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| 發表人 | 討論主題 | 發表時間 | 討論數 |
| 許毓昭 | 手術優先或是物理治療?婦女尿失禁治療的兩難決定 | 2013/12/30 上午 11:05:26 | 0 |
| 原 文 | 題 目 | Surgery versus Physiotherapy for Stress Urinary Incontinence |
| 作 者 | Julien Labrie, M.D., et, al_ENREF_1 | |
| 出 處 | N Engl J Med 369, 1124-33. | |
| 出版日期 | 2013 | |
| 評 論 |
婦女尿失禁是一個困擾女性的問題，隨著生活品質要求的提高，越來越多女性求助於醫療，希望能解決惱人的尿失禁問題。然而面對醫療抉擇，究竟是要採取保守的物理治療還是接受手術，對女性病患來說的確是一個困難的選擇，對醫師而言，究竟應該建議病人接受手術或亦是保守治療，也是一個值得深思的議題。最新一期的新英格蘭醫學雜誌針對著個議題有一篇非常精采的報導。 所謂骨盆腔物理治療是包括骨盆腔肌肉訓練的一系列療法，一直以來是大部分醫師推薦，對於尿失禁病人的第一線治療。好處是在於不需要手術，但是治療的效果有限，病患往往無法持之以恆，半途而廢，反而錯失了治療。尿道中段懸吊手術則是治療應力性尿失禁的手術。研究單位分析了230位優先接受物理治療、230位接優先受手術的病患，其中優先接受手術的病患改善程度高達90.8%而物理治療組只有64.4%。而完全治癒的比例則是85.2%跟53.4%。 這結論挑戰泌尿科醫師的傳統思維，站在治療病人的立場，醫師應該優先推薦使用手術治療，讓病人能夠有較好的治療結果與生活品質，而物理治療則應該推薦給無法進行手術或者不願意進行手術的病患，因為這樣的治療有著較差的結果。 |
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| abstract |
Background Physiotherapy involving pelvic-floor muscle training is advocated as first-line treatment for stress urinary incontinence; midurethral-sling surgery is generally recommended when physiotherapy is unsuccessful. Data are lacking from randomized trials comparing these two options as initial therapy. Methods We performed a multicenter, randomized trial to compare physiotherapy and midurethral- sling surgery in women with stress urinary incontinence. Crossover between groups was allowed. The primary outcome was subjective improvement, measured by means of the Patient Global Impression of Improvement at 12 months. Results We randomly assigned 230 women to the surgery group and 230 women to the physiotherapy group. A total of 49.0% of women in the physiotherapy group and 11.2% of women in the surgery group crossed over to the alternative treatment. In an intention-to-treat analysis, subjective improvement was reported by 90.8% of women in the surgery group and 64.4% of women in the physiotherapy group (absolute difference, 26.4 percentage points; 95% confidence interval [CI], 18.1 to 34.5). The rates of subjective cure were 85.2% in the surgery group and 53.4% in the physiotherapy group (absolute difference, 31.8 percentage points; 95% CI, 22.6 to 40.3); rates of objective cure were 76.5% and 58.8%, respectively (absolute difference, 17.8 percentage points; 95% CI, 7.9 to 27.3). A post hoc per-protocol analysis showed that women who crossed over to the surgery group had outcomes similar to those of women initially assigned to surgery and that both these groups had outcomes superior to those of women who did not cross over to surgery. Conclusions For women with stress urinary incontinence, initial midurethral-sling surgery, as compared with initial physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 1 year. (Funded by ZonMw, the Netherlands Organization for Health Research and Development; Dutch Trial Register number, NTR1248.) |
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