Division of Urogynecology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA; Department of Gynecology, Obstetrics and Gynecological Oncology, Medical University of Silesia, Bytom, Poland.
Division of Urogynecology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA.
Am J Obstet Gynecol. 2021 May;224(5):496.e1-496.e10. doi: 10.1016/j.ajog.2020.11.008. Epub 2020 Nov 15.
There are various indications and approaches for hysterectomy; yet, the difference in long-term risk of subsequent prolapse after surgery is not well studied.
To assess the risk of prolapse after abdominal, vaginal, and laparoscopic or robotic hysterectomy for up to 17 years from surgery.
A retrospective chart review study of women undergoing hysterectomy across all indications (benign and malignant) between 2001 and 2008 was conducted. An equivalent random sample of hysterectomy patients was selected each year. We compared demographic and other surgical characteristics data including age, race, parity, body mass index, indication and year of hysterectomy, blood loss, cervix removal, cuff suspension, and complications using chi-square, Kruskal-Wallis test, and Fisher's exact across the 3 groups. Presence and treatment of subsequent prolapse (based on patient symptoms, pelvic exam, International Classification of Diseases, Ninth Revision diagnosis, and current procedural terminology pessary or surgical codes) were compared with Kaplan-Meier survival analysis and Cox proportional hazards regression.
Of the 2158 patients, 1459, 375, and 324 underwent open, vaginal, and laparoscopic or robotic hysterectomy, respectively. The vaginal group (56) was older than the abdominal (52) or laparoscopic or robotic (49) groups, with a P value of <.05. Most patients were White with a mean body mass index of 30 kg/m. The main indication was cancer for abdominal (33%) and laparoscopic or robotic hysterectomy (25%) and prolapse for vaginal hysterectomy (60%). Time to prolapse was shortest after vaginal surgery (27 months) and longest after laparoscopic or robotic surgery (71 months). After controlling for confounders, including surgery indication, the hazard ratio for subsequent prolapse was no different among vaginal (hazard ratio=1.36 [0.77-2.45]), laparoscopic or robotic (hazard ratio=1.47 [0.80-2.69]), or open (reference) hysterectomy. Prolapse grade was similar across the 3 groups. About 50% of women with recurrent prolapse received physical therapy, pessary, or surgical treatment.
At the 17-year follow-up, the route of hysterectomy is not associated with a difference in recurrence, grade, or subsequent treatment of prolapse when the indication for hysterectomy is considered. Prolapse, as an indication for hysterectomy, increases risk for recurrence. Women planning a hysterectomy should be counseled appropriately about the risk of subsequent prolapse.
子宫切除术有多种适应证和方法，但术后发生脱垂的长期风险差异尚未得到充分研究。
评估经腹、经阴道、腹腔镜或机器人辅助子宫切除术治疗各种适应证（良性和恶性）患者术后 17 年内发生脱垂的风险。
对 2001 年至 2008 年间因各种适应证（良性和恶性）接受子宫切除术的所有患者进行回顾性图表审查研究。每年选择相同数量的子宫切除术患者作为对照。我们比较了人口统计学和其他手术特征数据，包括年龄、种族、产次、体重指数、手术适应证和时间、失血量、子宫颈切除、子宫颈残端悬吊术以及 3 组患者的并发症，采用卡方检验、克鲁斯卡尔-瓦利斯检验和 Fisher 确切概率法。通过 Kaplan-Meier 生存分析和 Cox 比例风险回归比较脱垂的发生和治疗（基于患者症状、盆腔检查、国际疾病分类第 9 版诊断、当前程序术语子宫托或手术代码）。
2158 例患者中，1459 例、375 例和 324 例分别接受了开腹、经阴道和腹腔镜或机器人辅助子宫切除术。阴道组（56 岁）患者的年龄大于开腹组（52 岁）或腹腔镜或机器人组（49 岁），P 值<0.05。大多数患者为白人，平均体重指数为 30kg/m。主要适应证为癌症，开腹和腹腔镜或机器人辅助子宫切除术的主要适应证为癌症（33%和 25%），经阴道子宫切除术的主要适应证为脱垂（60%）。阴道手术后发生脱垂的时间最短（27 个月），腹腔镜或机器人手术后发生脱垂的时间最长（71 个月）。在控制混杂因素，包括手术适应证后，阴道（危险比=1.36[0.77-2.45]）、腹腔镜或机器人（危险比=1.47[0.80-2.69]）或开腹（参照）子宫切除术的后续脱垂风险无差异。3 组患者的脱垂分级相似。约 50%复发性脱垂的患者接受了物理治疗、子宫托或手术治疗。
在 17 年的随访中，当考虑子宫切除术的适应证时，手术途径与脱垂的复发、分级或后续治疗无差异。脱垂作为子宫切除术的适应证，增加了复发的风险。计划接受子宫切除术的女性应就后续脱垂的风险进行适当的咨询。
