Bailliere's clinical obstetrics and gynaecology最新文献

Diagnostic categories in hyperandrogenism include polycystic ovary syndrome (PCOS) and its variants, adrenal and ovarian steroidogenic enzyme deficiencies, adrenal and ovarian androgen secreting tumours and other endocrine disorders such as hyperprolactinaemia, Cushing syndrome and acromegaly. About 95% of hyperandrogenic women will have PCOS. Endometrial hyperplasia can be prevented in hyperandrogenic, anovulatory women by the oral contraceptive pill or progestins. Hirsutism is best treated by a combination of the oral contraceptive pill and an anti-androgen. The first line of therapy for ovulation induction is clomiphene citrate, with human menopausal gonadotrophins (hMG) or laparoscopic ovulation induction reserved for clomiphene failures. hMG together with gonadotrophin-releasing hormone agonist may decrease the risk of spontaneous abortion following ovulation induction in PCOS. Weight loss should be vigorously encouraged to ameliorate the metabolic consequences of PCOS.

Defining the polycystic ovarian syndrome (PCOS) has challenged clinicians for many years. The clinical, hormonal and morphological definitions of PCOS have their own limitations and do not correspond exactly. Clinically, PCOS can be schematically divided into three components, i.e. hyperandrogenic, anovulatory and dysmetabolic. No one is specific for the syndrome. Hormonally, PCOS has recently been defined by the GnRH agonist test as a functional abnormality in ovarian androgen synthesis. This functional ovarian hyperandrogenism seems closely linked to hyperinsulinism secondary to an insulin resistance. Morphologically, ovarian ultrasonography has emerged in the last decade or so as a new diagnostic tool. However, the sonographic definition of the polycystic ovary (PCO) is controversial, mainly because of a lack of consensus about normative data. The aim of this review is to present the diagnostic dilemma in the diagnosis of PCOS and to discuss the prognostic significance of the PCO.

All anatomically important pelvic structures lie embedded in the fatty-fibrous connective tissue of the retroperitoneum from which they can be freed by blunt dissection in the correct tissue planes. By relying on fixed laparoscopic landmarks, the correct surgical planes of dissection can be found, and all vital structures freed and identified by a systematic dissection consisting of a precise sequence of operative steps. Once the retroperitoneal dissection has been completed and all vital structures identified, most gynaecological operations can be carried out safely and without much difficulty laparoscopically. A non-anatomical approach to laparoscopic pelvic surgery may be easier to learn, but it is neither very versatile nor very safe except in the simplest of cases.

The terminology of laparoscopically-assisted hysterectomies needs to be simplified and clarified. Laparoscopic hysterectomy should be used as a general term, whereas operative laparoscopy before hysterectomy, laparovaginal, laparoscopic total and subtotal hysterectomy should be used to describe the types of laparoscopic hysterectomy.

The complication rates from laparoscopic hysterectomy, abdominal hysterectomy and vaginal hysterectomy are similar. The lower febrile morbidity after laparoscopic hysterectomy may be due to improved pelvic visualization compared to vaginal and abdominal hysterectomy.

Controlled trials show that laparoscopic hysterectomy has advantages over abdominal hysterectomy which include reduced pain, reduced hospitalization time and earlier return to work.

Most abdominal hysterectomies can be replaced by laparoscpic or vaginal hysterectomies. Whether this happens will depend upon adequate training facilities.

The complications of hysterectomy are discussed, generally speaking their definition is poorly standardized and direct comparisons are extremely difficult. Furthermore, there is uncertainty as to what is meant by laparoscopic hysterectomy. The complications are discussed as post-operative fever, haemorrhage, injury to adjacent organs, other complications and life-threatening events. The incidence of post-operative infection and haemorrhage is least with the laparoscopic approach, but injury to surrounding organs is probably greater. In 1982, the Collaborative Review of Sterilization study data suggested an average woman of reproductive age with no pre-existing medical condition, no previous abdominal surgery, and who received prophylactic antibiotics, was best served by vaginal hysterectomy without colpororrhaphy rather than an abdominal procedure. This does not seem to have changed. The incidence of abdominal hysterectomy may be reduced by adding laparoscopy to vaginal hysterectomy to deal with adhesive disease, endometriosis or adnexal disease. Laparoscopic hysterectomy is feasible and safe but the indications for this approach have not yet been established.

Radical hysterectomy for the treatment of cervical cancer was first performed just over 100 years ago. Refinements of surgical technique and improvements in supportive measures, such as transfusions and antibiotics, have brought about a marked decrease in morbidity and mortality from surgery and improvement in overall survival. The indications for operation, pre-operative investigations and preparation, surgical technique, post-operative complications and their management, and factors influencing prognosis are discussed.

Hysterectomy is the most common non-pregnancy-related surgical procedure performed in the USA. The ratio of abdominal operations to vaginal operations is 3:1, which probably reflects surgeon's experience and practice styles, the absence of clear guidelines for selecting a surgical route, lack of patient knowledge about the options, and inappropriate decision-making. With the trend toward evidence-based and outcome-based practice, the indications and contraindications for abdominal, vaginal, and laparoscopically-assisted hysterectomy must be examined critically. In the author's extensive experience the rates of abdominal, vaginal, and laparoscopically-assisted procedures are 1.9, 88.7, and 9.4%, respectively. Techniques useful in vaginal hysterectomy with or without simultaneous oophorectomy, the pros and cons of simultaneous incidental appendectomy, and methods of protecting the ureter are discussed.

Supracervical hysterectomy is a viable alternative for those individuals requiring uterine extirpation without indications for cervical removal. The laparoscopic approach to this procedure provides even lower morbidity and therefore can enhance clinical outcomes. The procedure is versatile in that most patients are amenable pathologically to this approach, particularly those individuals with large lieomyomata. Five year follow-up data is presented on 236 cases performed by the author including clinical outcomes and morbidity information. The procedure as performed by the author is presented in detail with illustrations of critical aspects of the technique of LSH.

There are an increasing number of approaches to the surgical removal of the uterus; each of these has clinical advantages and disadvantages. This paper outlines the various forms of laparoscopic hysterectomy currently undertaken and attempts to compare outcome measures and complications with these new approaches.

In general laparoscopically-assisted vaginal hysterectomy appears to be associated with longer operating time but less post-operative pain and a shorter convalescent period than both abdominal and vaginal hysterectomy. Economic evaluation is dependent on local factors and upon the type of technique adopted. The use of disposable instrumentation profoundly influences the costs. Laparoscopically-assisted vaginal hysterectomy can be performed for similar or less total costs than conventional surgery providing techniques using re-usable equipment are employed.

The place of the laparoscope in facilitating hysterectomy is not yet defined. Techniques are continuing to evolve. The debate now appears to be how laparoscopic and vaginal surgical skills can be best combined to ensure the best possible patient outcome.