作者：Laurie Barclay, MD
出處：WebMD醫學新聞
December 23, 2008 — 根據12月婦產科期刊中一篇回溯世代研究報告的結果，40歲以下婦女進行子宮內膜燒灼術之後有較高的子宮切除風險。
舊金山北加州凱薩醫療中心的Mindyn K. Longinotti醫師等人寫道，以子宮內膜燒灼術消除子宮內膜被視為取代子宮切除的微創方式。最近的Cochrane回顧結論認為，新技術的成功率和併發症資料與第一代方法一樣好，但有關術後兩年之子宮切除率的資料有限。沒有長期追蹤下，難以準確告訴病患子宮內膜燒灼術是否較佳或者只是延後進行子宮切除。
研究目標在評估子宮內膜燒灼術後的子宮切除風險。
資料於2007年蒐集，總共有3,681名婦女、年紀介於25至60歲之間，在1999至2004年間於北加州凱薩醫療中心接受子宮內膜燒灼術；研究者評估的風險因素包括年紀、出現平滑肌瘤、住院病患與門診病患之手術比較，以及子宮內膜燒灼術的類型(第1代技術、射頻、熱液或者熱氣球；定義風險因素為使用單一變項和存活分析估計子宮切除的可能性。
在3,681名接受子宮內膜燒灼術的婦女中，774人(21%) 後來進行子宮切除，143人(3.9%)進行子宮保留手術，年紀可以顯著預測後續的子宮切除術(P < .001)；依據Cox迴歸分析，相較於45歲以上的婦女，小於等於45歲者進行子宮切除術的比率是2.1倍(95%信心區間1.8 - 2.4)。小於等於40歲者的子宮切除術風險超過40%，且隨著年齡層降低而提高。
相對的，子宮內膜燒灼術的類型以及出現平滑肌瘤，無法預測後續的子宮切除術，不過，個人的手術類型有一些預測價值。對於接受第一代子宮內膜燒灼術伴隨肌瘤切除的病患，子宮切除的風險降低(P = .02)；門診熱液子宮內膜燒灼之子宮切除風險增加(P < .001)。
研究作者寫道，對於預測子宮內膜燒灼術術後的子宮切除來說，年紀比手術類型或者出現平滑肌瘤更重要；40歲以下接受子宮內膜燒灼術的婦女，其子宮切除風險升高，而且不只在子宮內膜燒灼術後幾年，子宮切除風險到追蹤後八年仍持續增加。
研究限制包括準確識別的相關因素以及子宮內膜燒灼術失敗的定義，可能會低估不滿意的真實比率。
研究作者寫道，子宮內膜燒灼術治療月經過多，可以讓80%以上的45歲以上婦女在八年追蹤期間都保留子宮；對於40歲以下婦女，可能有40%機率會進行子宮切除，需要更長追蹤期間的其他研究來確認子宮內膜燒灼術是否可以取代舊技術，或者只是延遲那些進行手術時40歲以下者的子宮切除術時間而已。
北加州凱薩醫療中心支持本研究。研究作者宣稱沒有相關資金上的往來。
Endometrial Ablation at Younger Age Linked to Higher Risk for Subsequent Hysterectomy
By Laurie Barclay, MD
Medscape Medical News
December 23, 2008 — Endometrial ablation in women younger than 40 years is linked to a higher risk for subsequent hysterectomy, according to the results of a retrospective cohort analysis reported in the December issue of Obstetrics and Gynecology.
"Destruction of the endometrium by endometrial ablation has emerged as a minimally invasive alternative to hysterectomy," write Mindyn K. Longinotti, MD, from Kaiser Permanente Northern California in San Francisco, and colleagues. "A recent Cochrane review concluded that success rates and complication profiles of newer techniques compared favorably with first-generation methods, although they included limited data on hysterectomy rates beyond 2 years. Without long-term follow-up it is difficult to accurately counsel patients on whether endometrial ablation techniques are more likely to replace, or merely delay, hysterectomy."
The goal of this study was to assess risk factors for hysterectomy after endometrial ablation.
Data were collected through 2007 from 3681 women, aged 25 to 60 years, who underwent endometrial ablation from 1999 to 2004 at 30 Kaiser Permanente Northern California facilities. The investigators evaluated risk factors including age, the presence of leiomyomas, inpatient vs outpatient setting for the procedure, and type of ablation procedure performed (first-generation, radiofrequency, hydrothermal, or thermal balloon). Risk factors were identified, and the probability of hysterectomy was estimated with use of univariable and survival analyses.
Of the 3681 women who underwent endometrial ablation, 774 (21%) had subsequent hysterectomy, and 143 (3.9%) had uterine-conserving procedures. Age significantly predicted subsequent hysterectomy (P < .001); compared with women older than 45 years, women aged 45 years or younger were 2.1 times more likely to have a hysterectomy (95% confidence interval, 1.8 - 2.4), according to Cox regression analysis. Hysterectomy risk was more than 40% in women aged 40 years or younger and increased with each decreasing stratum of age.
In contrast, the type and setting of endometrial ablation procedure and the presence of leiomyomas did not predict subsequent hysterectomy. However, the individual types of procedures did have some predictive value. For patients undergoing first-generation endometrial ablation, concomitant myomectomy was associated with a decreased risk for hysterectomy (P = .02). Outpatient location for hydrothermal endometrial ablation was associated with an increased risk for hysterectomy (P < .001).
"Age is more important than type of procedure or presence of leiomyomas in predicting subsequent hysterectomy after endometrial ablation," the study authors write. "Women undergoing endometrial ablation at younger than 40 years of age are at elevated risk of hysterectomy, and rather than plateauing within several years of endometrial ablation, hysterectomy risk continues to increase through 8 years of follow-up."
Limitations of this study include those related to coding accuracy and use of a definition of endometrial ablation failure that was likely to underestimate the true rate of dissatisfaction.
"Endometrial ablation for menorrhagia permits uterine conservation in more than 80% of women over age 45 years when followed up to 8 years," the study authors write. "For women aged younger than 40 years, probability of hysterectomy is 40%....Additional studies with longer follow-up are necessary to determine whether endometrial ablation is more likely to replace, or merely delay, hysterectomy in women aged younger than 40 years at the time of the procedure."
Kaiser Permanente Northern California supported this study. The study authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2008;112:1214-1220.
[ 本帖最後由 goodcat1111 於 2009-1-7 10:57 編輯 ] |
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