{"id":2247,"date":"2020-05-04T19:56:54","date_gmt":"2020-05-04T16:56:54","guid":{"rendered":"http:\/\/www.ursak.org\/v3\/?page_id=2247"},"modified":"2020-05-06T12:07:19","modified_gmt":"2020-05-06T09:07:19","slug":"over-transpozisyonu","status":"publish","type":"page","link":"https:\/\/www.ursak.org\/v3\/bilgilendirme\/doktor-bilgilendirme\/over-transpozisyonu\/","title":{"rendered":"Over Transpozisyonu"},"content":{"rendered":"

Overlerin transpozisyonu (ooforopeksi, ovariopeksi), cerrahi m\u00fcdahale ile overlerin radyoterapi hedef alan\u0131ndan uzakla\u015ft\u0131r\u0131lmas\u0131 amac\u0131n\u0131 ta\u015f\u0131r. Radyoterapi kanser tedavisinin ayr\u0131lmaz bir bile\u015fenidir. Pelvisten k\u00f6ken alan serviks, endometrium, rektum ve mesane t\u00fcm\u00f6rlerin yan\u0131 s\u0131ra yine pelvik b\u00f6lgeye yerle\u015fen lenfomalar\u0131n tedavisinde radyoterapi \u00f6nemli bir yer almaktad\u0131r. Ne var ki, overlerin radyasyon etkisine \u00e7ok duyarl\u0131 oldu\u011funu bilmekteyiz.10 Gy \u2018a kadar d\u00fc\u015f\u00fck dozlarda bile over follik\u00fcllerinde DNA hasar\u0131, follik\u00fcl atrezisi ve over rezerv kayb\u0131 ya\u015fand\u0131\u011f\u0131 bildirilmektedir. Oysa lenfoma tedavisinde b\u00f6l\u00fcnm\u00fc\u015f dozlarda minimum 30 Gy, lokal ilerlemi\u015f servikal karsinomlarda ise 60 Gy ve \u00fczeri dozlara ihtiya\u00e7 duyulmaktad\u0131r.<\/p>\n

Over transpozisyonu radyoterapi planlanan serviks kanseri, vajinal kanser, uterin kanser, over disgerminomu olgular\u0131n\u0131n yan\u0131 s\u0131ra, pelvik osteosarkom, rabdomyosarkom, Hodgkin lenfoma, anorektal karsinom ve medulloblastom varl\u0131\u011f\u0131nda ge\u00e7ekle\u015ftirilebilir. Bug\u00fcne kadar ya\u015flar\u0131 11-40 aras\u0131nda de\u011fi\u015fen \u00e7ok say\u0131da olgu bildirilmi\u015ftir. 40 ya\u015f\u0131ndan b\u00fcy\u00fck kad\u0131nlarda, over rezervinin do\u011fal olarak azalm\u0131\u015f olmas\u0131 sebebiyle over transpozisyonun faydas\u0131 tart\u0131\u015fmal\u0131d\u0131r. Benzer \u015fekilde menopozdaki kad\u0131nlar ve over metastaz\u0131 riski ta\u015f\u0131yan olgular
da uygulama i\u00e7in uygun olmayan adaylard\u0131r.<\/p>\n\n\n\n\n\n\n\n\n\n\n
Over transpozisyonu i\u00e7in se\u00e7im kriterleri<\/strong><\/td>\n<\/tr>\n
Pelvik radyasyon gerektiren bir malignite<\/td>\n<\/tr>\n
Ya\u015f <40<\/td>\n<\/tr>\n
Serviks kanseri < 3cm<\/td>\n<\/tr>\n
Servikse s\u0131n\u0131rl\u0131 servikal kanser<\/td>\n<\/tr>\n
Lenfovask\u00fcler alan tutulumu yok<\/td>\n<\/tr>\n
Alt uterin segment tutulumu yok<\/td>\n<\/tr>\n
T\u00fcm\u00f6r\u00fcn yayg\u0131nl\u0131\u011f\u0131 MR ile kan\u0131tlanm\u0131\u015f<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Over Transpozisyonu Cerrahisi<\/h2>\n

