prolift (J&J); Perigee+Apogee (AMS); post. IVS (Tyco); Nazca (Promedon) VTH+ A-P colporrhaphy Huang & Wu 2008 Incont Pelvic Floor Dysfun

8 Hysterectomize or not? Uterine prolapse! Hysterectomize? X Vaginal vault prolapse!

9 Rationales Contents Standard procedure vs alternative Evidence-based: randomized control trial (RCT) Efficacy & surgical failure rate Alternatives to hysterectomy The effect on utero-vesical function The effect on surgical complications Further cancerous or pre-cancerous lesion Further surgery for abnormal uterine bleeding Other factors

10 Standard procedure vs alternative VTH has been the traditional surgical treatment Evidence-based: randomized control trial (RCT) to address hysterectomy and uterine preservation No available Non-inferiority trial No available

11 Abdominal sacrocolpopexy (ASC) Abdominal sacrocolpopexy: a comprehensive review (Nygaard IE et al Obstet Gynecol). Follow-up duration for most studies ranged from 6 months to 3 years. The success rate, when defined as lack of apical prolapse postoperatively, ranged from % and when defined as no postoperative prolapse, from %. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range %) and 4.9% (range 1.2% to 30.9%), respectively.

12 Alternatives to hysterectomy Transvaginal Manchester procedure Transvaginal uterosacral suspension/pliation Sacroapinous hysteropexy Abdominal Sacrohysteropexy/sacrocervicopexy Pectineal ligament suspension Combined: Retropubic suspension Laparoscopic procedure Round ligament plication/suspension Uterosacral plication/culdoplasty

13 Efficacy & surgical failure rate Diwan A 2004 Int Urogyncol J

14 transvaginal sacrospinous uterine 60 patients suspension (SSUS) 33 in the risk factor assessment 84.8% (28/33) 27 in a modified treatment to eliminate identified risk factors 96.3% (26/27). failure rate elongated cervix (3 of 4, 75%) third degree uterine prolapse (3 of 4, 75%) without either of these risk factors (6.9%, 2/29) [p = 0.007]. Rx: Concomitant partial trachelectomy Lin TY, Su TH et al J Formos Med Assoc

15 The effect of hysterectomy on utero-vesical function The impact of simple hysterectomy upon lower urinary function is still controversial. urinary symptoms urodynamic parameters Mobility bladder neck cross-sectional studies prospective controlled studied Long CY: 2008 Incont Pelvic Floor Dysfunct

16 Epidemiological cross-sectional studies The influence of age, parity, duration of previous oral contraceptive use, hysterectomy and menopause on the prevalence of urinary incontinence was evaluated by means of a postal questionnaire in women 46 to 86 years old who resided in Göteborg, Sweden. Urinary incontinence was more prevalent in women who had undergone hysterectomy (p < 0.05) (20.8% VS 16.4%)

17 Prospective studies of urinary symptoms

18 Urodynamic controlled studies ATH and BSO did not change the postoperative bladder loading functions in asymptomatic patients but that significant changes occurred in urethral functions. - average urethral length, functional urethral length and maximum urethral closing pressure were decreased - bladder discharging time was increased

19 Prospective studies of bladder neck mobility Demerci et al concluded that the cephalocaudal mobility of the bladder neck decreased during stress after ATH. Long et al who reported that the ventrodorsal mobility of the bladder neck decreased significantly following LH. Hypermobility of the bladder neck improved following hysterectomy.

20 The effect of hysterectomy on utero-vesical function Several cross-sectional studies retrospective analyses, an increase in the relative risk of urinary symptoms Numerous prospective controlled studied urinary symptoms: improved urodynamic parameters: improved or stable Mobility bladder neck: decreased Simple hysterectomy has no detrimental effects on vesico-urethral function. Long CY: 2008 Incont Pelvic Floor Dysfunct

21 Complications: infection & mesh erosion (Imparato E et al. 1992) 71 women who underwent sacrocolpopexy, 57 with concurrent hysterectomy; 21/57 had synthetic mesh, 36/ 57, the vaginal apex was directly approximated to the anterior vertebral longitudinal ligament. Mesh rejection occurred in 3 of 21 (14%) patients after hysterectomy, (2 women with Teflon; 1 woman with Mersilene), compared with none of the other women. (Culligan PJ et al. 2002) Similarly, mesh erosion in 3 of 11 (27%) women who underwent concomitant total hysterectomy, compared with 3 of 234 (1.3%) who did not (P <0.001).

22 Complications: infection & mesh erosion (Brizzolara S et al. 2002) reported no mesh erosion in 60 women undergoing sacrocolpopexy with hysterectomy compared with 1 of 64 without concurrent hysterectomy. (Fedorkow DM and Kalbfleisch RE 1993) examined early postoperative febrile morbidity in 86 women undergoing sacrocolpopexy and concomitant hysterectomy 149 women undergoing sacrocolpopexy alone. Prophylactic antibiotics and polypropylene (Prolene) mesh were used. Of note, surgeons left the vaginal cuff open to heal by secondary intention. no difference in early febrile morbidity or length of hospitalization.

23 Further cancerous or precancerous lesion Cervical Cancer Endometrial Cancer Ovarian cancer Other cancer demanding pelvic surgery

24 男女癌症死因 前十大男性癌症粗死亡率依序分別為 (1) 肝癌 (2) 肺癌 (3) 結腸直腸癌 (4) 口腔癌 (5) 胃癌 (6) 食道癌 (7) 攝護腺癌 (8) 非何杰金淋巴癌 (9) 胰臟癌 (10) 鼻咽癌 女性十大癌症粗死亡率依序分別為 (1) 肺癌 (2) 肝癌 (3) 結腸直腸癌 (4) 女性乳癌 (5) 子宮頸癌 (6) 胃癌 (7) 胰臟癌 (8) 膽囊癌 (9) 非何杰金淋巴癌 (10) 卵巢癌 2005

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26 Precancerous, invasive cervical carcinoma, Pap smear screening 年齡標準化率 ( 每十萬人口 ) 篩檢率原位癌發生率侵襲癌發生率死亡率 三年篩檢率 (%) 篩檢率 原位癌發生率 侵襲癌發生率 死亡率 發生年代 0 註 : 年齡標準化率係使用 2000 年世界標準人口為標準人口 子宮頸癌篩檢率與發生率及死亡率之長期趨勢, 民國 年

27 Endometrial carcinoma & sarcoma Endometrial carcinoma Sarcoma & MMMT

28 Further Childbearing Diwan A 2004 Int Urogyncol J

29 Summary-I Q1: Is hysterectomy mandatory during PRS? Ans: individualized with informed consent after sufficient information Q2: Does hysterectomy (or uterine preservation) compromise the success rate? Ans: some studies reported higher failure rate in uterine preservation group. Q3: Does hysterectomy increase the surgical complication rate? Ans: controversial; some favored, some against

30 Summary-II Q4: Does hysterectomy affect vesico-urinary function? Ans: retrospective study: increased risk; prospective study decreased or stable symptoms and urodynamic parameters Q5: The further pathologic condition after surgery? Cervical malignancy, uterine malignancy, Ans: The concurrent malignancy should be well evaluated The potential risks and higher difficulties to deal with further pelvic malignancy should be fully informed, Q6: The further Childbearing condition after surgery? Ans: The potential risks of failure after childbearing should be fully informed

31 歡迎各位蒞臨奇美 Thank you! 奇美醫院婦產部婦女泌尿科吳銘斌醫師