Derin İnfiltratif Endometriozis (DİE) Cerrahisi Sonrası Tekrar Operasyon veya Konservatif-Medikal Tedavi?
Özet
Derin infiltratif endometriozis (DIE), endometriozisin en agresif formu olup endometriozisten yakınan kadınların %20’sinde bulunur. Tek başına DIE ise vakaların %6.5’nu oluşturmaktadır. Pelvik organlarda anatomiyi ve organ fonksiyonlarını bozarak kadının yaşam kalitesini ciddi oranda düşürmektedir. Hastada lezyonun yerleşimine göre semptomlar da çeşitlilik (dismenore, disparoni, kronik pelvik ağrı) göstermektedir. En iyi tedavi yaklaşımının ne olduğu hala tartışmalı bir konudur. Tanı kesinleştiğinde, medikal tedavi ile semptomlar kontrol altına alınabilir. Medikal tedavide kullanılan hormonal terapiye cevap alınamazsa ya da hormonal tedavi açısından bir kontrendikasyon var ise, infertilite ya da ciddi ağrı semptomları mevcutsa cerrahi tedavi önerilebilir. Cerrahi tedavi sonrası yine medikal tedavi ile rekürrens önlenmeye çalışılır. Bazı durumlarda ikincil bir cerrahi tedavi gerekebilmektedir. İkincil cerrahi de konservatif bir cerrahi yöntem olabileceği gibi histerektomi gibi definitif bir cerrahi yöntem de olabilir. Cerrahi tedavinin amacı, tüm görünür endometriozis odaklarını çıkarmak, adezyolizis ile pelvik anatomiyi restore etmek, rekürrensleri önlemek, konsepsiyon oranlarını artırmak ve sonuç olarak yaşam kalitesini iyileştirmektir. Tüm bunları sağlarken komplikasyon oranlarını en aza indirmek de hedeflenmektedir. İkincil cerrahide uzun dönem ağrı kesici etki sağlamak üzere uterin denervasyon prosedürleri de cerrahi tedaviye eklenmektedir. Medikal tedavide kombine oral kontraseptifler, GnRH analogları, depo medroksiprogesteron asetat ve levonorgestrel salınımlı rahim içi araç kullanılmaktadır. Tüm bilgiler ışığında bugün güncel yaklaşımda hastanın bireysel özellikleri (tıbbi özgeçmiş, semptomlar, vb.) dikkate alınarak tedavi, hastaya özel tasarlanmalıdır.
DIE is the most agressive form of endometriosis and has been seen in 20 % of women with endometriosis. Isolated DIE has been observed in 6.5% of cases. It causes disturbance of pelvic anatomy and functions of the organs which leads to deterioration of quality of life. According to the placement of lesions, the symptoms vary (dysmenorrhea, dyspareunia, chronic pelvic pain). It has been controversial which treatment is superior; medical or surgical. Once the diagnosis is determined medical therapy can control the symptoms. If there is a contradiction for hormone therapy or if it is failed, if there are severe symptoms and infertilty, surgical treatment should be suggested. Medical therapy is also used postoperatively for prevention of recurrence. In some situations, secondary surgical treatment is needed. The secondary surgical procedure could be conservative or definitive as hysterectomy. The objective of the surgery is to excise all visible implants, restore pelvic anatomy and function of affected organs with adhesiolysis, prevent the recurrences and improve the quality of life as a result. Besides all of these, complication rates also should have been diminished. During the secondary surgical procedure, uterine denervation techniques are carried out. Combined oral contraceptives, GnRH agonists, depot medroxyprogesterone acetate and levonorgestrel-releasing intrauterine system are used as medical therapy components. In the light of all the information, the therapy should be tailored according to the individual characteristics of the patient such as symptoms and medical background.
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