\t\tOverlerin transpozisyonu laparotomi veya laparoskopi le ger\u00e7ekle\u015ftirilebilir. G\u00fcn\u00fcm\u00fczde a\u00e7\u0131k cerrahiye oranla \u00f6nemli avantajlar ta\u015f\u0131mas\u0131 sebebiyle laparoskopik yakla\u015f\u0131m tercih edilmektedir. Laparoskopik over transpozisyonu (LOT) ise \u201cmedial\u201d ve \u201clateral\u201d olarak adland\u0131r\u0131lan iki farkl\u0131 yakla\u015f\u0131m ile yap\u0131labilir. Medial transpozisyonda overler uterus arkas\u0131na yerle\u015ftirilmekte ve uterus radyoterapi etkisine kar\u015f\u0131 bir kalkan olarak kullan\u0131lmaktad\u0131r. Bu yakla\u015f\u0131m Hodgkin lenfomas\u0131 tedavisine kullan\u0131lm\u0131\u015ft\u0131r. Ancak her medial ve lateral yakla\u015f\u0131mlar\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 bir \u00e7al\u0131\u015fmada lateral LOT sonras\u0131 over fonksiyonlar\u0131n daha iyi bir \u015fekilde korundu\u011fu g\u00f6sterilmi\u015ftir (Grabenbauer et al. 1991).
\n\"\"LOT operasyonu standart bir laparoskopik cerrahinin \u00f6zelliklerini ta\u015f\u0131r. Standart cerrahiden farkl\u0131 yan\u0131 trokar giri\u015f noktalar\u0131n\u0131n farkl\u0131l\u0131\u011f\u0131d\u0131r. Overlerin transpoze edilece\u011fi noktan\u0131n pelvis bo\u015flu\u011funun \u00fczerinde bir seviyede olmas\u0131 sebebiyle trokarlar\u0131n daha y\u00fcksek seviyeden yerle\u015ftirilmesi operasyonu kolayla\u015ft\u0131racakt\u0131r. Veress i\u011fnesi ile umbilikus \u00fczerinden girilerek bat\u0131n insuffle edildikten sonra umbilikus ile ksifoid aras\u0131ndan bir giri\u015f noktas\u0131 tercih edilebilir. \u00c7e\u015fitli raporlarda \u00f6nerilen giri\u015f noktalar\u0131 \u015fematik olarak a\u015fa\u011f\u0131da sunulmu\u015ftur.
\nGerekli trokar giri\u015flerini takiben abdomen ve pelvis anatomisi de\u011ferlendirilir. Her iki tarafta \u00f6nce utero-ovarian ligaman koagule edilerek transekte edilir, over tek y\u00f6nden serbestle\u015ftirilir. Ard\u0131ndan mesosalpinks ve mesovarium disseke edilir. Takiben infundibulopelvik ligaman \u00fczerindeki periton a\u00e7\u0131l\u0131r, \u00fcreter korunarak ligaman serbestle\u015ftirilir ve overler anterolateral abdominal duvara do\u011fru transpoze edilir. Bu a\u015famada infundibulopelvik ligaman\u0131n kanlamay\u0131 bozacak \u015fekilde katlanmamas\u0131na \u00f6zen g\u00f6sterilmelidir. Overler kal\u0131c\u0131 s\u00fct\u00fcrler ile fasia transversalis \u00fczerine alt parakolik mesafeye fiske edilir. Overin \u00e7evresine konulacak iki adet hemostatik klip radyoterapi alan\u0131n\u0131n planlanmas\u0131 s\u0131ras\u0131nda over lokalizasyonunun belirlenmesinde yard\u0131mc\u0131 olacakt\u0131r. Overlerin ilak kemi\u011fin \u00fcst kenar\u0131n\u0131n (ilac crest) >1.5 cm \u00fczerindeki bir noktaya transpozisyonu pelvik radyoterapi s\u0131ras\u0131nda etkilenme riskini belirgin \u015fekilde azaltacakt\u0131r. Bu ama\u00e7la kolonun her iki yanda mobilize edilmesi gerekebilir.
\n\"\"
\nMedial yakla\u015f\u0131mda yukar\u0131da tarif edilen teknikten farkl\u0131 olarak utero-ovarian ligamanlar transekte edildikten sonra uterus arkas\u0131nda kar\u015f\u0131l\u0131kl\u0131 olarak uterosakral ligamanlara sabitlenir.
\nOperasyon s\u0131ras\u0131nda salpenjektomi yap\u0131l\u0131p yap\u0131lmamas\u0131 tart\u0131\u015fma konusudur. Literat\u00fcrde, biri \u00fclkemizden olmak \u00fczere, spontan gebelikler bildirilmektedir (Kurt et al. 2007, Terenziani et al. 2009). Salpenjektomi okult tubal metastazlar\u0131n yakalanmas\u0131n\u0131 sa\u011flayaca\u011f\u0131 gibi, olas\u0131 bir hidrosalpenks riskini de ortadan kald\u0131racakt\u0131r.
\nLOT operasyonu ile ilgili \u00f6rnek cerrahi videolar i\u00e7in a\u015fa\u011f\u0131daki linkleri kullanabilirsiniz:
\nhttps:\/\/youtu.be\/q-DAYY_gsBQhttps:\/\/www.youtube.com\/watch?v=vowP1Sy44zEhttps:\/\/www.youtube.com\/watch?time_continue=2&v=XH18DN7n-yohttps:\/\/www.youtube.com\/watch?v=YnaMmxlk1lM\t\t<\/p>\n

