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| 發表人 | 討論主題 | 發表時間 | 討論數 |
| 阮雍順 | 尿路動力學檢查對於接受應力性尿失禁手術婦女的臨床診斷、治療計畫以及手術結果的影響 | 2013/4/29 下午 12:10:43 | 0 |
| 原 文 | 題 目 | The effect of urodynamic testing on clinical diagnosis, treatment plan and outcomes in women undergoing stress urinary incontinence surgery |
| 作 者 | Sirls LT, Richter HE, Litman HJ, Kenton K, Lemack GE, Lukacz ES, Kraus SR, Goldman HB, Weidner A, Rickey L, Norton P, Zyczynski HM, Kusek JW | |
| 出 處 | Journal of Urology | |
| 出版日期 | Volume 189, Issue 1, January 2013, Pages 204-209 | |
| 評 論 |
尿失禁手術是治療應力性尿失禁的重要方法，雖然目前大部分醫師在為患者進行尿失禁手術前都會為患者先進行尿路動力學檢查，但是尿路動力學檢查的結果是否會影響手術的效果，甚至是否會改變治療的計畫，目前仍然沒有定論。在先前的德國研究顯示有八成的德國醫師只要stress test為陽性反應，不管尿路動力學檢查的結果，仍然會為患者進行手術，而且只有9%的醫師會根據尿道壓力(urethral pressure profile)的結果而選擇不同的手術方式。 本文作者Sirls LT等人結合各大尿失禁手術中心，評估294位應力性尿失禁患者，如果作手術前先進行尿路動力學檢查，是否會讓手術醫師改變手術治療的計畫，並進而影響治療的效果。他們的研究發現詳細的術前尿路動力學檢查和只做臨床理學檢查相比，確實會改變臨床的疾病診斷，其中過動性膀胱(overactive bladder)與內因性括約肌缺失(intrinsic sphincter deficiency)的診斷都減少，但是排尿功能障礙(voiding dysfunction)的診斷則增加。在這294位應力性尿失禁患者中有四位(1.4%)最後取消了手術，13位(4.4%)改變了手術吊帶與手術的方法，並有20位(6.8%)患者修正了手術吊帶的張力。但是術前的尿路動力學檢查並不影響手術的成功率，卻會增加術後急迫性尿失禁的治療。 同一批學者在去年五月也發表了類似的研究報告在新英格蘭醫學雜誌(NEJM)，他們的結論也是單純的臨床理學檢查後施行應力性尿失禁手術，術後的成功率和進行術前尿路動力學檢查組相當。但是當然對於手術者而言，術前的尿路動力學檢查可以增加臨床的疾病診斷正確率，增加手術的信心。術前做與不做尿路動力學檢查就取決於各位臨床醫師的判斷了!!! |
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| abstract |
PURPOSE: We evaluated the influence of preoperative urodynamic studies on diagnoses, global treatment plans and outcomes in women treated with surgery for uncomplicated stress predominant urinary incontinence. MATERIALS AND METHODS: We performed a secondary analysis from a multicenter, randomized trial of the value of preoperative urodynamic studies. Physicians provided diagnoses before and after urodynamic studies and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification and nonoperative therapy. Treatment plan changes and surgical outcomes between office evaluation and office evaluation plus urodynamic studies were compared by the McNemar test. RESULTS: Of 315 subjects randomized to urodynamic studies after office evaluation 294 had evaluable data. Urodynamic studies changed the office evaluation diagnoses in 167 women (56.8%), decreasing the diagnoses of overactive bladder-wet (41.6% to 25.2%, p <0.001), overactive bladder-dry (31.4% to 20.8%, p = 0.002) and intrinsic sphincter deficiency (19.4% to 12.6%, p = 0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p <0.001). After urodynamic studies physicians canceled surgery in 4 of 294 women (1.4%), changed the incontinence procedure in 13 (4.4%) and planned to modify mid urethral sling tension (more or less obstructive) in 20 women (6.8%). Nonoperative treatment plans changed in 40 of 294 women (14%). Urodynamic study driven treatment plan changes were not associated with treatment success (OR 0.96, 95% CI 0.41, 2.25, p = 0.92) but they were associated with increased postoperative treatment for urge urinary incontinence (OR 3.23, 95% CI 1.46, 7.14, p = 0.004). CONCLUSIONS: Urodynamic studies significantly changed clinical diagnoses but infrequently changed the global treatment plan or influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for postoperative urgency urinary incontinence. |
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