What was hot at the ICS Meeting 2013?(Part 1)

(from Neurourology and Urodynamics 33:2-8(2014))

 

 第43屆ICS Meeting去年在巴塞隆納舉行今年共1062篇文章發表，每年都會針對ICS meeting一些有趣的文章做摘錄，

以下就是各個topic的重點：

1.      女性尿失禁的治療：

(1)對於SUI術前是否該做urodynamic study仍然在爭議中，在摘要1.(abstract 1.)中，Rachaneni與Latthe (1.Rachaneni S, Latthe P. Urodynamics before stress incontinence surgery—A systematic review and meta-analysis. Neurourol Urodyn 2013;32:522–3.)做的RCT study中，發現並無差別，同時摘要2(2.Clement KD, Lapitan MC, Omar MI, et al. Do we need to perform urodynamics studies before surgery for urinary incontinence in women? Cochrane systematic review and meta-analysis. Neurourol Urodyn 2013;32:523–4.)的Clemen systemic review 7個study發現不管是否術前有做UDS，兩組人術後的結果是一樣的，但做UDS這組會高出5倍的機率改變處理方式，更可能是用藥物處理。

(2)對於單切口sling(single incision sling，SIS)，Mostafa et al(4. Mostafa A, Lim CP, Hopper LR, et al. Single incision mini-slings versus standard mid urethral slings in surgical management of female stress urinary incontinence: An updated systematic review meta-analysis of effectiveness and complications. Neurourol Urodyn 2013;32:526–8.)於(abstract 4)摘要4中review25個RCTs，追蹤12-24個月，發覺和傳統sling並無結果上的差別，但是SIS恢復較快，Abstrat 185(5. Tu LM, Erickson T, Ghelier E, et al. Twelve month results for an adjustable single incision sling in the treatment of female stress urinary incontinence. Neurourol Urodyn 2013;32:778–9.)、186(6. Munoz E, Garcia A, Oliver R, et al. Prospective study of a single incision mid urethral sling (contrasure needleless) for the treatment of female stress urinary incontinence using a retropubic approach. Efficacy, complicatiosn and quality of life at two years of follow up. Neurourol Urodyn 2013;32: 779–81.)、188(7. Masata J, Svabik K, Hubka P, et al. Randomized trial comparing the saftey and peri-operative complications of transobturator introduced tension-free vaginal tape (TVT-O) and single incision tape with adjustable length and

anchoring mechanism (AJUST): Three month results. Neurourol Urodyn 2013;32:783–4)在短中期追蹤也是這樣結果，仍待長期追蹤的結果。

(3)對於使用bulking agent 治療，Shobiri et al，指出約41%注射物質的位置不對，在intramural而非periurethral的位置，有可能導致的效果較差。

2. LUTS：infection和inflammation

(1)越來越多認為發炎和低度感染是導致LUTS(下泌尿道症狀，low urinary tract symptoms)的一部分原因，Vijaya et al.(21. Vijaya G, Dutta S, Singh AU, et al. Bacteria in the bladder wall of women with lower urinary tract symptoms: An interesting finding. Neurourol Urodyn 2013;32:695–6.)證明LUTS病人的bladder biopsy有明顯較大比例會culture出細菌(abstract123)Gill et al(23. Gill K, Horsley H, Kupelian AS, et al. Are we justified in the dismissing of microscopic pyuria of 1-9 WBC ml-1 as normal in symptomatic patients. Neurourol Urodyn 2013;32:696–7.)，也找到OAB與發炎相關的證據，當OAB病人與pyuria 1-9 cells/ul時，有兩種urothelial inflammation marker會上升(urinary lactoferrin和IL6)

(2)另外對於BPS/IC是根據症狀與cystoscopic hydrodistention後產生的glomerulation來診斷，但是卻會導致錯失60%臨床有明顯症狀的BPS/IC的病人。因為此criteria太嚴格，因此趨勢是朝向以症狀為主的定義。

花蓮慈濟醫院郭教授收集120位benign urologucal(symptom-based definition)的病人並詳細記錄finging後的膀胱鏡，發現此種non-specitic finding(glomerulation(abstrac54)(24. Gillenwater JY, Wein AJ. Summary of the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland, August 28–29, 1987. J Urol

1988;140:203–6.)

3.      Pelvic floor：懷孕與生產

在預防生產括約肌裂傷方面obstetric anal sphincterspincter tears(OASIS)Stedenfeldt et al(32. Stedenfedldt M, Øian P, Hals E, et al. A highly successful interventionalprogram reducing the incidence of OASIS from 4.7 to 2.0 percent in a large cohort. Neurourol Urodyn 2013;32:919–20.)證明了如何降低OASIS發生率，他們於挪威的5家醫院訓練產科醫師與助產士，尤其注重會陰支持(perineal support)與適當使用會陰切開術，分析40152個陰道生產發現OASIS發生率由訓練前4.7%下降至2%(這和以前會陰切開術的結論不同)。

4.      Pelvic organ prolapse的治療：

(1)骨盆底訓練.(PFMT)對於POP最近也證明有其良好效果。但Bo et(33. Bø K, Hilde G, Tennfjord MK, et al. Randomized controlled trial of pelvic floor muscle training to prevent and treat pelvic organ prolapse in post partum primiparous women. Neurourol Urodyn 2013;32:806–7.)，以RCT對於早期產後施行PFMT來評估其效果，針對175個初產婦，並以撕裂傷的嚴重程度分級並教導PFMT與在家訓練。全部的脫垂率是非常低的，在此study中，並無觀察到兩組在解剖學上脫垂的改善。

(2)Van der ploeg et al(36. Van der Ploeg JM, van der Steen A, Oude Rengerink K, et al. Multicentre randomized trial of vaginal prolapse repair versus vaginal prolapse repair with a midurethral sling in patients with pelvic organ prolapse and co-existing stress urinary incontinence. Neurourol Urodyn 2013;32:814–5.)隨機針對vaginal prolapse 修補會陰使用或不使用，midurethral sling，一年的追蹤之後，發現沒有做sling這組，有很高的risk有SUI(PR2.8，95%CI:1.7-4.7)。但病人尿失禁的嚴重程度並無顯著差別，但若與sling同時手術，手術的併發症會明顯上升。

(3)Velusamy et al(37. Velusamy A,WoodM, Foon R. A systematic reviewof catheterization following pelvic organ prolapse repair surgery. Neurourol Urodyn 2013;32:867–8.)針對脫垂手術後尿管放置，早期或晚期移除的7個RCT trial做review，發現導尿放置少於48小時，會有較少的UTI(RR0.24，95%CI0.17-0.36)但會有較大機會尿液滯留(RR3.67，95%CI2.35-5.72)。

(4)脫垂手術中保留子宮在最近越來越多，Rahmanou et al(38. Rahmanou P, Price N, Jackson S. One year follow up after laparoscopic hysteropexy and vaginal hysterectomy: A randomized study. Neurourol Urodyn 2013;32:870–1.)比較laparoscopic hysteropexy與vaginal hysterectomy，比較67位病人1年後追蹤，兩者的陰道症狀並無不同，但apical support在hysteropexy這組較好，這結果可顯示保留子宮可以當作病人的一個選項。

(待續)