Over Transpozisyonu Cerrahisinde Klinik Sonu\u00e7lar<\/h2>\n

Over Fonksiyonun Korunmas\u0131<\/h4>\n

Laparoskopik over transpozisyonu (LOT) sonras\u0131 over fonksiyonlar\u0131 de\u011ferlendiren bir meta-analiz olgular\u0131n %90\u2019\u0131nda hormonal aktivitenin korundu\u011funu g\u00f6stermektedir (Gubbala et al. 2014). Over fonksiyonu hastan\u0131n g\u00f6rd\u00fc\u011f\u00fc tedaviyle direkt olarak ili\u015fkilidir; \u00f6rne\u011fin LOT sonras\u0131 vajinal brakiterapi g\u00f6ren olgularda fonksiyonlar %90 oran\u0131nda korunurken bu oran vajinal brakiterapiye ek olarak eksternal radyoterapi alan olgularda %60 seviyesinde kalmaktad\u0131r (Morice et al. 2000).<\/p>\n

LOT Sonras\u0131 Fertilite<\/h4>\n

Literat\u00fcre LOT sonras\u0131 gebelik ba\u015far\u0131s\u0131 ile ilgili data olduk\u00e7a k\u0131s\u0131tl\u0131d\u0131r. Hodgkin lenfoma olgular\u0131nda LOT uygulanan 11 olguda takip eden 14 y\u0131l i\u00e7erisinde 14 gebelik rapor edilmi\u015ftir (11 do\u011fum, 3 gebelik kayb\u0131) (Sicam et al. 2012). LOT sonras\u0131 ovulasyon ind\u00fcksiyonu ve follik\u00fcl aspirasyonu ile elde edilen gebelik de bildirilmi\u015ftir (Roberts et al. 2015).
Yine LOT olgular\u0131nda ta\u015f\u0131y\u0131c\u0131 annelik program\u0131 ile elde edilen gebelikler de mevcuttur (Agorastos et al. 2009).<\/p>\n

