膀胱阴道瘘：初始手术治疗优于保守治疗

南卡罗莱纳州查尔斯顿——根据妇外科医师协会(SGS)2013年会上报告的一项多中心回顾性研究，大多数单纯性膀胱阴道瘘(VVF)患者最初采取手术治疗，其中多数病例治疗成功；相反，最初采用导管引流进行保守治疗的病例大多数未能获得成功。

VVF是最常见的泌尿道获得性瘘，在美国往往是由妇科手术导致的。无论其病因如何，都会对患者的身心造成严重影响。由于目前缺乏治疗VVF的标准疗法，保守治疗常被视为一线治疗，这种治疗策略的成功率到底是多少一直不明确，为此，辛辛那提州Good Samaritan医院的Susan H. Oakley医生等人开展了本研究，以便对VVF的治疗模式及相应结局进行阐释。

这项回顾性研究总共纳入了226例膀胱阴道瘘患者，平均年龄为49.5岁，她们于2006年7月~2011年6月间在12家参与本研究的大学医疗中心接受VVF治疗，大多数为绝经后女性(53%)，不吸烟(59.5%)及白人(71%)。在这些受试者中，有166例在发病时采用手术治疗，其中77.5%通过一次手术治疗成功。而在37例通过初次手术未治疗成功的病例中，有32例再次手术，其中56%获得成功。在接受保守治疗的60例患者中，仅12%在35天的中位插管时间内治疗成功，而另外53例未成功者转而接受了手术治疗，其中大多数获得成功。219例接受手术治疗的患者的总成功率为83%。在初始手术治疗的患者中，有41%接受了阴道修补术，23%接受了腹壁修补术，其余患者接受了电烙术等其他类型的修补术。在初始保守治疗未成功转为手术治疗的患者中，有41%接受了阴道修补术，53%接受了腹壁修补术，其余患者接受了其他类型的修补术。

本研究采用了回顾性设计，并缺少部分数据，导致研究者未能对所有相关变量进行完整分析。但该研究具有包括多中心设计及样本量大在内的优势。因此，其结果支持对单纯性VVF宜优选早期手术治疗这一建议。

此次GSG年会由美国外科医师协会联合主办。Oakley医生报告称无相关利益冲突。

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By: SHARON WORCESTER, Ob.Gyn. News Digital Network

CHARLESTON, S.C. – Most simple vesicovaginal fistulae are initially managed by surgery, which is successful in the majority of cases, according to a multicenter review from the Fellows’ Pelvic Research Network.

Conversely, most of those initially managed conservatively by catheter drainage fail to resolve.

Of 226 patients with vesicovaginal fistulae (VVF) included in the review, 166 were managed surgically at the outset, and 77.5% of these resolved with one surgery. Of 37 who did not resolve after initial surgery, 32 underwent a second surgery; 56% of these resolved, Dr. Susan H. Oakley reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 60 patients who were managed conservatively, only 12% resolved during a median duration of catheterization of 35 days. The 53 who did not resolve went on to have surgery; the majority of these patients resolved. The overall success rate in the study was 83% in the 219 who underwent surgery, said Dr. Oakley of Good Samaritan Hospital, Cincinnati.

The patients (mean age, 49.5 years) were treated for VVF at 1 of 12 participating academic medical centers between July 2006 and June 2011. Most patients were postmenopausal (53%), nonsmokers (59.5%) and white (71%).

Of those initially managed surgically, 41% underwent vaginal repair, 23% underwent abdominal repair, and the remaining patients underwent other types of repair such as electrocautery. Of those initially managed conservatively who underwent subsequent surgery, 41% underwent vaginal repair, 53% underwent abdominal repair, and the remaining patients underwent other types of repair.

"VVF are the most common acquired fistulae of the urinary tract, and in the United States, gynecologic surgery is often the cause. Regardless of the etiology, the physical and emotional effects on patients are profound," Dr. Oakley said, adding that because a standardized algorithm for the management of VVS is lacking, the purpose of this study was to describe practice patterns and treatment outcomes for VVF.

While conservative management is often suggested as first-line therapy, it has been unclear how often this strategy is successful, she said at the meeting, jointly sponsored by the American College of Surgeons.

Although limited by its retrospective nature and by missing data that prevented complete analysis of all of the variables of interest, the study does have several strengths, including the multicenter design and a large number of cases. The findings thus support a recommendation that early surgical management should be considered as the preferred approach to treating simple VVF, Dr. Oakley concluded.

She reported having no relevant financial disclosures.