阴道子宫切除术合并子宫骶韧带悬吊术后生殖器裂孔扩大与复合手术失败的关系

IF 4.3 4区 医学 Q1 OBSTETRICS & GYNECOLOGY Obstetrical & Gynecological Survey Pub Date : 2023-08-01 DOI:10.1097/ogx.0000000000001187
Megan S. Bradley, Amaanti Sridhar, Kimberly Ferrante, Uduak U. Andy, Anthony G. Visco, Maria E. Florian-Rodriguez, Deborah Myers, Edward Varner, Donna Mazloomdoost, Marie G. Gantz
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引用次数: 0

摘要

在阴道全子宫切除术中,子宫骶韧带悬吊术和骶棘韧带固定术通常采用原生组织顶端悬吊术。由于复发性盆腔器官脱垂在根尖悬吊后随着时间的推移而增加,不可改变和可改变的危险因素已被探讨。许多研究表明,复发性脱垂的一个危险因素是术前和术后生殖器裂孔(GH)的扩大。生长激素增大可能表明盆腔脏器的尾端移位,增加对阴道支撑物的压力。然而,短期随访、回顾性设计和缺乏患者对脱垂结果的看法限制了这些研究结果的总体影响。超级试验(研究子宫脱垂手术-随机)比较阴道网状子宫切除术和阴道子宫切除术合并子宫骶韧带悬吊的随机试验设计,术后长期随访。术后评估包括患者对脱垂症状的评估。本文的主要目的是评估阴道子宫切除术合并子宫骶韧带悬吊术在GH大小改变组中的疗效。该假说预测,与术前和术后GH尺寸较小的患者相比,术后4-6周GH尺寸持续增大的患者脱垂复发率更高。这项辅助分析的超级参与者接受阴道子宫切除术和子宫骶韧带悬吊,然后完成了2年的随访。根据术前至术后GH测量变化,将参与者分为3组。这些组是(1)持续增大的GH(“持续增大”),(2)改善的GH(“改善”),(3)术前和术后稳定或正常的GH(“稳定正常”)。脱垂被定义为脱垂超过处女膜1厘米的任何隔室。主要目的是比较GH组在24个月时的复合手术失败,其定义为以下任何一种情况:解剖失败,脱垂的再治疗,或令人烦恼的阴道隆起症状。次要结局包括复合手术失败因素、术后并发症、POP-Q测量和性交疼痛。共有81名女性被纳入这一次要分析。主要特征包括中位年龄65.6岁,“改善组”50例,“持续扩大组”14例,“稳定正常”组17例。值得注意的是,与改善组和稳定正常组相比,持续扩大组在基线时晚期前脱垂的患病率最高。此外,在指数手术过程中,后阴道破裂的发生率在各组之间有所不同,改善组比稳定正常组更常见。几乎所有患者的手术都是阴道子宫切除术和子宫骶韧带悬吊。研究发现,阴道子宫切除术后,在调整晚期前脱垂的患病率后,4-6周生长激素持续增大的女性术后2年的复合手术失败发生率与其他组相比并不高。与稳定正常组相比,持续扩大组复合手术失败的校正优势比为6.0(95%可信区间,1.0-37.5;P = 0.06)。最终,基线生长激素大小不是一个可改变的危险因素;然而,在进行术前和术后正常生长激素测量比较时,阴道后子宫切除术和阴道前壁脱垂之间确实存在关联。尽管如此,这项研究不能证实复发性脱垂的风险与按生长激素大小分组的患者之间的显著关系。
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Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension
ABSTRACT Commonly performed at the time of total vaginal hysterectomy to combat uterovaginal prolapse, uterosacral ligament suspension and sacrospinous ligament fixation are native tissue apical suspensions. Because recurrent pelvic organ prolapse increases over time after apical suspensions, nonmodifiable and modifiable risk factors have been explored. It is suggested by numerous studies that 1 risk factor for recurrent prolapse is an enlarged preoperative and postoperative genital hiatus (GH). An enlarged GH may be indicative of a caudal shift in pelvic viscera, increasing stress on vaginal supports. However, short-term follow-up, retrospective design, and lack of patient perspectives on prolapse outcomes limited the overall impact of those findings. The SUPeR trial (Study of Uterine Prolapse Procedures-Randomized) compared vaginal mesh hysteropexy with vaginal hysterectomy with uterosacral ligament suspension in a randomized trial design with long-term follow-up postoperatively. Postoperative assessments included the patient’s assessment of prolapse symptoms. The primary objective of this manuscript was to evaluate the efficacy of the vaginal hysterectomy with uterosacral ligament suspension amidst groups defined by surgical changes in GH size. The hypothesis predicted higher prolapse recurrence proportions for those with persistently enlarged GH size at 4–6 weeks postoperatively, compared with those with smaller preoperative and postoperative GH sizes. SUPeR participants included in this ancillary analysis underwent vaginal hysterectomy with uterosacral ligament suspension and then completed a 2-year follow-up. Based on preoperative to postoperative GH measurement changes, participants were divided into 3 groups. These groups were (1) persistently enlarged GH (“persistently enlarged”), (2) improved GH (“improved”), and (3) stable or normal GH preoperatively and postoperatively (“stably normal”). Prolapse was defined as any compartment with prolapse 1 cm or more beyond the hymen. The primary aim was comparison of composite surgical failure across the GH groups at 24 months, defined by any of the following conditions: anatomic failure, retreatment for prolapse, or symptoms of bothersome vaginal bulge. Secondary outcomes included the composite surgical failure components, postoperative complications, POP-Q measurements, and pain during intercourse. A total of 81 women were included in this secondary analysis. Predominant characteristics included a median age of 65.6 years, with 50 patients in the “improved group,” 14 patients in the “persistently enlarged” group, and 17 patients in the “stably normal” group. Notably, the prevalence of advanced anterior prolapse at baseline was greatest in the persistently enlarged group compared with that of both the improved and stably normal groups. Also, the prevalence of posterior colporrhaphy during the index procedure varied across groups and was more common in the improved group than the stably normal group. The surgery performed for almost all patients was a vaginal hysterectomy with uterosacral ligament suspension. The study found that following vaginal hysterectomy, after adjustment for the prevalence of advanced anterior prolapse, a woman with persistently enlarged GH at 4–6 weeks would not be at higher of composite surgical failure 2 years postsurgery when compared with other groups. The adjusted odds ratio for composite surgical failure in the persistently enlarged group compared with the stably normal group was 6.0 (95% confidence interval, 1.0–37.5; P = 0.06). Ultimately, baseline GH size is not a modifiable risk factor; however, there does appear to be an association between postvaginal hysterectomy and anterior vaginal wall prolapse when performing a presurgical and postsurgical comparison of normal GH measurements. Nonetheless, this study was not able to confirm a significant relationship between risk of recurrent prolapse and patients grouped by GH size in this manner.
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来源期刊
CiteScore
2.70
自引率
3.20%
发文量
245
审稿时长
>12 weeks
期刊介绍: ​Each monthly issue of Obstetrical & Gynecological Survey presents summaries of the most timely and clinically relevant research being published worldwide. These concise, easy-to-read summaries provide expert insight into how to apply the latest research to patient care. The accompanying editorial commentary puts the studies into perspective and supplies authoritative guidance. The result is a valuable, time-saving resource for busy clinicians.
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