Komplikasyonlar<\/h4>\n

Her cerrahi gibi LOT operasyonu da anesteziye ba\u011fl\u0131 komplikasyonlarla birlikte kanama, enfeksiyon, transf\u00fczyon gereksinimi ve kom\u015fu organ yaralanmas\u0131 riski ta\u015f\u0131r. Bug\u00fcne dek LOT sonras\u0131 bildirilen komplikasyonlar \u015fu \u015fekilde \u00f6zetlenebilir:<\/p>\n

    \n
  • Rezid\u00fcel t\u00fcm\u00f6r oda\u011f\u0131n\u0131n b\u0131rak\u0131lmas\u0131 (Irtan et al. 2013)<\/li>\n
  • Kar\u0131n duvar\u0131nda trokar yerinde metastaz (Picone et al. 2003)<\/li>\n
  • Kronik pelvik veya abdominal a\u011fr\u0131, ooforektomi gerekiren over kistleri (Pahisa et al. 2008)<\/li>\n
  • Over torsiyonu (Gomez-Hidalgo et al. 2015)<\/li>\n<\/ul>\n

    Uygulaman\u0131n Yayg\u0131nl\u0131\u011f\u0131<\/h4>\n

    Radyoterapi g\u00f6recek olan hastalarda ovarian fonksiyonlar\u0131n ve fertilite \u015fans\u0131n\u0131n korunmas\u0131 a\u00e7\u0131s\u0131ndan ba\u015far\u0131 vadeden over transpozisyonu uygulamas\u0131 halen yayg\u0131n \u015fekilde \u00f6nerilmemekte ve uygulanmamaktad\u0131r. 2018 y\u0131l\u0131 sonunda AJOG\u2019de yay\u0131nlanan bir \u00e7al\u0131\u015fma pelvik radyoterapi alacak olan hastalar\u0131n %10\u2019undan daha az\u0131nda (%6.9) LOT uygulamas\u0131 yap\u0131ld\u0131\u011f\u0131n\u0131 g\u00f6stermektedir (Selter et al. 2018). LOT uygulama oran\u0131 serviks kanseri olgular\u0131 i\u00e7in %8.2, anal kanser i\u00e7in %5 ve uterin kanser i\u00e7in %2 olarak tan\u0131mlanm\u0131\u015ft\u0131r. \u00d6zel sigortal\u0131lar\u0131n LOT \u015fans\u0131 daha y\u00fcksek g\u00f6r\u00fclmektedir. Beklenilece\u011fi \u00fczere radyoterapi \u00f6ncesi sitored\u00fcktif cerrahi uygulanan olgularda LOT uygulama olas\u0131l\u0131\u011f\u0131 daha y\u00fcksektir.<\/p>\n

