Rak sromu to rzadki nowotwór, który najczęściej dotyka kobiety w starszym wieku. U pacjentek z tym schorzeniem podstawą leczenia jest wulwektomia – polegająca na usunięciu zmiany nowotworowej oraz częściowym lub całkowitym wycięciu narządów płciowych. Zabieg jest poważny, obarczony powikłaniami i długotrwałym procesem gojenia się ran.
Podstawą leczenia nowotworu sromu jest zabieg operacyjny. Wulwektomia polega na wycięciu zmiany nowotworowej, a także zajętych chorobowo narządów. Stosuje się ją w zaawansowanych stadiach nowotworu, w których wielkość zmiany przekracza 4 cm. W zależności od wielkości zmiany, jej głębokości lub w przypadku naciekania, wykonuje się również limfadenektomię. W radykalnym leczeniu raka sromu konieczne może być również wytrzewienie miednicy mniejszej.
Metody leczenia chirurgicznego
Nie istnieje standardowa operacja dla wszystkich pacjentek z rakiem sromu. Zabieg i jego radykalność dobierane są indywidualnie.
W leczeniu schorzenia stosuje się m.in. metodę Hackera, która polega na usunięciu zmiany pierwotnej z szerokim marginesem tkanek. Zgodnie z obecnymi zaleceniami należy usuwać zmianę z marginesem zdrowych tkanek powyżej 1 cm. Natomiast już przy zachowaniu 1 cm marginesu w usuniętym materiale można osiągnąć 100-procentową radykalność zabiegu. Jeżeli margines jest mniejszy niż 8 mm, szanse na miejscowy nawrót nowotworu sięgają 22 proc.
By minimalnie ograniczyć inwazyjność zabiegu i zmniejszyć rozległość rany, przeprowadzane są również biopsje węzła wartowniczego, w którym może pojawić się przerzut raka. Usunięcie węzła wartowniczego obecnie zalecane jest pacjentkom z niskim zaawansowaniem nowotworu.
Wytrzewienie miednicy mniejszej wykonuje się w zaawansowanych nowotworach sromu, w przypadkach, gdy komórki nowotworowe objęły odbytnicę, pochwę, cewkę moczową oraz pęcherz moczowy. Warunkiem wykonania wytrzewienia jest brak przerzutów odległych oraz na węzły chłonne okołoaortalne, a także lokalizacja guza, która pozwoli na jego usunięcie z zachowaniem marginesu tkanek niezmienionych. Wytrzewienie dzieli się na przednie (radykalne wycięcie sromu wraz z węzłami chłonnymi pachwinowymi, usunięcie pęcherza moczowego, pochwy oraz macicy), tylne (radykalne wycięcie sromu wraz z węzłami chłonnymi pachwinowymi, resekcji odbytnicy z częścią esicy oraz usunięcie macicy wraz z przydatkami) i całkowite (całkowite wycięcie sromu, węzłów chłonnych i wszystkich narządów miednicy małej).
Usunięcie pochwy, sromu i węzłów chłonnych
W 1990 r. zaproponowano nomenklaturę ISSVD, która określa głębokość, powierzchowność i rozległość usunięcia pochwy, sromu lub węzłów chłonnych pachwinowych i udowych.
Najważniejszą kwestią w wyborze zakresu leczenia chirurgicznego raka sromu jest umiejscowienie zmiany pierwotnej oraz jej rozległość. Srom usunięty może być częściowo i całkowicie. Usunięcie powierzchowne polega na wycięciu najbardziej powierzchownej warstwy skóry i tkanki podskórnej. Natomiast usunięcie głębokie ma na celu wycięcie sromu do granicy powierzchownego rozcięgna przepony moczowo-płciowej i/lub okostnej łonowej. W obrębie pochwy zabieg polega na częściowym lub całkowitym wycięciu narządu, ale operacja może również obejmować rozszerzone wycięcie pochwy, polegające na wycięciu narządu razem z przypochwiem niezależnie od powierzchni wycinanej pochwy.
Limfadenektomię (usunięcie węzłów chłonnych pachwinowych i udowych) wykonuje się powierzchownie (wycięcie węzłów chłonnych znajdujących się ponad więzadłem pachwinowym i powięzią szeroką i sitową) a także głęboko (usunięcie węzłów chłonnych poniżej powięzi szerokiej i sitowej), przy czym najbardziej proksymalnym usuwanym węzłem jest węzeł chłonny pachwinowy głęboki. Usunięcie węzłów chłonnych pachwinowych może być jednoetapowe – jeżeli jednocześnie usuwany jest srom i węzły pachwinowe, lub dwuetapowe – radykalne wycięcie sromu, a po kilkunastu dniach resekcja węzłów chłonnych.
Przeciwwskazania i powikłania po wulwektomii sromu
Zabiegowi wycięcia zmiany nowotworowej lub radykalnemu usunięciu sromu poddawać się mogą pacjentki, u których nie doszło do przerzutów do węzłów chłonnych okołoaortalnych i odległych, u których nowotwór ograniczony jest do miednicy mniejszej i nie nacieka na jej ściany. Czynnikami ryzyka powikłań po zabiegu są: wiek pacjentki, szczególnie po 80. roku życia, a także ogólnoustrojowe choroby współistniejące (choroby układu krążenia, układu oddechowego, moczowego, pokarmowego, stany zapalne narządu płciowego, cukrzyca, żylaki kończyn dolnych), otyłość, zakażenia, przebyte operacje czy choroba zatorowo-zakrzepowa.
Zabieg wulwektomii obarczony jest ryzykiem wystąpienia powikłań. Do wczesnych należą zaburzenia czucia przedniej powierzchni uda, choroba zakrzepowo-zatorową, zapalenie okostnej spojenia łonowego, torbiele limfatyczne i zakażenie dróg moczowych. Do powikłań późnych zalicza się obrzęki kończyn, wypadanie lub obniżenie ścian pochwy, a także przepukliny udowe i pachwinowe oraz zaburzenia mikcji.
Limfadenektomia związana jest z częstszym rozchodzeniem się ran, a także ich infekcjami, powstawaniem torbieli limfatycznych i przewlekłym obrzękiem kończyn dolnych.
Rany po wulwektomii sromu należą do ran trudno gojących się. Pacjentkom zaleca się terapię specjalistycznymi opatrunkami. O wyborze odpowiedniego opatrunku dostosowanego do rany decydować powinien lekarz.
Źródła:
A. Olejek, M. Kucharzewski, K. Stencel-Gabriel, I. Gabriel, Metody pielęgnacji ran po zabiegach wulwektomii, Leczenie Ran (2016);13 (2), str. 51-55
J. J. Sznurkowski, L. Bodnar, M. Bidziński, A. Bieńkiewicz i wsp., Zalecenia Polskiego Towarzystwa Ginekologii Onkologicznej dotyczące diagnostyki i leczenia raka sromu, Curr Gynecol Oncol 2017, 15 (1), str. 45–53
forumginekologii.pl
onkologia.org.pl
onkonet.pl
Przeczytaj także: Asystent dermatologiczny Google pomoże w rozpoznawaniu chorób skórnych
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Hey there this is somewhat of off topic but I was wanting to know if blogs use WYSIWYG editors or if you have to manually code with HTML. I’m starting a blog soon but have no coding knowledge so I wanted to get advice from someone with experience. Any help would be enormously appreciated!