    Over Transpozisyonu ile ilgili kaynaklar<\/p>\n

    1. Christianson MS and Oktay K. Advances in fertility-preservation surgery: navigating new frontiers. Fertil Steril 112:438-445, 2019.<\/em>
    2. Nicholson K et al. 1288 robotic ovarian and fallopian tube transposition. A video presentation. Jorunal of Minimally Invasive Gynecology. 26:195, 2019.<\/em>
    3. Hoekman EJ et al. Ovarian function after ovarian transposition and additional pelvic radiotherapy: a systematic review. Eur J Surg Oncol 45:1328-1340,2019.<\/em>
    4. Gubbala et al. Outcomes of ovarian transposition in gynaecological cancers; a systematic review and meta-analysis. J Ovar Res. 2014;7:69.<\/em>
    5. Williams et al. Laparoscopic oophoropexy and ovarian function in the treatment of Hodgkin disease. Cancer. 1999;86:2138\u20132142.<\/em>
    6. Grabenbauer et al. Ovariopexy and the treatment of Hodgkin\u2019s disease. Strahlenther Onkol. 1991;167:273\u2013276.<\/em>
    7. Morice et al. Ovarian transposition for patients with cervical carcinoma treated by radiosurgical combination. Fertil Steril. 2000;74:743\u2013748.<\/em>
    8. Kurt et al. Successful spontaneous pregnancy in a patient with rectal carcinoma treated with pelvic radiotherapy and concurrent chemotherapy: the unique role of laparoscopic lateral ovary transposition. Eur J Gynaecol Oncol. 2007; 28:408\u2013410.<\/em>
    9. Terenziani et al. Oophoropexy: a relevant role in preservation of ovarian function after pelvic irradiation. Fertil Steril. 2009;91:935.<\/em>
    10. Sicam et al. Treatment of fallopian tube metastasis in cervical cancer after laparoscopic ovarian transposition. J Minim Invasive Gynecol. 2012;19:262\u2013265.<\/em>
    11. Roberts et al. Fertility preservation in reproductive-age women facing gonadotoxic treatments. Curr Oncol. 2015;22:294\u2013304.<\/em>
    12. Agorastos et al. Long-term follow-up after cervical cancer treatment and subsequent successful surrogate pregnancy. Reprod Biomed Online. 2009;19:250\u2013251.<\/em>
    13. Gomez-Hidalgo et al. Ovarian torsion after laparoscopic ovarian transposition in patients with gynecologic cancer: a report of two cases. J Minim Invasive Gynecol. 2015;22:687\u2013690.<\/em>
    14. Irtan et al. Ovarian transposition in prepubescent and adolescent girls with cancer. Lancet Oncol. 2013;14: e601\u2013e608.<\/em>
    15. Picone et al. Abdominal wall metastasis of a cervical adenocarcinoma at the laparoscopic trocar insertion site after ovarian transposition: case report and review of the literature. Gynecol Oncol. 2003;90:446\u2013449.<\/em>
    16. Pahisa et al. Laparoscopic ovarian transposition in patients with early cervical cancer. Int J Gynecol Cancer. 2008;18:584\u2013589.<\/em>
    17. Selter et al. Utilization of ovarian transposition for fertility preservation among young women with pelvic malignancies who undergo radiotherapy. Am J Obstet Gynecol 2018;415.<\/em>
    18. Wallace et al. Predicting age of ovarian failure after radiation to a field that includes the ovaries. Int J Radiat Oncol Biol Phys. 2005;62:738\u2013744.<\/em>
    19. Moawad et al. Laparoscopic ovarian transposition before pelvic cancer treatment: Ovarian function and fertility preservation. JMIG 2017;24:28-35.<\/em>
    20. Swift et al. Laparoscopic ovarian transposition prior to pelvic radiation for gynecologic cancer. Gyn Onco Rep 2018; 24:78-82.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

    Overlerin transpozisyonu (ooforopeksi, ovariopeksi), cerrahi m\u00fcdahale ile overlerin radyoterapi hedef alan\u0131ndan uzakla\u015ft\u0131r\u0131lmas\u0131 amac\u0131n\u0131 ta\u015f\u0131r. Radyoterapi kanser tedavisinin ayr\u0131lmaz bir bile\u015fenidir. Pelvisten k\u00f6ken alan serviks, endometrium, rektum ve mesane t\u00fcm\u00f6rlerin yan\u0131 s\u0131ra yine pelvik b\u00f6lgeye yerle\u015fen lenfomalar\u0131n tedavisinde radyoterapi \u00f6nemli bir yer almaktad\u0131r. Ne var ki, overlerin radyasyon etkisine \u00e7ok duyarl\u0131 oldu\u011funu bilmekteyiz.10 Gy \u2018a kadar […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2174,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2247","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/pages\/2247","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/comments?post=2247"}],"version-history":[{"count":8,"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/pages\/2247\/revisions"}],"predecessor-version":[{"id":2534,"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/pages\/2247\/revisions\/2534"}],"up":[{"embeddable":true,"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/pages\/2174"}],"wp:attachment":[{"href":"https:\/\/www.ursak.org\/v3\/wp-json\/wp\/v2\/media?parent=2247"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}